Risk Factors Associated with Under-Five Stunting, Wasting, and Underweight Based on Ethiopian Demographic Health Survey Datasets in Tigray Region, Ethiopia

Background Stunting, wasting, and underweight among children are major problems in most regions of Ethiopia, including the Tigray region. The main objective of this study was to assess the risk factors associated with stunting, wasting, and underweight of children in the Tigray region. Methods The information collected from 1077 children born 5 years before the survey was considered in the analysis. Multivariable binary logistic regression analysis was fitted to identify significant risk factors associated with stunting, wasting, and underweight. Results Male children and rural born were having a higher burden of both severe and moderate stunting, wasting, and underweight than females and urban born. Among male children, 27.6%, 4.10%, and 14.2% of them were stunted, wasted, and underweight, respectively. Protected drinking water (odds ratio (OR) = 0.68; 95% confidence interval (CI): (0.50, 0.92)) was associated with stunting. Maternal age at birth less than 20 years (OR = 0.66; 95% CI: (0.45, 0.97)) and being male (OR = 2.04; 95% CI: (1.13, 3.68)) were associated with high risk of underweight. No antenatal care follow-up (OR = 2.20; 95% CI: (1.04, 4.64)) was associated with wasting, while the poor wealth index, diarrhea, low weight at birth (<2.5 kg), lower age of a child, and 3 or more under-five children in a household were significantly associated with stunting, wasting, and underweight. Conclusions Being born in rural, being male, unprotected drinking water, smaller weight at birth, no antenatal follow-ups, diarrhea, and poor household wealth were factors associated with increased stunting, wasting, and underweight. Thus, interventions that focus on utilization of antenatal care services, improving household wealth, and improving access to protected drinking water were required by policymakers to decrease stunting, wasting, and underweight more rapidly.


Introduction
Globally, about 151 million children under 5 years of age suffer from chronic malnutrition and 67 million under-five were wasted in 2017 [1]. Among these malnourished underfive, 55% of all stunted children under 5 years of age have been from Asia and 39% were living in Africa, while 69% of all wasted children under 5 years of age resided in Asia and 27% of wasted under-five lived in Africa. Moreover, UNI-CEF, WHO, and World Bank Group Joint Child Malnutrition estimate in 2018 that about 35.60% of under-five in east Africa were stunted [2].
Malnutrition among under-five declined from 32.6% to 22.2% between 2000 and 2017 worldwide [3]. In 2018, UNICEF reported that about 3.1 million children died of undernutrition and malnutrition contributes to more than half of global child deaths [4]. Though there is a global decline in the malnutrition rates of under-5, the risk of malnutrition remains high and it is the major cause of under-five morbidities and mortalities of African especially sub-Saharan Africa [5]. Burundi has the highest stunting (57.7%) followed by Malawi (47.1%); Niger has the highest wasting (18%), followed by Burkina Faso (15.5%); and Burundi has the highest underweight (28.8%), followed by Despite the fact that a number of studies have been done on the identification of factors that are associated with under-5 stunting, wasting, and underweight in the Tigray region, none of them uses the nationally representative data for the Tigray region. The progress made in decreasing under-five stunting, wasting, and underweight in the region is still high, and more effort is needed to improve the barriers for further reduction. More research studies are, therefore, required to inform policymakers to implement appropriate intervention programs. To address this gap, we conducted an all-inclusive cross-sectional analysis of the recent 2016 Ethiopian Demographic Health Survey, to assess the risk factors for stunting, wasting, and underweight. Therefore, the main objective of this study was to assess the risk factors associated with stunting, wasting, and underweight of under-five in the Tigray region.

Description of the Study Area.
The Tigray National Regional State is located in the northern part of Ethiopia. According to the 2007 Census, the state's population size was 3,136,267 of which 1,594,102 were females. The urban residents of the region were 468, 478 and its rural residents 2,667,789 [32].

Source of Data.
The data onto this study were extracted from the Ethiopian Demographic and Health Survey (EDHS) 2016. The Central Statistics Agency (CSA), the Ministry of Health (MOH), and the Ethiopian Public Health Institute together conducted the survey from January 18, 2016-June 27, 2016, where the United States Agency for International Development (USAID) funded the project. The survey implemented a two-stage sample design. In the first stage, 645 enumeration areas were selected with probability related to size. In the second stage, 28 households per cluster of equal probability systematic were selected from the household list. All women of 15-49 years that were either stable inhabitant or visitors, who lived at least one night in the household before the survey, were eligible for the interview. Data were gathered by conducting face-to-face interviews for women that met the eligibility criteria.

Variables of the Study.
Determinants of stunting, wasting, and underweight in this study were selected from the available similar studies on the subject; the main predictors explored for under-five nutritional status were grouped into demographic, socioeconomic, and environmental factors related to mothers and households. Then, the nutritional status of a child was calculated based on the three anthropometric indicators: wasting (weight-for-height), stunting (height-for-age), and underweight (weight-forage). The dependent variables of this study were stunting, wasting, and underweight among children aged 0-59 months.

Statistical
Analysis. Data analysis was done using SPSS version 21.0 (2018). The descriptive statistics such as frequencies and proportions were used to summarize the distribution of selected background characteristics of the sample. To estimate the effect of each demographic, socioeconomic, and environmental factors on under-five stunting, wasting, and underweight (odds ratio (OR) with 95% confidence intervals (CI)), logistic regression analysis was fitted. Bivariate analysis based on Pearson chi-square tests was used for testing association with the predictors and outcome variable under-5 stunting, wasting, and underweight. All significant predictor variables (p < 0.05) in the bivariate analysis were included in the multivariate logistic regression analysis. The goodness of fit of the fitted models was checked using the Hosmer and Lemeshow test (HLT).

Descriptive Statistics.
More than two-thirds of the children were from mothers aged 15-20 years at first birth (67%). Nearly one child in 10 children was from rural areas (88%) while the remaining 12% of the children were living in urban areas. According to Table 1, children from uneducated mothers have a higher percentage (67.2%) of samples. Similarly, the highest percentage of children (52.5%) belonged to a mother whose husband has no education at all, while only 8% has a secondary or higher education.
The majority (42.0%) of the respondents used unprotected drinking water and 38% of them used protected well while only one-fifth (20%) of respondents had piped sources of drinking water. Similarly, more than half (58.5%) of the respondents had no toilet facility, and 41.5% had toilet facilities. More than half (52.3%) of respondents had two under-five children in the household, more than one-third (36.3%) had one under-five child in households, and only 11.4% of respondents had at least three children less than five years in households in the past five years preceding the survey. More than half (52.8%) belonged to the poor wealth index, while 32% belonged to rich household wealth indices.
About 54% of children belong to mothers that did not attend any antenatal care services during pregnancy, and only one from five (22%) had attended at least four antenatal visits during pregnancy. On the other hand, only 11.40% of mothers have attended postnatal care services. The percentage of age distribution of samples included in the study was almost consistent with all age groups. The vast majority (86%) of children included reported that they had no diarrhea two weeks before the survey. Similarly, about 85% of children born five years before the survey had no anemia. As the vaccination is concerned, 78% of them have received vitamin A in the last 6 months, about 74% have received measles, and about 40% have received tetanus.
Results showed that about 19.4% of the children were first birth, about 44% were second, third, or fourth, and 36% were had birth order at least a fifth. The vast majority (53.5%) of women have been engaged in the agricultural sector while 21% were housewives without a formal job. The proportion of children currently breastfeeding was nearly two-thirds (63%), and only 3% of the under-five included in the study was born through the Cesarean section birth. As high as 89% of children were born at home outside health facilities and more than 97% of births were singleton. Concerning birth weight, about 34% of under-five included in the study had a birth weight less than 2.5 kg, about 46% had 2.50-4 kg, and 20% had more than 4 kg (Table 1). Table 2, under-five stunting, wasting, and underweight were higher in the rural areas, and about 92.4% stunted, 89.5% wasted, and 91.4% of underweight were reported among rural children born five years before the survey. As indicated in Figure 1, among rural children, 21.5%, 2.90%, and 9.30% were severely stunted, wasted, and underweight, respectively.

Bivariate Analysis. According to
Regarding maternal education, the percentage of stunting, wasting, and underweight among children born of the uneducated mother was relatively higher than that of attending at least a primary education. Among children born to a woman with no education, 71.0%, 71.9%, and 71.6% were stunted, wasted, and underweight, respectively. Similarly, stunting, wasting, and underweight among under-five children differed significantly with the partners' level of education, with those of no education, having a higher proportion of experiencing stunting (58.2%), wasting (52.6%), and underweight (59.9%). Only 2.10%, 1.80%, and 1.90% of children born from a woman whose partner has higher education in the last five years prior to the survey were stunted, wasted, and underweight.
As maternal age was concerned, the highest percentage of under-5 stunting, wasting, and underweight was among children belonging to older age women. About 30%, 23.7%, and 28% of under-five children whose mother aged 35 and older were stunted, wasted, and underweight, respectively, while only 3.50%, 5.30%, and 4.70% of children whose mother is 15-19 years old were stunted, wasted, and underweight, respectively. Similarly, stunting, wasting, and underweight among under-five differed significantly with the sources of drinking water, and those used unprotected well have the highest proportion of stunting (49.4%), wasting (40.3%), and underweight (47.1%), respectively, while only 15.2%, 20.2%, and 15.6% of children belonging to the household using piped source experienced under-five stunting, wasting, and underweight, respectively. On the other hand, 61.8%, 64.9%, and 60.3% of children belonging to a family with no toilet facilities had experienced underfive stunting, wasting, and underweight, respectively ( Table 2).
With regard to mother's antenatal care follow-ups and baby postnatal care visits, the result shows that among children born from mothers who were not receiving any antenatal care, 58.4%, 57%, and 61.1% were stunted, wasted, and underweight, respectively, while 92.6%, 96.5%, and 97.7% of stunting, wasting, and underweight were reported among children who had not attended any postnatal checkup. Similarly, looking at birth weight of a child, high proportion of stunting (41.3%), wasting (42.1%), and underweight (48.6%) was associated with lower birth weight (<2.50 kg). About 46%, 55%, and 44% of stunting, wasting, and underweight were reported among children with second, third, or fourth birth order. Also, the percentage of stunting increases with child age between 2 and 4 years and the lowest proportion of stunting was reported among infants.
In this study, the prevalence of severe stunting (22.9%) and underweight (10.3%) is markedly higher than the previous studies that reported 7.90% severely stunting and 3.20% severely underweight in Bure Town, west Gojjam Zone [17]. Children born in rural areas five years preceding the survey were more likely severely stunted (21.5%) and severely underweight (9.30%) than their urban counterparts. The possible reason for this might be a lack of healthcare and food insecurity programs in rural areas. Moreover, male children are highly severely stunted (27.3%) and severely underweight (12.2%) than females. This figure is higher than that reported in the study in the Bure Town of west Gojjam [17], 10.7% of severely stunted and 6% of severely underweight.
In the multivariate logistic regression analysis, it was found that being born of a weight less than 2.50 kg was associated with a higher risk of stunting, wasting, and underweight than about average (2.50-4 kg) or larger size at birth (>4 kg). Several studies in the literature reported babies born of smaller size were at higher risk of stunting [15,37]    wasting, and underweight. This might be for the reason that low birth weight is in turn associated with a range of adverse outcomes of first childhood life.
Being born of a mother with a younger age at birth (less than 20 years) was associated with a lower risk of underweight compared to being born of mothers older than 20 years. This finding was in contradiction with the results of those children born of mothers at an earlier age having a higher chance of experiencing under-five underweight [38,39].
Antenatal care visits during pregnancy were identified as a strong predictor of under-5 wasting in the multivariate analysis after controlling for the effect of other covariates. Results show that children born of mothers that do not attend any antenatal care service at the time of pregnancy have a significantly higher risk of wasting compared to those born of mothers that attended at least four antenatal visits. Previous research studies [17,26,40] also revealed that antenatal follow-ups during pregnancy have been significantly associated with a reduced chance of wasting. The reason for this may be access to medical treatments for pregnancy which is helpful for the mother to protect her child from different infections. Another possible explanation for this result might be following antenatal care enables mothers to be aware of the advantages of breastfeeding and other feeding practices of their infants. Moreover, the World Health Organization also recommends that a woman should have at least four antenatal visits by health professionals during pregnancy.
Another significant risk factor attributed to stunting among under-five was wealth indices and source of improved drinking water. Children that were born in poor household were at the risk of stunting and underweight. The possible explanation for this might be mothers from households having the rich or middle wealth status were more likely to provide micronutrients in reached foods and seek medical treatment for their children. Previous literature also reported that the poor wealth index is strongly correlated with under-five stunting [15,17,23,24,26,41,42]. Furthermore, better of households has better access to food and higher cash incomes than poor households, allowing them a quality diet, better access to medical care, and more money to spend on essential nonfood items such as hygiene products. Similarly, unprotected sources of drinking water were strongly associated with a higher risk of stunting. This is consistent with available literature that states that improved sources of drinking water are a strong predictor of child stunting [15,16,23]. Child diarrhea was found to be a significant association with wasting and underweight, such that children who had diarrhea in the last six months preceding the survey had an increased risk of wasting and underweight compared to those who did not have diarrhea. This finding is in agreement with studies [17,24] which show a significant association with diarrhea recently and under-five wasting and underweight. This is due to the fact that diarrhea accelerates the onset of acute malnutrition by reducing food intake and increasing catabolic reactions in the organism.
On the other hand, the high number of under-five children in families was more likely to be associated with under-5 stunting and underweight. Various literature studies indicated that larger under-five children in households were significantly positively associated with stunting and wasting [15,24]. This may be because the large household size is widely regarded as a risk factor for stunting and underweight particularly for infants and young children due to food insecurity.
Age of a child was independently related to stunting and wasting. Similar previous research studies [23][24][25] reported that child age had a significant association with stunting and wasting of the children. Being a male child was highly positively associated with underweight. Studies have shown that boys had a significantly worse nutritional status than girls [15,43,44]. Mother's occupation, maternal or partner's education level, birth order, place of delivery, birth type, and mode of delivery were not significantly associated with experiencing stunting, wasting, and underweight.

Conclusions
Children from mothers who were not attending antenatal care during pregnancy were at higher risk of wasting. Thus, treatment of mothers during pregnancy should be given due attention. Children of age 0-11 months and 12-23 months are more at risk of wasting. Thus, efforts should be made to communicate through health and nutrition education, the importance of feeding breast milk exclusively up to 6 months, and thereafter introducing other supplementary nutrient-rich foods.
Interventions that focus on children born with lower weight at birth (<2.5 kg) and children born in rural areas are required for improving the child stunting, wasting, and underweight though and improving healthcare services and food insecurity programs in rural areas. Children who use unprotected drinking water are at high risk of stunting. Thus, efforts should be made to improve access to safe drinking water. Children who have diarrhea two weeks before the date of the survey are significantly vulnerable to wasting and underweight than those who have not. Therefore, efforts should be made in improving environmental sanitation and personal hygiene to prevent exposure to diarrhea.
The authors also recommended further investigation based on trend analysis which had to be conducted to see the trend in under-five stunting, wasting, and underweight to achieve the sustainable development goal targets.