The Use of Complex Survey Design Models to Identify Determinants of Malnutrition in Ethiopia

Children’s nutritional status has specific impact and health problems in childhood growth and adulthood. This paper attempts to identify the socio-economic, geographic and demographic determinants of malnutrition among under-five children in Ethiopia. The 2016 Ethiopian Demographic and Health Survey were used for this study. The generalized linear model was adopted for analysis. The Hosmer and Lemeshow test is used to test the goodness of fit of the logistic regression model. The findings and comparison of estimates using logistic regression model with and without complex survey design were presented and then comparison was made using design effects. The results revealed that model that considers the complex nature of the design performs better than model that do not take into account. This study suggests that improving the health status, stable work status and educational level of mothers consequently, can reduce malnourished children in Ethiopia. Address for correspondence: Dawit Getnet Ayele Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD 21205, USA Cell: +1 (443) 554 6721 Email: dayele1@jhu.edu, ejigmul@yahoo.com The present paper is extracted from the thesis title "Statistical models to study the BMI of under-five children in Ethiopia" of Ashenafi Argaw Yirga submitted at University of KwaZulu-Natal, School of Mathematics, Statistics and Computer Science, South Africa under the supervision of Dr. Sileshi Fanta Melesse, Prof. Henry Godwell Mwambi and Dr. Dawit Getnet Ayele. INTRODUCTION Child malnutrition is a very common public health problem in the world, especially in developing countries. The nutritional status of children under the age of five is an important outcome measure of children’s health. This is because, the early days of child life is very important for future growth and development. Therefore, identifying factors that affect the nutritional status of under five children is very important for possible intervention activities. It can also assist policymakers to know and understand the areas that need considerable attention to enhance the planning and evaluation of health policies to prevent the child’s death. For this reason, a national nutrition strategy and program has been developed and implemented by the government of Ethiopia (Ethiopian Demographic and Health Survey 2016). One of the objectives of the 2009 Ethiopian National Nutrition Strategy was to enhance good nutritional practices through health education, and treatment of micronutrients to the most vulnerable groups of the society, especially, for under five children and pregnant and lactating mother. However, the poor nutritional status of children and women has been a severe problem in Ethiopia. In 2016 Ethiopian Demographic and Health Survey (EDHS), children’s nutritional status and health data were collected. In this nationally representative sample survey, measurements of children’s weight and height were recorded. The purpose of these anthropometric measurements was to determine if children are growing normally. One of the important factors for child health is the child’s weight or size at birth. This is the major indicator of the child’s health which is related to childhood illnesses and survival. The major weight group with a higher risk of early death is for those children whose birth weight is less than 2.5 kilograms (CSA and ICF 2016). Wasting, or low weight for height, is a strong predictor of mortality among children under five years of age. It is usually the result of acute significant food shortage and/or disease (Datar et al. 2013). According to UNICEF-progress for children 2007 report, there were 24 developing counJ Hum Ecol, 66(1-3): 1-11 (2019) DOI: 10.31901/24566608.2019/66.1-3.3142 © Kamla-Raj 2019 PRINT: ISSN 0970-9274 ONLINE: ISSN 2456-6608 2 ASHENAFI ARGAW YIRGA, SILESHI FANTA MELESSE, DAWIT GETNET AYELE ET AL. tries with wasting rates of ten percent or more, indicating a serious problem urgently requiring a response. The highest child malnutrition is found in the Sub-Saharan Africa countries. Ethiopia is among those countries with the highest rate of stunting in Sub-Saharan Africa. Universally, in 2011, eight percent of under five children were wasted (that is, weight for height below -2SD). This figure shows a eleven percent decrease compared to 1990 (De Onis et al. 2012). For the case of stunted children, the majority (90%) of children live in Africa and Asia. Moreover, sixteen percent of under five children were underweight (that is, weight for age below -2SD) in 2011. This is thirty six percent less compared to 1990. An estimated 159 million children under five years of age, or 23.8 percent, were stunting in 2016, 15.8 percent decrease from an estimated 255 million in 1990 worldwide (Achadi et al. 2016). For the case of Ethiopia, on an average twenty nine percent of children are underweight (low weight-for-age) and nine percent are severely underweight (CSA and ICF 2016). Even though the occurrence of stunting and underweight among children under five years of age worldwide has decreased since 1990, overall improvement is unsatisfactory and millions of children remain at risk (De Onis et al. 2012). Determinants of Malnutrition of Children under Five Years in Rwanda was studied by in 2016. This study uses the 2010 Rwanda Demographic and Health Survey data. From the result, it was identified that the age of child, birth order, gender of child, birth weight, fever, mother’s education level, mother’s age at the birth, body mass index, mother’s knowledge on nutrition, anemia, province, source of drinking water, multiple births, and wealth index have effects on malnutrition status (Habyarimana et al. 2016). The prevalence of malnutrition was studied in Sub-Saharan African Countries by Akombi et al. (2017). Their finding indicates that the prevalence is highest within countries in East Africa and West Africa. This was compared to the WHO Millennium development goals. In their study, they suggested that nutrition interventions have to be given attention in East Africa and West Africa. Lara et al. (2017) studied the nutritional status of children in the Eastern Mediterranean Region (EMR). The result gives an important understanding of the nutrition situation of children. The result focused on two main parts of the EMR (Nasreddine et al. 2018). Therefore, from the result, it was possible to identify gaps and challenges in present nutritional assessment studies. The important points include the three-way problem of malnutrition in relation to underweight, nutrient inadequacies, and overweight/obesity. Many research studies have shown how various socio-economic and demographic factors affect the malnutrition of children under the age of five. A recent study in Oromia region showed that thirty-five percent of non-pregnant women in this region had a BMI lower than 18.5, indicative of a high probability of getting underweighted children (Getahun et al. 2017). Underweight is commonly used as an indicator for malnutrition. It is influenced by the height and weight of a child/person and is thus a composite nature of stunting and wasting makes interpretation complex. The design of the Ethiopian Demographic and Health Survey was complex survey design. The sample was stratified and selected in twostages with unequal sampling weights. Many studies used simple binary or ordinal logistic regression which does not include the complex nature of the sampling design. The purpose of this study was to identify the socio-economic, geographic and demographic determinants of malnutrition among under five children in Ethiopia by taking into account the complex nature of the sampling design.