Socioeconomic Inequalities In Stunting Research Articles

Explaining urban-rural disparity in prevalence of stunting and wealth related inequality in Ethiopia: A decomposition analysis

Background: Stunting is a global health concern. It has consequences on child survival, growth, and development. The absolute level of stunting has been decreasing in Ethiopia although the prevalence is still high varying across socioeconomic determinants and geographical location with a larger burden among the disadvantaged group and the rural areas. The objective of the study was to explain the rural-urban disparity in the prevalence of stunting and explore the level and determinants of wealth related inequality in stunting in Ethiopia. Method: Data were drawn from the 2016 Ethiopian Demographic and Health Survey. The dependent variables were stunting and wealth related inequality in stunting. A multivariate decomposition analysis was employed to decompose the urban-rural disparity in the prevalence of stunting into meaningful components. A concentration index was used to quantify the magnitude of inequalities in stunting and multilevel linear regression model was used to identify determinants of socioeconomic inequality in stunting. STATA version 14 software was used for data management and analysis. Result: Differences in observed characteristics of children, maternal characteristics, their household and environment explained 82.8% of the gap in the prevalence of stunting between rural and urban areas. A further decomposition of the gap in stunting showed that differences in maternal characteristics contributed to 36.7% of the gap in stunting, variation in household characteristics explained 31.7% of the gap and 13.6% of the gap in stunting was due to differences in child characteristics in the two areas. The study also found a significant propoor wealth related absolute inequality in stunting (-0.133). Age of child, maternal education level, maternal age and place of residence were found to be significantly associated with socioeconomic inequality in stunting. Conclusion: Rural-urban disparities in child stunting need to focus principally on bridging gaps in socio-economic situations of rural and urban women and households and improving the quality of rural infrastructure. Health policy makers should work together across sectors and develop strategies for effective inter sectoral actions to adequately address the social determinants of inequity and reduce inequalities in stunting. Rural-urban disparities in child stunting need to focus principally on bridging gaps in socio-economic situations of rural and urban women and households and improving the quality of rural infrastructure. Health policy makers should work together across sectors and develop strategies for effective inter sectoral actions to adequately address the social determinants of inequity and reduce inequalities in stunting.

Explaining changes in wealth inequalities in child health: The case of stunting and wasting in Nigeria

BackgroundMalnutrition is a major cause of child death, and many children suffer from acute and chronic malnutrition. Nigeria has the second-highest burden of stunting globally and a higher-than-average child wasting prevalence. Moreover, there is substantial spatial variation in the prevalence of stunting and wasting in Nigeria. This paper assessed the socioeconomic inequalities and determinants of the change in socioeconomic inequalities in child stunting and wasting in Nigeria between 2013 and 2018.MethodsData came from the 2013 and 2018 Nigeria Demographic and Health Survey. Socioeconomic inequalities in stunting and wasting were measured using the concentration curve and Erreygers’ corrected concentration index. A pro-poor concentration index is negative, meaning that the poor bear a disproportionately higher burden of stunting or wasting than the wealthy. A positive or pro-rich index is the opposite. Standard methodologies were applied to decompose the concentration index (C) while the Oaxaca-Blinder approach was used to decompose changes in the concentration indices (ΔC).FindingsThe socioeconomic inequalities in child stunting and wasting were pro-poor in 2013 and 2018. The concentration indices for stunting reduced from -0.298 (2013) to -0.330 (2018) (ΔC = -0.032). However, the concentration indices for wasting increased from -0.066 to -0.048 (ΔC = 0.018). The changes in the socioeconomic inequalities in stunting and wasting varied by geopolitical zones. Significant determinants of these changes for both stunting and wasting were changes in inequalities in wealth, maternal education and religion. Under-five dependency, access to improved toilet facilities and geopolitical zone significantly explained changes in only stunting inequality, while access to improved water facilities only significantly determined the change in inequality in wasting.ConclusionAddressing the socio-economic, spatial and demographic determinants of the changes in the socioeconomic inequalities in child stunting and wasting, especially wealth, maternal education and access to sanitation is critical for improving child stunting and wasting in Nigeria.

Socioeconomic Inequalities in Child Malnutrition in Bangladesh: Do They Differ by Region?

Socioeconomic inequality in child malnutrition is well-evident in Bangladesh. However, little is known about whether this inequality differs by regional contexts. We used pooled data from the 2011 and 2014 Bangladesh Demographic and Health Survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five. The analysis included 14,602 children aged 0–59 months. We used logistic regression models and the Concentration index to assess and quantify wealth- and education-related inequalities in child malnutrition. We found stunting and underweight to be more concentrated among children from poorer households and born to less-educated mothers. Although the poverty level was low in the eastern regions, socioeconomic inequalities were greater in these regions compared to the western regions. The extent of socioeconomic inequality was the highest in Sylhet and Chittagong for stunting and underweight, respectively, while it was the lowest in Khulna. Regression results demonstrated the protective effects of socioeconomic status (SES) on child malnutrition. The regional differences in the effects of SES tend to diverge at the lower levels of SES, while they converge or attenuate at the highest levels. Our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of Bangladesh.

A Decomposition Analysis of Inequality in Malnutrition among Under-Five Children in Iran: Findings from Multiple Indicator Demographic and Health Survey, 2010

Nutritional status at the early stages of children's lives is essential for growth and development not only in infancy but also in adult life. This study aimed to measure the inequality in malnutrition among under-five children in Iran and explore the impact of socioeconomic factors on this inequality using a regression-based decomposition approach. Data were extracted from Iran's Multiple-Indicator Demographic and Health Survey 2010. The concentration index of stunting, underweight, and wasting were applied in order to measure the magnitude of socioeconomic inequality in child malnutrition. Moreover, the concentration indices were decomposed to understand the contribution of socioeconomic variables in childhood malnutrition inequality. The obtained concentration indices of stunting, underweight, and wasting were respectively -0.177, -0.092, and -0.031. Socioeconomic inequality in stunting and underweight was statistically significant, however this socioeconomic gradient was not observed in wasting. More than 50% of the inequality in stunting and about 63% of the inequality in underweight were influenced by socioeconomic status. Furthermore, maternal education was associated with 19% and 22% of inequality in stunting and underweight respectively. The average reduction of malnutrition indices at the national level hides the burden of malnutrition among children in poor families. If government and policymakers seek to solve this problem, they have to take direct and targeted actions to eliminate the existing inequalities in the socioeconomic determinants associated with malnutrition.

Assessing socioeconomic inequalities in the reduction of child stunting in sub-Saharan Africa

Health and nutrition in early childhood are essential for survival, growth and adult life outcomes. As such, a number of global and national interventions have been pursued to improve early childhood health and nutrition. However, child malnutrition is pervasive and endemic across the sub Saharan Africa. This paper therefore assesses the nature and trends of socioeconomic inequalities in child stunting. The paper proceeds to decompose the causes of such socioeconomic-related inequalities over the period covered. We used data from Demographic and Health Surveys (DHSs) for ten sub-Saharan African countries conducted between 2000 and 2016. The study employs an extension to the concentration index for binary health outcomes to measure socioeconomic inequalities in stunting and decompose the causes of inequalities in stunting using a generalized decomposition technique based on recentered influence function regressions. The results show substantial pro-rich inequalities in child stunting across sub-Saharan Africa. The incidence of stunting are concentrated among children living in households with low socioeconomic status. In spite of persistent declines in the prevalence of stunting among children under 5 years across the study countries since 2000, trends in socioeconomic inequalities in stunting are mixed. We find significant contributions of child, maternal, and household characteristics to inequalities in child stunting. The results suggest that there is the need to design and target nutrition-based interventions at children in low socioeconomic households. In addition, promoting female education and improving access to health and nutrition information will be key to improving child nutrition across the region.

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

BackgroundAlthough 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.MethodsData 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.ResultsEven 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.ConclusionsDespite 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.

Socio-economic Inequality in Stunting among Children Aged 6-59 Months in a Ugandan Population Based Cross-sectional Study

Socio-economic status is an important predictor of stunting, however published population based studies on socio-economic inequalities in stunting among children under-five years of age is scarce in Uganda. Data from the 2016 Uganda Demographic and Health Survey was used to identify possible socio-economic inequalities in stunting among 3941 children aged 6-59 months. Multivariate binary logistic regression models were fitted to calculate the odds ratios and their corresponding 95% confidence intervals for stunting by maternal formal education and household wealth index. The overall prevalence of stunting among children was 30.1%. The risk of stunting was higher among children whose mothers had no formal education (OR: 4.35; 95% CI, 2.45-7.71), attained primary (OR: 2.74 95% CI, 1.62-4.63) and secondary level education (OR: 2.30 95% CI, 1.34-3.96) compared to those whose mothers attained tertiary level education. Similarly higher risk of stunting was found among children that lived in the poorest (OR: 1.78 95% CI, 1.23-2.59), poorer (OR: 1.88; 95% CI, (1.28-2.74), middle (OR: 1.91, 95% CI, 1.31-2.77) and richer households (OR: 1.60; 95% CI, 1.10-2.32) compared to those in the richest households. Socio-economic differences in stunting among children under-five years of age were found. Targeting stunting prevention interventions to less affluent mother-child dyads and households might be important in reducing social inequalities in stunting among children under-five years of age in Uganda.

Socioeconomic Inequality in Malnutrition in Under-5 Children in Iran: Evidence From the Multiple Indicator Demographic and Health Survey, 2010.

ObjectivesThe aim of this study was to assess the socioeconomic inequality in malnutrition in under-5 children in Iran in order to help policymakers reduce such inequality.MethodsData on 8443 under-5 children were extracted from the Iran Multiple Indicator Demographic and Health Survey. The wealth index was used as proxy for socioeconomic status. Socioeconomic inequality in stunting, underweight, and wasting was calculated using the concentration index. The concentration index was calculated for the whole sample, as well as for subcategories defined in terms of categories such as area of residence (urban and rural) and the sex of children.ResultsStunting was observed to be more prevalent than underweight or wasting. The results of the concentration index at the national level, as well as in rural and urban areas and in terms of children’s sex, showed that inequality in stunting and underweight was statistically significant and that children in the lower quintiles were more malnourished. The wasting index was not sensitive to socioeconomic status, and its concentration index value was not statistically significant.ConclusionsThis study showed that it can be misleading to assess the mean levels of malnutrition at the national level without knowledge of the distribution of malnutrition among socioeconomic groups. Significant socioeconomic inequalities in stunting and underweight were observed at the national level and in both urban and rural areas. Regarding the influence of nutrition on the health and economic well-being of preschool-aged children, it is necessary for the government to focus on taking targeted measures to reduce malnutrition and to focus on poorer groups within society who bear a greater burden of malnutrition.

Explaining changes in child health inequality in the run up to the 2015 Millennium Development Goals (MDGs): The case of Zambia.

BackgroundChild health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality.MethodsData from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0–5 years (n = 5,616 in 2007 and n = 12,714 in 2014). We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect—measured as an elasticity—of each determinant on stunting/fever.ResultsWhile average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce.The increase in the inequality (CI) of determinants accounted for the largest part (42.5%) of the increase in inequality of stunting, while the increase in the effect of determinants explained 35% of the increase. The determinants with the greatest total contribution (change in CI plus change in effect) to the increase in inequality of stunting were mother’s height and weight, wealth, birth order, facility delivery, duration of breastfeeding, and maternal education.For fever, almost all (86%) the increase in inequality was accounted for by the increase in the effect of determinants of fever, while the distribution of determinants mattered less. The determinants with the greatest total contribution to the increase in inequality of fever were wealth, maternal education, birth order and breastfeeding duration.In the multilevel model, we found that the likelihood of a child being stunted or experiencing fever depends on the community in which they live.ConclusionsTo curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition (which may be related to maternal weight and height), complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with.

Increasing socioeconomic inequality in childhood undernutrition in urban India: trends between 1992-93, 1998-99 and 2005-06.

This article examines the trends and pattern in socioeconomic inequality in stunting, underweight and wasting among children aged <3 years in urban India over a 14-year period. We use three successive rounds of the National Family Health Survey data conducted during 1992-93, 1998-99 and 2005-06. The selected socioeconomic predictors are household wealth and mother's education level. We use principal component analysis to compute a separate wealth index for urban India for all three rounds of the survey. We have used descriptive statistics, concentration index and pooled logistic regression to analyse the data. The results show that between 1992-93 and 2005-06, the prevalence of childhood undernutrition has declined across household wealth quintiles and educational level of mothers. However, the pace of decline is much higher among the better-off socioeconomic groups than among the least-affluent groups. The result of pooled logistic regression analysis shows that the socioeconomic inequality in childhood undernutrition in urban India has increased over the study period. The salient findings of this study call for separate programmes targeting the children of lower socioeconomic groups in urban population of India.

Persistent inequalities in child undernutrition: evidence from 80 countries, from 1990 to today.

Global progress in reducing the burden of undernutrition tends to be measured at the population level. It has been hypothesized that population-level improvements may mask widening socioeconomic inequalities, but little attempt has been made to assess whether this is true. Original data from 131 demographic health surveys and 48 multiple indicator cluster surveys from 1990 to 2011 were used to examine trends in socioeconomic inequalities in stunting and underweight, as well as the relationship between changes in prevalence and changes in inequality, in 80 countries. Socioeconomic inequality is measured using the corrected concentration index. Countries with a higher prevalence of stunting tend to have larger socioeconomic inequalities in stunting (Spearman rank correlation = -0.27 P = 0.014). In most countries, there has been no change in inequality in stunting: in 31 out of 53, the 90% confidence intervals around the changes overlap the zero value. In the remaining 22, there was a reduction in inequality in 11 and an increase in 11. The distributional patterns underlying the summary inequality statistics vary considerably across countries, but in most there have been considerable gains to the poorest quintile. Reductions in the prevalence of undernutrition have generally not been accompanied by widening inequalities. However, inequalities have also not been narrowing. Rather, the picture is one of a strong persistence of existing inequalities. In addition, there are different distributional patterns underlying changes in the summary indices of inequality which will need to be taken into consideration in designing programmes to reach the poor.

Mother's education is the most important factor in socio-economic inequality of child stunting in Iran.

Malnutrition is one of the most important health problems, especially in developing countries. The present study aimed to describe the socio-economic inequality in stunting and its determinants in Iran for the first time. Cross-sectional, population-based survey, carried out in 2009. Using randomized cluster sampling, weight and height of children were measured and anthropometric indices were calculated based on child growth standards given by the WHO. Socio-economic status of families was determined using principal component analysis on household assets and social specifications of families. The concentration index was used to calculate socio-economic inequality in stunting and its determinants were measured by decomposition of this index. Factors affecting the gap between socio-economic groups were recognized by using the Oaxaca-Blinder decomposition method. Shahroud District in north-eastern Iran. Children (n 1395) aged <6 years. The concentration index for socio-economic inequality in stunting was -0·1913. Mother's education contributed 70 % in decomposition of this index. Mean height-for-age Z-score was -0·544 and -0·335 for low and high socio-economic groups, respectively. Mother's education was the factor contributing most to the gap between these two groups. There was a significant socio-economic inequality in the studied children. If mother's education is distributed equally in all the different groups of Iranian society, one can expect to eliminate 70 % of the socio-economic inequalities. Even in high socio-economic groups, the mean height-for-age Z-score was lower than the international standards. These issues emphasize the necessity of applying new interventions especially for the improvement of maternal education.

Socio-economic inequalities in malnutrition among children and adolescents in Colombia: the role of individual-, household- and community-level characteristics.

To examine socio-economic inequalities in malnutrition among Colombian children and adolescents, and to assess the contribution of individual-, household- and community-level factors to those inequalities. Cross-sectional data were used from two sources: 2005 Colombian Demographic and Health Survey and 2005 Colombian census. Malnutrition outcomes included stunting and overweight. Multilevel Poisson models were used to estimate the association between individual, household and contextual characteristics and malnutrition. Changes in prevalence ratios of the poorest quintile (v. richest) were compared to assess the contribution of different characteristics to inequalities in malnutrition. Population-based, representative of Colombia. Children and adolescents <18 years of age (n 30 779) from the Colombian Demographic and Health Survey. Children and adolescents living in the poorest households were close to five times more likely to be stunted, while those from the richest households were 1.3–2.8 times more likely than their poorest counterparts to be overweight. Care practices and household characteristics, particularly mother’s education, explained over one-third of socio-economic inequalities in stunting. The proportion explained by access to services was not negligible (between 6% and 14 %). Access to sanitation was significantly associated with a lower prevalence of stunting for all age groups. Between 14% and 32% of socio-economic disparities in overweight were explained by maternal and household characteristics. Mother’s overweight was positively associated with overweight of the child. Socio-economic inequalities in stunting and overweight coexist among children and adolescents in Colombia. Malnutrition inequalities are largely explained by household characteristics, suggesting the need for targeted interventions.

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974–2007

To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34,409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.