Socio-Economic Inequalities in Child Stunting Reduction in Sub-Saharan Africa.
ABSTRACT: Stunting in children less than five years of age is widespread in Sub-Saharan Africa. We aimed to: (i) evaluate how the prevalence of stunting has changed by socio-economic status and rural/urban residence, and (ii) assess inequalities in children's diet quality and access to maternal and child health care. We used data from nationally representative demographic and health- and multiple indicator cluster-surveys (DHS and MICS) to disaggregate the stunting prevalence by wealth quintile and rural/urban residence. The composite coverage index (CCI) reflecting weighed coverage of eight preventive and curative Reproductive, Maternal, Neonatal, and Child Health (RMNCH) interventions was used as a proxy for access to health care, and Minimum Dietary Diversity Score (MDDS) was used as a proxy for child diet quality. Stunting significantly decreased over the past decade, and reductions were faster for the most disadvantaged groups (rural and poorest wealth quintile), but in only 50% of the countries studied. Progress in reducing stunting has not been accompanied by improved equity as inequalities in MDDS (p < 0.01) and CCI (p < 0.001) persist by wealth quintile and rural-urban residence. Aligning food- and health-systems' interventions is needed to accelerate stunting reduction more equitably.
Project description:Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7-8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity.
Project description:<h4>Objective</h4>Socioeconomic inequalities in child growth failure (CGF) remain one of the main challenges in Ethiopia. This study examined socioeconomic inequalities in CGF and determinants that contributed to these inequalities in Ethiopia.<h4>Methods</h4>The Ethiopia Demographic and Health Surveys 2000 and 2016 data were used in this study. A pooled unweighted sample of the two surveys yielded 21514 mother-child pairs (10873 in 2000 and 10641 in 2016). We assessed socioeconomic inequalities in CGF indicators using the concentration curve and concentration index (CI). We then decomposed the CI to identify percentage contribution of each determinant to inequalities.<h4>Results</h4>Socioeconomic inequalities in CGF have increased in Ethiopia between 2000 and 2016. The CI increased from -0.072 and -0.139 for stunting, -0.088 and -0.131 for underweight and -0.015 and -0.050 for wasting between 2000 and 2016, respectively. Factors that mainly contributed to inequalities in stunting included geographical region (49.43%), number of antenatal care visits (31.40%) and child age in months (22.20%) in 2000. While in 2016, inequality in stunting was contributed mainly by wealth quintile (46.16%) and geographical region (-13.70%). The main contributors to inequality in underweight were geographical regions (82.21%) and wealth quintile (27.21%) in 2000, while in 2016, wealth quintile (29.18%), handwashing (18.59%) and access to improved water facilities (-17.55%) were the main contributors. Inequality in wasting was mainly contributed to by maternal body mass index (-66.07%), wealth quintile (-45.68%), geographical region (36.88%) and paternal education (33.55%) in 2000, while in 2016, wealth quintile (52.87%) and urban areas of residence (-17.81%) were the main driving factors.<h4>Conclusions</h4>This study identified substantial socioeconomic inequalities in CGF, and factors that relatively contributed to the disparities. A plausible approach to tackling rising disparities may involve developing interventions on the identified predictors and prioritising actions for the most socioeconomically disadvantaged groups.
Project description:<h4>Background</h4>Coverage levels for essential interventions aimed at reducing deaths of mothers and children are increasing steadily in most low-income and middle-income countries. We assessed how much poor and rural populations in these countries are benefiting from national-level progress.<h4>Methods</h4>We analysed trends in a composite coverage indicator (CCI) based on eight reproductive, maternal, newborn, and child health interventions in 209 national surveys in 64 countries, from Jan 1, 1994, to Dec 31, 2014. Trends by wealth quintile and urban or rural residence were fitted with multilevel modelling. We used an approach akin to the calculation of population attributable risk to quantify the contribution of poor and rural populations to national trends.<h4>Findings</h4>From 1994 to 2014, the CCI increased by 0·82 percent points a year across all countries; households in the two poorest quintiles had an increase of 0·99 percent points a year, which was faster than that for the three wealthiest quintiles (0·68 percent points). Gains among poor populations were faster in lower-middle-income and upper-middle-income countries than in low-income countries. Globally, national level increases in CCI were 17·5% faster than they would have been without the contribution of the two poorest quintiles. Coverage increased more rapidly annually in rural (0·93 percent points) than urban (0·52 percent points) areas.<h4>Interpretation</h4>National coverage gains were accelerated by important increases among poor and rural mothers and children. Despite progress, important inequalities persist, and need to be addressed to achieve the Sustainable Development Goals.<h4>Funding</h4>UNICEF, Wellcome Trust.
Project description:<h4>Background</h4>Guatemala has the highest prevalence of stunting among under-five children in Latin America. We aimed to compare indigenous and non-indigenous under-five child populations in relation to stunting, as well as to explore the intersectionality of ethnicity by wealth and by place of residence. We also studied how the ethnic inequalities changed over time, using five ENSMI surveys from 1995 to 2014.<h4>Methods</h4>Five national health surveys carried out between 1995 and 2014 were analysed. World Health Organization (WHO) 2006 growth standards were used to calculate stunting prevalence. Self-reported ethnicity was classified as indigenous or nonindigenous. Wealth was measured through an asset-based index, and households were classified into quintiles (for analyses of the whole populations) or tertiles (for analyses of intersectionality with ethnicity). Area of residence was recorded as urban or rural, according to country definition.<h4>Results</h4>Overall stunting prevalence declined by 9.8 percentage points (95% CI -16.4 to - 3.3) from 1995 to 2014. The slope index for absolute inequalities in stunting - which corresponds to the difference in prevalence between the wealthiest and poorest households - ranged from - 52.9 to - 60.4 percentage points, with no significant change over time. Children in rural areas were consistently more stunted than those in urban areas, but rural indigenous children were significantly worse than any other group. Indigenous children in the poorest tertile of family wealth consistently presented the highest stunting prevalence, compared to all other groups. Time trends in stunting were assessed through the average annual absolute change (AAAC). The fastest decline was observed among indigenous children from the middle wealth tertile (AAAC = - 1.21 percentage points per year (pp/y); 95% CI - 1.45 to - 0.96) followed by nonindigenous children also from the middle tertile (AAAC = - 0.80 pp./y; 95% CI - 0.99 to - 0.60). Stunting prevalence in the two poorest tertiles of indigenous children in 2015 was similar to what nonindigenous children presented in 1995, 20 years earlier. In the wealthiest tertile, indigenous children were far worse off than nonindigenous children 20 years earlier.<h4>Conclusions</h4>In terms of stunting prevalence, poor and rural indigenous children are twenty years behind nonindigenous children with similar characteristics.
Project description:<h4>Background</h4>Understanding the burden and contextual risk factors is critical for developing appropriate interventions to control undernutrition.<h4>Methods</h4>This study used data from the 2014 Ghana Demographic and Health Survey to estimate the prevalence of underweight, stunting, and wasting. Single multiple logistic regressions were used to identify the factors associated with underweight, wasting and stunting. The study involved 2720 children aged 0-59 months old and mother pairs. All analyses were done in STATA/IC version 15.0. Statistical significance was set at p<0.05.<h4>Results</h4>The prevalence of underweight, wasting and stunting were 10.4%, 5.3%, and 18.4% respectively. The age of the child was associated with underweight, wasting and stunting, whereas the sex was associated with wasting and stunting. Normal or overweight/obese maternal body mass index category, high woman's autonomy and middle-class wealth index were associated with a lower odds of undernutrition. The factors that were associated with a higher odds of child undernutrition included: low birth weight (<2.5 kg), minimum dietary diversity score (MDDS), a higher (?4th) birth order number of child, primary educational level of husband/partner and domicile in the northern region of Ghana.<h4>Conclusion</h4>There is still a high burden of child undernutrition in Ghana. The age, sex, birth weight, birth order and the MDDS of the child were the immediate factors associated with child undernutrition. The intermediate factors that were associated with child undernutrition were mainly maternal related factors and included maternal nutritional status and autonomy. Distal level factors which were associated with a higher odds of child undernutrition were the wealth index of the household, paternal educational status and region of residence. We recommend that interventions and policies for undernutrition should address socioeconomic inequalities at the community level while factoring in women empowerment programmes.
Project description:Our study aims to examine the disparity of under-5 child stunting prevalence between urban and rural areas of Tanzania in the past three decades, and to explore factors affecting the rural-urban disparity. Secondary analyses of Tanzania Demographic and Health Surveys (TDHS) data drawn from 1991-1992, 1996, 1999, 2004-2005, 2009-2010, and 2015-2016 surveys were conducted. Under-5 child stunting prevalence was calculated separately for rural and urban children and its decline trends were examined by chi-square tests. Descriptive analyses were used to present the individual-level, household-level, and societal-level characteristics of children, while multivariable logistic regression analyses were performed to examine determinants of stunting in rural and urban areas, respectively. Additive interaction effects were estimated between residence and other covariates. The results showed that total stunting prevalence was declining in Tanzania, but urban-rural disparity has widened since the decline was slower in the rural area. No interaction effect existed between residence and other determinants, and the urban-rural disparity was mainly caused by the discrepancy of the individual-level and household-level factors between rural and urban households. As various types of determinants exist, multisector nutritional intervention strategies are required to address the child stunting problem. Meanwhile, the intervention should focus on targeting vulnerable children, rather than implementing different policies in rural and urban areas.
Project description:Global stunting prevalence has been nearly halved between 1990 and 2016, but it remains unclear whether this decline has benefited poor and rural populations within low- and middle-income countries (LMICs).We assessed time trends in stunting among children <5 y of age (under-5) according to household wealth and place of residence in 67 LMICs.Stunting prevalence was analyzed in 217 nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 67 countries with ?2 surveys between 1993 and 2014. National estimates were stratified by wealth and area of residence, comparing the poorest 40% with the wealthiest 60%, and those residing in urban and rural areas. Time trends were calculated for LMICs by using multilevel regression models weighted by under-5 population, with stratification by wealth and by residence. Trends in absolute (slope index of inequality; SII) and relative (concentration index; CIX) inequalities were calculated.Mean prevalences in 1993 were 53.7% in low-income and 48.2% in middle-income countries, with annual average linear declines of 0.76 and 0.72 percentage points (pp), respectively. Although similar slopes of declines were observed for the poorest 40% and wealthiest 60% groups in all countries (0.78 and 0.74 pp, respectively), absolute and relative inequalities increased over time in low-income countries (SII increased from -19.3% in 1993 to -23.7% in 2014 and CIX increased from -6.2% to -10.8% in the same period). In middle-income countries, socioeconomic inequalities remained stable. Overall, stunting prevalence decreased more rapidly among rural than for urban children (0.78 and 0.55 pp, respectively).The prevalence of stunting is decreasing. Poor-rich gaps are stable in middle-income countries and slightly increasing in low-income countries. Rural-urban inequalities are decreasing over time.
Project description:BACKGROUND:Inequalities in progress towards achievement of Millennium Development Goal four (MDG-4) reflect unequal access to child health services. OBJECTIVE:To examine the time trends, socio-economic and regional inequalities of under-five mortality rate (U5MR) in Nepal. METHODS:We analyzed the data from complete birth histories of four Nepal Demographic and Health Surveys (NDHS) done in the years 1996, 2001, 2006 and 2011. For each livebirth, we computed survival period from birth until either fifth birthday or the survey date. Using direct methods i.e. by constructing life tables, we calculated yearly U5MRs from 1991 to 2010. Projections were made for the years 2011 to 2015. For each NDHS, U5MRs were calculated according to child's sex, mother's education, household wealth index, rural/urban residence, development regions and ecological zones. Inequalities were calculated as rate difference, rate ratio, population attributable risk and hazard ratio. RESULTS:Yearly U5MR (per 1000 live births) had decreased from 157.3 (95% CIs 178.0-138.9) in 1991 to 43.2 (95% CIs 59.1-31.5) in 2010 i.e. 114.1 reduction in absolute risk. Projected U5MR for the year 2015 was 54.33. U5MRs had decreased in absolute terms in all sub groups but relative inequalities had reduced for gender and rural/urban residence only. Wide inequalities existed by wealth and education and increased between 1996 and 2011. For lowest wealth quintile (as compared to highest quintile) hazard ratio (HR) increased from 1.37 (95% CIs 1.27, 1.49) to 2.54 ( 95% CIs 2.25, 2.86) and for mothers having no education (as compared to higher education) HR increased from 2.55 (95% CIs 1.95, 3.33) to 3.75 (95% CIs 3.17, 4.44). Changes in regional inequities were marginal and irregular. CONCLUSIONS:Nepal is most likely to achieve MDG-4 but eductional and wealth inequalities may widen further. National health policies should address to reduce inequalities in U5MR through 'inclusive policies'.
Project description:<h4>Background</h4>Prevalence of child stunting in the Democratic Republic of Congo (DRC) is among the highest in the world. There is a need to systematically investigate how stunting operates at different levels of determination and identify major factors contributing to the development of stunting. The aim of this study was to look for key determinants of stunting in the DRC.<h4>Methods</h4>This study used data from the DRC Demographic Health Survey 2013-14 which included anthropometric measurement for 9030 under 5 year children. Height-for-Age Z score was calculated and classified according to the WHO guideline. The association between stunting and bio-demographic characteristics was assessed using logistic regression.<h4>Results</h4>Prevalence of stunting was much higher in boys than girls. There was a significant rural urban gap in the prevalence of stunting with rural areas having a larger proportion of children living with stunting than urban. Male children, older than 6 months, preceding birth interval less than 24 months, being from lower wealth quintiles had the highest odds of stunting. Several provinces had in particular high odds of stunting. Early initiation of breastfeeding, mother's age more than 20 years at the time of delivery had lower odds of stunting. The taller the mother the less likely the child was to be stunted. Similarly, mother's BMI, access to safe water, access to hygienic toilet, mother's education were found negatively correlated with child stunting in the bivariate logistic regression, but they lost statistical significance in multivariate analysis together with numbers of children in the family and place of residence.<h4>Conclusions</h4>Child stunting is widespread in the DRC and increasing prevalence is worrisome. This study has identified modifiable factors determining high prevalence of stunting in the DRC. Policy implementation should in particular target provinces with high prevalence of stunting and address modifiable determinants such as reducing socioeconomic disparity. Nutrition promotion intervention, including early initiation of breastfeeding should be an immediate priority.
Project description:BACKGROUND:Existing studies in Tanzania, based mostly on rural samples, have primarily focused on individual behaviors responsible for the lower utilization of maternal health care. Relatively less attention had been paid to inequalities in structural circumstances that contribute to reduced utilization of maternal health care. More importantly, scholarship concerning the impact of the rural-urban divide on socioeconomic disparities in the utilization of maternal health care is virtually nonexistent in Tanzania. METHODS:Drawing from the Demographic Health Survey (2015-2016) conducted in Tanzania, our study includes a total of 3,595 women aged between 15-49 years old, who had given birth in five years before the month of the interview and living in both rural and urban Tanzania. The maternal health care utilization was assessed by four variables (i.e., antenatal care, skilled delivery assistance, the before and after discharging postnatal care). The independent variables were wealth, education, residence, parity, occupation, age, and the head of the household's sex. We used bivariate statistics and logistic regression to examine the rural-urban differences in the influence of education and wealth on maternal health care utilization. RESULTS:Significantly lower use of maternal health care in rural than urban areas demonstrated a stark rural-urban divide in Tanzania. We documented socioeconomic inequalities in maternal health care utilization in the form of lower odds of the utilization of such services among women with lower levels of education and household wealth. The educational inequalities in the utilization of skilled delivery assistance (or = 0.37, 95% CI: 0.16, 0.86; p = 0.021) and (before discharge) postnatal care (or = 0.60, 95% CI: 0.38, 0.95; p = 0.030) were significantly wider in rural than urban areas. The differences in the odds of the utilization of skilled delivery assistance between women in poorer wealth quintile and women in richer household wealth quintile were also significantly wider in rural areas than in urban areas. However, the statistically significant rural-urban divides in the impacts of socioeconomic status on antenatal care and (after discharge) postnatal care were not observed. CONCLUSION:This study establishes the need for consideration of the rural-urban context in the formulation of policies to reduce disparities in maternal health care utilization in Tanzania.