Risk Factors of Standalone and Coexisting Forms of Undernutrition Among Children in Sub-Saharan Africa: A Study Using Data from 26 Country-Based Demographic and Health Surveys.

Introduction: Undernutrition in low- and middle-income countries (LMICs) remains a leading public health challenge. It accounts for one-third of the under-five mortality rate in sub-Saharan Africa (SSA). This study applied the composite index of anthropometric failure (CIAF) to assess the prevalence of various standalone and coexisting forms of undernutrition and identify associated risk factors.

Methods: Nationally representative demographic health survey (DHS) data from 26 SSA countries were used. A multilevel multinomial logistic regression analysis was conducted considering the hierarchical nature of DHS data and more than two categories of outcome variable. Four models were fitted and the model with the highest log-likelihood and lowest deviance was chosen as the best-fitted model. The adjusted relative risk ratio (aRRR) with its corresponding 95% confidence interval (CI) was presented as a measure of the effect.

Results: The overall prevalence of undernutrition among under-five children in SSA was 34.59% (95% CI: 34.35-34.82). Additionally, 20.49% (95% CI: 20.30-20.69) and 14.09% (95% CI: 13.92-14.26) of under-five children had standalone and coexisting undernutrition, respectively. The mother's educational level and household wealth status were the most significant shared drivers for standalone and coexisting undernutrition. On the other hand, child and health service factors were differentiating factors between standalone and coexisting undernutrition. Age of the child, sex of the child, type of birth, birth weight, adherence to age-appropriate feeding, antenatal care visit (ANC), place of delivery, and maternal educational status were the most significant determinants of various undernutrition forms in 0-23-month-old children. For 24-59-month-old children, age of the child, sex of the child, type of birth, household wealth status, and maternal education were identified as the main determinants of different forms of undernutrition.

Conclusions: Our analysis revealed that distal factors were shared risk factors among standalone and coexisting forms of undernutrition. However, proximal and intermediate factors varied in the type and strength of the association between standalone and coexisting undernutrition. This implies that holistic and category-specific strategies are needed to significantly reduce undernutrition among under-five children in SSA.