Introduction
Methods
Data source
Study design, sample size, and sampling procedures
Data collection procedure
Description of variables
Variables | Description |
---|---|
Concurrent anemia and stunting (CAS) | Defined when a child was both anemic and stunted. Anemia status was measured by hemoglobin level < 11 g/dL and categorized as anemic and non-anemic [3]. Stunting was measured by length-for-age < − 2 z-score and categorized as stunted and non-stunted. |
Basic (distal) factors
| |
Residence place | Categorized as urban and rural. |
Region | Categorized as mainly agrarian and mainly pastoral. |
Household wealth category | First, household wealth index was developed by principal component analysis, using asset variables collected during the survey [19]. Then, the index was used to rank the households into low, middle and high wealth categories. |
Caregiver’s education status | Categorized as illiterate/none, primary, and secondary and above. |
Underlying (intermediate) factors
| |
Water source | Categorized as improved and unimproved. |
Toilet facility | Categorized as improved and unimproved. |
Proximal (immediate) factors
| |
Child sex | Categorized as boy and girl. |
Child age | Categorized into < 12 and 12–23 months of age. |
Birth size | Assessed by the subjective reporting of the mother about the size of the child at birth and categorized as large, average and small. Birth size was used as a proxy measure of birth weight. |
History of infection | Assessed by whether the child had fever, diarrhea, or cough in the last two weeks preceding the survey. Categorized as yes and no. |
Breastfeeding duration | Categorized as < 12 and 12–23 months. |
Early breastfeeding initiation | Assessed by initiation of breastfeeding within the first hour after birth. Categorized as yes and no. |
Deworming tablet use | Assessed by whether the child received deworming table within the previous 6 months. Categorized as yes and no. |
Vitamin A supplement use | Assessed by whether the child received vitamin A supplement within in the previous 6 months. Categorized as yes and no. |
Iron supplement use | Assessed by whether the child received iron supplement within the previous 7 days. Categorized as yes and no. |
Complementary food groups | During the survey, caregivers were asked to recall the type of food the child was fed in the 24 h (one day) prior to the survey. The frequency of feeding during the same period was also assessed. The data were collected by trained interviewers, following the 5-Step Multiple-Pass Method. Using the WHO/UNICEF [39] and the DHS guidelines [19] for the assessment of infant and young child feeding practices, the food items were further categorized into 7 food groups: (1) meat, (2) egg, (3) milk, (4) grains, roots, and tubers, (5) legumes and nuts, (6) vitamin-A rich fruits and vegetables (VARFV), and (7) other fruits and vegetables (OFV). Using the 7 food groups above and following the WHO/UNICEF [39] and the DHS guidelines [19], dietary diversity and meal frequency indexes were determined for each child. The diversity and frequency indexes were used to determine whether the child met the WHO/UNICEF recommendations for dietary diversity and meal frequency. |
Minimum dietary diversity (MDD) | Assessed by whether the child received ≥4 complementary food items from the 7 food groups within the previous 24 h. Categorized as yes and no [39]. |
Minimum meal frequency (MMF) | Assessed by whether the child was fed with complementary food ≥3 times if on breastfeeding, or ≥ 4 times if not on breastfeeding, within the previous 24 h. Categorized as yes and no [39]. |
Statistical analysis
Result
Sociodemographic characteristics of the sample
Variables | Weighted frequency (%) | CAS Prevalence (95% CI) | P-value* | |
---|---|---|---|---|
Basic factors
| ||||
Residence place | Urban | 11.9 | 16.1 (12.0–20.2) | 0.001 |
Rural | 88.1 | 25.0 (23.3–26.7) | ||
Region (state) | Pastoral | 6.4 | 22.6 (16.2–29.1) | 0.606 |
Agrarian | 93.6 | 24.4 (22.8–26.1) | ||
Wealth category | Low | 44.1 | 31.7 (26.4–37.1) | < 0.001 |
Middle | 22.5 | 16.4 (11.0–21.9) | ||
High | 33.4 | 14.5 (11.0–17.9) | ||
Caregivers education | No | 61.0 | 23.4 (19.6–27.2) | < 0.001 |
Primary | 30.6 | 18.5 (14.1–22.9) | ||
Secondary+ | 8.4 | 13.5 (6.4–20.5) | ||
Underlying factors
| ||||
Water source type | Not improved | 50.1 | 22.9 (19.1–26.8) | 0.065 |
Improved | 49.9 | 17.9 (14.1–21.7) | ||
Toilet facility type | Not improved | 90.2 | 21.1 (18.2–24.1) | 0.001 |
Improved | 9.8 | 17.2 (10.3–24.1) | ||
Proximal factors
| ||||
Child sex | Boy | 46.9 | 21.2 (17.2–25.2) | 0.033 |
Girl | 53.1 | 20.1 (16.5–23.8) | ||
Child age | < 12 months | 34.9 | 12.1 (8.5–15.7) | < 0.001 |
12–23 months | 65.1 | 25.4 (21.8–29.1) | ||
Birth size | Small | 27.0 | 29.7 (23.7–35.8) | < 0.001 |
Average | 40.7 | 19.1 (15.1–23.2) | ||
Large | 32.3 | 15.3 (11.0–19.5) | ||
Infection historya | No | 62.4 | 20.0 (16.6–23.4) | 0.031 |
Yes | 37.6 | 21.6 (17.2–25.9) | ||
Breastfeeding duration | < 12 months | 38.4 | 22.1 (18.5–25.7) | 0.692 |
12–23 monhs | 61.6 | 25.4 (21.8–29.1) | ||
Early breastfeeding initiation | No | 10.9 | 22.4 (14.0–30.9) | 0.533 |
Yes | 89.1 | 20.4 (17.6–23.2) | ||
Deworming | No | 90.8 | 20.5 (17.7–23.3) | 0.802 |
Yes | 9.2 | 22.0 (12.2–31.8) | ||
Vitamin A supplement | No | 56.4 | 18.0 (14.5–21.5) | 0.043 |
Yes | 43.6 | 23.8 (19.6–28.0) | ||
Iron supplement | No | 92.1 | 20.1 (17.2–22.9) | 0.337 |
Yes | 7.9 | 25.4 (16.4–34.5) | ||
Grains and tubers | No | 27.8 | 25.5 (19.6–31.4) | 0.349 |
Yes | 72.2 | 19.1 (16.1–22.1) | ||
VARFV | No | 72.3 | 21.3 (18.1–24.5) | 0.088 |
Yes | 27.7 | 18.9 (14.0–23.8) | ||
OFV | No | 82.8 | 22.2 (19.2–25.3) | 0.006 |
Yes | 17.2 | 14.1 (8.9–19.3) | ||
Meat | No | 91.6 | 21.5 (18.6–24.3) | 0.050 |
Yes | 8.4 | 13.8 (6.8–20.9) | ||
Milk | No | 61.7 | 22.2 (18.7–25.6) | 0.013 |
Yes | 38.3 | 18.0 (13.7–22.2) | ||
Legumes and nuts | No | 79.1 | 22.3 (19.1–25.4) | 0.064 |
Yes | 20.9 | 14.8 (9.7–19.9) | ||
Egg | No | 83.3 | 21.3 (18.3–24.3) | 0.348 |
Yes | 16.7 | 17.9 (12.0–23.7) | ||
MDDb | No | 84.6 | 22.7 (19.7–25.8) | 0.010 |
Yes | 15.4 | 11.0 (0.06–15.9) | ||
MMFc | No | 57.3 | 19.4 (15.9–22.9) | 0.022 |
Yes | 42.7 | 22.3 (18.0–26.5) |
Prevalence of CAS
Factors associated with CAS
Variables | Model-1a | Model-2b | Model-3c | ||||
---|---|---|---|---|---|---|---|
AOR (95%CI) |
P*
| AOR (95%CI) |
P*
| AOR (95%CI) |
P*
| ||
Residence place | Urban | Reference | < 0.001 | ||||
Rural | 1.29 (1.18–1.41) | ||||||
Household wealth category | Low | 1.91 (1.53–2.39) | < 0.001 | ||||
Middle | 1.10 (0.84–1.44) | 0.480 | |||||
High | Reference | ||||||
Caregiver education | No education | 2.14 (1.33–3.44) | < 0.001 | ||||
Primary | 2.38 (1.47–3.86) | < 0.001 | |||||
Secondary+ | Reference | ||||||
Water source | Unimproved | 1.08 (0.81–1.45) | 0.606 | ||||
Improved | Reference | ||||||
Toilet facility | Unimproved | 0.96 (0.58–1.57) | 0.857 | ||||
Improved | Reference | ||||||
Child sex | Girl | Reference | 0.015 | ||||
Boy | 1.25 (1.04–1.50) | ||||||
Child age | < 12 months | Reference | < 0.001 | ||||
12–23 months | 1.65 (1.57–1.73) | ||||||
Birth size | Large | Reference | |||||
Average | 1.21 (0.90–1.40) | 0.317 | |||||
Small | 1.99 (1.58–2.51) | < 0.001 | |||||
Infectiond | No | Reference | 0.048 | ||||
Yes | 1.14 (1.00–1.30) | ||||||
Vitamin A supplement | No | 1.19 (1.06–1.33) | 0.003 | ||||
Yes | Reference | ||||||
VARFV | No | 1.15 (1.04–1.27) | 0.006 | ||||
Yes | Reference | ||||||
OFV | No | 1.25 (0.90–1.73) | 0.178 | ||||
Yes | Reference | ||||||
Meat | No | 1.55 (1.17–2.05) | 0.002 | ||||
Yes | Reference | ||||||
Milk | No | 1.14 (0.90–1.44) | 0.276 | ||||
Yes | Reference | ||||||
Legumes | No | 1.38 (1.05–1.81) | 0.021 | ||||
Yes | Reference | ||||||
MDDe | No | 1.29 (0.93–1.78) | 0.122 | ||||
Yes | Reference | ||||||
MMFf | No | 1.22 (1.04–1.37) | 0.020 | ||||
Yes | Reference |