Risk factors of concurrent malnutrition among children in Ethiopia: a bivariate spatial modeling approach

Figures & data

Figure 1. Map of Ethiopia.

Table 1. Study variables.

Variable	Description	Summary
Dependent/Outcome variable
Stunting (HAZ)	Standardized Height-for-Age.	Continuous: $\mathbf{M}\mathbf{i}\mathbf{n}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=-5.98$, $\mathbf{M}\mathbf{e}\mathbf{d}\mathbf{i}\mathbf{a}\mathbf{n}=-1.45$, $\mathbf{M}\mathbf{a}\mathbf{x}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=5.98$
Underweight (WAZ)	Standardized Weight-for-Age.	Continuous: $\mathbf{M}\mathbf{i}\mathbf{n}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=-5.81$, $\mathbf{M}\mathbf{e}\mathbf{d}\mathbf{i}\mathbf{a}\mathbf{n}=-1.19$, $\mathbf{M}\mathbf{a}\mathbf{x}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=4.14$
Wasting (WHZ)	Standardized Weight-for-Height.	Continuous: $\mathbf{M}\mathbf{i}\mathbf{n}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=-4.97,\mathbf{M}\mathbf{e}\mathbf{d}\mathbf{i}\mathbf{a}\mathbf{n}=-0.57,\mathbf{M}\mathbf{a}\mathbf{x}\mathbf{i}\mathbf{m}\mathbf{u}\mathbf{m}=4.91$
Fixed Effect Covariate
Education	Mothers' highest education level.	Categorical: 0- No Education, 1- Primary, 2- Secondary, 3 - Higher
Wealth	Family wealth index.	Categorical: 0- Poorest, 1- Poorer, 2- Middle, 3- Rich, 4- Richer, 5- Richest
Settlement	Place of settlement.	Binary: 0- Rural, 1- Urban
Gender	Child's gender.	Binary: 0- Female, 1- Male
Water source	House holed water source.	Binary: 0- Unimproved System, 1- Improved System
Toilet type	House hold type of toilet system.	Binary: 0- Unimproved, 1- Improved
Presence of cough	Child have cough in the last two weeks.	Binary: 0- No, 1- Yes
Presence of diarrhea	Child have diarrhea in the last two weeks.	Binary: 0- No, 1- Yes
Presence of fever	Child have fever in the last two weeks.	Binary: 0- No, 1- Yes
Breastfed	Child is being breast fed.	Binary: 0- No, 1- Yes
Mass media	Parents or caregiver listens to radio, TV, or reads newspapers.	Binary: 0- No, 1- Yes
Random Effect Covariate
Child's age	The age of the child (in months) on the day of survey.	$\mathbf{M}\mathbf{i}\mathbf{n}=0,\mathbf{M}\mathbf{e}\mathbf{d}=28,\mathbf{M}\mathbf{a}\mathbf{x}=59$
Mother's age	The age of the mother or caregiver (in years) on the day of survey.	$\mathbf{M}\mathbf{i}\mathbf{n}=15,\mathbf{M}\mathbf{e}\mathbf{d}=28,\mathbf{M}\mathbf{a}\mathbf{x}=49$
Spatial Effect Covariate
Region	The region identity among the eleven regions of the country.	Categorical $\in \{1,2,3,\dots ,11\}$
Antenatal and Postnatal care visit	Frequency of child visits to antenatal/postnatal care	Categorical $\in \{0,1,2,\dots 12\}$
Contraceptive	Type of contraceptive used	Categorical: 0- No use, 1- Traditional, 2- Modern
Birth order	A child birth position in the household	Categorical: 1- First-born, 2- Second-born, 3- Third born,…, 14- Fourteen-born
Birth interval	Birth spacing: the interval between successive births	Categorical: 1- less than a year, 2- less than two years,…, 20-less than twenty years
Cluster	Cluster identification number	Numeric: $1,2,3,\dots ,635$

Table 2. The fixed effect estimates of the bivariate model.

	Stunting and Underweight				Stunting and Wasting				Underweight and Wasting
	mean	sd	2.50%	97.50%	mean	sd	2.50%	97.50%	mean	sd	2.50%	97.50%
Gender (Ref=Female)
Male*	−0.057	0.023	−0.103	−0.011	−0.066	0.025	−0.115	−0.016	−0.051	0.021	−0.092	−0.010
Highest Education Level (Ref=No Edu)
Primary*	0.113	0.031	0.051	0.174	0.082	0.034	0.016	0.148	0.077	0.028	0.022	0.132
Secondary*	0.325	0.064	0.201	0.450	0.204	0.068	0.070	0.338	0.117	0.056	0.006	0.227
Higher*	0.322	0.088	0.149	0.494	0.248	0.094	0.062	0.433	0.224	0.078	0.071	0.377
Household Wealth Index (Ref=Poorest)
Poorer	−0.021	0.036	−0.093	0.050	−0.007	0.039	−0.084	0.069	0.007	0.032	−0.056	0.071
Middle*	0.207	0.040	0.129	0.285	0.136	0.043	0.052	0.220	0.094	0.035	0.025	0.164
Rich*	0.276	0.044	0.190	0.361	0.201	0.047	0.109	0.293	0.169	0.039	0.093	0.245
Richest*	0.366	0.059	0.250	0.482	0.299	0.064	0.174	0.424	0.303	0.053	0.200	0.406
Improved Toilet System (Ref=No)
Yes*	0.299	0.072	0.158	0.439	0.213	0.077	0.062	0.364	0.170	0.064	0.046	0.295
No. of children under 5 (Ref=0 & 1)
2–3	−0.043	0.038	−0.118	0.032	−0.032	0.041	−0.113	0.048	−0.024	0.034	−0.091	0.042
>4	0.108	0.083	−0.054	0.270	0.039	0.089	−0.135	0.213	−0.025	0.073	−0.169	0.119
Birth order (Ref=1)
2–4*	−1.461	0.055	−1.569	−1.353	−1.091	0.057	−1.203	−0.978	−0.990	0.047	−1.083	−0.898
>5*	−1.568	0.054	−1.674	−1.463	−1.168	0.056	−1.278	−1.059	−1.056	0.046	−1.146	−0.966
Birth Interval (Ref < 2 years)
2-5 years*	0.146	0.030	0.088	0.204	0.107	0.032	0.045	0.169	0.082	0.026	0.030	0.134
>5years*	0.346	0.049	0.249	0.442	0.263	0.053	0.158	0.367	0.217	0.044	0.131	0.303
Antenatal and Postnatal care visit (Ref=0&1)
2–3	0.159*	0.037	0.086	0.233	0.089*	0.040	0.010	0.167	0.021	0.033	−0.044	0.086
>3	0.551*	0.115	0.325	0.776	0.310*	0.123	0.068	0.552	0.079	0.102	−0.122	0.279
Type of contraceptive used (Ref=N0)
Traditional	−0.043	0.181	−0.398	0.311	0.076	0.194	−0.305	0.457	0.194	0.161	−0.122	0.508
Modern*	0.115	0.031	0.054	0.175	0.089	0.033	0.024	0.153	0.085	0.027	0.032	0.139
Settlement (Ref=Rural)
Urban	−0.070	0.053	−0.173	0.034	−0.061	0.057	−0.172	0.050	−0.055	0.047	−0.147	0.037
Mass media(Ref=No)
Yes*	0.111	0.031	0.051	0.172	0.096	0.033	0.031	0.161	0.103	0.027	0.050	0.157
Presence of Diarrhea (Ref=No)
Yes*	−0.100	0.039	−0.177	−0.022	−0.096	0.042	−0.179	−0.013	−0.121	0.035	−0.190	−0.052
Presence of Fever (Ref=No)
Yes*	−0.105	0.042	−0.188	−0.023	−0.104	0.045	−0.193	−0.016	−0.130	0.037	−0.204	−0.057
Presence of Cough(Ref=No)
Yes	0.000	0.039	−0.077	0.077	0.001	0.042	−0.082	0.084	0.004	0.035	−0.064	0.072
Child Being Breatfed (Ref=No)
Yes*	−0.244	0.029	−0.301	−0.186	−0.173	0.031	−0.234	−0.111	−0.127	0.026	−0.178	−0.076

The reference category is denoted as Ref. The significant categories are indicated by *, identified by the noninclusion of zero in the credible interval. A significant lower posterior mean indicates the risk factor contributing relatively larger to the prevalence of malnutrition.

Figure 2. The probability of excess prevalence of (a) stunting in the presence of underweight, (b) wasting in the presence of stunting, (c) underweight in the presence of stunting, (d) stunting in the presence of wasting, (e) wasting in the presence of underweight, and (f) underweight in the presence of wasting. High probability value signifies strong evidence of malnutrition prevalence that exceeds the country's average prevalence, and consequently, increase in susceptibility of children in the region. (a) Stunting${}_{-\left(\mathrm{s}\mathrm{t}\mathrm{u}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{u}\mathrm{n}\mathrm{d}\mathrm{e}\mathrm{r}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\right)}$, (b) Wasting${}_{-\left(\mathrm{s}\mathrm{t}\mathrm{u}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{w}\mathrm{a}\mathrm{s}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\right)}$, (c) Underweight${}_{-\left(\mathrm{s}\mathrm{t}\mathrm{u}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{u}\mathrm{n}\mathrm{d}\mathrm{e}\mathrm{r}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\right)}$, (d) Stunting${}_{-\left(\mathrm{s}\mathrm{t}\mathrm{u}\mathrm{n}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{w}\mathrm{a}\mathrm{s}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\right)}$, (e) Wasting${}_{-\left(\mathrm{u}\mathrm{n}\mathrm{d}\mathrm{e}\mathrm{r}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{w}\mathrm{a}\mathrm{s}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\right)}$ and (f) Underweight${}_{-\left(\mathrm{u}\mathrm{n}\mathrm{d}\mathrm{e}\mathrm{r}\mathrm{w}\mathrm{e}\mathrm{i}\mathrm{g}\mathrm{h}\mathrm{t}\mathrm{a}\mathrm{n}\mathrm{d}\mathrm{w}\mathrm{a}\mathrm{s}\mathrm{t}\mathrm{i}\mathrm{n}\mathrm{g}\right)}$.

Table 3. Spatial effect estimated from the BCAR model.

	Joint model of Stunting and Underweight				Joint model of Stunting and Wasting				Joint model of Stunting and Underweight
	Stunting				Wasting				Underweight
Region	mean	sd	2.5%	97.5%	mean	sd	2.5%	97.5%	mean	sd	2.5%	97.5%
Addis Ababa	0.258*	0.092	0.078	0.438	−0.206*	0.098	−0.398	−0.014	0.253*	0.090	0.077	0.430
Afar	−0.165*	0.054	−0.271	−0.058	−0.196*	0.058	−0.310	−0.082	−0.284*	0.053	−0.388	−0.180
Amhara	−0.457*	0.051	−0.557	−0.357	0.162*	0.055	0.055	0.269	−0.198*	0.050	−0.296	−0.100
Beneshangul Gumuz	−0.356*	0.055	−0.464	−0.249	0.104	0.059	−0.011	0.219	−0.160*	0.054	−0.266	−0.054
Dire Dawa	0.021	0.073	−0.123	0.164	−0.373*	0.078	−0.527	−0.220	−0.169*	0.072	−0.310	−0.029
Gambela	0.391*	0.064	0.266	0.516	−0.174*	0.068	−0.308	−0.041	0.128*	0.063	0.005	0.251
Harari	0.114	0.070	−0.025	0.251	−0.136	0.075	−0.284	0.012	0.065	0.070	−0.072	0.201
Oromia	0.013	0.042	−0.069	0.095	0.357*	0.045	0.269	0.445	0.162*	0.040	0.083	0.241
SNNPR	−0.085	0.047	−0.176	0.007	0.518*	0.050	0.420	0.616	0.230*	0.046	0.139	0.320
Somali	0.573*	0.046	0.483	0.663	−0.149*	0.049	−0.246	−0.053	0.127*	0.045	0.038	0.216
Tigray	−0.307*	0.050	−0.406	−0.208	0.093	0.054	−0.013	0.199	−0.154*	0.050	−0.252	−0.057
	Joint model of Stunting and Wasting				Joint model of Underweight and Wasting				Joint model of Underweight and Wasting
	Stunting				Wasting				Underweight
Region	mean	sd	2.5%	97.5%	mean	sd	2.5%	97.5%	mean	sd	2.5%	97.5%
Addis Ababa	0.729*	0.097	0.538	0.921	−0.080	0.081	−0.239	0.080	0.848*	0.081	0.689	1.007
Afar	−0.251*	0.057	−0.364	−0.139	−0.214*	0.048	−0.309	−0.120	−0.399*	0.048	−0.493	−0.305
Amhara	−0.554*	0.054	−0.660	−0.448	0.131*	0.045	0.042	0.219	−0.325*	0.045	−0.413	−0.237
Beneshangul Gumuz	−0.428*	0.058	−0.543	−0.313	0.075	0.049	−0.020	0.170	−0.260*	0.048	−0.355	−0.166
Dire Dawa	0.172*	0.078	0.020	0.324	−0.357*	0.065	−0.484	−0.230	−0.019	0.064	−0.144	0.107
Gambela	0.429*	0.068	0.296	0.562	−0.149*	0.056	−0.260	−0.038	0.185*	0.056	0.076	0.295
Harari	0.264*	0.075	0.117	0.412	−0.096	0.062	−0.219	0.026	0.253*	0.062	0.131	0.375
Oromia	−0.157*	0.044	−0.243	−0.071	0.308*	0.037	0.236	0.381	−0.037	0.036	−0.108	0.035
SNNPR	−0.221*	0.050	−0.319	−0.123	0.479*	0.041	0.398	0.561	0.061	0.041	−0.020	0.141
Somali	0.409*	0.049	0.313	0.505	−0.170*	0.041	−0.250	−0.090	−0.051	0.040	−0.131	0.028
Tigray	−0.392*	0.054	−0.498	−0.287	0.072	0.045	−0.015	0.160	−0.257*	0.044	−0.344	−0.170

The spatial effects significantly different from zero are indicated by *, and identified by the noninclusion of zero in the credible interval. Relatively to the country's average prevalence, a lower posterior mean signifies the region with more aggravated prevalence of malnutrition.

Figure 3. The relative change in the prevalence of (a) stunting and underweight, (b) stunting and wasting, (c) wasting and underweight with respect to a child's age, and (d) stunting and underweight, (e) stunting and wasting, (f) wasting and underweight with respect to a mothers' age. A declining curve signifies increasing prevalence, and a rising curve signifies a lowering prevalence.

Figure A1. Cluster-specific random intercept of stunting and underweight in Ethiopia. The vertical bars are the credible intervals.

Figure A2. Cluster-specific random intercept of stunting and wasting in Ethiopia. The vertical bars are the credible intervals.

Figure A3. Cluster-specific random intercept of underweight and wasting in Ethiopia. The vertical bars are the credible intervals.

Figure A4. The relative change in the prevalence of stunting with respect to a child's age (a) and mothers' age (b), underweight with respect to a child's age (c) and mothers' age (d) and wasting with respect to a child's age (e) and mothers' age (f).

Figure A5. Prevalence of (a) stunting, (d) underweight, (g) wasting, the significance of (b) stunting (e) underweight, (h) wasting, and the probability of high prevalence of (c) stunting, (f) underweight, and (i) wasting. The black portions indicates regions with significant high prevalence and the white portion indicates significant lower prevalence region.

Table C1. Fixed effects estimates of the univariate model.

	Stunting			Underweight			Wasting
		Credible interval			Credible interval			Credible interval
	mean	0.025quant	0.975quant	mean	0.025quant	0.975quant	mean	0.025quant	0.975quant
(Intercept)	−1.617	−45.497	42.227	−1.394	−45.177	42.354	−0.652	−44.456	43.116
Education
No education	0.000
Primary education	0.117*	0.019	0.216	0.109*	0.037	0.182	0.046	−0.031	0.123
Secondary	0.422*	0.223	0.620	0.246*	0.099	0.393	−0.002	−0.157	0.154
Higher	0.348*	0.073	0.623	0.304*	0.101	0.507	0.161	−0.054	0.376
Wealth index
Poorest	0.000
Poorer	−0.039	−0.152	0.075	−0.002	−0.085	0.082	0.027	−0.062	0.116
Milddle	0.243*	0.118	0.368	0.168*	0.076	0.260	0.027	−0.071	0.124
Rich	0.303*	0.167	0.440	0.246*	0.145	0.346	0.098	−0.008	0.205
Richest	0.362*	0.177	0.547	0.370*	0.233	0.507	0.238*	0.093	0.383
Source of water
Unimprove	0.000
Improve	−0.109*	−0.193	−0.025	−0.076*	−0.138	−0.014	−0.009	−0.075	0.057
Toilet type
Unimprove	0.000
Improve	0.342*	0.118	0.566	0.261*	0.096	0.426	0.088	−0.087	0.263
Settlement
Rural	0.000
Urban	−0.067	−0.232	0.098	−0.060	−0.181	0.062	−0.047	−0.176	0.081
Mass media
No	0.000
Yes	0.102*	0.006	0.199	0.120*	0.048	0.191	0.090*	0.015	0.166
Gender
Female	0.000
Male	−0.071	−0.145	0.002	−0.041	−0.096	0.013	−0.058*	−0.116	−0.001
No of children under 5
$<2$	0.000
$2\mathrm{\&}3$	−0.049	−0.169	0.071	−0.034	−0.123	0.054	−0.011	−0.105	0.082
$>3$	0.177	−0.082	0.436	0.043	−0.148	0.235	−0.100	−0.303	0.102
Birth order
$<2$	0.000
2-4	0.051	−43.829	43.894	0.037	−43.747	43.784	0.018	−43.786	43.785
$>5$	−0.054	−43.933	43.789	−0.052	−43.835	43.695	−0.024	−43.827	43.743
No of children
<2years	0.000
2-5 years	0.171*	0.078	0.264	0.127*	0.059	0.196	0.041	−0.032	0.113
$>5$years	0.397*	0.242	0.551	0.310*	0.196	0.424	0.129*	0.008	0.249
Antenatal and Postnatal care visit
$<2$	0.000
2-3	0.227*	0.110	0.344	0.095*	0.009	0.182	−0.056	−0.147	0.035
$>3$	0.788*	0.428	1.148	0.340*	0.074	0.605	−0.173	−0.454	0.107
Contraceptive
No	0.000
Traditional	−0.159	−0.725	0.406	0.069	−0.349	0.487	0.341	−0.101	0.783
Modern	0.113*	0.016	0.209	0.105*	0.034	0.175	0.065	−0.010	0.140
Presence of diarrhea
No	0.000
Yes	−0.071	−0.195	0.052	−0.122*	−0.213	−0.030	−0.125*	−0.222	−0.029
Presence of Fever
No	0.000
Yes	−0.078	−0.209	0.054	−0.134*	−0.232	−0.037	−0.128*	−0.231	−0.025
Presence of cough
No	0.000
Yes	−0.005	−0.128	0.118	0.003	−0.087	0.094	0.003	−0.093	0.099
Breast feeding
No	0.000
Yes	−0.290*	−0.382	−0.199	−0.202*	−0.270	−0.135	−0.057	−0.129	0.014

The significant factors are indicated by *.