Factors Associated With Childhood Malnutrition Biology Essay

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Multivariate multilevel logistic regression was used to analyse factors associated with childhood malnutrition due to the nature of the dataset. A 2-level model for binary response y, a child malnourished (stunted, wasted or underweight), for children i residing in community j of the form was specified:

πij: yij ~ Bernoulli(1, πij)

Probability was linked to a number of categorical predictor X and a random effect for each level by a logit-link function as shown below

The linear predictor consists of a fixed part which estimates the conditional coefficients for the explanatory variables and a random intercept attributable to communities ().

Two models were constructed for each outcome measure. The first model, an empty model, was without any explanatory variable i.e., simple component of variance analysis. The second model controlled for all explanatory variables simultaneously. P value of < 0.05 was used to define statistical significance.

Fixed effects

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The results of the fixed effects (measures of association) were presented as adjusted odds ratio with their corresponding 95% confidence intervals (CIs).

Random effects

The intraclass correlation (ICC) and proportional change in variance

The possible contextual effect was measured by the intra-community correlation (ICC). The ICC which represents the proportion of the overall variance in the probability of the individual outcome is related to the community level, and is also used as a measure of clustering of childhood malnutrition level in the communities. The ICC was computed by the latent variable method propounded by (Snijders & Bosker,)61 :

where Vc represents community variance. A high ICC in the empty model means high clustering of childhood malnutrition in the community and therefore a strong community effect on under-five children's malnutrition. A low ICC, on the hand, depicts the presence of a weak community's influence on under-five malnutrition.

The variance explained by different explanatory variables was calculated as:

Where is the variance in the empty model and is variance in the full model.

The Median odds ratio (MOR)

Following the ideas of (Larsen & Merlo; Larsen et al)62;63 with respect to community effects, the random effects were described using odds ratios. MOR of 1 depicts no community variance. On the other hand, the higher the MOR, the more important are the contextual effects for understanding the probability of being malnourished. The MOR directly depends on the community-level variance and can be calculated using the formula below:

where Vc is the community-level variance and 0.6745 is the 75th percentile of the standard normal distribution with mean zero and variance one.

Thereafter, testing of the fit of various models to better understand the relationship between the explanatory and outcome variables was done. Regression diagnostic test with the use of log likelihood ratio test was used to test the goodness of fit of the models as soon as the best explanatory/predictive models were got. The models provided robust and valid results. The putting together of the predictor variables in a single analytical framework would help in having a reliable and accurate information that would help and guide policy makers when designing their interventional and control programmes for childhood under-nutrition.

RESULTS

Descriptive Analysis

In Nigeria, the prevalence of malnutrition as stated in table 2 indicates that under-five children of about 7,322(25.6%) are stunted, 2,450 (8.6%) are underweight while 5446 (19.0%) are wasted. Figure 1 shows percentage of children that were stunted across the 37 states in Nigeria. The percentage of stunted children ranged from as low as 8.2% in Enugu state to as much as 36.7% in Sokoto state.

Figure 1: Percentage stunted children across the 37 states, Nigeria 2008

Figure 2 shows percentage of children that were wasted across the 37 states in Nigeria. The percentage of wasted children ranged from as low as 5.2% in Enugu state to as much as 36.6% in Sokoto state.

Figure 2: Percentage wasted children across the 37 states, Nigeria 2008

Figure 3 shows percentage of children that were underweight across the 37 states in Nigeria. The percentage of underweight children ranged from as low as 2.6% in Ekiti state to as much as 22.7% in Bauchi state.

Figure 3: Percentage of underweight children across the 37 states, Nigeria 2008

The prevalence of stunting, underweight and wasting were 35.0%, 10.4% and 27.7% in age group 24-35 months while it was 33.9%, 9.0% and 24.1% in age group 48-59 months respectively as reported in table 3. There is significantly higher prevalence of malnutrition amongst under-five children who were residing in rural areas, breastfed longer than usual, have higher birth order number, sex is male, did not complete immunization and those who were borne with low birth weight..

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In the same vein, under-nutrition is highest in children borne to under-nourished mothers with respect to BMI status and whose mothers are not working. The prevalence is highest in the under-fives whose parents were the poorest with respect to wealth index status and those that had no formal education. Children borne to young mothers (15-24 years) had highest level of malnutrition.

Bivariate analysis

Table 4 shows bivariate analysis of the data.

There was statistically significant association between age of child with stunting and wasting but not for underweight. Compared to age group 0-11 months, the odds of stunting in children of age group 48-59 months increased by about 3 folds (OR 3.09; 95% CI 2.81-3.41, p<0.001). Similarly, compared to age group 0-11 months, the odds of underweight in a child of age group 48-59 months increased by more than 2 folds (OR 2.49; 95% CI 2.24-2.77, p<0.001).

Sex of the child was significantly associated with stunting but not for underweight and wasting. Male children were 10% more likely to be stunted compared with female children (OR 1.10; 95% CI 1.05-1.16, p<0.001), there was increased odds of underweight if the sex of a child was male by 4% (OR 1.04; 95% CI 0.95-1.12, p=0.422), but not statistically significant and likewise there was increased odds of wasting by 2% (OR 1.02; 95% CI 0.96-1.08, p=0.476) which was also not significant

Birth order of a child was statistically significantly associated with all the three indicators of under-five malnutrition. Compared to birth order level one, the likelihood of a child being undernourished was increased if the birth order level of the child was two or more.

There was statistically significant association between low birth weight and stunting, also for wasting but not for underweight. The odds of being stunted increased by 8% (OR 1.08; 95% CI 1.01-1.56, p=0.018) if a child had low birth weight. Similarly, the odds of being wasted was increased by 10% (OR 1.10; 95% CI 1.02-1.19, p=0.012) if a child was borne with low birth weight.

Being a child from twin or higher order pregnancy was significantly associated with wasting but not with stunting and underweight. A child of twin or higher order pregnancy was 18% more likely to be wasted compared to a single birth child (OR 1.18; 95% CI 1.01 -1.38, p=0.036).

Mother's age group in years was not statistically significantly associated with all the three measures of assessing childhood malnutrition though, the odds of malnutrition reduced as the mother's age increased. The odds of being stunted reduced by 1% (OR 0.99; 95% CI 0.93-1.06, p=0.846), underweight by 4% (OR 0.96; 95% CI 0.87-1.06, p=0.446) and wasted by 6% (OR 0.94; 95% CI 0.88-1.01, p=0.096) if mother's age group is 25-34 compared to 15-24.

Educational levels of the mothers had significant association with all the measures of malnutrition used. Compared to mothers with no formal education, the odds of a child having stunted growth was reduced by 65% (OR 0.35; 95% CI 0.29-0.41, p<0.001), underweight by 69% (OR 0.31; 95% CI 0.24-0.42, p<0.001) and wasted by 77% (OR 0.23; 95% CI 0.19-0.29, p<0.001) if the mother had higher (tertiary education) degree.

Similarly, compared to mothers who are not working, the odds of a child having stunted growth was reduced by 13% (OR 0.87; 95% CI 0.81-0.93, p<0.001), underweight growth by 14% (OR 0.86; 95% CI 0.78-0.95, p=0.004) and wasted growth by 13% (OR 0.87; 95% CI 0.81-0.94, p<0.001) if the mother was doing manual job.

For mother's BMI, the likelihood of having a child with all the three malnutrition indices was increased if the mother's BMI is <18.5 kg/m² and reduced if the BMI is ≥ 25.0 kg/m².

There was also statistically significant association between breast feeding duration and all the three measures of childhood malnutrition. The odds of a child being malnourished increased with prolonged breast feeding duration.

Under-five children whose mothers had highest health seeking behaviour index in quantiles had odds of being stunted reduced by 47% (OR 0.53; 95% CI 0.48-0.58, p<0.001), underweight by 60% (OR 0.40; 95% CI 0.35-0.46, p<0.001) and wasted by 66% (OR 0.34; 95% CI 0.36-0.38, p<0.001) compared to those from the least health seeking behaviour index mothers in quantiles.

Incomplete immunization status of a child increased the odds of being stunted by 58% (OR 1.58; 95%CI 1.50-1.67, p<0.001), underweight by 37% (OR 1.37; 95%CI 1.26-1.49, p<0.001) and wasted by 50% (OR 1.50; 95% CI 1.41-1.59, p<0.001).

There was statistically significant association between low birth interval and likelihood of being stunted and wasted but not for underweight.

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The numbers of under-five children in a household had significant association with all the measures of malnutrition used. Compared to household with one child, the odds of a child having stunted growth was increased by about 18 folds (OR 17.92; 95% CI 11.93-26.92, p<0.001), underweight by about 18 folds (OR 17.95; 95% CI 8.51-37.86, p<0.001) and wasted by more than 18 folds (OR 18.50; 95% CI 11.43-29.94, p<0.001) if the numbers of children was 4 or more.

There was statistically significant association between being a child from minor ethnic group and the likelihood of being underweight and wasted but not for stunting. Children from female headed household had reduced odds of being stunted by 18% (OR 0.82; 95% CI 0.75-0.90, p<0.001), underweight by 34% (OR 0.66; 95% CI 0.56-0.78, p<0.001) and wasted by 29% (OR 0.71; 95% CI 0.63-0.79, p<0.001) compared to those from male headed household.

Under-five children who lived in the poorest household (lowest wealth index quintile) were more than twice likely to be stunted (OR 2.33; 95% CI 1.94-2.50, p<0.001), twice likely to be underweight (OR 1.89; 95% CI 1.63-2.20, p<0.001) and more than thrice to be wasted (OR 3.06; 95% CI 2.72-3.46, p<0.001) compared to those from the richest households (highest wealth index quintile).

Children from polygamous families had increased odds of being stunted, underweight and wasted compared to those from monogamous families. In like manner, those from the rural areas had increased odds of being stunted, underweight and wasted compared to those from the urban centres.

Compared with children from the North Central, children from the North East were 17%, 121% and 80% more likely to be stunted (OR 1.17; 95%CI 1.07-1.26, p<0.001), underweight (OR 2.21; 95%CI 1.92-2.54, p<0.001) and wasted (OR 1.80 95%CI 1.64-1.98, p<0.001) respectively. Similarly, children from North West were more likely to be stunted, underweight and wasted than their counterparts from the North Central. However, compared with children from North Central, children from the South South were better off with respect to all the malnutrition measurement indices (see Table 4).

Multilevel analyses

Table 5 shows results of fitting the model including individual- and community-level factors (Full Model). With all factors controlled for in the multilevel analyses, child's age was statistically significantly associated with the risk of childhood malnutrition. Male child were more likely to be stunted than female child (adjusted odds ratio [AOR] 1.18; 95% CI 1.10 - 1.26). The association between child's sex, wasting and underweight was not statistically significant. Children with high birth order 10% more likely to be wasted than children with low birth order (AOR 1.10; 95% CI 1.02 - 1.19). The association between birth order, stunting and underweight was not statistically significant. Children of product of multiple births were 87%, 103% and 55% more likely to be stunted, wasted and underweight respectively. Children born with low birth weight were 21%, 38% and 18% more likely to be stunted, wasted and underweight respectively. Children of mothers with higher education were 44% and 52% less likely to be wasted and underweight respectively. Children of underweight mothers were 26%, 42% and 15% more likely to be stunted, wasted and underweight respectively. Children of overweight mothers were 21%, 32% and 20% less likely to be stunted, wasted and underweight respectively. Generally the odds of a child being malnourished increased with the increasing breast feeding duration. Children with lower than usual birth interval were 19% and 13% more likely to be stunted and wasted respectively. Children from ethnic minority were more likely to be wasted and underweight respectively. The odds of being stunted increases with increasing wealth index. When all the factors were controlled, the association between all the three measures of childhood malnutrition, maternal health seeking behaviours, mother's occupation, and vaccination, number of under-five children, family type, and house held were not statistically significant.

When other factors were controlled for in the model, only community-level illiteracy rate remained statistically significantly associated with childhood malnutrition, all other factors became non-significant. For each one per cent increase in community illiteracy rate, the odds of a child being wasted (AOR 1.37; 95% CI 1.16 - 1.62) and underweight (AOR 1.50; 95% CI 1.19 - 1.88) increased by 37% and 50% respectively.

Table 2 Prevalence of Malnutrition among children aged 0-59 months in Nigeria.

Outcomes Variables

N (%)

Stunting

7322(25.6)

Underweight

2450(8.6)

Wasting

5446(23.6)

Table 3 Prevalence of under-nutrition types at various levels of explanatory variables

Characteristics/variables and

their values

Stunting

(N (%))

Underweight

(N (%))

Wasting

(N (%))

Child factors

Age of child in months

0-11

820(14.2)

538(9.3)

652(11.3)

12-23

1819 (37.0)

612 (12.4)

1395(28.4)

24-35

1584(35.0)

472 (10.4)

1256(27.7)

36-47

1631(33.9)

439(9.1)

1099(22.8)

48-59

1468(33.9)

389(9.0)

1044(24.1)

Sex of the child

Male

3866(26.5)

1268(8.7)

2646(18.8)

Female

3456(24.6)

1182(8.4)

2800(19.2)

Birth order

One

4590(24.9)

1489(8.1)

3260(17.7)

≥Two

2732(26.7)

961(9.4)

2186(21.4)

Child of multiple births

Single birth

7058(25.5)

2363(8.5)

5238(18.9)

Twin or higher order

264(27.4)

87(9.0)

208(21.6)

Birth weight (grams)

<2500g

1210(28.5)

430(10.1)

1013(23.9)

≥2500g

6000(25.3)

1991(8.4)

4359(18.4)

Maternal factors

Mother's age in years

15-24

1867(25.8)

631(8.7)

1408(19.4)

25-34

3617(25.6)

1185(8.4)

2608(18.5)

35-49

1838(25.2)

634(8.7)

1430(19.6)

Educational levels

No formal education

4287(29.7)

1615(11.2)

3544(24.6)

Primary

1681(25.7)

442(6.8)

1107(16.9)

Secondary

1181(18.6)

342(5.4)

701(11.1)

Higher

173(12.9)

51(3.8)

94(7.0)

Breastfeeding duration in months

<6

357(7.6)

242(3.0)

188(4.0)

6-12

1217(19.4)

518(10.6)

976(15.6)

13-24

5119(33.3)

1522(17.1)

3799(24.7)

>24

293(47.5)

50(15.2)

225(36.5)

Immunization

Incomplete

3805(30.5)

1241(10.0)

2809(22.5)

Complete

3517(21.7)

1209(7.5)

2637(16.3)

Maternal health seeking behaviour index in quantiles

5th quantile(Highest)

984(18.8)

282(5.4)

554(10.6)

4th quantile

1188(24.1)

353(7.2)

803(16.3)

3rd quantile

1536(27.0)

472(8.3)

1177(20.7)

2nd quantile

1446(28.9)

484(9.7)

1131(22.6)

1st quantile (Least)

1771(30.5)

721(12.4)

1504(25.9)

Mother's BMI (kg/m²)

<18.5

1129(34.0)

414(12.5)

1012(30.5)

18.5-24.9

5006(26.6)

1658(8.8)

3700(19.7)

≥25.0

1090(18.7)

349(6.0)

669(11.5)

Mother's occupation

Not working

2387(26.4)

861(9.5)

1807(20.0)

Manual

2370(23.7)

832(8.3)

1785(17.9)

White collar

2522(26.6)

747(7.9)

1827(19.3)

Birth Interval

≥24 months

5880(25.3)

1976(8.5)

4359(18.7)

<24 months

1442(26.8)

474(8.8)

1087(20.2)

Household and Socioeconomic factors

No of children under five

One

24(2.2)

7(0.6)

17(1.5)

Two

1660(22.8)

539(7.4)

1170(16.0)

Three

3049(27.5)

971(8.8)

2220(20.0)

≥Four

2589(28.3)

933(10.2)

2039(22.3)

Ethnicity

Ethnic Major

4319(25.7)

1720(10.2)

3525(20.9)

Ethnic Minor

2954(25.4)

715(6.1)

1880(16.2)

Types of family

Monogamous

4427(24.5)

1512(8.4)

3195(17.7)

Polygamous

2593(28.4)

841(9.2)

2036(22.3)

Head of household

Female

594(22.3)

160(6.0)

390(14.6)

Male

6728(25.9)

2290(8.8)

5056(19.5)

Wealth index

5th quintile (richest)

592(15.6)

230(6.0)

360(9.5)

4th quintile

1001(21.1)

316(6.7)

700(14.7)

3rd quintile

1454(25.9)

406(7.2)

1035(18.5)

2nd quintile

1993(29.0)

674(9.8)

1508(22.0)

1st quintile (poorest)

2282(30.0)

824(10.8)

1843(24.2)

Residence

Rural

5738(27.3)

1893(9.0)

4309(20.5)

Urban

1584(20.8)

557(7.3)

1137(14.9)

Regions

North Central

1336(26.5)

293(5.8)

797(15.8)

North East

1938(29.6)

758(12.0)

1658(25.3)

North West

2402(30.2)

909(11.4)

1984(25.0)

South East

327(13.4)

127(5.2)

228(9.3)

South South

611(18.4)

135(4.1)

340(10.2)

South West

Poverty rate

Low

High

Illiteracy rate

Low

High

Unemployment rate

Low

High

Proper sanitation

Yes

No

Safe water

Yes

No

708(21.3)

3156(21.9)

4166(29.3)

3031(21.1)

4291(30.1)

3436(23.9)

3886(27.2)

3553(24.7)

3769(26.4)

3286(22.9)

4036(28.2)

201(6.1)

970(6.7)

1480(10.4)

779(5.4)

1671(11.7)

1067(7.4)

1383(9.7)

1313(9.1)

1137(8.0)

1175(8.2)

1275(8.9)

439(13.2)

2112(14.6)

3334(23.4)

1807(12.6)

3639(25.5)

2447(17.0)

2999(21.0)

2767(19.2)

2679(18.8)

2419(16.9)

3027(21.2)

N-number of children; %-proportion (percentage)

Table 4 Univariate analysis showing association of Malnutrition with Predictor Variables

Characteristics/variables and

their values

Stunting

OR(CI)

Underweight

OR(CI)

Wasting

(CI)

Child factors

Age of child in months

0-11

1.00

1.00

1.00

12-23

3.54(3.22-3.89)***

1.38(1.22-1.56)***

3.10(2.80-3.44)***

24-35

3.25(2.95-3.57)***

1.13(0.99-1.29)

3.01(2.71-3.34)***

36-47

3.09(2.81-3.40)***

0.98(0.86-1.11)

2.32(2.09-2.58)***

48-59

3.09(2.81-3.41)***

0.96(0.84-1.10)

2.49(2.24-2.77)***

Sex of the child

Female

1.00

1.00

1.00

Male

1.10(1.05-1.16)***

1.04(0.95-1.12)

1.02(0.96-1.08)

Birth order

One

1.00

1.00

1.00

≥Two

1.10(1.04-1.16)**

1.18(1.08-1.28)***

1.27(1.19-1.34)***

Breastfeeding duration in months

<6

1.00

1.00

1.00

6-12

2.95(2.60-3.34)***

1.67(1.43-1.95)***

4.45(3.79-5.23)***

13-24

6.11(5.46-6.84)***

2.04(1.77-2.34)***

7.92(6.82-9.21)***

>24

11.06(9.13-13.39)***

1.63(1.19-2.24)**

13.84(11.12-17.24)***

Immunization

Complete

1.00

1.00

1.00

Incomplete

1.58(1.50-1.67)***

1.37(1.26-1.49)***

1.50(1.41-1.59)***

Child of multiple births

Single birth

1.00

1.00

1.00

Twin or higher order

1.11(0.96-1.28)

1.07(0.85-1.33)

1.18(1.01-1.38)*

Birth weight (grams)

≥2500g

1.00

1.00

1.00

<2500g

1.08(1.01-1.56)*

1.04(0.94-1.16)

1.10(1.02-1.19)*

Maternal factors

Mother's age in years

15-24

1.00

1.00

1.00

25-34

0.99(0.93-1.06)

0.96(0.87-1.06)

0.94(0.88-1.01)

35-49

0.97(0.90-1.05)

1.00(0.89-1.12)

1.01(0.93-1.10)

Educational levels

No formal education

1.00

1.00

1.00

Primary

0.82(0.76-0.87)***

0.57(0.51-0.64)***

0.62(0.58-0.67)***

Secondary

0.54(0.50-0.58)***

0.45(0.40-0.51)***

0.38(0.35-0.42)***

Higher

0.35(0.29-0.41)***

0.31(0.24-0.42)***

0.23(0.19-0.29)***

Maternal health seeking behaviour index in quantiles

1st quantile(Least)

1.00

1.00

1.00

2nd quantile

0.93(0.85-1.00)

0.75(0.67-0.85)***

0.83(0.76-0.91)***

3rd quantile

0.84(0.78-0.92)***

0.64(0.57-0.72)***

0.75(0.66-0.82)***

4th quantile

0.73(0.67-0.79)***

0.55(0.48-0.62)***

0.56(0.54-0.61)***

5th quantile (Highest)

0.53(0.48-0.58)***

0.40(0.35-0.46)***

0.34(0.36-0.38)***

Mother's BMI (kg/m²)

<18.5

1.42(1.31-1.53)***

1.47(1.31-1.53)***

1.79(1.65-1.94)***

18.5-24.9

1.00

1.00

1.00

≥25.0

0.63(0.59-0.68)***

0.66(0.59-0.68)***

0.53(0.48-0.58)***

Mother's occupation

Not working

1.00

1.00

1.00

Manual

0.87(0.81-0.93)***

0.86(0.78-0.95)**

0.87(0.81-0.94)***

White collar

1.01(0.95-1.08)

0.81(0.73-0.90)***

0.96(0.89-1.03)

Birth Interval

≥ 24 months

1.00

1.00

1.00

<24 months

1.08(1.01-1.16)*

1.04(0.94-1.16)

1.10(1.02-1.19)*

Household and Socioeconomic factors

No of children under five

One

1.00

1.00

1.00

Two

13.38(8.90-20.13)***

12.62(5.97-26.67)***

12.33(7.61-19.99)***

Three

17.23(11.47-25.87)***

15.18(7.20-32.01)***

16.15(9.98-26.14)***

≥Four

17.92(11.93-26.92)***

17.95(8.51-37.86)***

18.50(11.43-29.94)***

Ethnicity

Ethnic Major

1.00

1.00

1.00

Ethnic Minor

1.02(0.96-1.07)

1.74(1.59-1.90)***

1.38(1.29-1.46)***

Types of family

Monogamous

1.00

1.00

1.00

Polygamous

1.22(1.16-1.29)***

1.11(1.02-1.21)*

1.34(1.26-1.42)***

Head of household

Male

1.00

1.00

1.00

Female

0.82(0.75-0.90)***

0.66(0.56-0.78)***

0.71(0.63-0.79)***

Wealth index

5th quintile (richest)

1.00

1.00

1.00

4th quintile

1.45(1.30-1.62)***

1.11(0.93-1.32)

1.65(1.45-1.89)***

3rd quintile

1.90(1.71-2.11)***

1.21(1.03-1.44)*

2.17(1.91-2.46)***

2nd quintile

2.22(2.00-2.46)***

1.69(1.45-1.98)***

2.69(2.38-3.05)***

1st quintile (poorest)

2.33(2.11-2.58)***

1.89(1.63-2.20)***

3.06(2.72-3.46)***

Residence

Urban

1.00

1.00

1.00

Rural

1.43(1.34-1.52)***

1.25(1.14-1.38)***

1.47(1.37-1.58)***

Regions

North Central

1.00

1.00

1.00

North East

1.17(1.07-1.26)***

2.21(1.92-2.54)***

1.80(1.64-1.98)***

North West

1.20(1.11-1.30)***

2.10(1.83-2.40)***

1.77(1.62-1.94)***

South East

0.38(0.40-0.49)***

0.89(0.72-1.10)

0.55(0.47-0.64)***

South South

0.63(0.56-0.70)***

0.69(0.56-0.85)***

0.61(0.53-0.70)***

South West

Poverty rate

Low

High

Illiteracy rate

Low

High

Unemployment rate

Low

High

Proper sanitation

Yes

No

Safe water

Yes

No

0.75(0.68-0.84)***

1.00

1.48(1.40-1.56)***

1.00

1.60(1.53-1.70)***

1.00

1.19(1.13-1.26)***

1.00

1.10(1.04-1.15)**

1.00

1.32(1.25-1.40)***

1.05(0.87-1.26)

1.00

1.61(1.48-1.75)***

1.00

2.32(2.24-2.53)***

1.00

1.34(1.23-1.45)***

1.00

0.86(0.79-0.94)***

1.00

1.10(1.01-1.19)***

0.81(0.71-0.92)**

1.00

1.79(1.68-1.90)***

1.00

2.38(2.24-2.53)***

1.00

1.30(1.22-1.38)***

1.00

0.97(0.92-1.03

1.00

1.32(1.25-1.40)***

OR-odds ratio; CI- Confidence Interval; BMI-Body Mass Index

*, p<0.05; **, p<0.005; ***, p<0.001

Table 5: Factors associated with childhood malnutrition identified by multilevel logistic regression, Nigeria 2008

Stunting

Wasting

Underweight

Covariates

AOR

95% CI

P-value

AOR

95% CI

P-value

AOR

95% CI

Child's age

0-11

1.00

1.00

1.00

12-23

2.37

(2.04 -2.74)

<0.001

1.98

(1.68-2.34)

<0.001

1.05

(0.85-1.30)

24-35

2.12

(1.82-2.47)

<0.001

1.91

(1.60-2.27)

<0.001

0.87

(0.70-1.09)

36-47

2.08

(1.78- 2.42)

<0.001

1.43

(1.20-1.71)

<0.001

0.71

(0.57-0.90)

48-59

2.04

(1.74 -2.38)

<0.001

1.55

(1.29-1.85)

<0.001

0.71

(0.57-0.90)

Male (vs. female)

1.18

(1.10-1.26)

<0.001

1.07

(1.00-1.15)

0.054

1.04

(0.95-1.15)

High birth order

0.99

(0.92-1.06)

0.802

1.10

(1.02-1.19)

0.014

1.03

(0.92-1.14)

Multiple birth

1.87

(1.52-2.31)

<0.001

2.03

(1.62-2.54)

<0.001

1.55

(1.14-2.10)

Birth weight

1.21

(1.10-1.33)

<0.001

1.38

(1.25-1.53)

<0.001

1.18

(1.03-1.34)

Mother education

No education*

1.00

1.00

1.00

Primary

1.09

(0.98-1.20)

0.104

0.98

(0.88-1.10)

0.748

0.91

(0.78-1.07)

Secondary

0.95

(0.84-1.08)

0.472

0.84

(0.72-0.97)

0.019

0.77

(0.63-0.95)

Higher

0.81

(0.64-1.02)

0.071

0.56

(0.42-0.76)

<0.001

0.48

(0.32-0.72)

Maternal Health seeking behaviour index

1st quantile (Least)*

1.00

1.00

1.00

2nd quantile

1.01

(0.91-1.12)

0.896

1.03

(0.92-1.15)

0.656

1.10

(0.95-1.27)

3rd quantile

0.96

(0.86-1.07)

0.416

0.98

(0.87-1.10)

0.692

0.97

(0.83-1.14)

4th quantile

0.94

(0.82-1.06)

0.314

0.94

(0.82-1.09)

0.431

1.08

(0.90-1.31)

5th quantile (Highest)

0.79

(0.68-0.91)

0.001

0.72

(0.61-0.85)

<0.001

0.83

(0.66-1.05)

Mother's BMI

Under weight

Normal*

1.26

1.00

(1.15-1.39)

<0.001

1.42

1.00

(1.28-1.57)

<0.001

1.15

1.00

(1.00-1.31)

Over weight

0.79

(0.72-0.86)

<0.001

0.68

(0.61-0.76)

<0.001

0.80

(0.69-0.92)

Mother's occupation

Not working*

1.00

1.00

1.00

White collar

1.02

(0.93-1.11)

0.652

1.06

(0.96-1.17)

0.244

0.99

(0.88-1.13)

Manual

1.03

(0.94-1.14)

0.475

1.08

(0.97-1.20)

0.153

1.01

(0.88-1.16)

Breast feeding

<6 months*

1.00

1.00

1.00

6-12 months

2.14

(1.83-2.49)

<0.001

4.06

(3.35-4.92)

<0.001

1.53

(1.26-1.85)

13-24 months

2.51

(2.11-2.99)

<0.001

4.40

(3.54-5.46)

<0.001

1.70

(1.33-2.16)

>24 months

3.49

(2.70-4.50)

<0.001

5.85

(4.36-7.86)

<0.001

1.30

(0.86-1.96)

Vaccination

1.03

(0.96-1.11)

0.385

1.00

(0.92-1.08)

0.927

1.06

(0.95-1.17)

Low birth interval

1.19

(1.09-1.30)

<0.001

1.13

(1.03-1.25)

0.009

1.10

(0.97-1.24)

Number of under-5

One*

1.00

1.00

1.00

Two

0.83

(0.49-1.40)

0.486

0.74

(0.40-1.36)

0.331

0.83

(0.36-1.90)

Three

0.84

(0.50-1.41)

0.498

0.78

(0.42-1.42)

0.412

0.79

(0.35-1.81)

≥Four

0.78

(0.46-1.31)

0.343

0.74

(0.40-1.36)

0.332

0.86

(0.38-1.98)

Ethnicity

0.99

(0.89-1.10)

0.860

1.29

(1.15-1.46)

<0.001

1.55

(1.32-1.82)

Family type

1.08

(1.00-1.17)

0.053

1.07

(0.98-1.16)

0.152

0.91

(0.81-1.03)

Household head

1.02

(0.89-1.16)

0.803

0.96

(0.82-1.12)

0.621

0.83

(0.66-1.04)

Wealth index

5th quintile (Richest)*

1.00

1.00

1.00

4th quintile

1.21

(1.04-1.41)

0.014

1.12

(0.93-1.34)

0.230

0.81

(0.64-1.03)

3rd quintile

1.49

(1.26-1.77)

<0.001

1.17

(0.96-1.43)

0.123

0.75

(0.58-0.98)

2nd quintile

1.54

(1.28-1.86)

<0.001

1.09

(0.88-1.36)

0.423

0.80

(0.60-1.06)

1st quintile (Poorest)

1.58

(1.29-1.93)

<0.001

1.13

(0.89-1.43)

0.309

0.74

(0.55-1.01)

Rural (vs. urban)

1.05

(0.92-1.19)

0.446

1.01

(0.87-1.18)

0.873

1.05

(0.85-1.28)

Region

North central*

1.00

1.00

1.00

North east

1.08

(0.92-1.26)

0.335

1.50

(1.25-1.80)

<0.001

1.74

(1.35-2.23)

North west

1.12

(0.95-1.32)

0.167

1.24

(1.03-1.51)

0.025

1.26

(0.97-1.64)

South east

0.50

(0.40-0.62)

<0.001

0.66

(0.51-0.85)

0.002

0.89

(0.63-1.26)

South south

0.69

(0.58-0.83)

<0.001

0.84

(0.68-1.04)

0.118

1.06

(0.78-1.44)

South west

0.93

(0.78-1.11)

0.419

0.94

(0.75-1.16)

0.546

0.95

(0.71-1.28)

Poverty rate

0.98

(0.86-1.12)

0.781

1.06

(0.90-1.24)

0.485

1.01

(0.81-1.25)

Illiteracy rate

1.02

(0.88-1.18)

0.774

1.37

(1.16-1.62)

<0.001

1.50

(1.19-1.88)

Unemployment rate

1.06

(0.95-1.17)

0.294

1.00

(0.89-1.13)

0.984

0.95

(0.81-1.11)

Proper sanitation

1.00

(0.90-1.11)

0.962

1.07

(0.95-1.22)

0.266

1.07

(0.91-1.26)

Safe water

1.06

(0.96-1.18)

0.248

0.98

(0.87-1.11)

0.748

0.88

(0.75-1.03)

AOR- Adjusted odds ratio; CI- Confidence Interval; BMI-Body Mass Index

MEASURES OF VARIATION

As shown in Table 6, empty model (the null model), there was a significant variation in the odds of childhood malnutrition (stunting [=0.282, p<0.001], wasting [=0.517, p<0.001], and underweight [=0.666, p<0.001]) across the communities. The intra-community correlation coefficient (ICC) indicated by the estimated intercept component variance, 5.4%, 9.5% and 11.9% of the variance in the stunting, wasting and underweight could be attributed to the community-level factors respectively. The variations in the childhood malnutrition across communities remained statistically significant, even after controlling for individual and community-level factors (Full Model). As determined by proportional change in variance, the full model account for about 45.0%, 57.1% and 43.4% in the odds of stunting, wasting and underweight across the communities respectively.

Table 6: Community variance: results of multilevel random intercept model (measures of variation)

Stunting

Wasting

Underweight

Empty model

Full model

Empty model

Full model

Empty model

Community-level

Variance (SE)

0.282 (0.025)

0.155 (0.020)

0.517 (0.042)

0.222 (0.027)

0.666 (0.062)

Explained variation (%)

reference

45.0

reference

57.1