ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCE

SCHOOL OF PUBLIC HEALTH

SOCIOECONOMIC INEQUALITY IN CHILDHOOD

UNDERNUTRITION IN ETHIOPIA; A SECONDARY ANALYSIS
OF THE 2016 ETHIOPIAN DEMOGRAPHIC AND HEALTH
SURVEY

A THESIS SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES OF

ADDIS ABABA UNIVERSITY SCHOOL OF PUBLIC HEALTH IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS
OF SCIENCE IN HEALTH ECONOMICS

JUNE 2023

ADDIS ABABA, ETHIOPIA

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 ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

socioeconomic inequality in childhood undernutrition in Ethiopia; a

secondary analysis of the 2016 Ethiopia demographic and health survey
Investigator: Nebiyu Maseresha (BSc)

Advisors: Dr. Anagaw Derseh (Phd)

Mrs. Berhan Tasew (MPH)

A Thesis Submitted to the School of Graduate Studies of Addis Ababa University

School of Public Health in Partial Fulfillment of the Requirements for the Degree
of Masters in Science with Specialty in Health Economics

June, 2023

Addis Ababa, Ethiopia

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Acknowledgement

I would like to express my deepest gratitude to my advisors Dr. Anagaw Derseh & Mrs. Berhan
Tasew for their support and guidance during the whole Process of this proposal development.
Furthermore, I would like to thank Addis Ababa University School of public health for providing
favorable conditions for the thesis.

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 Table of Contents

Contents
Acknowledgement ....................................................................................................................... 3
Table of Contents ........................................................................................................................ 4
List of Tables............................................................................................................................... 6
List of Figures ............................................................................................................................. 7
Acronyms ....................................................................................................................................8
Abstract .......................................................................................................................................9
1. Introduction ....................................................................................................................... 10
1.1. Background ................................................................................................................. 10
1.2. Statement of the Problems ........................................................................................... 12
1.3. Significance of the Study ............................................................................................. 13
2. Literature Review .............................................................................................................. 14
2.1. Theoretical Literature .................................................................................................. 14
2.1.1. Definition of basic concepts ................................................................................. 14
2.1.2. Child Development and undernutrition ................................................................. 14
2.1.3. Global strategies to reduce Undernutrition ............................................................ 16
2.1.4. Strategies and programs to address undernutrition in Ethiopia .............................. 16
2.2. Empirical literature ...................................................................................................... 17
3. Objective ........................................................................................................................... 19
3.1. General Objective ........................................................................................................ 19
3.2. Specific Objectives ...................................................................................................... 19
4. Methods............................................................................................................................. 20
4.1. Study Area and Setting ................................................................................................ 20
4.2. Source Population ....................................................................................................... 20
4.3. Study Population ......................................................................................................... 20
4.4. Inclusion and exclusion ............................................................................................... 21
4.5. Study Design ............................................................................................................... 21
4.6. Sampling Procedure .................................................................................................... 21
4.7. Sample Size Estimation ............................................................................................... 22
4.8. Variables and Measurement......................................................................................... 22

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 4.9. Description of dependent and independent variables .................................................... 23
4.10. Measurement and analysis ....................................................................................... 24
4.11. Ethical Clearance ..................................................................................................... 27
4.12. Dissemination of Results ......................................................................................... 27
5. Result ................................................................................................................................ 28
5.1. Background characteristics .......................................................................................... 28
5.2. Inequality in children undernutrition ............................................................................ 33
6. Discussion ......................................................................................................................... 38
6.1. Strength and limitation ................................................................................................ 40
7. Conclusion and recommendation ....................................................................................... 41
8. References ......................................................................................................................... 42
Annex I ..................................................................................................................................... 47

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List of Tables

Table 1 Distribution of socio demographic characteristics among children in Ethiopia, EDHS

2016 .......................................................................................................................................... 28
Table 2 Weighted distribution of undernutrition (stunting, underweight and wasting) in Ethiopia
disaggregated by key socio-demographic characteristics of 2016 DHS ...................................... 31
Table 3Result of concentration Index for wealth status and undernutrition in Ethiopia EDHA
2016 .......................................................................................................................................... 35
Table 4 concentration Index by different sociodemographic characteristics of respondents in
Ethiopia EDHA 2016 ................................................................................................................ 36

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List of Figures

Figure 1: percentage of undernutrition of children under 5 years of age of 2016 EDHS.............. 30

Figure 2Concentration curve for level of wealth index based inequality in Stunting in Ethiopia,
DHS 2016 ................................................................................................................................. 33
Figure 3Concentration curve for level of wealth index based inequality in underweight in
Ethiopia, DHS 2016 .................................................................................................................. 34
Figure 4Concentration curve for level of wealth index based inequality in wasting in Ethiopia,
DHS 2016 ................................................................................................................................. 34

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Acronyms

CI Concentration Index
CSA Central Statistical Agency
EDHS Ethiopian Demographic and health Survey
MOH Ministry of Health
NNP National Nutrition Plan
SD Standard Deviation
SDG Sustainable Development Goal
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization

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Abstract

According to the income position of the country, the proportion of affected children varies. More
than two third of stunted children and almost three quarters of wasted children reside in lower-
middle income nations, where less than half of all children under the age of five lives. Ethiopia is
one of the nations that is most afflicted by child undernourishment and is not on pace to achieve
SDG target 2.2 by 2030.

The study used secondary data analyses of EDHS 2016 data sets in order to assess the
socioeconomic inequality in undernutrition and to explore the inequality by key socio-
demographic characteristics.

The background characteristics of the population were presented via tables and graphs and
descriptive statistics. Graphs were also used to depict the trend, and regional variance was also
discussed. Due to the two stage sampling procedure utilized in the EDHS data set, sample
weights were used in all analyses. The analysis made use of Stata version 16.
The three-stage inequality study for stunting, wasting, and underweight used the concentration
curves, CIs, and decomposition of the concentration index. Concentration indices were used to
explain the disparity in concentration curves after concentration curves for stunting, wasting, and
underweight were shown.
In order to investigate the elements that contributed to the socioeconomic inequality in
undernutrition, a socioeconomic decomposition analysis was lastly conducted.
Both the concentration curve and concentration index showed that the inequality in
undernutrition by Stunting (-0.147), underweight (-0.143) and wasting (-0.054), all this
indicating that undernutrition is more concentrated among the poorest than the better-off
households. This inequality varies between region and residence. Therefore, FDRE should work
to minimize this inequality and the variation among residence and regions.

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1. Introduction

1.1. Background

To guarantee correct organ development and optimal performance, the creation of a strong
immune system, and adequate mental growth and development, children’s must have adequate
nutrition in the early years of their life (1). A health population is necessary for both social and
economic development so that people can learn new skills and contribute to their society (2).
Particularly important are the first 1000 days, beginning at conception and lasting until the infant
is about two years old. Stunting, wasting and micronutrient deficiencies can result from
inadequate maternal nutrition before to conception and while the child is in the womb, the
absence of exclusive breast feeding for the first six months and the inability of caregivers to
provide a wide and nourishing range of first foods (3). The repercussions can have significant
and long lasting effects on children and their communities. Numerous detrimental effects of
undernutrition include increased permanent brain damage, diminished cognitive function, and
unfavorable effects on social development (4).
Child undernutrition continues to be a key public health problem in developing countries
including Ethiopia. According to UNICEF, WHO, World Bank Group Joint Child Malnutrition
Estimates, globally a total of 149.2 million children (22.0%) are stunted and 45.4 million (6.7 %)
wasted in 2020. Two out of five stunted children and more than one quarter of wasted children
lived in Africa. When we see the trend of stunting at the global level, its reduced from 32.4% in
2000 to 22.0% in 2020. Even if, the percentage is declining, the number of stunted children is
risen in Africa, which was from 49.7 million in 2000 to 61.4 million in 2020 (5). In Ethiopia, the
trend of stunting shows that 51% (In 2005) to 37% (in 2019); the wasting is from 33% (in 2005)
to 21(in 2019) and underweight from 12% (2005) to 7 %( 2019) (6).
The UN Sustainable Development Goals (SDGs) cast nutrition as the central input and outcome,
building on the global nutrition targets set by the world health Assembly. Sustainable
Development Goal 2 specifically calls on member state to “end hunger, achieve food security,
improve nutrition, and promote sustainable agriculture.” In fact, nutrition related metrics are in
12 out of the 17 SDGS. The United Nations general assembly formally declared the decade of
action on nutrition (2016-2025), strengthening the global commitment to eradicating hunger and
avoiding all kinds of malnutrition (5). This announcement added to the global ambition. 163
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nations now have comprehensive or topic specific policies, strategies, and plans that are related
to nutrition, according to World Health Organization (7).
Ethiopia’s government has set a goal to eradicate undernutrition entirely by year 2030. As a
result, numerous techniques and programs were established to lower the level of undernutrition.
growth and transformation plan (GTP), National Nutrition Plan (NNP), the Seqota Declaration
(SD), National Food Security Strategy, Nutrition Sensitive agriculture (NSa) strategy, school
health and Nutrition Strategy (ShNS), the Productive Safety Net Program (PSNP), and Food
Safety and Quality related regulatory activities (FDRE Food and Nutrition Policy 2018) are few
strategies and programs. With the objective of eradicating hunger, achieving food security,
enhancing nutrition, and promoting sustainable agriculture by 2030, the Seqota Declaration
adopted Sustainable Development Goal 2 (SDG2). All of these have been developed in
cooperation with various nongovernmental organizations, including Micronutrient Initiatives
(MI), United Nations Children’s Fund (UNICEF), and Save the Children. However, according to
the Mini EDHS results, correspondingly 37%, 7%, and 21% of children under the age of five
were stunted, wasted, and underweight (8-10).
Therefore, this study will assess the trend and socio economic inequality in childhood nutrition in
Ethiopia using EDHS data.

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1.2. Statement of the Problems

Around 45% of all childhood deaths worldwide, which largely occur in low and middle income
nations, are attributed to the alarming undernutrition rate (11, 12).
To meet the goals of the sustainable development agenda and the world health assembly, which
calls for a reduction of childhood stunting of 40% by 2025 and by 50% by 2020, the global
progress made during the past two decades is insufficient. With the exception of low income
nations, the number of children with stunting decreased across all national income group of
concern. The number of stunted children also decreased across broad, with the exception of sab
Saharan African, where is rose by 7 million between 2000 and 2020 (5).
According to the income position of the country, the proportion of affected children varies. More
than two third of stunted children and almost three quarters of wasted children reside in lower-
middle income nations, where less than half of all children under the age of five lives. India is
contributing the big share of the globe stunting, 24 .2 % of world’s stunted under five children
live in India (5).
Ethiopia is one of the nations that is most afflicted by child undernourishment and is not on pace
to achieve SDG target 2.2 by 2030. According to the 2019 mini EDHS, 7% of children are
wasted, 21% of all children are underweight, and 37% of children under five are short for their
age or stunted (below -2 SD). In addition, 12%, 1%, and 6% of all children under the age of five,
respectively, are severely stunted, wasted, and underweight (6).
As well as accounting for around 35% of the disease burden among children the age of five and
11% of all global disability adjusted life years, it has both immediate and long term repercussions
that are crucial to children’s physical and intellectual development (13).
According to a social and economic impact research carried out in Ethiopia, undernutrition is
responsible for 28% of child mortality there and accounts for an 8% decrease in the labor force.
The projected yearly costs of child undernutrition in Ethiopia are 55.5 billion birr, or around
16.5% of GDP (14).
Few studies were conducted in analyzing the national representative data EDHS, their main focus
were to see the prevalence at regional prevalence and contributing factors and also their variation
(15-17). Whereas, the current study uses many determinant variables at the same time, which
will help to generalize the study findings at the national level and mainly focuses on the socio
economic inequality in undernutrition and to explore by key socio-demographic characteristics.
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1.3. Significance of the Study

It will be challenging to meet the worldwide target for reducing malnutrition by 2025 at current
rate of progress, notwithstanding the Ethiopian government’s efforts and advancements in this
area. The results of this study will be incorporated into the Ethiopian government’s strategy to
eradicate undernutrition by 2030.
Unlike previous studies, this study will use concentration index analyses specifically Erreygers
Normalized CI to explore the socioeconomic inequality by key socio-demographic factors in the
undernutrition. These could guide the design of equity sensitive health and nutrition programs
It also used as an input or reference for the future studies and nutritional programs

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2. Literature Review

2.1. Theoretical Literature

2.1.1. Definition of basic concepts

Malnutrition results when the body's needs for nutrients and its use of those nutrients are out of
balance. Malnutrition can take many different forms, and there are two main types:
undernutrition and over nutrition (20).
Undernutrition is characterized as a person consuming insufficient amounts of nutrients and
energy to meet their demands for maintaining good health (21). Suboptimal nutrition might
manifest as stunting, wasting, and underweight. Under 2 standard deviations from the median
height-for-age, weight-for-height, and weight-for-age, as assessed by the 2006 World Health
Organization (WHO) Child Growth Standards, respectively, cause stunting, wasting, and
underweight in children younger than 59 months (22).
A youngster that is too young for his or her height is considered to be stunting. These kids may
have significant, irreparable physical and cognitive harm as a result of their growth being
stunted. Stunting has terrible consequences that can last a lifetime and even harm future
generations (5).
A child who is too thin for his or her height is referred to as "wasting." The failure to gain weight
or recent fast weight loss is the causes of wasting. Although there are treatments available, a
youngster who is moderately or severely wasted has a higher risk of dying (5).

Low weight for age is referred to as underweight. It is known as the indicator for evaluating
changes in the severity of malnutrition over time and is a composite measure of stunting and
wasting (5).

2.1.2. Child Development and undernutrition

Healthy eating begins even before birth. During pregnancy and childbirth, the child is affected by
the mother's poor nutrition. Underweight and anemia in the mother raise the risk of preterm birth
and low birth weight, which in turn raises the risk of stunting and wasting in the newborn (23).

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Micronutrient requirements rise due to the fetus's growing needs; many pregnant mothers
struggle with concealed hunger or micronutrient deficits. Anemia can result from iron deficiency.
In actuality, nutritional anemia is more frequently caused by iron deficiency (24). Folate shields
the developing fetus from neural-tube abnormalities such spinal bifida (25). Preeclampsia and
preterm delivery are risk factors that calcium lowers (26). In particular during the third trimester,
vitamin A stimulates fetal development and immunological function. Finally, low birth weight,
poor fetal neural development, preterm delivery, and increased neonatal mortality are all linked
to mothers' zinc deficiency (27).
Malnutrition can have a negative impact on brain development during pregnancy and the early
years of children, influencing cognition, preparation for school, behavior, and productivity into
the school-age years and beyond. A child's lifetime of brain function can be established by giving
them the vital nutrients of glucose, protein, fatty acids, and micronutrients throughout this time.
A healthy child's ability to engage with their surroundings and caregivers can promote continued
brain growth (28).
Breastfeeding should be done exclusively for the first six months and then continue until the
child is two years old or older, according to UNICEF and WHO. For the child, breastfeeding has
several advantages, especially in the first hour of life. The initial milk a mother produces, called
colostrum, shields a baby's developing immune system from inflammation and infection. It is not
simply food; it is a potent medicine specifically formulated to meet the needs of the newborn that
can drastically lower the chance of mortality (3).
Although complementary foods should be introduced to infants around 6 months, only about 2/3
of infants who are 6 to 8 months old do so globally. But way too many start much early. In the
regions of Latin America and the Caribbean and East Asia and the Pacific, over 50% of
newborns 4-5 months old and 15% of infants 2-3 months old are already eating food (29).
Children benefit most from eating foods of animal origin, such as meat, fish, eggs, and dairy
products, starting at the age of six months. These foods are helpful in giving children the
important minerals and vitamins A, iron, zinc, and calcium that they require between the ages of
six and 23 months. ASF promotes development and physical activity while enhancing cognitive
function (3, 29). ASF is densely packed with a variety of necessary micronutrients and is ideal
for younger children's smaller stomachs. Early childhood stunting is also linked to low ASF

15
consumption. However, ASF, particularly eggs and dairy, are more expensive and consumed less
in low-income rural settings (3, 29).
From the time they are 2 to 4 years old, toddlers begin to make their own food choices and
frequently eat outside the home, exposing them to influences other than their parents and primary
caregivers (3).
In populations that experience chronic undernourishment, a malnutrition cycle exists, and during
this cycle, pregnant women's nutritional needs are not met. Therefore, babies born to these moms
are underweight at birth, unable to grow to their full potential and maybe stunted, making them
vulnerable to infections, illness, and early mortality. When low birth weight mothers develop into
malnourished children and adults and are more likely to deliver low birth weight babies as well,
the cycle is exacerbated (30).

2.1.3. Global strategies to reduce Undernutrition

The Sustainable Development Goals (SDGs) must be met in order to end hunger, achieve food
security, improve nutrition, support sustainable agriculture, guarantee healthy lives, and advance
well-being for all ages (SDGs 1–3), among other objectives. Malnutrition must decrease in order
to accomplish these objectives (31, 32).
Governments have pledged to the global targets to reduce chronic undernutrition (stunting) by
40% by 2025 and to reduce and maintain the prevalence of acute undernutrition (wasting) to less
than 5% in children under the age of five due to the impacts of childhood undernutrition (33).

2.1.4. Strategies and programs to address undernutrition in Ethiopia

As part of its national development plan, Ethiopia has a number of policies and programs in place
to lower the incidence of malnutrition. The National Nutrition Plan (NNP), the Seqota
Declaration (SD), the Growth and Transformation Plan (GTP), Nutrition Sensitive Agriculture
(NSa) Strategy, School Health and Nutrition Strategy (ShNS), Productive Safety Net Program
(PSNP), and Food Safety and Quality Related Regulatory Activities are a few of the major
strategies and programs (34). In order to end hunger, ensure food security, improve nutrition, and
support sustainable agriculture by 2030, the Seqota Declaration adopted Sustainable
Development Goal 2 (SDG2) (8).

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2.2. Empirical literature

In the absence of inescapable biological reasons, health inequality refers to a discrepancy in

some defined health outcome across groups that is perceived as unjust and undesirable. The most
significant causes of health disparities are racial or ethnic background, socioeconomic position,
gender, and place of residence (35, 36).

Studies, which examined a substantial body of literature and data from almost 100 low- and
middle-income countries, discovered that poor women and their children fared worse than those
from better-off families in terms of mortality and undernutrition (37–39).
Stunting and underweight are more prevalent in children from lower socioeconomic households
and those born to mothers with less education, according to the pooled data analysis of the
Bangladesh DHS that looked at socioeconomic disparities in stunting and underweight among
children under five among 14,602 children aged 0-59 months. Despite having low poverty rates,
the eastern regions saw bigger socioeconomic disparities than the western regions (40).
The prevalence of childhood undernutrition has decreased between 2004 and 2014, according to
another study carried out in Bangladesh using decomposition analysis from four rounds of the
Bangladesh Demographic Health Survey (BDHS) data. However, the rate of undernutrition is
higher among children of mothers who have less education, reside in rural areas, and come from
the lowest wealth quintile. Nearly half of the overall disparity in childhood stunting and
underweight frequency was caused by socioeconomic status, with maternal education coming in
second place among the causes (41).
According to a study done in India, between 1992–1993 and 2005–2006, undernutrition in
children decreased across household wealth quintiles and mother education levels. However,
compared to the least wealthy categories, the rate of decline is substantially faster among the
socioeconomically better off groups. In urban India, the socioeconomic inequality in childhood
undernutrition has increased over the research period, according to the results of pooled logistic
regression analysis (42).
In a study conducted in Iran, it was found that stunting was more common than underweight or
wasting. Inequality in stunting and underweight was statistically significant, and children in the
lower quintiles were more malnourished, according to the results of the concentration index at
the national level, as well as in rural and urban areas and in terms of children's sex. The

17
concentration index value of the wasting index was not statistically significant nor was it
sensitive to socioeconomic level (43).
Independent of the child's age, sex, birth order, length of breastfeeding, birth weight, mother's
age at childbirth, body mass index, education, and household access to safe drinking water and
hygienic toilet facilities, as well as residence and geographic region, the 2003 Ghana
Demographic and Health Survey study in Ghana found that children in the poorest 20% of
households are more than twice as likely to suffer from stunting as children in the richest 20% of
households. In addition, children in the middle and next poorest quintiles are significantly more
likely than children in the richest 20% of households to be chronically undernourished (44).
A concentration index analysis of the Nigeria Demographic and Health Survey (NDHS) from
2003 to 2013 revealed a rise in childhood stunting and underweight in Nigeria. Child age (0–23
months), mother education (no education), household wealth index (poorest family), type of
residence (rural), and geopolitical zone (North East, North West) were the socioeconomic factors
that contributed to the rise in child undernutrition (45).
In Ethiopia, a study on underweight using four EDHS from 2000, 2005, 2011, and 2016 revealed
that, after controlling for confounders, 41, 33, 29, and 24% of the sampled under-five children
were underweight, respectively. Children were more likely to be underweight in the 2016 EDHS
if they were male. Compared to children whose mothers were over 45, children whose mothers
were under 20 years old were more likely to be underweight. Compared to kids whose mothers
had higher education, those with no education or only a primary education were more likely to be
underweight (46).
According to a decomposition study on stunting performed on a nationally representative sample
of 8855 children under the age of 5 from the 2016 Ethiopian Demographic and Health Survey,
the prevalence of stunting overall was 38%, with a notable pro-poor socioeconomic imbalance.
Stunting affected 45.1% and 26.9% of the socioeconomically poorest and richest groups,
respectively. The primary factor, which alone accounted for 33% of the socioeconomic
difference in stunting, was the caregivers' educational status. This was followed by the
caregivers' region of residence (11%) and birth weight (6%). Stunting reduction efforts may be
accelerated by equity-sensitive initiatives that give vulnerable populations priority and work to
reduce socioeconomic inequality (47).

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3. Objective

3.1. General Objective

 To assess the socioeconomic inequality in childhood undernutrition in Ethiopia by using

decomposition Analysis of EDHS 2016.
3.2. Specific Objectives

 To assess the socioeconomic inequality in Stunting

 To Assess the socioeconomic inequality in underweight
 To assess the socioeconomic inequality in Wasting
 To explore the socioeconomic inequality by key socio-demographic factors

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4. Methods

4.1. Study Area and Setting

This study used the 2016 EDHS data sets to assess the socioeconomic inequality of childhood
undernutrition and its contributing factors. The government of Ethiopia is conducting the
demographic health survey with 5 years apart since 2000. The 2016 EDHS was implemented by
the Central Statistical Agency (CSA) under the aegis of the Ministry of Health (MOH). ICF
provided technical assistance through the DHS Program, which is funded by the United States
Agency for International Development (USAID) and offers support and technical assistance for
the implementation of population and health surveys in countries worldwide (48).
Ethiopia is a landlocked country located in Eastern Africa with a population of more than 110
million based upon the 2007 census projected population. It borders six countries Eritrea,
Djibouti, Somalia, Kenya, South Sudan and Sudan. The country occupies an area of 1.1 million
square kilometers ranging from 4600 m above sea level at Ras Dashen mountain to 148m below
sea level at Dankil (Dallol) depression (48,49).
Ethiopia is a federal parliamentary republic, the prime minster is serving as head of government.
Administratively, Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern
Nations Nationalities and Peoples (SNNP), Gambella, Harari, Addis Ababa, and Dire Dawa are
the nine administrative regions and two administrative cities that make up Ethiopia (49,50).

4.2. Source Population

All children under 5 years of age during the data collection of the survey were used as the source
population

4.3. Study Population

All children under five years of age and who are included in the sampled population of EDHS
2016.

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4.4. Inclusion and exclusion

Children’s with complete data set was included in the analyses, including anthropometric
measurements, their personal and household characteristics. But, if they miss the data for the
selected variables (weight and height of the child, sex and age of the child, and regarding the
maternal characteristics includes maternal age, education, and occupation and the household
characteristics includes place of residence, region and household assets/wealth status) were
excluded from the analyses.

4.5. Study Design

This study used Secondary analyses of cross-sectional data from the recent 2016 Ethiopia
Demographic and Health Surveys. The analysis included the data sets of 10,752 under five
children included in the EDHS 2016.

4.6. Sampling Procedure

The EDHS used stratified, two-stage cluster design, and the Enumeration Areas utilized in the
2007 Census served as the sampling units for the first stage of the stratified. The list of all
enumeration areas (EAs) produced for the 2007 PHC is contained in the census frame. An EA is
a region that typically has 181 households within it. Information regarding the EA location, the
type of dwelling (urban or rural), and the projected number of residential households are all
included in the sampling frame (48).
21 sampling strata were produced after stratifying each region into urban and rural areas. In two
steps, independent selections of EA samples were made in each strata. By classifying the
sampling frame within each sampling stratum prior to sample selection, in accordance with
administrative units at various levels, and by using a probability proportional to size selection at
the first stage of sampling, implicit stratification and proportional allocation were achieved at
each of the lower administrative levels (48).

21
The sample allocation was carried out using an equal allocation, with 25 EAs chosen from eight
regions, to ensure that survey precision is equivalent across regions. However, 35 EAs for each
of the three major regions—Amhara, Oromia, and SNNP—were chosen.
The second round of sampling was made up of households, and a certain number of houses per
cluster were chosen randomly from the newly constructed household listing, which is an
exhaustive list of all the households for the chosen EAs (48).
.
4.7. Sample Size Estimation

As was mentioned in the sampling design, there are two stages to the sampling process. At each
lower level of the administrative division, implicit stratification and proportional allocation were
achieved in the first stage by sorting the sampling frame within each sampling stratum prior to
sample selection and using the probability proportional to size selection. In the second stage, a
set number of households per cluster were chosen using equal probability systematic selection
from the newly constructed house hold listing.
Finally, a national representative sample of 18,060 households were selected for the EDHS
2016(48).

4.8. Variables and Measurement

Based upon the relevant literature reviewed, selected variables were used in order to assess the
inequality on childhood undernutrition and its contributing factors.

Outcome variables
Three well-respected anthropometric measures created by the World Health Organization
(WHO), including the height-for-age z-score (HAZ), weight-for-age z-score (WAZ), and weight-
for-height z-score (WHZ), were used to measure childhood undernutrition. In accordance with
the WHO child growth standard guidelines, z scores (HAZ, WAZ, and WHZ) will be computed
using survey data on child heights, weights, and ages. The difference between a person's
measurement and the reference population's median measurement for that person's age or height,
divided by the reference population's standard deviation, is known as the Z-score or standard
deviation (SD). Regardless of the indication chosen, the cut-off for Z-scores is -2 standard
deviation (SD) (22).
22
If a child's HAZ score is less than minus two (2) SD from the reference population's mean, the
child is considered stunted. Similar to WAZ, WHZs that are less than 2 SD will be regarded as
wasting and underweight, respectively.
.
Major explanatory variables
Different socioeconomic and maternal factors, such as stunting, wasting, and underweight, have
been linked to various forms of undernutrition, according to numerous research. The
decomposition analysis will take into account a variety of explanatory variables based on the
published research, including the age and sex of the children, the mother's age, education, access
to electronic media, place of residence, and socioeconomic status.
Like EDHS analysis, this study also uses the wealth index variable to measure the socioeconomic
status of households. It serves as an indicator of level of wealth that is consistent with
expenditure and income measures. The index will be created using principal components analysis
on household asset data and divides wealth into five quintiles at the national level: The poorest
households were placed in the lowest 20% quintile, followed by the poorest households in the
next 20% quintile, middleclass homes in the next 20% quintile, and lastly the richest and
wealthiest households in the top 40% quintile.

4.9. Description of dependent and independent variables

Stunting: A child is defined as stunted If child's height-for-age z-score is less -2 standard

deviations (SD) from the international median (WHO, 2006) healthy reference group.
Underweight: a child is Under-Weighted If child's weight-for-age z-score is less -2 standard
deviations (SD) from the international median (WHO, 2006) healthy reference
Wasting: a child defined wasted If child's weight-for-height z-score is less -2 standard deviations
(SD) from the international median (WHO, 2006) healthy reference group

23
Wealth Index: is used as a proxy to assess households' economic status and generated based on
the principal component analysis, was divided into five quintiles: poorest, poorer, middle, richer,
and richest
Place of residence: Urban and Rural (48).
Region: Ethiopia is divided into nine geographical regions and two administrative cities (48).
Maternal Education: educational status of the mother and classified in to Four, No formal
education, Primary, secondary and more than secondary (48)

Maternal occupational status: currently working or not (48)

Age of the mother: Below 20 years, 20-29, 30-39 and 40-49 years (48)

Child age: Divided in to childe less than 24 months and child from 24-59 month (48)

Sex of the child: Male or Female

4.10. Measurement and analysis

Descriptive statistics, frequencies and proportions were used to describe the background
characteristics of the study population and graphs and tables used to present.
Prevalence/percentage were used to see the trend and presented by graph and regional variation
and trend will also be presented and discussed. Due to the two-stage cluster sampling strategy
used in the EDHS dataset, sample weights were used in every analyses. The analysis was
conducted using Stata version 16.
For stunting, wasting, and underweight, the inequality analysis was completed in three steps:
plotting the concentration curves, reviewing the CIs, and deconstructing the concentration index.
Stunting, wasting, and underweight concentration curves were shown, and concentration indices
explained the disparity in the concentration curves. In order to further investigate the elements
that contributed to the socioeconomic discrepancy in undernutrition, a socioeconomic
decomposition analysis was also conducted.

Concentration curve
The distribution of diseases among the various socioeconomic categories is shown by the
concentration curve's pattern and magnitude of discriminations. As a result, the concentration
curve that was created would plot the cumulative proportion of undernutrition in children

24
(including stunting, wasting, and underweight) against the cumulative percentage of the
population from the poorest to the richest. The cumulative proportion of the samples'
socioeconomic status is shown against the cumulative proportion of the health outcomes
(stunting, wasting, and underweight) in the vertical axis.
The concentration curve will be above the equity line if undernutrition is more prevalent among
the poor. The concentration curve will, however, be below the equity line if the health
consequence (undernutrition) is more concentrated among the wealthy. However, malnutrition
will be evenly distributed throughout all socioeconomic groups when the concentration curve and
the equity line cross. There is complete equality in childhood malnutrition with regard to the
wealth index if the concentration curve perfectly equals the 45_straight line (19).

Concentration index
The area between the concentration curves and the equity line is doubled in the CI, which
summarizes the data present in each concentration curve. The distance between the concentration
curves and the equity line will be measured using CIs. The negative CI shows that undernutrition
is more prevalent among the lower socioeconomic strata and that the curve is over the 45_ line.
The value of concentration indices would be positive if the curves were below the equity line,
where malnutrition would be more prevalent among those in the upper socioeconomic strata.
Additionally, a score of 0 (zero) denotes complete equality, meaning that there is no
socioeconomic disparity for child undernutrition (19, 51).
The following formula for the concentration index will be used (19)

Where CI is the concentration index,

h is the childhood undernutrition, and
r is the fractional rank of the individual in the distribution
of wealth index,
μ is the mean of the child malnutrition variables, and
cov is the covariance.

25
The value of the CI lies between −1 and +1 (ie, −1 ≤ CI ≤ + 1), where −1 refers to the case where
malnutrition is fully concentrated among the poorest quintile, and +1 refers to the case where
malnutrition is fully concentrated among the richest quintile.

Decomposition of socioeconomic inequalities

Finally, the estimated CIs will be decomposed to realize the contribution of individual
socioeconomic characteristics in childhood undernutrition (52). The regression model for the
health outcome (y) to the set of k determinants (xk) can be expressed as follows:

Here, βk is the coefficient of xk, and ε is the error term. The concentration index of y denoted (C)
can be written as follows:

Here, μ is the mean of health outcome variable (y); xk is the mean of xk (kth determinant
variable); the concentration index of xk is denoted by Ck, and GCϵ is the generalized
concentration for the error term(ε). (βk xk)/ μ denotes the elasticity of the undernutrition with
respect to the explanatory variables. In other words, this quantity indicates the amount of change
in dependent variables (ie, height-for-age, weight-for-age, and weight-for-height) related to the
one-unit change in the explanatory variables. Decomposition analyses will be done for all of the
three measurements of undernutrition in the year of 2016 EDHS.

26
4.11. Ethical Clearance

After the proposal was reviewed and approved, the Addis Abeba University School of Public
Health's IRB issued the ethical clearance. To download and utilize the EDHS 2016 data on
socioeconomic inequality in children undernutrition in Ethiopia, a permission letter was obtained
from the Demographic and Health Surveys (DHS) online archive (Annex 1).

4.12. Dissemination of Results

The College of Health Sciences' school of public health will receive and review the study's final
report. The findings will be presented at scientific meetings and in peer-reviewed academic
publications. Informed policy decisions, planning, monitoring, and evaluation of programs on
child health in specific and general will be made using this information, at both the national and
regional levels.

27
5. Result

5.1. Background characteristics

The mean age was 28.64 (SD +17.66) months and more than half (51.28%) were males.
Regarding maternal background characteristics, more than half (65.85%) were had no education,
and 72.84% were not currently working.

Household characteristic of the study participants 88.93% were rural residents, and 43.86% were
from Oromia region. Regarding the wealth status, around half were below the middle group,
23.83 % poorest and 23.03% were of poorer.

Table 1 Distribution of socio demographic characteristics among children in Ethiopia, EDHS 2016

No Variable Weighted Percentage

1 Wealth Index
Poorest 23.87
poorer 23.03
Middle 20.81
Rich 17.81
Richest 14.48
2 Region
Tigray 6.66
Afar 0.99
Amhara 19.03
Oromia 43.86
Somali 4.49
Beninshangul 1.09
SNNPR 20.76
Gambella 0.23
Harari 0.23
Addis Ababa 2.23
Diredawa 0.42
3 Place of residence
Rural 11.07

28
 Urban 88.93
4 Maternal Educational Level
No Education 65.85
Primary 26.93
Secondary 4.78
Higher 2.44
5 Husband’s Educational Level
No Education 47.67
Primary 39.37
Secondary 7.82
Higher 4.42
Don’t know 0.72
6 Occupational status
Not Working 72.84
Working 27.16
7 Sex of the child
Male 51.28
Female 48.72
8 Age of child
Less than 6 month 11.78
6-11 10..48
12-23 19.6
24-35 18.51
36.-47 19.06
48-59 20.56
9 Maternal age in year
15-19 years 3.46
20-29 71.85
30-39 23.38
40-49 1.31

29
Totally A weighted sample of 8855, 9033 and 8919 were considered for stunting, underweight
and wasting analyses respectively and of them 38.39%, 23.73% and 10.09% of children were
stunted, underweight and wasted, respectively.

percentage of undernutrition percentage

45
40
35
30
25
20
15
10
5
0
stunting underweight wasting

Figure 1: percentage of undernutrition of children under 5 years of age of 2016 EDHS

the result of showed that the rate of undernutrition differs by some sociodemographic
characteristic like wealth status, region, residence and maternal education.

Regarding stunting, it is higher in Amhara (47.2%) and lower in Addis Ababa (14.7%) among
regions and higher among rural residents (39.9%). The prevalence in poorest wealth quantile is
45.1%) which is the highest from other groups. Mother’s with no education is also with 41.63%
highest rate of stunting.

As stunting, poorest wealth quantile group (31%) and rural residents (24.9%) holds higher
prevalence of underweight. The prevalence of stunting is higher in Afar (36.2%) and lower in
Addis Ababa (5.2%) among regions. When we see the educational and working status of
mothers, Underweight is higher among mother with no Education (27.4%) and currently not
working (24.2%).

Among the five wealth quantile groups, Wasting is higher among the poorest wealth quantile
group (14%) and lower among the richer group (7%). Somali (23.1%), Afar (18.2%) and
Gambella (14%) are the three top regions in the prevalence of wasting.

30
Table 2 Weighted distribution of undernutrition (stunting, underweight and wasting) in Ethiopia
disaggregated by key socio-demographic characteristics of 2016 DHS

No Variable Stunting underweight Wasting

no.(%) no.(%) no.(%)
1 Wealth Index
Poorest 921 (45.09) 653 (30.95) 290 (13.96)
poorer 895 (43.06) 579 (27.37) 205 (9.79)
Middle 703 (37.73) 437 (23.22) 195 (10.39)
Richer 559 (34.72) 282 (17.23) 112 (7.00)
Richest 322 (25.54) 192 (14.93) 98 (7.74)
2 Region
Tigray 233 (38.85) 138 (22.61) 69 (11.39)
Afar 34 (40.66) 31 (36.20) 16 (18.21)
Amhara 819 (47.17) 511 (29.10) 173 (9.98)
Oromia 1,407 (36.25) 892 (22.50) 415 (10.60)
Somali 99 (26.95) 106 (28.00) 87 (23.13)
Beninshangul 40 (42.83) 33 (34.47) 10 (10.81)
SNNPR 715 (39.12) 406 (21.67) 114 (6.23)
Gambella 5 (23.33 ) 4 (18.28) 3 (13.96)
Harari 6 (31.85) 4 (20.14) 2 (10.95)
Addis Ababa 29 (14.68) 10 (5.17) 7 (3.06)
Dire Dawa 14 (41.22 ) 10 (27.65) 3 (10.42)
3 Place of residence
Urban 253 (26.15) 138 (14.05) 90 (9.28)
Rural 3,146 (39.89) 2,006 (24.91) 810 (10.19)
4 Educational Level
No Education 2,420 (41.63) 1,627 (27.44) 637 (10.86)
Primary 854 (35.34) 447 (18.09) 217 (8.94)
Secondary 91 (21.40) 49 (11.31) 31 (7.35)
Higher 35 (17.42) 21 (10.47) 15 (7.45)
6 working status
Not Working 1,595 (24.17) 642 (9.86)
working 549 (22.55) 258 (10.72)

31
7 Sex of the child
Male 1,863 (41.23) 1,173 (25.32) 473 (10.33)
Female 1,536 (35.43) 970 (22.06) 428 (9.85)
8 Child Age in month
Less than 6 month 162 (16.110 131 (12.44) 149 (15.18)
6-11 163 (17.19) 149 (15.46) 130 (13.66)
12-23 722 (41.01) 426 (23.81) 226 (12.73)
24-35 804 (48.42) 445 (26.33) 156 (9.32)
36.-47 796 (47.00) 452 (26.28) 117 (6.80)
48-59 753 (42.06) 540 (29.74) 122 (6.72)
9 Maternal age
15-19 years 115 (38.91) 72 (23.28) 36 (12.31)
20-29 2,410 (37.64) 1,525 (23.40) 622 (9.65)
30-39 816 (39.96) 518 (24.77) 237 (11.49)
40-49 58 (51.33) 29 (25.27) 5 (4.28)

32
5.2. Inequality in children undernutrition

This study has utilized both the concentration curve and concentration index to assess the
socioeconomic inequality in undernutrition for the three indicators separately and decomposition
analyses to further see the factors which contributed for the inequality. All the three
concentration graphs showed that there is inequality as the concentration curve lies above the
line of equality. This indicates that undernutrition is more concentrated among the poor than the
better off (Fig .2,3 and 4).

Figure 2Concentration curve for level of wealth index based inequality in Stunting in Ethiopia, DHS
2016

33
Figure 3Concentration curve for level of wealth index based inequality in underweight in Ethiopia,
DHS 2016

Figure 4Concentration curve for level of wealth index based inequality in wasting in Ethiopia, DHS
2016

34
As all the three indicators are binary, the study used Erreygers [Link] and the result described
for each indicator below (Table 6). Like the concentration curve, the concentration index also
showed that children from poor households were more likely to be stunted, underweight or
wasted when compared to the children from the better-off household

Table 3Result of concentration Index for wealth status and undernutrition in Ethiopia EDHA 2016

Index No of Index value St. Error P-Value

observations
Erreygers Norm. CI 8855 -0.147 0.0118 <0.001
for Stunting
Erreygers Norm. CI 9033 -0.143 0.010 <0.001
for underweight
Erreygers Norm. CI 8919 -0.054 0.007 <0.001
for Wasting

The Inequality varies by different socio-demographic characteristics, Regarding Inequality in

stunting is higher in Dire Dawa and Lower in Afar among regions, Urban Residence is higher in
inequality in all forms of under nutrition when compared to Rural residence. Being currently
working also holds higher inequality in all forms of under nutrition.

Regarding Inequality in Underweight, It’s higher in Dire Dawa and lower in Addis Ababa.
Currently working and urban residence also holds higher Inequality when compared to their
counterparts.

Addis Ababa had higher Inequality in Wasting and Gambella is the lowest from other regions.
Urban residence when compared to the rural and currently not working compared to currently
working had higher Inequality in Wasting.

35
Table 4concentration Index by different sociodemographic characteristics of respondents in
Ethiopia EDHA 2016

No Variable CI in Stunting CI in underweight CI in Wasting

(SE) (SE) (SE)
1 Region
Tigray (Ref) -0.076 (0.036) -0.123 (0.031) -0.053 (0.023)
Afar -0.050 (0.039) -0.117 (0.037) -0.05689(0.030)
Amhara -0.150 (0.038) -0.130(0.034) -0.021 (0..023)
Oromia -0.164 (0.029) -0.130 (0.025) -0.013 (0.019)
Somali -0.114 (0.030) -0.125 (0.029) -0.053 (0.028)
Beninshangul -0.168 (0.041) -0.206 (0.039) -0.026 (0.026)
SNNPR -0.138 (0.033) -0.121 (0.028) -0.056 (0.016 )
Gambella -0.100 (0.041) -0.083 (0.037) -0.007(0.033)
Harari -0.182 (0.049) -0.204 (0.041) -0.093 (0.033)
Addis Ababa -0.135 (0.040) -0.069 (0.025) -0.112 (0.021)
Dire Dawa -0.340 (0.053) -0.300 (0.047) -0.045 (0.034)
3 Place of residence
Urban -0.317 (0.024) -0.163 (0.019) -0.08 (0.016)
Rural -0.096 (0.013) -0.125 (0.041) -0.05 (0.008)
4 Educational Level
No Education -0.087 (0.015) -0.105 (0.013) -0.052 (0.009)
Primary -0.142 (0.022) -0.107 (0.018) -0.049 (0.013)
Secondary -0.144 (0.037) -0.116 (0.029) 0.026 (0.024)
Higher -0.0410.049) -0.009 (0.039) -0.113 (0.033)
6 working status
Not Working -0.124 (0.014) -0.142 (0.012) -0.058 (0.008)
Working -0.221 (0.023) -0.145 (0.019) -0.051 (0.014)
7 Sex of the child
Male -0.137 (0.016) -0.139 (0.015) -0.056 (0.010
Female -0.156 (0.016) -0.147 (0.014) -0.050 (0.010)
8 Child Age in month
Less than 6 month 0.002 (0.028) -0.012 (0.023) -0.041 (0.027)

36
 6-11 -0.119 (0.028) -0.122 (0.026) -0.066 (0.025)
12-23 -0.175 (0.027) -0.166 (0.022) -0.086 (0.018)
24-35 -0.092 (0.028) -0.157 (0.024) -0.025 (0.016)
36.-47 -0.203 (0.028) -0.186(0.024) -0.044 (0.014)
48-59 -0.173 (0.027) -0.143 (0.025) -0.062 (0.013)
9 Maternal age
15-19 years -0.080 (0.063) -0.170 (0.053) -0.097 (0.042)
20-29 -0.157 (0.013) -0.153 (0.011) -0.065 (0.008)
30-39 -0.123 (0.025) -0.106 (0.021) -0.010 (0.016)
40-49 -0.105 (0.123) -0.183 (0.105) -0.047 (0.049)

37
6. Discussion

This study was conducted to examine the socio-economic inequality in undernutrition and its
contributing factors in Ethiopia by using EDHS 2016. First of all, all the three indicators of
undernutrition, stunting, underweight and wasting were assessed by using descriptive statistics
and then used concentration curve and concentration index to examine the inequality.

Based upon the finding, undernutrition is decreasing when compared to the previous two EDHS
results, EDHS 2005 and EDHS 2011, but still needs focus as there are a number of children are
still living with stunting, weighting and/or wasting. The prevalence of Stunting was reduced
from 51 in 2005 to 38 now (2016). Similarly, underweight and stunting were reduced from 33
and 12 (in 2005) to 24 and 10 respectively (53).

There is variation of prevalence among region, residence, maternal education and working status.
All the three indicators were having high prevalence among the poorest group of wealth index.
Which is almost similar with other studies conducted in Zimbabwe (54), Nigeria (45), India (32),
Iran (55), and in Bangladesh (40).

Regarding residence also, rural residence had higher rate of stunting, underweight and wasting.

Regarding region variation, Amhara (47.2), Benishangul (42.8%) and Dire Dawa (41.2%) were
the three higher rate of stunting among regions and Addis Ababa (14.7%) is the lower.
Underweight were scored higher in Afar (36.2%), Beninshangul (34.5%) and Amhara (29.10%).
Somali (23.1%) is leading in the prevalence of wasting followed by Afar (18.2%) and Gambella
(13.9%). Addis Ababa scored the least in all the three indicators of undernutrition, stunting
(14.7%), underweight (5.2%) and wasting (3.1%).

The concentration curve and concentration index showed that all the three indicators were more
concentrated among the lowest socioeconomic group. This finding is almost similar with a study
conducted in Zimbabwe (54), Nigeria (45), India (32), Iran (55), and in Bangladesh (40).

The socioeconomic inequality shows difference between regions. The inequality in Stunting and
underweight showed higher in DireDawa and lower in Afar and Addis Ababa in Stunting and
Underweight respectively. Regarding the inequality in Wasting, it is higher in Addis Ababa and
lower in Gambella.

38
Regarding residence, all inequality in all forms of undernutrition is higher in urban residence
when compared to their rural counterparts.

Occupational status is the other showed difference in inequality of undernutrition. Being

currently working holds higher inequality in Stunting and wasting. Whereas, mother’s currently
not working is higher in inequality in Wasting.

39
6.1. Strength and limitation

The strength of this study is Using EDHS data which have standardized data collection
procedures with good response rate and nationally representative. The study used recommended
Inequality analyses.

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40
7. Conclusion and recommendation

This study has showed that there is a socioeconomic inequality in all forms of undernutrition.
This inequality differs from region to region and urban to rural residence. So, the FDRE has to
give more emphases to reduce this inequality and attention has to be given for those regions with
higher rate of socioeconomic inequality.

41
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Annex I

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