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Background: Poor nutrition is the leading risk-factor for child mortality in
Sub-Saharan-Africa. Therefore, improving nutrition is critical. It requires
effective multi-sectoral intervention efforts based on regular data to monitor
and analyze country progress.
Objective: The aim of the present study was to determine the common risk
factors associated with stunting, underweight and wasting among children 0-59
months.
Methods: Sample of data from 9,696 children aged 0-59 months was obtained
from the 2016 Ethiopia Demographic and Health Survey (EDHS). IBM SPSS
statistics (v21.0) based cluster multilevel logistic regression analyses were
used to identify significant risk-factors associated with stunting, underweight
and wasting.
Results: Overall, the national prevalence of children classified as stunting
was 37.8%, underweight was 26.8% and wasting was 12.9%. However, significantly
higher prevalence of child under-nutrition was recorded with increasing
child-age-bracket and among those residing in rural regions of the country.
Multivariable analysis revealed that the most consistent and common risk
factors associated with stunting, underweight and wasting are administrative
region (outside capital), household’s wealth index (lowest quintile), perceived
birth size (small), sex of child (male), child age (later age), place of
delivery (home delivery) and exposure to media (no/less exposure to
television).
Conclusion: Strategy with broad intervention approaches are required targeting
risk factors to child under-nutrition including socio-economic status, maternal
education, health (nutrition) of the mother and promotion of healthy
environment, with emphases to rural regions.
Keywords: Undernutrition, Multilevel analysis, Children 0-59 months
Abbreviations:
AOR: Adjusted Odds Ratio; BMI: Body Mass Index;
CGF: Child Growth Failure; CI: Confidence Interval; COR: Crude Odds Ratio; CSA:
Central Statistical Agency; DHS: Demographic and Health Survey; GBD: Global
Burden of Diseases; LANEA: Leveraging Agriculture for Nutrition in East Africa;
MDGs: Millennium Development Goals; PCA: Principal Component Analysis; SAS
(software): Statistical Analysis System; SDG: Sustainable Development Goal;
SNNPR: Southern Nation Nationality People’s Region; SSA: Sub-Saharan Africa;
UNFPA: United Nations Population Fund; UNICEF: United Nations Children’s Fund;
USAID: United States Agency for International Development
INTRODUCTION
Improvement of
child survival is a long-standing international priority [1-3], as insufficient growth during childhood
is associated with poor health outcomes and an increased risk of death [4]. Despite geographic differences,
substantial progress has been accomplished in reducing child mortality and
absolute inequalities in rates of child death across countries worldwide during
the last few decades.
During MDG era,
many countries in Africa also achieved marked reductions in under-5 and
neonatal mortality [1]. The number of
stunted children had fallen in all regions except Sub-Saharan Africa, where the
numbers increased by about one third between 1990 and 2013 [7]. Although there are differences on exact
reports [6,8]; findings from the Global
Burden of Diseases, Injuries and Risk Factors Study 2016 (GBD 2016) shows that,
an estimated of 36.6% children under five were stunted, 8.6% wasted and 19.5%
underweight in SSA in the year 2015 [8].
Moreover, child
growth failure (CGF) was the second leading risk factor for child mortality in
SSA, accounting for more than 23% of deaths of children under five [8]. Despite striking sub-national
heterogeneity in levels and trends of child growth [4], between 2000 and 2015, nearly all African countries
demonstrated improvements for children under 5 years old for stunting, wasting,
and underweight, the core components of child growth failure. The prevalence of
malnutrition was highest within countries in East Africa and West Africa
compared to the WHO Millennium development goals target for 2015 [9].
In Ethiopia,
for example, national DHS report shows a slight decline in the trends of
nutritional status for under five children during 2011 to 2015 [10]. This national report shows a decline in
stunting from 44% in 2011 to 38% in 2016 and a decline in underweight from 29%
in 2011 to 24% in 2016. However, the rate of child wasting has been remained
stagnant at 10% in the country. These data suggest that despite the substantial
global progress that has been achieved, under-nutrition remains unacceptably
high in Ethiopia and far from being solved.
There are
limited or incomplete assessments of risk factors of child growth failure
(CGF), conducted at (sub)-regional level, as well as the Demographic and Health
Surveys, which report at the first administrative subdivision [4]. Although the work so far has shown coarse
sub-national disparities in CGF, it provides an incomplete picture on the
common risk factors associated with child nutrition at national level. The
factors associated with child under-nutrition are multi-factorial and
interdependent [11]. A multi-stage
clustered analysis that targets the distant, immediate and proximate
determinants of CGF as per adopted by UNICEF [12]
are required to fully determine predictors at national level.
Therefore,
potential risk factors have been identified based on UNICEF conceptual
framework model for child nutrition comprehensively for Ethiopian population to
carry out clustered analysis. Analysis that fully exploits the complex nature
of child under-nutrition ranging from community-, household-, environmental-,
socioeconomic and cultural influences has identified for under 5 children in
Ethiopia.
Hence, this
study used data from the recent National Demographic and Health Survey (EDHS
2016) to determine the common risk factors for stunting, underweight and wasting
among Ethiopian children aged 0-59 months. The outcome of the study will have
policy implications and contributions for Ethiopia towards WHO member states
broader agenda to improve nutrition by 2025 [1,4,13],
including stunting, wasting, low birth weight and overweight in children under
five, and further achieve Sustainable Development Goal (SDG) aimed to end all
forms of malnutrition by 2030.
METHODS
Study design and data sources
This study
analyzed data obtained from the 2016 Ethiopia Demographic and Health Survey
(2016 EDHS) implemented by the Central Statistical Agency (CSA) from January
18, 2016 to June 27, 2016. The survey was conducted by the Central Statistical
Agency (CSA) with ICF provided technical assistance through the DHS Program, a
USAID-funded project providing support and technical assistance in the
implementation of population and health surveys in countries worldwide [10]. The government of Ethiopia, the United
States Agency for International Development (USAID), the government of the Netherlands,
the Global Fund, Irish Aid, the World Bank, the United Nations Population Fund
(UNFPA), the United Nations Children’s Fund (UNICEF) and UN Women were sources
of funding for to carry out the 2016 EDHS.
Administratively,
Ethiopia has nine geographical regions and two administrative cities. The
sample for the 2016 EDHS was designed to provide estimates of key indicators
for the country as a whole, for urban and rural areas separately and for each
of the nine regions and the two administrative cities. Sample was stratified
and selected in two stages and each region was stratified into urban and rural
areas, yielding sampling strata. First, a total of urban and rural areas were
selected with probability proportional to enumeration areas (EAs) size and with
independent selection in each sampling stratum and household listing were
carried out in all the selected EAs. Then, a fixed number of households per
cluster were selected with an equal probability systematic selection from the
created household listing.
Accordingly, a
total of 18,008 households sample were selected for the survey and of this
17,067 households were occupied. However, 16,650 were successfully interviewed
yielding a response rate of 98%. In the interviewed households, 16,583 eligible
women were identified for individual interviews and interviews were completed
with 15,683 women, yielding a response rate of 95%.
Of the total of
10,752 children under age 5 were eligible for height and weight measurements,
9696 children were included in our analysis. For some eligible children,
however, complete or valid data were not obtained due to misclassifications or
errors. Therefore, data of 8,855 children (for height-for-age), 8,919 children
(for weight-for height) and 9,033 children (for weight-for-age) of eligible
children with complete and credible measurement were analyzed.
Height and
weight measurements were carried out on children under age 5 in all selected
households. Weight measurements were obtained using lightweight SECA
mother-infant scales with a digital screen designed and manufactured under the
guidance of UNICEF. Height measurements were carried out using a Shorr
measuring board, in recumbent position for under 2 years’ old children while
standing height was recorded for older children.
Dependent variables
The three main
indicators used to define under-nutrition (i.e., underweight, stunting and
wasting) represent different histories of nutritional insult to the child [14,15]. According to WHO Press [16], prevalence of moderate and severe stunting,
underweight and wasting among children aged 0-59 months is defined as the
proportion of children with a height-for-age, weight-for-height or
weight-for-age z score that is more than two standard deviations below the 2006
WHO growth reference population, respectively.
Stunting (height-for-age): Height-for-age index identifies past
under-nutrition or chronic malnutrition and it cannot measure short term
changes in malnutrition [14]. Therefore,
there is increasing agreement among the nutrition community about the use of
length/height-for-age as the indicator to monitor the long-term impact of
chronic nutritional deficiencies [17].
For children below 2 years of age, the term is length-for-age; above 2 years of
age, the index is referred to as height-for-age. Children whose Height-for-age
is below minus two standard deviations (−2SD) from the WHO Multicentre Growth
Reference Study median [18] are
classified as stunted.
Underweight (weight-for-age): Underweight, based on weight-for-age,
is a composite measure of stunting and wasting and is recommended as the indicator to assess changes in the magnitude of malnutrition
over time [14]. The advantage of this
index is that it reflects both past (chronic) and/or present (acute)
under-nutrition, but it cannot distinguish between the two. Children whose
weight-for-age is below minus two standard deviations (−2SD) from the WHO
Multicentre Growth Reference Study median [18]
are classified as underweight.
Wasting (weight-for-height): The weight-for-height index measures
body mass in relation to height and reflects current nutritional status [14]. The index is calculated using growth
standards published by the WHO in 2006 [18].
These growth standards were generated through data collected in the WHO
Multicentre Growth Reference Study [18]
and expressed in standard deviation units from the Multicentre Growth Reference
Study median. Children with weight-for-height Z-scores below minus two standard
deviations (−2SD) from the median of the WHO reference population are
considered wasted.
Independent variables
Based on the
UNICEF general model for causes of malnutrition [12], the conceptual framework for child under nutrition in Ethiopia
were prepared and potential risk factors were classified into five categories.
These are community level factors, socio-demographic factors, environmental
factors, media factors and proximate determinants, as presented in Figure 1. The figure also demonstrates
the community level factors which included administrative zones and type of
residence (urban or rural); whereas, socio-demographic, environmental and media
factors were considered as household level determinants.
The
national-level wealth quintiles were derived from the household wealth index,
which serves as an indicator consistent with expenditure and income measures [10]. Households were given scores based on the
number and kinds of consumer goods they own, ranging from a television to a
bicycle or car, in addition to housing characteristics such as source of
drinking water, toilet facilities, and flooring materials. These scores were
derived using principal component analysis (PCA). National wealth quintiles were
compiled by assigning the household score to each usual (de jure) household
member, ranking each person in the household population by her (his) score and
then dividing the distribution into five equal categories, each comprising 20%
of the population. These five national-level wealth quintile categories are:
poorest, poor, middle, rich and richest. The bottom 40% of the households was
referred to as the poorest and poor households, the next 20% as the
middle-class households and the top 40% as rich and richest households.
STATISTICAL ANALYSIS
The index of
child undernutrition including stunting, underweight and wasting were expressed
as dichotomous variables. Then, these were examined against sets of independent
variables in order to determine the factors associated with stunting,
underweight and wasting in children under-five years in Ethiopia.
Data analyses
were performed with IBM SPSS statistics (version 21.0) for Windows, taking into
account the complex nature of the cluster sample design. A multivariable
logistic regression analysis was conducted at multilevel, based on the
conceptual framework adapted from UNICEF (Figure
1). Each level factors, namely: community-level, household-level and
immediate-level factors were entered into the model independently to determine
their association with the outcome variables. During multivariate, a stepwise
backward elimination was performed and factors significantly associated with
the study outcomes were retained. In order to determine the adjusted risk of
the independent variables, the odds ratios with 95% CI were calculated and
those with p<0.05 were retained in the final model.
RESULTS
Characteristics of independent variables
Dependent variables
Table 2 shows prevalence
rate of undernutrition categorized by child age and types of residence in the
study setting. Despite there exists differences by geographic area and child
age, the overall prevalence of stunting, underweight and wasting were found to
be 37.8%, 26.8% and 12.9%, respectively. Higher prevalence of stunting (26.5%)
and underweight (18.0%) has been observed among children in the later-age group
(24-59 months) when compared with children under 2 years of age. Moreover, the
prevalence of stunting and underweight was nearly two-fold higher among
children residing in rural as compared to those in urban.
Common risk factors associated with under-nutrition
Table 3 presents multiple
level analysis (COR/AOR: 95% CI) of common risk factors associated with
stunted, underweight and wasted children aged 0-59 months in Ethiopia. Children
living outside the capital (Addis Ababa) were significantly more predisposed to
stunting, underweight and wasting than those in the capital. Children of
uneducated parents and residing in rural areas had significantly higher odds of
being stunned and underweight compared with those of educated parents and
dwelling in urban areas.
Taking into
account household wealth index as an indicator consistent with expenditure and
income measures; children living in households categorized to lowest
national-level wealth quintiles and that do not/least watch television had
significantly higher odds of their children being stunted, underweight and
wasted as compared with those residing in higher wealth quintile and exposed to
the media frequently.
Moreover,
children of Mothers with BMI less than 18.5 kg/m2 were significantly
more susceptible to underweight and wasting than mothers with BMI greater than
18.5 kg/m2. Male children were significantly more predisposed to
stunting, underweight and wasting than those of female children. Children in
the late-aged group (≥ 12 months) had significantly higher odds of being stunned
and underweight compared with those under 12 months of age; while, the later
had significantly higher odds of being wasted.
Lastly,
children who were delivered at home/other places and children who were
perceived to be small by their mothers at birth were more likely to be stunned,
underweight and wasted than those delivered at a health facility and perceived
to have been average/large. Child’s health status was also significantly
associated with underweight. Children who had diarrhea in the two weeks preceding
the survey were more likely to be underweight compared with children who had
not been contracted diarrhea.
DISCUSSION
This study has
explored the updated national-level prevalence of undernutrition among under
five years’ children, and common risk factors associated with stunting,
underweight and wasting in Ethiopia. Our analysis reported higher
national-level of undernutrition among children under age five; with 37.8%
stunted, 26.8% underweight and 12.9% wasted. However, there exist some clear geographic
inequalities (urban-rural) and variations by child’s age. Children age 24-59
months were the most affected by stunting, underweight and wasting; whereas,
relatively lower rates were observed among under 1 year infants (Table 2). It’s even very interestingly
to note that the rate of stunting and underweight among the three child-age
brackets (i.e., 0-11 months, 12-23 months and 24-59 months) has increased
geometrically with an increased child-age bracket, almost by double and triple,
respectively.
The prevalence
rate of child undernutrition recorded in our study is still higher than the
Joint Child Malnutrition Estimates by UNICEF/WHO/World Bank Group for African
in 2017 [20], which reported 31.2%
stunting, 5.2% underweight and 7.4% wasting in the region. Despite moving in
the right direction, our finding reveals that Ethiopia has been making
insufficient progress to reach the World Health Assembly targets set for 2025
and the Sustainable Development Goals set for 2030. Therefore, the country need
to put more effort in improving children’s nutrition, which requires effective
and sustained multi-sectoral nutrition programming over the long-term. This
makes our finding important to monitor and analyze country progress going
forward in relation to United Nations targeted goal of improving child
nutrition.
Child
undernutrition increases the risk of neonatal and child mortality and future
maternal reproductive outcomes [4]. Child
growth failure (CGF) is the specific subset of child under-nutrition, excluding
micronutrient deficiencies, that is characterized by the relationship between
insufficient height and weight at a given age and this subset is most
universally described in terms of univariate ‘growth standards’, for which
age-specific heights and weights are compared to healthy reference populations.
By the
Millennium Development Goal (MDG) era, Ethiopia achieved a slight reduction in
under-5 and neonatal mortality [10]. Yet,
the pace of progress toward these goals substantially varied at the
sub-national level, demonstrating an essential need for tracking even more
local trends in child mortality in Ethiopia. Our study here has provided not
only estimates for national prevalence of undernutrition but also a
comprehensive assessment of risk factors associated with stunting, underweight
and wasting to inform policy makers. The importance of addressing risks factors
in context and informs the need for more efforts to reduce child undernutrition
in the country.
Despite
expected disparities over time, geographic inequalities persisted among
countries with the lowest and highest child mortality rates [1]; the underlying causes of child
malnutrition are similar across all countries in SSA and globally as outlined
in the UNICEF conceptual framework for child nutrition [12]. Malnutrition is a multi-sectoral, multi-level problem that
results from the complex interplay between household and individual
decision-making, agri-food, health and environmental systems that determine
access to services and resources and related policy processes [21]. Food intake or infection or a combination
of the two and other factors including poverty, low parental education, poor
feeding practices, economic status, residence, family size, living in
developing countries, number of under five children in one family, as well as
urban and rural differences [3].
East Africa has
the potential and capacity to produce enough food for its local consumption and
a large surplus for export to the world market [22].
However, the region is grossly affected by natural and manmade factors such as
population growth, food shortages, unfavorable climatic and drought conditions
as well as limited access to land for agricultural purposes [9]. These factors
seriously undermine progress toward improving agricultural productivity, food
and nutrition security to promote child nutrition in the region.
Leveraging
Agriculture for Nutrition in East Africa (LANEA) mapped evidence across
agriculture—nutrition pathways in East Africa and reported that effective food
systems had positive impact on child nutrition [21].
However, most households in SSA do not have adequate nutrition knowledge for
decision making that accounts for the full cost-benefit analysis of a balanced
diet. Feeding practices in typical African households are mostly geared to
abetting hunger as a singularity [23] and
so nutrition is rarely considered or factored into food security strategies. As
a result, they miss opportunities to diversify their diet beyond cereal based
foods around other nutrient-rich food stuffs such as pulses, seeds and animal
source foods. All these factors affect the nutritional status of an individual
child and may eventually lead to chronic under-nutrition especially, among low
income urban and most rural households.
In the present
study, children who resided in the rural area and outside the capital (Addis
Ababa) of Ethiopia had a significantly higher risk of being stunned,
underweight and wasted. Children living outside capital, especially, Amhara,
Benishangul-Gumuz, Afar and Dire Dawa regions had significantly higher odds of
being stunted and underweight. Whereas, children residing in Somali, Afar and
Benishangul-Gumuz region had significantly higher odds of being wasted compared
with those in capital. This could be due to big variations in diversities
between geopolitical regions in terms of resources, agricultural production and
food security [24] and other factors such
as feeding practices, access to education and household wealth [10]. Regions outside capital such as Amhara,
Tigray, Oromia, SNNPR, Somali, Benishangul Gumuz and Gambella one way or the
other partly characterized by sub-optimal agricultural production and even some
are acutely food insecure due to recurrent El Niño contributing to the worst
drought in more than 50 years in Ethiopia [24].
Moreover, the
proportions of children who are stunted and underweight decline with increasing
mother’s education and increasing household wealth. National study (EDHS 2016)
also confirms that children born to mothers with higher education and household
wealth were more likely to receive breastfeeding including pre-lacteal feeding,
compared with children of mothers with lower education level and household
wealth [10]. Although, there is a
significant regional variation exists in the proportion of children who receive
the minimum acceptable diet; children in urban areas (19%) are more likely to
fed according to the minimum acceptable dietary standards than those in rural
areas (6%); with the highest level of 27% in Addis Ababa and the lowest levels
(2-3%) in Affar, Somali and Amhara [10].
However, the likelihood that a child is receiving the minimum acceptable diet
generally improves with the mother’s education level and household wealth,
demonstrating the importance of working on educating mothers and improving
household wealth in the course of alleviating child undernutrition.
In addition,
sex of a child, mother’s perception of the birth size of their child and place
of delivery were significantly associated with the three indicators of child
growth outcome in the study setting. Children who were delivered at home/other
places and children who were perceived to be small by their mothers at birth
were more likely to be stunned, underweight and wasted than those delivered at a
health facility and perceived to have been average/large. This is consistent
with results of previous studies in Nigeria [11]
that reported birth size as a valid indicator of nutritional status
demonstrating the importance of women’s health and prenatal care for giving
their offspring a better chance in life.
The present
finding highlights the importance of adequate nutrition during the first 1000
days, beginning at conception and extending through to the second birthday of a
child, is a critical window for preventing undernutrition and its long-term
consequences [23,25,26]. Poor feeding
practices during this vulnerable period can increase the risk of
undernutrition, and this can impair the physical and cognitive development,
weaken the ability of the child to fight against deadly infectious diseases [27] and eventually leading to reduced school
performance, lower economic productivity, shorter adult stature and decreased
offspring birth weight in long-terms.
Moreover,
children delivered at home tend to have poorer nutritional status than children
delivered at a health facility in the study population. This finding is
consistent with similar studies in other African countries [11]. Usually, home delivery is practiced by
women of lower educational status [11,28];
and such women are tending to lack the necessary knowledge needed to make
informed decisions concerning the health of their child. And also, women who
deliver at home miss out the opportunity for the valuable post-natal counseling
provided at the health facilities, which may help in improving the nutritional
status of both mother and child.
Although, the
basic biological reason for it is not clear; our finding shows male children
sustains a significantly higher risk of being undernourished compared with
their female counterparts. This finding is consistent with a meta-analysis of
16 demographic and health surveys in SSA that reported boys to be more stunted
than girls [29]. In SSA, male children
under five years of age are more likely to become stunted than females, which
might suggest that boys are more vulnerable to health inequalities than their
female counterparts in the same age groups. In several of the surveys, sex
differences in stunting were more pronounced in the lowest socioeconomic status
(SES) groups.
Study shows
that changes in maternal BMI correlates with long term changes in childhood
malnutrition [30]. Our present study also
shows that children whose mothers had a BMI less than 18.5 kg/m2
were significantly more likely to be underweight and wasted than those whose
mothers had a higher BMI than 18.5 kg/m2. A similar cross-sectional
study conducted in Nigeria also reported same findings [11], demonstrating the need to work on improving in maternal BMI as
one of the strategy to reduce childhood malnutrition. In this regards,
encouraging experience has been reported from Bangladesh [30], which indicated that without significant
nutritional transition among under 5 years’ children; improvement in maternal
BMI over the past 15 years was accompanied by a reduction in malnutrition in
under 5 years.
Several
literatures including PATH communication message [31] and Lancet Series [32] indicated that good nutrition is essential
for child growth, development, and immune system function to boost children’s
defenses against infectious diseases like diarrhea. However, the children most
vulnerable to diarrheal disease are often malnourished. The relentless cycle of
malnutrition and diarrhea places a great burden on developing countries and on
children, in particular. In consistent with the message, our study also shows
that children who suffered a contraction of diarrhea in the two weeks preceding
the survey tend to be more nutritionally deprived than children who did not.
This suggests that, addressing malnutrition within an integrated approach
against diarrheal disease is key in helping children reach their full
potential.
Reports from
Brown [33] also confirmed the deleterious
effect of diarrhea on children’s nutritional status. Thus, promotion of
breastfeeding to prevent diarrhea and reduce its nutritional complications,
continued feeding during illness and supplementation with selected
micronutrients, both to prevent enteric infections and to reduce their
severity, are all important nutritional aspects in the control of diarrheal
diseases and their associated nutritional complications.
At last, our
study presents the significance of household’s exposure to information in
improving child nutrition. Children from households who were exposed to
information, particularly television are less prone to child undernutrition.
This finding is also similar to that of a cross-sectional study conducted in
Nigeria [11], which reported a positive
association between frequent exposure to television and improved child malnutrition.
The strength of
this study lies in the fact that prevalence estimates for child undernutrition
are relatively robust, allowing the possibility to track national changes over
time. The national estimates presented here are based on data from national household
surveys. The analysis based data population-based with a large sample size
covering most part of the country and used most updated national data available
(2016 DHS dataset) to estimate the prevalence of stunting, underweight and
wasting. However, due to the cross-sectional nature of the study design, the
association between observed risk factors and the dependent variables might not
be necessarily causal relationship.
Moreover,
national household surveys data are collected infrequently and measure
malnutrition at one point in time (e.g. during several months of field work),
making it difficult to capture the rapid fluctuations in wasting that can occur
over the course of a given year, as incidence data (i.e., the number of new
cases that occur during the calendar year) would allow for better tracking of
changes over time, do not exist.
CONCLUSION
In conclusion, our study highlights the need
for multi-sectoral intervention approach in addressing the multiple level
causes of child under-nutrition, demanding to adopt a multi-strategy
community-based approach that targets the immediate, underlying and basic
determinants. At the individual level, interventions should focus on educating
mothers on the basics of proper nutrition and the need to make necessary
preparation such as adequate maternal nutrition for optimal BMI before and
during pregnancy and lactation. Broad approaches targeting women’s
socio-economic status and nutrition of the mother is importantly needed from
before conception as well as throughout pregnancy and breastfeeding.
At the
community level, healthcare systems that facilitate public health interventions
such as maternal-and-child health programs need to be made accessible to women
in rural areas. There is also a need for interventions to promote health care
seeking and the treatment of childhood infections including diarrhea, as well
as maternal health and nutrition (before) during pregnancy to reduce low birth
weight in children. Then after; optimal breastfeeding in the first two years of
life, nutritious and safe foods in early childhood and a healthy environment
including access to basic services are key ingredients to prevent child
under-nutrition.
ACKNOWLEDGMENT
We acknowledge archives and data managers of
the Demographic and Health Surveys (DHS) Program, ICF (USA) for authorizing to
download Survey data from the Demographic and Health Surveys (DHS) Program.
FINANCIAL SUPPORT
This research received no specific grant from
any funding agency, commercial or not-for-profit sectors.
CONFLICT OF INTEREST
N/A
AUTHORSHIP
Mr. Berra conceived and designed the study,
implementation, data interpretation, wrote the manuscript and provided critical
revisions of the manuscript.
ETHICS
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