Determinants of nutritional status among children under age 5 in Ethiopia: further analysis of the 2016 Ethiopia demographic and health survey

Malnutrition during childhood is the outcome of insufficient food intake, diarrhea and other infections, lack of sanitation, and low parental education [1, 2]. Poor diets and disease are due to food insecurity, inadequate maternal and child care, and poor health services and environment [3]. These factors cause measurable adverse effects on body function and clinical outcome [4]. This problem leads to most of the anthropometric deficits found among children under age 5 in the world’s least developed countries [5]. Despite existing interventions to address child malnutrition, it is still a major global public health problem [6]. Child malnutrition is an underlying cause for almost half (45%) of child deaths, particularly in low socioeconomic communities of developing countries [7]. Globally in 2018, an estimated 149 million children under age 5 were stunted and 49 million children were wasted [8].

In sub-Saharan Africa, the prevalence of stunting is declining but remains over 30% [8]. Among sub-Saharan countries, the prevalence of wasting in Ethiopia is 10%, and the prevalence of stunting is 38% [9]. Within Ethiopia, there is a regional variation in stunting and wasting. Amhara, Benishangul-Gumuz, Afar, and Dire Dawa are the most affected by child stunting (41–46%), whereas wasting is highest in Somali (23%), Afar (18%), and Gambella (14%) [9]. The reason may be hard-to-reach areas of Afar, Somali, Benishangul-Gumuz, and Gambella were characterized by drought-related public health and nutrition problems [10]. The current rate of progress is not fast enough to reach the World Health Organization (WHO) global target of a 40% reduction in the number of stunted children by 2025 [11].

Thus to achieve this global target for 2025 in Ethiopia, a situational analysis is required to determine how many children under age 5 are stunted and wasted and to assess key determinants of malnutrition in specific social and geographical locations [11]. Among the factors that cause child malnutrition in Ethiopia are insufficient availability of food, inadequate provision of a healthy environment, such as sanitation and hygiene, women’s status concerning decision-making power, and factors related to political economy [12, 13]. Some studies have linked low birth weight, maternal short stature, household wealth quintile, place of residence, region, mother’s education, child’s age and sex, and perceived birth size to children’s nutritional status [14, 15]. However, other studies [16‐18] have found consistent disparities in the prevalence of child malnutrition in terms of children’s age, sex, and birth size.

At the policy and program level, Ethiopia has many strategies and programs to reduce levels of malnutrition as part of its national development agenda. Some of the major strategies and programs include: the growth and transformation plan (GTP), National Nutrition Plan (NNP), the Seqota Declaration (SD), National Food Security Strategy, Nutrition Sensitive agriculture (NSa) strategy, school health and Nutrition Strategy (ShNS), the Productive Safety Net Program (PSNP), and Food Safety and Quality related regulatory activities [19]. The Seqota Declaration adopted Sustainable Development Goal 2 (SDG2), with the aim to end hunger, achieve food security, and improve nutrition, and promote sustainable agriculture by 2030 [20].

The Government of Ethiopia through the Ministry of Health also launched the health extension program in 2003 to achieve the country’s progress in meeting the Millennium Development Goals (MDGs). The health extension workers are mainly to improve access to care in rural communities. They spend 15% of their time with infants and children under age 5 [21]. All of these listed efforts have brought positive impact in improving food and nutrition security [19]. However, there was a fragmented approach leading to inadequate multi-sectorial coordination in responding to food and nutrition demand. As a result, severe malnutrition has remained a serious challenge [19]. Thus, this finding will be used as a source of information to implement the newly introduced national food and nutrition policy. Understanding the extent and the causes of the problem will allow for appropriate planning and interventions. This study will help health practitioners and other policymakers to enable a multi-sectoral response to malnutrition by identifying its determinants among children under age 5. This is important to achieving the Sustainable Development Goals and to meeting the global target by 2025.

As Table 1 shows, the majority of children (61%) were age 24–59 months, more than half (51%) were male, and 18% were first-order births. The great majority of mothers were married (95%), age 20–49 (90%), and not working (72%). About three-fourths of mothers (74%) had normal body mass index (BMI). The large majority of households (86%) were male-headed, and 89% were in the rural areas of Ethiopia. By region, over three-quarters of children were located in just three regions: 19% in Amhara; 44% in Oromia; and 21% in SNNP. Nearly half of households (46%) were in the poorest or poorer wealth quintiles, versus a third (33%) in the richer or richest quintiles.

This study assessed the determinants of nutritional status among children under age 5 in Ethiopia. Study results show that child’s age, sex, and perceived birth weight, mother’s educational status, BMI, and maternal stature, and region, wealth quintile, type of toilet facility, and type of cooking fuel had significant associations with stunting. Child’s age, sex, and perceived birth weight, mother’s BMI, and residence and region showed significant associations with wasting.

This study shows that the risk of stunting increased with age of child. Previous studies in Ethiopia have shown similar results [22‐24]. The reason might be that as children grow older they have greater energy needs. Besides, stunting reflects chronic malnutrition that can be manifested after long-term nutritional deficiency, while wasting reflects acute undernutrition. As child’s age increase, there is the probability that the child will receive childhood vaccinations, which reduce exposure to disease. For example [25] found that children vaccinated against measles are less likely to be wasted.

In Ethiopia as in many developing countries, complementary feeding is a challenge for children age 6–23 months [26]. Studies in other developing countries [26‐28] found that complementary foods given to infants in the second 6 months of age and beyond are often inadequate in energy density.

In our study, female children were less likely to be stunted and wasted than boys. This finding is consistent with a meta-analysis in sub-Saharan Africa [16], a study in the Northern Ethiopia [29], and research in Myanmar [30]. However, it is contrary to findings of studies in Tanzania [31], Pakistan [32], India [33], and Kenya [34] that girls had a higher prevalence of stunting than boys. Example [16, 35, 36] found that sex differences in nutritional status might be due to biological differences in morbidity between boys and girls in their early life. This may also apply to our findings on wasting. A review of complementary feeding reported that boys have higher birth weights than girls and grow faster during infancy, resulting in greater energy needs [36]. Furthermore, another study on Guatemalan infants reported that women perceived male children to be hungrier and less likely to be satisfied by breastfeeding alone [37], placing them at increased risk of infections.

Regarding our findings on perceived weight of child at birth, the risks of stunting and wasting were higher among children perceived to have low birth weight. These findings are consistent with previous studies in Zambia [38], Bangladesh [39‐41], India [42], Malaysia [43], and Indonesia [44], and may be due to the poor nutrition of mothers during pregnancy. This finding is supported by our results of the association between mother’s BMI and stunting and wasting in children. Ramakrishnan [45] reported that children born of overweight mothers are less likely to be stunted and wasted due to adequacy of protein and energy intakes of mothers during pregnancy [45]. A similar study in Nepal [46] also showed that as maternal BMI increased there was a reduction in children’s stunting, and wasting.

Our study found that children born to mothers with short stature were more likely to be stunted. This result is in line with previous studies in South Africa [14]; and Ghana [15]. This association reflects the fact that women who were stunted during their own childhood are more likely to give birth to stunted children [47].

Higher level of mothers’ educational attainment was positively associated with stunting in children. This is in line with previous related studies in the Philippines [48], Libya [49], Ethiopia [24], Uganda [50], Mozambique [51], and Ghana [15]. As stated in different studies, the reasons include that educated women are better informed about optimal child care practices [52], have better hygiene practices [53, 54], feeding [55], and childcare during illness [55‐57], have a greater ability to use the health system [58], and are more empowered to make decisions [53]. In our study, however, in about two-thirds of cases (65%), the mothers had not attended formal education, and as a result their knowledge on childcare may not have been enough.

Our study found regional variation in stunting and wasting in Ethiopia. Compared with Tigray, the reference region, children from Addis Ababa were less likely to be either stunted or wasted, while children in Gambella were less likely to be stunted, and children in SNNP were less likely to be wasted. Interestingly, children in the Somali region were less likely to be stunted but more likely to be wasted compared with Tigray. This could be because wasting is characterized by acute malnutrition that can be caused by temporary increased food insecurity from extreme weather events, drought, and shifts in agricultural practices [59, 60]. Previous research in Ethiopia [61] showed the association between malnutrition varied across regions due to variation in cultivated area.

We found that children from the richest, richer, and middle household wealth quintiles were less likely to be stunted compared with children from the poorer and poorest quintiles. As mentioned, in the DHS surveys household wealth is measured as an index reflecting household material living standards, which include the types of water sources and sanitation facilities used by the household. Our study found that children in households with non-improved toilet facilities and traditional fuel types were more likely to be stunted. Previous studies in Nepal [62] and other Asian countries [63] have found that household asset accumulation is an important predictor of nutritional improvement.

Environmental factors such as unimproved water, unimproved sanitation, and biomass fuel are the second largest global attributable burden as cause of child stunting [64]. A study of 137 developing countries reported that an estimated 7.2 million cases of stunting were attributable to unimproved sanitation [64]. In Ethiopia, more than half of rural households (56%) use unimproved toilet facilities [9]. In rural areas of Ethiopia, more than one in three households (39%) have no toilet facility, versus 7% in urban areas [9]. Related studies in Sri Lanka [65‐68] revealed that malnutrition among children is still a major health problem associated with poor sanitation and personal hygiene. However, a study conducted in rural Zimbabwe [69] found improved water, sanitation, and hygiene interventions in rural areas in low-income countries were unlikely to reduce stunting more than the effect of improved infant and child feeding alone. This implies integration of improved infant diets with improved water, sanitation, and hygiene is a logical approach to improve nutritional status of under-five children.

The great majority of Ethiopian households (93%) use traditional fuels such as wood, charcoal, and dung cake to meet their daily needs, and most households (59%) cook food outside [10]. Indoor air pollution and smoking are causes of low birth weight and could possibly impact stunting [45]. Another study in India reported associations between air pollution and stunting [70]; children living in households using biofuel were more likely to be stunted compared with children living in households using cleaner fuels ([70]).

The strength of this study was that it used nationally representative sample from urban and rural settings of the nine regional states and two urban administrations which allow generalization of the results. Therefore, these study findings could help as an intervention to policy makers, charity organizations across the globe for places having similar settings. It also applied all of the DHS data principles, like weighting. Regarding limitations, the cross-sectional data cannot examine causation or seasonal variation of nutritional outcomes. The other limitation is that during DHS data collection measurements of children’s height obtained by laying down children under age 2 may considered as a source of human error.

Our study found that child, maternal, and household characteristics were significantly associated with stunting and wasting among of children under age 5. Despite efforts made by the Ethiopian government and improvements in reducing malnutrition, rates of stunting and wasting remain high. The consequences of child malnutrition are grave and include poor performance in school and low adult economic productivity. The findings imply that a multi-sectorial and multidimensional approach is important to address malnutrition in Ethiopia. The education sector should promote maternal education and policies to reduce cultural and gender barriers. The health sector should provide health education to families to encourage positive behaviors toward childcare and infant feeding practices. In addition, the health and human services sectors can promote use of improved toilets. To reduce stunting due to traditional fuel usage in households, the energy sector should help households to access clean energy. Further research is suggested to explore the impact of seasonal food insecurity and climatic events on stunting and wasting and to examine the associated factors affecting nutritional status among children over time, using decomposition analysis.