Social determinants of inequalities in child undernutrition in Bangladesh: A decomposition analysis

Decoding India's Child Malnutrition Puzzle: A Multivariable Analysis Using a Composite Index

BACKGROUND

This study examines the levels and predictors of malnutrition in Indian children under 5 years of age.

METHODS

Composite Index of Anthropometric Failure was applied to data from the India National Family Health Survey 2019-2021. A multivariable logistic regression model was used to assess the predictors.

RESULTS

52.59% of children experienced anthropometric failure. Child predictors of lower malnutrition risk included female gender (adjusted odds ratio (AOR) = 0.881) and average or large size at birth (AOR = 0.729 and 0.715, respectively, compared to small size). Higher birth order increased malnutrition odds (2nd-4th: AOR = 1.211; 5th or higher: AOR = 1.449) compared to firstborn. Maternal predictors of lower malnutrition risk included age 20-34 years (AOR = 0.806), age 35-49 years (AOR = 0.714) compared to 15-19 years, normal BMI (AOR = 0.752), overweight and obese BMI (AOR = 0.504) compared to underweight, and secondary or higher education vs. no education (AOR = 0.865). Maternal predictors of higher malnutrition risk included severe anemia vs. no anemia (AOR = 1.232). Protective socioeconomic factors included middle (AOR = 0.903) and rich wealth index (AOR = 0.717) compared to poor, and toilet access (AOR = 0.803). Children's malnutrition risk also declined with paternal education (primary: AOR = 0.901; secondary or higher: AOR = 0.822) vs. no education. Conversely, malnutrition risk increased with Hindu (AOR = 1.258) or Islam religion (AOR = 1.369) vs. other religions.

CONCLUSIONS

Child malnutrition remains a critical issue in India, necessitating concerted efforts from both private and public sectors. A 'Health in All Policies' approach should guide public health leadership in influencing policies that impact children's nutritional status.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

Examining determinants of stunting in Urban and Rural Indonesian: a multilevel analysis using the population-based Indonesian family life survey (IFLS)

BACKGROUND

In Indonesia, chronic malnutrition leading to stunted growth in children represents a significant issue within the public health domain. The prevalence of stunting varies between urban and rural areas, reflecting disparities in access to nutrition, healthcare, and other socioeconomic factors. Understanding these disparities is crucial for developing targeted interventions to address the issue.

METHODS

The study used data from the fifth wave of the Indonesian Family Life Survey (IFLS), which is a national cross-sectional population-based survey conducted across approximately 13 provinces in Indonesia in 2014-2015. Multivariate and Multilevel logistic regression models were utilized in the analysis to determine the factors associated with the prevalence of stunting in Indonesian children.

RESULTS

The multivariate logistic regression analysis indicated that among children aged 24-59 months in Indonesia, stunting was associated with the age of the child, birth weight, maternal nutritional status, and residence. Subsequently, the multilevel logistic regression analysis revealed that in rural areas, the age of the child and birth weight exhibited significant associations with stunting. Conversely, in urban areas, stunted children were influenced by 7 factors, including the child's age (months), age of weaning, birth weight (kg), mother and father's age, place of birth, and maternal nutritional status.

CONCLUSIONS

Variations in childhood stunting between urban and rural regions in Indonesia were observed, indicating a differential prevalence. The study's findings suggests the importance of age-appropriate nutritional support, healthcare interventions, and growth monitoring. Focused interventions are vital, potentially encompassing initiatives such as improving access to maternal and child healthcare services, promoting adequate nutrition during pregnancy and infancy, and facilitate greater parental engagement in childcare responsibilities.

Trends and long-term variation explaining nutritional determinants of child linear growth: analysis of Bangladesh Demographic and Health Surveys 1996-2018

OBJECTIVE

To examine the height-for-age z-score (HAZ) of 0-35 months' children along with stunting prevalence to identify trends, changes and available nutrition-sensitive and specific determinants that could help explain the long-term variation in child linear growth using successive Bangladesh Demographic and Health Surveys (BDHS) data from 1996 to 2018.

DESIGN

The BDHS pooled data are used for determining the key outcome variables HAZ, stunting and severe stunting. Trends, kernel-weighted local polynomial smoothing illustrations, pooled multivariable linear probability model (LPM), ordinary least squares method (OLS) and regression decomposition were used.

PARTICIPANTS

Mothers having 0-35 months' children, the most critical age range for growth faltering.

RESULTS

The mean HAZ increased by 0·91(±1·53) with 0·041 annual average change, while the percentages of stunting (-26·63 ± 0·54) and severe stunting (-21·12 ± 0·48) showed a reduction with 1·21 and 0·96 average annual changes, respectively. The average HAZ improvement (0·42 ± 1·56) in urban areas was less than the rural areas (1·16 ± 1·44). Similar patterns followed for stunting and severe stunting. The prenatal doctor visits (3064·65 %), birth in a medical facility (1054·32 %), breastfeeding initiation (153·18 %) and asset index (144·73 %) demonstrated a huge change. The findings of OLS, LPM and regression decomposition identified asset index, birth order, paternal and maternal education, bottle-fed, prenatal doctor visit, birth in a medical facility, vaccination, maternal BMI and ever-breastfed as influencing factors to predict the long-term changes of stunting and severe stunting.

CONCLUSION

The nutrition-sensitive and specific factors identified through regression decomposition describing long-term variation in child linear growth should be focused further to attain the sustainable development goals.

Social determinants of stunting in Malay children aged <5 years in Malaysia

OBJECTIVE

This study aims to assess social determinants of stunting among children aged <5 y within the Malay ethnicity in Malaysia.

METHODS

This study used data from the National Health and Morbidity Survey 2016: Maternal and Child Health. It includes a sample of 10 686 children, ages 0 to 59 mo, of Malay ethnicity. Height-for-age z score was determined based on the World Health Organization Anthro software. A binary logistic regression model was used to examine the association between the selected social determinants and the occurrence of stunting.

RESULTS

About 22.5% of children aged <5 y of Malay ethnicity were stunted. For those ages 0 to 23 mo, stunting is more prevalent in boys, in rural areas, and in those who have screen exposure, whereas a reduction of stunting was observed for those children whose mothers work in the private sector and in those who consume formula milk and meat. As for those ages 24 to 59 mo, there was a higher prevalence of stunting for those with self-employed mothers and reduced prevalence in children with hygienic waste disposal practices as well as those who play with toys.

CONCLUSIONS

The prevalence of stunting among children of Malay ethnicity aged <5 in Malaysia necessitates immediate intervention. It is pertinent to facilitate early identification of those children at risk of stunting for additional care to promote healthy growth.

Experiences of parents and stakeholders in caring for, and supporting children with special needs in Ghana

We studied the caring, parenting, and support services for children with special needs in Ghana. Many of the study participants reported re-adjusting their lives in virtually every domain-social, economic, and emotional to deal with and manage the new realities. How parents navigate this space varied considerably from setting to setting. Regardless of individual and interpersonal resources, community, institutional, and policy circumstances seemed to exacerbate notions of disability. In many instances, parents had a low depth of suspicion about the precursors to disabling events in their children. Parents are constantly pursuing health care, including a cure for their children with disabilities. Views about "otherness" were noted, and these tended to undermine medical interpretations/explanations of disability generally, which in turn affected formal education and health-seeking for children. Institutional arrangements exist to encourage parents to invest in their children regardless of their perceived abilities. However, these do not seem to be sufficient, particularly for health and formal education. Programming and policy implications are highlighted.

Wealth- and education-related inequalities in minimum dietary diversity among Indonesian infants and young children: a decomposition analysis

Background

Over the last two decades, Indonesia has experienced remarkable economic growth. However, the percentage of infants and young children meeting the minimum dietary diversity (MDD) criteria has stagnated. Despite the growing body of evidence of the association between MDD and socioeconomic factors, there is little information about socioeconomic inequalities in MDD in Indonesia.

Objectives

The current study seeks to quantify the wealth- and education-related inequalities in MDD among infants and young children in Indonesia and determine the contribution of different factors to these disparities.

Methods

We included a total of 5038 children aged 6–23 months of the 2017 Indonesia Demographic and Health Survey. We measured wealth- and education-related inequalities using the concentration curve and Wagstaff normalised concentration index. Using a concentration index decomposition analysis, we then examined factors contributing to wealth- and education-related inequalities in MDD.

Results

The concentration indices by household wealth and maternal education were 0.220 (p < 0.001) and 0.192 (p < 0.001), respectively, indicating more concentration of inequalities among the advantaged population. The decomposition analysis revealed that household wealth (29.8%), antenatal care (ANC) visits (16.6%), paternal occupation (15.1%), and maternal education (11.8%) explained the pro-rich inequalities in MDD in Indonesia. Maternal education (26.1%), household wealth (19.1%), ANC visits (14.9%), and paternal occupation (10.9%) made the most considerable contribution to education-related inequalities in MDD.

Conclusions

There is substantial wealth- and education-related inequalities in MDD. Our findings suggest an urgent need to address the underlying causes of not reaching dietary diversity by promoting infant and young child feeding equity in Indonesia.

What explains the large disparity in child stunting in the Philippines? A decomposition analysis

OBJECTIVE

About one-third of under-five Filipino children are stunted, with significant socio-economic inequality. This study aims to quantify factors that explain the large gap in stunting between poor and non-poor Filipino children.

DESIGN

Using the 2015 Philippine National Nutrition Survey, we conducted a linear probability model to examine the determinants of child stunting and then an Oaxaca-Blinder decomposition to explain the factors contributing to the gap in stunting between poor and non-poor children.

SETTING

Philippines.

PARTICIPANTS

1881 children aged 6-23 months participated in this study.

RESULTS

The overall stunting prevalence was 38·5 % with a significant gap between poor and non-poor (45·0 % v. 32·0 %). Maternal height, education and maternal nutrition status account for 26 %, 18 % and 17 % of stunting inequality, respectively. These are followed by quality of prenatal care (12 %), dietary diversity (12 %) and iron supplementation in children (5 %).

CONCLUSIONS

Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.

Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis

OBJECTIVE

Risk factors predisposing infants to community-acquired bacterial infections during the first 2 months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship.

METHODS

Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59 days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection.

RESULTS

Among 63 114 infants born, 14 655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99).

CONCLUSION

Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials.

Poor and non-poor gap in under-five child nutrition: a case from Nepal using Blinder-Oaxaca decomposition approach

INTRODUCTION

Many low-and middle-income countries (LMICs) have improved health indicators in the past decades, however, there is a differential in outcomes between socioeconomic groups. Systematic analysis of drivers of child nutrition gap between non-poor and poor groups has a policy relevance in Nepal and other countries to make progress towards universal health coverage (UHC). The objective of this paper was to estimate the mean height-for-age z scores (HAZ) gap between under-five children belonging to non-poor and poor groups, divide the gap into components (endowments, coefficients and interaction), and identify the factors that contributed most to each of the component.

METHODS

Information about 6277 under-five children was extracted from the most recent nationally representative Nepal Multiple Indicator Cluster Survey (MICS) 2019. HAZ was used to assess nutritional status of children. Wealth index was used to categorize children into non-poor and poor. Mean HAZ gap between groups was decomposed using Blinder-Oaxaca technique into components: endowments (group difference in levels of predictors), coefficients (group difference in effects of predictors), and interaction (group difference due to interaction between levels and effects of predictors). Detailed decomposition was carried out to identify the factors that contributed most to each component.

RESULTS

There was a significant non-poor and poor gap in nutrition outcome measured in HAZ (0.447; p < 0.001) among under-five children in Nepal. The between-group mean differences in the predictors of study participants (endowments) contributed 0.210 (47%) to the gap. Similarly, the between-group differences in effects of the predictors (coefficients) contributed 0.308 (68.8%) towards the gap. The interaction contributed -0.071 (15.8%) towards minimizing the gap. The predictors/variables that contributed most towards the gap due to (i) endowments were: maternal education, province (Karnali, Sudurpaschim, Madhesh), residence (rural/urban), type of toilet facility and ethnic group (Dalit and Muslim); (ii) coefficients were: number of under-five children in family, ethnic group (Dalit and Muslim), type of toilet facility, maternal age and education.

CONCLUSION

Decomposition of the child nutrition gap revealed that narrowing the inequality between wealth groups depends not only on improving the level of the predictors (endowments) in the poor group but also on reducing differential effects of the predictors (coefficients).

Inequality in health opportunities in Indonesia: long-term influence of early-life circumstances on health

Background

This study explores inequality of opportunity in terms of the health of adult Indonesian people, associated with household and parental circumstances in childhood and adolescence.

Methods

Exploiting the longitudinal nature of the Indonesian Family Life Survey, this study measures inequalities relating to being underweight, overweight, hypertensive and diabetic across adult Indonesians aged between 20 and 35 through the dissimilarity index. This study explores their determinants by decomposing the observed inequality levels into contributing factors. Moreover, this study sheds light on the underlying mechanisms through which early-life circumstances influence the health of grown-up respondents, by estimating the intermediate effects of early-life circumstances on current lifestyles.

Results

For all health conditions, health risks are unequally distributed (all p<0.01). Demographic factors and parental health are major contributors to inequalities relating to being underweight, overweight and hypertensive. Family structure and parental occupation are major contributors to inequality in diabetes. The greater part of this inequality is explained by the indirect pathways through which early-life circumstances mediate current diet and exercise habits.

Conclusions

The results suggest that such interventions that compensate for disadvantaged early-life circumstances would be essential in reducing future health risks and mitigating health inequality.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12889-022-13714-8).

Maternal Underweight and Its Association with Composite Index of Anthropometric Failure among Children under Two Years of Age with Diarrhea in Bangladesh

Malnutrition in women has been a long-standing public health concern, with serious effects on child survival and development. Maternal body mass index (BMI) is an important maternal nutritional indicator. There are few published studies although child anthropometric failures do not occur in isolation and identifying children with single versus several co-occurring failures can better capture cases of growth failure in combination: stunting, wasting, and underweight. In the context of multiple anthropometric failures, traditional markers used to assess children's nutritional status tend to underestimate overall undernutrition. Using the composite index of anthropometric failure (CIAF), we aimed to assess the association between maternal undernutrition and child undernutrition among children with diarrhea under the age of two and to investigate the correlates. Using 1431 mother-child dyads from the Antibiotic for Children with Diarrhea (ABCD) trial, we extracted children's data at enrollment and on day 90 and day 180 follow-ups. ABCD was a randomized, multi-country, multi-site, double-blind, placebo-controlled clinical trial. The Bangladesh site collected data from July 2017 to July 2019. The outcome variable, CIAF, allows combinations of height-for-age, height-for-weight, and weight-for-age to determine the overall prevalence of undernutrition. The generalized estimating equation was used to explore the correlates of CIAF. After adjusting all the potential covariates, maternal undernutrition status was found to be strongly associated with child undernutrition using the CIAF [aOR: 1.4 (95% CI: 1.0, 1.9), p-value = 0.043] among the children with diarrhea under 2 years old. Maternal higher education had a protective effect on CIAF [aOR: 0.7 (95% CI: 0.5, 0.9), p-value = 0.033]. Our study findings highlight the importance of an integrated approach focusing on maternal nutrition and maternal education could affect a reduction in child undernutrition based on CIAF.

Inequalities in childhood stunting: evidence from Sudan multiple indicator cluster surveys (2010-2014)

Background

Leaving no one behind has been an important marker of the Sustainable Development Goals. Closing the gap in malnutrition between children of different backgrounds aligns well with the tenet of this international agenda. To this end, high-quality evidence of the magnitude and trends of socioeconomic and geographic related existing inequalities in the childhood stunting among Sudanese children emanate from this study help for policy maker and planners to design and implement effective interventions to narrow down inequality.

Methods

We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) for our analysis of stunting inequality. Following standard equity analysis methods recommended by the WHO, we performed the disaggregated analysis of stunting across five equity stratifiers: Wealth, education, residence, sex, and sub-national regions. Then, we summarized stunting inequality through four measures of inequality: Difference, Ratio, Slope Index of Inequality (SII), and Relative Index of Inequality (RII). The point estimates of stunting were accompanied by 95% confidence intervals to measure the statistical significance of the findings.

Results

In this study, the national average childhood stunting prevalence was increased by 4% from 2010 to 2014. The findings revealed stark inequalities in stunting in all the studied dimensions of inequality. Huge inequality has existed along the wealth quintiles. Simple difference measure for education was increased by four points and simple relative measure decreased by one point for economic status.

Conclusions

Sex, residence and, geographically related inequalities remain unchanged over time, while economic status and educational inequality had seen a change by some inequality measures over the same time period.

Geographic and Socioeconomic Disparity in Child Undernutrition across 514 Districts in Indonesia

BACKGROUND

Globally, in 2020, 45 million children were estimated to be wasted, and 149 million children under five years of age were estimated to be stunted. Undernutrition makes children in particular much more vulnerable to disease and death. Our study aims to examine geographic and socioeconomic disparities in child undernutrition across 514 districts in Indonesia.

METHODS

Employing both geospatial and quantitative analyses (descriptive statistics and Ordinary Least Squares regressions), we analyzed the disparities in the prevalence of underweight, severe underweight, wasting, severe wasting, stunting, and severe stunting among districts. Child undernutrition data were from Indonesia Basic Health Survey (Riskesdas) 2018, which included a sample of 93,620 children under five years. Socioeconomic data were from the World Bank.

RESULTS

We found a relatively large geographic and socioeconomic disparity in child undernutrition in Indonesia. By region, districts in the Papua region (including Maluku and Nusa Tenggara) had a significantly higher prevalence of underweight and wasting than those in the Java region (including Bali). Districts in Papua had 44%, 121%, 38%, and 57% higher prevalence of underweight, severe underweight, wasting, and severe wasting, respectively. Similarly, the poorest districts had a significantly higher prevalence of underweight, wasting, and stunting than the wealthiest districts. The poorest districts had 30%, 83%, 16%, 21%, and 74% higher prevalence of underweight, severe underweight, wasting, stunting, and severe stunting, respectively. These results were similar among rural districts.

CONCLUSION

There is a significant disparity in child undernutrition across districts in Indonesia. The government needs to prioritize the reduction of child undernutrition, especially in rural areas, districts outside of Java and Bali, and the poorest and least educated areas.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Sociodemographic risk factors of under-five stunting in Bangladesh: Assessing the role of interactions using a machine learning method

This paper aims to demonstrate the importance of studying interactions among various sociodemographic risk factors of childhood stunting in Bangladesh with the help of an interpretable machine learning method. Data used for the analyses are extracted from the Bangladesh Demographic and Health Survey (BDHS) 2014 and pertain to a sample of 6,170 under-5 children. Social and economic determinants such as wealth, mother's decision making on healthcare, parental education are considered in addition to geographic divisions and common demographic characteristics of children including age, sex and birth order. A classification tree was first constructed to identify important interaction-based rules that characterize children with different profiles of risk for stunting. Then binary logistic regression models were fitted to measure the importance of these interactions along with the individual risk factors. Results revealed that, as individual factors, living in Sylhet division (OR: 1.57; CI: 1.26-1.96), being an urban resident (OR: 1.28; CI: 1.03-1.96) and having working mothers (OR: 1.21; CI: 1.02-1.44) were associated with higher likelihoods of childhood stunting, whereas belonging to the richest households (OR: 0.56; CI: 0.35-0.90), higher BMI of mothers (OR: 0.68 CI: 0.56-0.84) and mothers' involvement in decision making about children's healthcare with father (OR: 0.83, CI: 0.71-0.97) were linked to lower likelihoods of stunting. Importantly however, risk classifications defined by the interplay of multiple sociodemographic factors showed more extreme odds ratios (OR) of stunting than single factor ORs. For example, children aged 14 months or above who belong to poor wealth class, have lowly educated fathers and reside in either Dhaka, Barisal, Chittagong or Sylhet division are the most vulnerable to stunting (OR: 2.52, CI: 1.85-3.44). The findings endorse the need for tailored-intervention programs for children based on their distinct risk profiles and sociodemographic characteristics.

Trends in child growth failure among children under five years of age in Ethiopia: Evidence from the 2000 to 2016 Demographic and Health Surveys

INTRODUCTION

In a majority of low- and middle-income countries (LMICs), levels of child growth failure (CGF) have steadily declined since 2000. However, some countries show a different trend. Despite continued investment from the government of Ethiopia as well as donors, CGF levels are still high in Ethiopia. This study aimed to assess trends in CGF and associated sociodemographic, economic and water, sanitation, and hygiene (WASH) factors from 2000 to 2016 in Ethiopia.

METHODS

Data were taken from four rounds of the Ethiopia Demographic and Health Survey (EDHS). Children aged between 0 to 59 months were included. CGF indicators were categorised based on height-for-age z-score (HAZ) < -2 Standard deviation (SD), weight-for-age z-score (WAZ) < -2 SD and weight-for-height z-score (WHZ) < -2 SD. CGF trends were estimated for predicted probabilities and odds ratios (ORs) between 2000 and 2016.

RESULTS

A total sample size of 31978 for HAZ, 32045 for WAZ and 32246 for WHZ were included in the current study. Stunting decreased from an adjusted odds ratio (AOR) = 0.77 (95% CI: 0.67 to 0.88) in 2005 to an AOR = 0.45 (95% CI: 0.39 to 0.53) in 2016 compared with the year 2000. Compared with data in 2000, underweight decreased from an AOR of 0.70 (95% CI: 0.61 to 0.80) in 2005 to an AOR of 0.43 (95% CI: 0.36 to 0.50) in 2016. Wasting declined from an AOR of 0.91 (95% CI: 0.75 to 1.10) in 2005 to an AOR of 0.76 (95% CI: 0.61 to 0.94) in 2016, compared with data in 2000.

CONCLUSIONS

Between 2000 to 2016, there was a decline in CGF levels albeit the levels are still relatively high compared with the World Health Organization (WHO) cut-off levels for public health concern. Observed rates of change varied across sociodemographic, economic and WASH factors which suggest that interventions tailored towards addressing the imbalances across those factors are required.

Are fathers a good substitute for mothers? Paternal care and growth rates in Shodagor children

Biparental care is a hallmark of human social organization, though paternal investment varies between and within societies. The facultative nature of paternal care in humans suggests males should invest when their care improves child survival and/or quality, though testing this prediction can be challenging because of the difficulties of empirically isolating paternal effects from those of other caregivers. Additionally, the broader context in which care is provided, vis-à-vis care from mothers and others, may lead to different child outcomes. Here, we examine the effects of paternal care on child growth among Shodagor fisher-traders, where fathers provide high levels of both additive and substitutive care, relative to mothers. We modeled seasonal z-scores and velocities for height, weight, and body mass index (BMI) outcomes using linear mixed models. Our evidence indicates that, as predicted, the context of paternal care is an important predictor of child outcomes. Results show that environmental seasonality and alloparental help contribute to a nuanced understanding of the impact of Shodagor paternal care on child physiology.

Model and variable selection using machine learning methods with applications to childhood stunting in Bangladesh

Childhood stunting is a serious public health concern in Bangladesh. Earlier research used conventional statistical methods to identify the risk factors of stunting, and very little is known about the applications and usefulness of machine learning (ML) methods that can identify the risk factors of various health conditions based on complex data. This research evaluates the performance of ML methods in predicting stunting among under-5 aged children using 2014 Bangladesh Demographic and Health Survey data. Besides, this paper identifies variables which are important to predict stunting in Bangladesh. Among the selected ML methods, gradient boosting provides the smallest misclassification error in predicting stunting, followed by random forests, support vector machines, classification tree and logistic regression with forward-stepwise selection. The top 10 important variables (in order of importance) that better predict childhood stunting in Bangladesh are child age, wealth index, maternal education, preceding birth interval, paternal education, division, household size, maternal age at first birth, maternal nutritional status, and parental age. Our study shows that ML can support the building of prediction models and emphasizes on the demographic, socioeconomic, nutritional and environmental factors to understand stunting in Bangladesh.

Distribution of wealth-stratified inequalities on maternal and child health parameters and influences of maternal-related factors on improvements in child health survival rate in Bangladesh

This study investigates the influence of household socioeconomic status and maternal risk factors and health-care service availability on changes in the under-five mortality rate (U5MR) in Bangladesh. Potential risk factors that influence U5MRs were investigated using multilevel logistic regression analysis and 29,697 data points from the Bangladesh Demographic and Health Surveys, 2004-2014. Maternal and child health parameters such as childhood morbidity, low vaccination coverage, poor utilization of perinatal care, and malnutrition were found to be more concentrated in poorer households. Pooled estimates indicated that the aggregate odds of U5MR risk declined by 18% to 2007 to 38% to 2014 compared to 2004. However, inadequate antenatal care, short birth interval, primiparity, illiteracy, delayed conception, and low socioeconomic status were significantly associated with a higher risk of under-five mortality. The magnitude of inequality using these measures were significantly associated with large variations in U5MR changes. Although a significant reduction in U5MR in Bangladesh was found in this study, substantial socioeconomic variations still persist. The analysis suggests that decreasing inequality in society is required for further reductions in child mortality. This will help to achieve a more equitable distribution of child and neonatal outcomes and assist the achievement of Sustainable Development Goals 3.2 by 2030.

Changes in socio-economic inequality in nutritional status among children in EAG states, India

OBJECTIVE

The primary purpose of this study is to examine changes in socio-economic inequality in nutritional status (stunting and underweight) among children in Empowered Action Group (EAG) states.

DESIGN

The study is based on the most recent two wave's cross-sectional data from the National Family Health Survey (NFHS) conducted in 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4). The study used height-for-age (stunting) and weight-for-age (underweight) of children as anthropometric indicators.

SETTING

EAG states including Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand and Uttar Pradesh in India.

PARTICIPANTS

The study includes a total of 11 858 (NFHS-3) and 92 630 (NFHS-4) children under 5 years of age.

RESULT

The socio-economic inequality in stunting remained unchanged in all EAG states. At the same time, the inequality in underweight decreased during 2005-2016. On decomposing, the factors contributing to socio-economic inequality revealed that household wealth index, mother's education and mother's nutritional status were the largest contributors to stunting (47 %, 24 % and 8 %) and underweight (51 %, 21 % and 16 %), respectively, in 2015-2016.

CONCLUSION

The study concluded the socio-economic inequality in underweight among children under 5 years of age increased over the years in EAG states in India. Altogether, household wealth index, mother's education and mother's nutritional status contributed to nearly 80 % to inequality in stunting and 90 % to inequality in underweight in 2015-2016. Hence, efforts should be made to minimise the socio-economic inequality in the nutritional status of children, particularly in EAG states in India.

Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

BACKGROUND

Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.

OBJECTIVE

This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.

METHODS

We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.

RESULTS

Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.

CONCLUSIONS

Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

"In the Past, the Seeds I Planted often Didn't Grow." A Mixed-Methods Feasibility Assessment of Integrating Agriculture and Nutrition Behaviour Change Interventions with Cash Transfers in Rural Bangladesh

Combining agriculture with behaviour change communication and other nutrition-sensitive interventions could improve feeding practices to reduce maternal and child undernutrition. Such integrated intervention requires rigorous design and an appropriate implementation strategy to generate an impact. We assessed feasibility and acceptability of an intervention package that combines nutrition counselling, counselling and support for home-gardening, and unconditional cash transfers delivered to women on a mobile platform for improving maternal and child nutrition behaviours among low-income families in rural Bangladesh. We used mixed-methods including in-depth interviews with women (20), key-informant interviews with project workers (6), and a cross sectional survey of women (60). Women well-accepted the intervention and reported to be benefited by acquiring new skills and information on home gardening and nutrition. They established homestead gardens of seasonal vegetables successfully and were able to find a solution for major challenges. All women received the cash transfer. Ninety-one percent of women spent the cash for buying foods, 20% spent it on purchasing seeds or fertilizers and 57% used it for medical and livelihood purchases. Project staff and mobile banking agent reported no difficulty in cash transfer. Combining nutrition-specific and -sensitive interventions is a feasible and acceptable approach. Using mobile technologies can provide additional benefits for the intervention to reach the disadvantage families in rural settings.

Evidence of gut enteropathy and factors associated with undernutrition among slum-dwelling adults in Bangladesh

BACKGROUND

Adult undernutrition (BMI <18.5 kg/m2) is responsible for immune deficits, increased risk of disease burden, and higher rates of mortality. The prevalence of adult undernutrition in Bangladesh is substantial, but there have been few studies on the etiology of this condition for the inhabitants of urban slums.

OBJECTIVE

The aim of this study was to identify the factors associated with undernutrition among slum-dwelling adults in Bangladesh.

METHODS

A case-control study was conducted in the Bauniabadh area of Dhaka, Bangladesh. 270 adult participants (135 cases with a BMI <18.5 and 135 controls with a BMI between 18.5 and 24.9) aged 18-45 y were enrolled between October 2018 and January 2019. Sociodemographic variables, dietary diversity, micronutrient deficiencies, psychological symptoms, infection, and biomarkers of gut health were assessed to identify the factors associated with undernutrition using multivariable logistic regression analysis.

RESULTS

A higher number of siblings [adjusted odds ratio (aOR): 1.39; 95% CI: 1.11, 1.77], increased self-reporting questionnaire-20 score (an instrument to screen mental health disorders and detect psychological symptoms) (aOR: 1.12; 95% CI: 1.04, 1.23), elevated fecal concentration of α-1 antitrypsin (aOR: 4.82; 95% CI: 1.01, 25.29), and anemia (aOR: 3.63; 95% CI: 1.62, 8.58) were positively associated with undernutrition in adults. Age (aOR: 0.90; 95% CI: 0.84, 0.96), dietary diversity score (aOR: 0.75; 95% CI: 0.56, 0.99), C-reactive protein (aOR: 0.82; 95% CI: 0.73, 0.92), Helicobacter pylori infection (aOR: 0.11; 95% CI: 0.05, 0.23), and always washing hands before eating or preparing foods (aOR: 0.33; 95% CI: 0.12, 0.87) were associated with reduced odds of undernutrition among the study population.

CONCLUSIONS

Our results indicate that undernutrition in slum-dwelling adults in Bangladesh is associated with numerous physiological and sociodemographic factors, including evidence of gastrointestinal inflammation and altered intestinal permeability.

Prioritizing the Scale-Up of Evidence-Based Nutrition and Health Interventions to Accelerate Stunting Reduction in Ethiopia

Despite some progress, stunting prevalence in many African countries including Ethiopia remains unacceptably high. This study aimed to identify key interventions that, if implemented at scale through the health sector in Ethiopia, can avert the highest number of stunting cases. Using the Lives Saved Tool (LiST), the number of stunting cases that would have been averted, if proven interventions were scaled-up to the highest wealth quintile or to an aspirational 90% coverage was considered. Stunting prevalence was highest among rural residents and households in the poorest wealth quintile. Coverage of breastfeeding promotion and vitamin A supplementation were relatively high (>50%), whereas interventions targeting women were limited in number and had particularly low coverage. Universal coverage (90%) of optimal complementary feeding, preventive zinc supplementation, and water connection in homes could have each averted 380,000-500,000 cases of stunting. Increasing coverage of water connection to homes to the level of the wealthiest quintile could have averted an estimated 168,000 cases of stunting. Increasing coverage of optimal complementary feeding, preventive zinc supplementation, and Water, Sanitation and Hygiene (WASH) services is critical. Innovations in program delivery and health systems governance are required to effectively reach women, remote areas, rural communities, and the poorest proportion of the population to accelerate stunting reduction.

Explaining the fall of socioeconomic inequality in childhood stunting in Indonesia

In spite of the enormous economic progress and development witnessed in Indonesia in the last few decades, still more than 30% of Indonesian children under the age of five suffer from stunting, or low height for age. This concern is exacerbated by the fact that stunting remains more concentrated among the poorer households, leading to further intergenerational transmission of poverty and ill health. We examine recent trends in the evolution of the prevalence of childhood stunting and severe stunting, its socioeconomic inequality and the factors that appear to have contributed to these developments. Using the two most recent waves of the Indonesia Family Life Survey (IFLS), we study the changes in the prevalence of (severe) stunting between 2007 and 2014 for children aged 0-59 months and their socioeconomic-inequality using the Erreygers Concentration Index (EI) and its regression-based decomposition. We find a significant drop in the rate of severe stunting but not in stunting, as well as a significant reduction in the degree of absolute inequality of stunting. A decomposition analysis shows that household wealth, maternal education, institutional delivery, and availability of adequate sanitation contribute most to socioeconomic inequality in under-five stunting. Further analysis of the change in inequality over time indicates that the reduction in the association of wealth with stunting and a substantial improvement of health care access of the poor (as proxied by immunizations and institutional deliveries) play the most important role in narrowing the stunting gap between richer and poorer kids. General economic growth, poverty reduction, and implementation of pro-poor health and social programs during the studied period such as the expansion of health insurance coverage for the poor (Jamkesmas) and Conditional Cash Transfer program (Program Keluarga Harapan, PKH) are some plausible explanations of the observed result.

Inequality of childhood undernutrition in Bangladesh: A decomposition approach

BACKGROUND

Undernutrition is one of the major public health concerns in Bangladesh. This study examined the trends and patterns of childhood undernutrition, inequality, and its socioeconomic contributors in Bangladesh.

METHODS

Data were extracted from the last four rounds of the Bangladesh Demographic Health Survey (BDHS). A regression-based decomposition method was applied to assess the socioeconomic contributors of inequality.

RESULTS

Although the prevalence of childhood undernutrition has declined during the period 2004 to 2014, the rate of undernutrition is higher among the children of mothers who had lower education, live in rural areas, and are from the poorest wealth quintile. Socioeconomic status accounted for almost half of the total inequality in the prevalence of both stunting and underweight among children, whereas maternal education was ranked second among the contributors.

CONCLUSIONS

Findings of the study indicate that undernutrition inequalities in terms of socioeconomic aspects appear to have widened over time. Improving economic activity and maternal education will improve the nutritional status of children and as a consequence reduce inequality. Therefore, investments in education, creation of working opportunities, and empowerment of vulnerable and disadvantaged people along with nutrition-specific interventions will be important measures to eliminate this inequality at the population level.

The contribution of dietary and non-dietary factors to socioeconomic inequality in childhood anemia in Ethiopia: a regression-based decomposition analysis

Objective

There is a scarcity of evidence on socioeconomic inequalities of childhood anemia in Ethiopia. We determined the magnitude of socioeconomic inequality in anemia and the contribution of dietary and non-dietary factors to the observed inequality, using a nationally representative data of 2902 children included in the 2016 Ethiopian demographic and health survey. The data were collected following a multistage, stratified cluster sampling strategy. We followed the Blinder–Oaxaca regression-based approach to decompose the inequality and determine the relative contribution (%) of the dietary and non-dietary factors to the observed inequality.

Result

We found a significant pro-poor socioeconomic inequality in childhood anemia in Ethiopia. A third (~ 33%) of the inequality was attributable to compositional differences in the dietary determinants of anemia (dietary diversity, meal frequency, and breastfeeding factors). Non-dietary factors like residence place, maternal education, and birth weight) jointly explained ~ 36% of the inequality. Maternal education was the single most important factor, accounting alone for ~ 28% the inequality, followed by rural residence (~ 17%) and dietary diversity (~ 16%). Efforts to narrow socioeconomic gaps and/or designing equity sensitive interventions by prioritizing the poor in health/nutrition interventions stands worth of consideration to reduce the burden of childhood anemia in Ethiopia and beyond.

Association of food security and other socio-economic factors with dietary diversity and nutritional statuses of children aged 6-59 months in rural Bangladesh

INTRODUCTION

Dietary diversity score (DDS) is a proxy indicator for measuring nutrient adequacy. In this study, we aimed to identify the nutritional statuses and current patterns of DDS among children between 6-59 months old and their associations with different individual and household level factors in rural Bangladesh.

METHODS

The Nobokoli programme of World Vision Bangladesh was implemented in Mymensingh, Sherpur, Rangpur, Dinajpur, Thakurgaon, Panchagar, and Nilphamari districts of Bangladesh between 2014 and 2017. A cross-sectional community household survey was administered between July and October 2014 to collect baseline data to evaluate the Nobokoli programme. A total of 6,468 children between 6-59 months old were included in the final analysis. Anthropometric data was collected following WHO guidelines on using wooden height and digital weight scales. We collected food intake information for the past 24 hours of the survey. The WHO's child growth standard medians were used to identify the nutritional indices of stunting, wasting, and underweight. Food items consumed were categorized into nine food groups and the DDS was constructed by counting the consumption of food items across these groups during the preceding 24 hour period. The association of DDS and nutritional status (stunting, wasting and underweight) with sociodemographic factors and household food security status were examined using multivariable models; linear regression and logistics regression respectively.

RESULTS

The prevalence of stunting, wasting and underweight among children aged 6-59months were 36.8%, 18.2% and 37.7% respectively. Our findings revealed that almost all children ate any form of starch followed by consumption of milk or milk products (76%) and fleshy meat /fish (61%) respectively. The mean DDS among children was 3.93(sd 1.47). Forty percent of the children obtained a DDS score less than 4. Multivariable analysis suggested that children whose mothers had higher educational attainment and are skilled workers had higher DDS (15% and 48% respectively) compared to their counterparts. The DDS showed strong positive association with household wealth status. Children from food secure households had 26% higher DDS compared to children from food insecure households. Similarly, increasing maternal education and household wealth were found to be protective against childhood stunting and undernutrition.

DISCUSSION

Our findings reiterate the need for improving household socioeconomic factors and household food security status for improving dietary diversity practices and nutritional status of children. Evidence-based solutions are needed to be implemented and expanded at scale to ensure appropriate dietary practices and improve nutritional status of the children in local context.

Assessing the Intergenerational Linkage between Short Maternal Stature and Under-Five Stunting and Wasting in Bangladesh

Short maternal stature is identified as a strong predictor of offspring undernutrition in low and middle-income countries. However, there is limited information to confirm an intergenerational link between maternal and under-five undernutrition in Bangladesh. Therefore, this study aimed to assess the association between short maternal stature and offspring stunting and wasting in Bangladesh. For analysis, this study pooled the data from four rounds of Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014 that included about 28,123 singleton children aged 0–59 months born to mothers aged 15–49 years. Data on sociodemographic factors, birth history, and anthropometry were analyzed using STATA 14.2 to perform a multivariable model using ‘Modified Poisson Regression’ with step-wise backward elimination procedures. In an adjusted model, every 1 cm increase in maternal height significantly reduced the risk of stunting (relative risks (RR) = 0.960; 95% confidence interval (CI): 0.957, 0.962) and wasting (RR = 0.986; 95% CI: 0.980, 0.992). The children of the short statured mothers (<145 cm) had about two times greater risk of stunting and three times the risk of severe stunting, 1.28 times the risk of wasting, and 1.43 times the risk of severe wasting (RR = 1.43; 95% CI: 1.11, 1.83) than the tall mothers (≥155 cm). These findings confirmed a robust intergenerational linkage between short maternal stature and offspring stunting and wasting in Bangladesh.

Reducing childhood malnutrition in Bangladesh: the importance of addressing socio-economic inequalities

OBJECTIVE

To obtain projections of the prevalence of childhood malnutrition indicators up to 2030 and to analyse the changes of wealth-based inequality in malnutrition indicators and the degree of contribution of socio-economic determinants to the inequities in malnutrition indicators in Bangladesh. Additionally, to identify the risk factors of childhood malnutrition.

DESIGN

Cross-sectional study. A Bayesian linear regression model was used to estimate trends and projections of malnutrition. For equity analysis, slope index, relative index and decomposition in concentration index were used. Multilevel logistic models were used to identify risk factors of malnutrition.

SETTING

Household surveys in Bangladesh from 1996 to 2014.

PARTICIPANTS

Children under the age of 5 years.

RESULTS

A decreasing trend was observed for all malnutrition indices. In 1990, predicted prevalence of stunting, wasting and underweight was 55·0, 15·9 and 61·8 %, respectively. By 2030, prevalence is projected to reduce to 28·8 % for stunting, 12·3 % for wasting and 17·4 % for underweight. Prevalence of stunting, wasting and underweight were 34·3, 6·9 and 32·8 percentage points lower in the richest households than the poorest households. Contribution of the wealth index to child malnutrition increased over time and the largest contribution of pro-poor inequity was explained by wealth index. Being an underweight mother, parents with a lower level of education and poorer households were the key risk factors for stunting and underweight.

CONCLUSIONS

Our findings show an evidence-based need for targeted interventions to improve education and household income-generating activities among poor households to reduce inequalities and reduce the burden of child malnutrition in Bangladesh.

Socioeconomic inequality in stunting among under-5 children in Ethiopia: a decomposition analysis

Objective

Ethiopia bears a high stunting burden. However, there is a paucity of evidence on the socioeconomic inequalities of stunting in Ethiopia. Thus, this study was aimed to determine the degree of socioeconomic inequality in stunting and decompose it to the social determinants of stunting. We used a nationally representative sample of 8855 children, aged below 5 years, from the Ethiopian demographic and health survey, conducted in 2016. Subjects were recruited following a two-stage cluster sampling. The socioeconomic status was measured by the household wealth index, categorized into quantiles. The inequality in stunting between the poorest and the richest socioeconomic groups was decomposed into its contributing social factors following the Blinder–Oaxaca decomposition approach.

Result

The overall prevalence of stunting was 38%, with a significant pro-poor socioeconomic inequality. The prevalence of stunting among the poorest and the richest socioeconomic categories was 45.1% and 26.9%, respectively. Caregivers education status was the main contributor, accounting alone for 33% of the socioeconomic inequality in stunting, followed by region of residence (11%) and birth size (6%). Equity sensitive interventions, which prioritize the vulnerable groups might help to narrow the socioeconomic inequality as well as fasten the progress towards the goal of stunting reduction.

Trends and predictors of inequality in childhood stunting in Nepal from 1996 to 2016

BACKGROUND

Although decreasing in trend, one-in-three children remain stunted in Nepal and its distribution is unequal among different socioeconomic and geographical subgroups. Thus, it is crucial to assess inequalities in stunting for designing equity focused interventions that target vulnerable groups with higher burden of stunting. This study measures trends and predictors of socioeconomic inequalities in childhood stunting in Nepal.

METHODS

Data from five rounds (1996-2016) of Nepal Demographic and Health Survey, nationally representative cross-sectional surveys, were used. Levels and trends of absolute and relative disparity in stunting between the poorest and the richest wealth quintiles, and among all quintiles were assessed by calculating absolute and relative difference, concentration curve and index. Average marginal effects of predictors on stunting were calculated using probit regression. The concentration index was subsequently decomposed into contributing factors.

RESULTS

Even though stunting consistently declined in all wealth quintiles between 1996 and 2016, reduction was relatively higher among the richer quintiles compared to poorer ones. The absolute difference between the poorest and the richest quintile increased from 24.7 in 1996 (64.5% in poorest - 39.8% in richest) to 32.7 percentage points in 2016 (49.2-16.5%). The relative disparity also increased; the ratio of stunting in the poorest to the richest quintile was 1.6 in 1996 and 3.0 in 2016. The concentration index increased (in absolute value) from - 0.078 in 1996 to - 0.147 in 2016 indicating that stunting was disproportionately concentrated in poorer households and socioeconomic inequalities worsened from 1996 to 2016. Decomposition analysis revealed that in 1996, wealth (61%), caste/ethnicity (12%), mother's education (12%) and birth order (9%) were the major contributors to observed socioeconomic inequalities in stunting; while in 2016, wealth (72%), mother's BMI (12%) and birth order (9%) were the major contributors.

CONCLUSIONS

Despite remarkable improvements in average stunting over the last two decades, substantial socioeconomic inequalities in stunting exists and is determined not only by immediate factors but also by underlying and contextual factors which emphasize the need for coherent actions across different sectors. In addition to reducing inequalities in wealth, nutrition programming should be focused on most disadvantaged subgroups which are prone to both stunting and relative poverty.

Exploring the intergenerational effects of undernutrition: association of maternal height with neonatal, infant and under-five mortality in Bangladesh

Background

Global or regional evidence showed maternal height as a strong predictor of child survival. However, there is limited information that confirms the intergenerational effect of short maternal height on the risk of offspring mortality in Bangladesh. Therefore, this study aimed to examine the association of maternal height with neonatal, infant and under-five mortality in Bangladesh.

Methods

It was a pooled analysis of data from four rounds of Bangladesh Demographic and Health Surveys 2004, 2007, 2011 and 2014. We included singleton children aged 0-59 months born to mothers aged 15-49 years (n = 29 698). Mothers were interviewed to collect data on maternal and child characteristics, and socio-demographic information. Maternal height was measured using an adjustable measuring board calibrated in millimetres. We used STATA V.14.2 and adjusted for the cluster sampling design. Multivariate 'Modified Poisson Regression' was performed using stepwise backward elimination procedures to examine the association between maternal height and child death.

Results

In the adjusted model, every 1 cm increase maternal height was associated with a reduced risk of neonatal mortality (relative risk (RR) = 0.973, 95% CI 0.960 to 0.986), infant mortality (RR = 0.980, 95% CI 0.969 to 0.991) and under-five mortality (RR = 0.982, 95% CI 0.972 to 0.992). Children of the shortest mothers (height<145 cm) had 1.73 times greater risk of neonatal mortality, about 1.60 times greater risk of infant mortality and 1.48 times greater risk of under-five mortality compared with those of tall mothers (height≥155 cm). Among the children of the shortest mothers (height<145 cm), the absolute probabilities for neonatal, infant and under-five mortality were 4.4%, 6.0% and 6.5%, respectively, while for the children of the tall mothers (height≥ 155 cm), the absolute probabilities for neonatal, infant and under-five mortality were 2.6%, 3.7 %, and 4.4%, respectively.

Conclusion

These findings suggest a robust intergenerational linkage between short maternal height and the risk of neonatal, infant and under-five mortally in Bangladesh.

Mobile-Based Nutrition Counseling and Unconditional Cash Transfers for Improving Maternal and Child Nutrition in Bangladesh: Pilot Study

Background

Inappropriate feeding practices, inadequate nutrition knowledge, and insufficient access to food are major risk factors for maternal and child undernutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, a cost-effective delivery platform is needed to achieve complete, population-wide coverage of these interventions.

Objective

This study aimed to assess the feasibility, acceptability, and perceived appropriateness of an intervention package consisting of voice messaging, direct counseling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of a child’s life in a poor rural community in Bangladesh.

Methods

We conducted a mixed-methods pilot study. We recruited 340 pregnant or recently delivered, lactating women from rural Bangladesh. The intervention consisted of an unconditional cash transfer combined with nutrition counseling, both delivered on a mobile platform. The participants received a mobile phone and BDT 787 per month (US $10). We used a voice messaging service to deliver nutrition-related messages. We provided additional nutrition counseling through a nutrition counselor from a call center. We carried out cross-sectional surveys at baseline and at the end of the study, focus group discussions, and in-depth interviews with participants and their family members.

Results

Approximately 89% (245/275) of participants reported that they were able to operate the mobile phones without much trouble. Charging of the mobile handsets posed some challenges since only approximately 45% (124/275) households in our study had electricity at home. Approximately 26% (72/275) women reported they had charged their mobile phones at their neighbor’s house, while 34% (94/275) reported that they charged it at a marketplace. Less than 10% (22/275) of women reported difficulties understanding the voice messages or direct counseling through mobile phones, while only 3% (8/275) of women reported they had some problems withdrawing cash from the mobile bank agent. Approximately 87% (236/275) women reported spending the cash to purchase food for themselves and their children.

Conclusions

The nature of our study precludes any conclusion about the effectiveness of the intervention package. However, the high coverage of our intervention and the positive feedback from the mothers were encouraging and support the feasibility, acceptability, and appropriateness of this program. Further research is needed to determine the efficacy and cost-effectiveness of mobile-based nutrition counseling and unconditional cash transfers in improving maternal and child nutrition in Bangladesh.

Prevalence and associated factors for stunting among 6-12 years old school age children from rural community of Humbo district, Southern Ethiopia

Background

Stunting is one of the most serious and challenging public health problems in Ethiopia, which constitute a significant obstacle to achieving better child health outcomes. This study aimed to assess the prevalence and factors associated with stunting among 6–12 years old children in Humbo district, Southern Ethiopia.

Methods

This was a cross-sectional study conducted among 633 children 6–12 years old living in Humbo district, Southern Ethiopia, from March to April, 2015. A multistage cluster sampling technique was used to select participants from households in eight Villages in the study area. Height was measured using standard methods and height for age Z-score was computed to assess stunting. EPI info version 3.5.4 was used for data entry, whereas Anthroplus software and SPSS version 20.0 were used for computation of height for age Z-scores and statistical analyses respectively. Simple and multiple logistic regression analyses were used to examine factors associated with stunting in the study sample, using 95% confidence limits (statistical significance set at p < 0.050).

Results

Prevalence of stunting was 57%, about, 3.5% were severely stunted, 27.3% moderately stunted and 26.4% mildly stunted, and the mean (SD) was − 1.1 (±1.2). About 7 (1.1%) boys and 15 (2.4%) girls were severely stunted. Age groups 10–12 years had significantly higher rate of stunting than others. Age (AOR = 1.7, 95% CI = 1.1–2.6), big family size (AOR = 4.6, 95% CI = 2.2–9.5) and field disposal of wastes (AOR = 2.7, 95% CI = 1.2–5.8) were factors significantly associated with stunting.

Conclusion

This study exposed high rate of stunting among school age children. Stunting remains a noticeable attribute of rural school age children. Findings suggest the need to implement evidence-based school-aged rural children nutrition policy and strategies as well as need for intervention to improve domestic waste management system in the rural community.

Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh

Background

Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship.

Objective

The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh.

Methods

A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted.

Results

A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing.

Conclusion and policy implications

Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs.

Social determinants of inequalities in child undernutrition in Bangladesh: A decomposition analysis

Socioeconomic inequalities in child undernutrition remain one of the main challenges in Bangladesh. The social determinants of health are mostly responsible for such inequalities across different population groups. However, no study has examined the relative contribution of different social determinants to the socioeconomic inequality in child undernutrition in Bangladesh. Our objective is to measure the extent of socioeconomic-related inequalities in childhood stunting and identify the key social determinants that potentially explain these inequalities in Bangladesh. We used data for children younger than 5 years of age for this analysis from 2 rounds of Bangladesh Demographic and Health Surveys conducted in 2004 and 2014. We examined the socioeconomic inequality in stunting using the concentration curve and concentration index. We then decomposed the concentration index into the contributions of individual social determinants. We found significant inequality in stunting prevalence. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well-off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, health-seeking behavior of the mothers, sanitation, fertility, and maternal stature were the major contributors to the disparity in stunting prevalence in Bangladesh. Equity is a critical component of sustainable development goals. Health policymakers should work together across sectors and develop strategies for effective intersectoral actions to adequately address the social determinants of equity and reduce inequalities in stunting and other health outcomes.