Nutrition 103 104 (2022) 111786

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Nutrition
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Review article

Applied nutritional investigation spatial variation and determinants of

stunting among children aged less than 5 y in Ethiopia: A spatial and
multilevel analysis of Ethiopian Demographic and Health Survey 2019
Tadesse Tarik Tamir MSc *, Masresha Asmare Techane MSc, Melkamu Tilahun Dessie MSc,
Kendalem Asmare Atalell MSc
Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

A R T I C L E I N F O A B S T R A C T

Article History: Objectives: Stunting is a major global public health problem, associated with physical and cognitive impair-
Received 24 February 2022 ments. Spatial variations in childhood stunting were observed due to changes in contextual variables from
Received in revised form 17 May 2022 area to area, implying that geography is a crucial component in the development of strategies against child-
Accepted 17 June 2022
hood stunting. However, to our knowledge, there are no up-to-date studies on the distribution of childhood
stunting and its determinants in Ethiopia. Thus, the aim of this study was to investigate the spatial distribu-
Keywords:
tion and determinants of stunting among children aged <5 y in Ethiopia.
Spatial distribution
Methods: Geospatial and multilevel analysis of the Ethiopia Demographic and Health Survey 2019 data was
Stunting
Children aged <5 y
done to investigate the spatial distribution and determinants of stunting among children aged <5 y in Ethio-
Children pia. The analysis included 5753 weighted children aged <5. Spatial autocorrelations analysis was done to
Determinants, Ethiopia assess the spatial dependency of stunting. Hot spot and cluster outlier analysis was used to observe the spa-
tial clustering of stunting. Kriging interpolation was used to predict stunting in an unsampled area. A multi-
level logistic regression model was fitted to identify determinants of stunting. Adjusted odds ratio with 95%
confidence interval (CI) was calculated and variables having a P < 0.05 were declared statistically significant.
Result: The national prevalence of stunting was 36.81% (95% CI, 35.48% 38.15%), with significant spatial var-
iations across Ethiopia. Spatial clustering of stunting was detected in the northern, northwestern, northeast-
ern, and southwestern parts of Ethiopia. Age and sex of the child, birth interval, birth type, household wealth
status, maternal education, region, and community-level illiteracy were factors significantly associated with
stunting.
Conclusion: Stunting significantly varies across Ethiopia, with the highest prevalence in Northern Ethiopia.
Older age, poor family wealth, maternal illiteracy, and community illiteracy level were the significant deter-
minants of stunting in children aged <5 y in this study. Policymakers should design interventions to reduce
stunting among children aged <5 y through accessing education for women and applying economic empow-
erment strategies in the hot spot areas.
© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction
Stunting is the result of chronic and recurrent malnutrition and
refers to a child who is too short for his or her age, which leads to
the failure to grow both physically and cognitively [1]. Length and
height are the best predictors of chronic malnutrition/stunting [2].
Stunting is defined as length/height for age >2 SD below the
median reference of the population [2]. The effects of stunting are
*Corresponding author: Tel.: +251918743681.
E-mail address: tadestar140@gmail.com (T.T. Tamir).
devastating and can last a lifetime [1]. Stunting holds children back
from reaching their full physical and mental potential [3].
Globally in 2020, 149 million children under the age of 5 y were
estimated to be stunted, with a defined geographic variation across
different regions of the world [4,5]. The prevalence of stunting in
children under the age of 5 has decreased over the past 2 decades,
but it is still more common in South Asia and Sub-Saharan Africa
than elsewhere [6]. The 2019 Mini Ethiopian Demographic and
Health Survey reported that the prevalence of stunting in Ethiopia
was 37%, which indicates that stunting remains a major public
health problem in the country [7]. Many factors have significantly

https://doi.org/10.1016/j.nut.2022.111786
0899-9007/© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
2 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786
contributed to stunting in children aged <5 y such as having a lower
household income level, being male sex, ages of the child >12 mo
[8,9], nonexclusive breastfeeding [10], small size of the child at birth,
low maternal education, and being multiple births [9].
The World Health Organization (WHO) has a goal to reduce the
prevalence of stunting by 40% in 2025 [11]. The government of
Ethiopia has also decided to end child undernutrition, specifically
stunting, by 2030 with a commitment to the “Seqota” Declaration
[12], including the school feeding program [13]. However, the
magnitude is still high and triggers a search for several factors
related to the problem for planning targeted intervention.
Geographic differences in childhood stunting have been docu-
mented because of changes in contextual variables from one loca-
tion to the next, demonstrating that geography is an important
component in childhood stunting [14]. Understanding the level of
the specific spatial distribution of stunting by using the current
national data is important in planning and implementing geo-
graphically targeted and optimized nutritional interventions in
Ethiopia. Therefore, this study aimed to assess the spatial distribu-
tion and determinants of stunting among children aged <5 y in
Ethiopia.
Methods
Study setting
This study was conducted in Ethiopia to investigate the spatial variations and
determinants of stunting in the country. Ethiopia is in East Africa, with an esti-
mated surface area of 1.1 million square kilometers. The country had an estimated
total population of 115 million in 2020, which makes it the 12th and second-most
populous county globally and in Africa, respectively. In Ethiopia, about 16% of the
total population is children aged <5 y. More than 80% of the population resides in
rural areas, which are dependent on rain-fed agriculture, and 26% of the popula-
tion lives below the national poverty level. Ethiopia has a three-tier health system,
containing primary, secondary, and tertiary health care. Malnutrition is a major
public health problem in developing countries.
Data source
The data for the outcome variable (stunting), explanatory variables, and geo-
spatial data for this study were obtained from the Ethiopian Demographic and
Health Survey (EDHS) 2019, which was accessed in the Measure EDHS website
Fig. 1. Prevalence of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.
through a formal request. The EDHS survey used a two-stage stratified cluster
sampling. In the first stage, 305 clusters/enumeration areas (stratified to 93 urban
and 212 rural) were selected. In the second stage, a fixed number of 30 households
were selected. Women 15 to 49 y of age were interviewed and anthropometric
measurements were taken on children aged <5 y in the households.
Study variables
Outcome variable
The outcome variable for this study was stunting, which was dichotomized as
“yes = 1” for a child with length or height/age  2 Z score and “no = 0” for a child
with height/age > 2 Z score.
Explanatory variables
Two-level explanatory variables were considered due to the hierarchical
nature of the EDHS data. The first level (individual level) factors consist of sociode-
mographic and economic factors such as age, sex, type of birth, birth interval
(months), maternal educational status, and wealth index. The second level (com-
munity level) factors consist of the region, residence, community illiteracy level,
and community poverty level. The community illiteracy and community poverty
levels were aggregated from the individual-level factors; maternal educational
status and household wealth status (wealth index), respectively. Regarding the
analysis of aggregation, first, the individual variables were recategorized and cross
tabulations were done with the cluster variable by using Stata version 14 (Stata-
Corp, College Station, TX, USA). Next, the proportion of illiteracy and poverty was
computed using Microsoft Excel 2013. Then, the proportions from excel were
imported to Stata and combined with the original set of variables in Stata. Finally,
we categorized the proportion of illiteracy and poverty into levels.
Data management and analysis
The data for our analysis was extracted from the Kids Record (KR) data set.
After accessing the data from the Measure EDHS website, data extraction, data
weighting, data cleaning, and recoding were carried out. ArcGIS version 10.8 was
used for spatial analysis and Stata version 14 for nonspatial statistical analysis.
Sample weights were applied to compensate for the unequal probability of selec-
tion between the strata that have been geographically defined. A detailed explana-
tion of the weighting procedure can be found in the methodology of the EDHS final
report [EMDHS 2019].
Spatial analysis
The Global Moran’s index spatial autocorrelation was done to test whether
stunting was clustered, dispersed, or randomly distributed. Moran’s I value is
between 1 and 1, a positive Moran’s I value indicates the clustering of similar val-
ues and a negative value indicates the clustering of dissimilar values.
 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786 3

Fig. 2. Regional prevalence of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.

The Getis-Ord Gi* hot spot analysis is used to identify spatial clusters of high
values (hot spot) and a spatial cluster of low value (cold spot).
The purely spatial scan statistics using the Bernoulli model were fitted to
detect significant clusters through generating a circular window on the map. The
cases (i.e., stunted children), controls or non-cases (i.e., not stunted children), the
location ID, and coordinate files (latitude and longitude) were fitted in the Ber-
noulli model. For each SaTScan window, location (latitude and longitude) with its
radius, population, cases, log-likelihood ratio, relative risk (RR) and P-value will be
assigned. The circular window with a high log-likelihood ratio was the primary
window.
Ordinary kriging interpolation was used to estimate the prevalence of stunting
at unsampled locations in Ethiopia.
Determinants of stunting
individual- and community-level factors with the outcome variable separately.
Finally, in the final model, all the individual- and community-level factors were fit-
ted together with the outcome variable. The intracluster correlation coefficient
(ICC) was calculated to estimate the between-cluster variations. The model fitness
was checked using the deviance ( 2 log-likelihood). Adjusted odds ratio (OR) with
95% confidence interval (CI) was calculated and used as the measure of association.
Variables having P < 0.05 were declared statistically significant.
Result
Sociodemographic characteristics of respondents and study
population

A two-level random intercept model was fitted to identify individual and com-
munity-level factors associated with stunting among children under the age of 5 y.
In the first step, we fitted the null or empty two-level model, which is the model
with an intercept and community effect. In the second step, we fitted all the
This analysis included 5753 children aged <5 y. Slightly more
than half (51.61%) of the study participants were male children.
Regarding maternal education, 3149 mothers (54.74%) were not

Fig. 3. Spatial autocorrelation of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.
4 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786
Fig. 4. Hot spot analysis of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.
educated. More than three-fourths of participants (76.92%) were
rural residents (Table 1).
Prevalence of stunting among children aged <5 y in Ethiopia (EDHS
2019)
The overall weighted prevalence of stunting was 36.81% at 95% CI
(35.48% 38.15%) among children aged <5 y in Ethiopia (Fig. 1).The
highest prevalence of stunting was observed in Afar, Oromia, Southern
Nations, nationalities and peoples region and Tigray regions (Fig. 2).
Spatial analysis
Spatial autocorrelation
The spatial autocorrelation analysis showed a significant spatial
dependency of stunting across Ethiopia. The Global Moran’s I value
and Z score were 0.38 and 8.48, respectively with P < 0.001 (Fig. 3).
Hot spot analysis
The spatial hot spot analysis shows that spatial clustering of
stunting was detected in the northern, northwestern, northeast-
ern, and southwestern sections of Ethiopia (Fig. 4).
Spatial scan statistics analysis
The SaTScan analysis identified 104 significant clusters. The red
window in Figure 5 indicates the significant clusters. All the signifi-
cant clusters were primary (most likely) clusters. These most likely
clusters were located at 13.987653 n, 37.973904 E at 545.08 km
radius Tigray, Amhara, Afar, Benishangul and border of Oromia
regions of Ethiopia (Table 2 and Fig. 5).
Spatial interpolation
The spatial kriging interpolation shows that the highest pre-
dicted prevalence of stunting was observed in northern,
 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786 5

Fig. 5. Spatial SaTScan analysis of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.

northwestern, southwestern, and southeastern sections of Ethiopia
(Fig. 6).
Multilevel Analysis
Table 3 shows the multilevel binary logistic regression analysis
results; the age and sex of the child, birth interval, birth type,
household wealth status, maternal education, region and commu-
nity level of illiteracy were factors significantly associated with
stunting in the final model. The odds of stunting were higher for
children in the 6 to 11, 12 to 23, 24 to 35, 36 to 47, and 48 to 59 mo
age groups compared with children who were 0 to 5 mo old with
adjusted OR (aOR) of 1.53 (95% CI, 1.12 2.11), 2.93 (95% CI,
2.24 3.84), 4.63 (95% CI, 3.55 6.03), 3.82 (95% CI, 2.92 4.99), 3.43
(95% CI, 2.63 4.47), and 1.22 (95% CI, 1.08 1.38), respectively.
Male children were 1.22 times more likely to be stunted than
female children (aOR, 1.22; 95% CI, 1.08 1.38). Children born mul-
tiple had higher odds of stunting than those born single with an
aOR of 2.19 (95% CI, 1.46 3.29). The odds of stunting (aOR, 1.26;
95% CI, 1.07 1.48) was higher among children with a birth interval
of 24 mo than their counterparts. Children of mothers with no edu-
cation were 1.82 times (95% CI, 1.24 2.67) more likely to get
stunted than children of mothers with higher-level education.
Children aged <5 y living in a household in the poorest, poor, mid-
dle, and rich wealth quintiles were 1.69 (95% CI, 1.21 2.36), 1.64
(95% CI, 1.18 2.27), 1.90 (95% CI, 1.38 2.61), and 1.69 (95% CI,
1.25 2.27) times more likely to get stunted compared with chil-
dren living in a household in the richest wealth quintile.
The regions Tigray, Afar, Amhara, Oromia, Somali, SNNPR, and
Harari had higher odds of stunting with respective AOR of 3.85
6 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786

Table 1 Discussion
Sociodemographic characteristics of respondents and children aged <5 y in Ethio-
pia, Ethiopian Demographic and Health Survey 2019 (N = 5753)
The aim of this study was to assess spatial distribution and
Variables Category Frequency (n) Percent (%) determinants of stunting among children aged <5 y in Ethiopia
Age (mo) 0 5 618 10.74 using data from EDHS 2019. The result of this finding shows that
6 11 542 9.42 the national prevalence of stunting among children aged <5 y in
12 23 1068 18.56 Ethiopia was 36.81% at 95% CI (35.48% 38.15%). The finding of this
24 35 1172 20.37 study was consistent with a study in Rwanda 38% [15], the preva-
36 47 1131 19.66
48 59 1222 21.24
lence of stunting computed from EDHS 2016 was 38% [9]. This con-
Sex Male 2969 51.61 sistency may be due to the reason that all these studies were done
Female 2784 48.39 based on data from demographic and health survey. Additionally,
Type of birth Single 5586 97.10 Ethiopia and Rwanda are low-income countries (have a relatively
Multiple 167 2.90
similar socioeconomic status), which may be a possible reason
Birth interval (mo) <24 1091 18.96
24 4662 81.04 behind having an inline national prevalence of stunting.
Maternal education None 3149 54.74 Nonetheless, the prevalence of stunting in the present study
Primary 1823 31.69 was lower than the UNICEF report of stunting in Sub-Saharan
Secondary 480 8.34 Africa (40%) [16], prevalence pooled by systematic review and
Higher 301 5.23
Wealth index Middle Poorest 1964 34.14
meta-analysis of stunting among children aged <5 y in Ethiopia
Poorer 994 17.28 (42%) [17] 41.5% [18]. The discrepancy may be due to a methodo-
Richer 805 13.99 logical difference; the present study revealed the prevalence from
Richest 738 12.83 demographic and health survey data, but systematic review and
Residence Urban 1328 23.08
meta-analysis studies pooled different single prevalence studies
Rural 4425 76.92
Region Tigray 454 7.89 conducted at different times.
Afar 652 11.33 The prevalence of stunting in the present study was higher than
Amhara 511 8.88 a study done in China (20%) [19] and in Pakistan (21%) [20]. The
Oromia 719 12.50 possible reason for this discrepancy could be due to the differences
Somali 637 11.07
in the levels of socioeconomic status among the countries; Ethiopia
Benishangul 530 9.21
SNNPR 660 11.47 has lower socioeconomic status than Pakistan and China [21]. It
Gambela 450 7.82 may also be plausible that countries with a middle or high socio-
Harari 447 7.77 economic position have a potential of combating nutritional issues
Addis Ababa 291 5.06
like stunting by providing appropriate nutritional supply and vari-
Dire Dawa 402 6.99
Community illiteracy level Low 2921 50.77 ety to their population than low-income countries like Ethiopia
High 2832 49.23 [22].
Community poverty level Low 2936 51.03 The hot spot spatial analysis of this study identified spatial vari-
High 2817 48.97 ation of stunting at the cluster level. Similar to the previous study
SNNPR, Southern Nations Nationalities and Peoples Region. in Ethiopia [23], statistically significant hot spot areas of stunting
were more specific to the northern parts of the country; in Tigray,
Afar, Amhara, Benishangul, and the Northern border of Oromia
regions. The identified clusters may represent places where child-
(95% CI, 2.33 6.38), 1.76 (95% CI, 1.06 2.93), 2.21 (95% CI, hood stunting prevention and control interventions should be
1.33 3.67), 1.79 (95% CI, 1.07 2.99), 1.67 (95% CI, 1.01 2.76), given priority. Differential dietary intake, environmental varia-
and 1.98 (95% CI, 1.21, 3.26) compared with Addis Ababa. Chil- tions, socioeconomic, and cultural factors may all have a role in the
dren living in a community with a high level of illiteracy were increased prevalence of stunting in these areas [24].
1.36 (95% CI, 1.11 1.66) times more likely to develop stunting In multivariate multilevel logistic regression analysis age, sex,
compared with those living in a community with a low level of birth interval, birth type, wealth index, maternal education, region
illiteracy. of residence, and community level of illiteracy were found to

Table 2
Spatial scan statistics analysis of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019

Cluster Enumeration areas (cluster) detected Coordinates/Radius Population Cases RR LLR P- value

1 8, 1, 9, 6, 7, 22, 13, 12, 21, 11, 2, 14, 56, 10, 16, 4, 23, 1850 839 1.51 59.32 <0.0001
17, 5, 3, 15, 82, 83, 25, 84, 78, 20, 35, 36, 39, 24, 55,
85, 18, 27, 37, 38, 57, 19, 62, 58, 59, 61, 74, 54, 81,
75, 46, 29, 53, 60, 45, 44, 65, 70, 76, 165, 71, 63, 79,
51, 34, 162, 80, 64, 72, 66, 52, 33, 77, 163, 30, 73,
148, 159, 47, 48, 67, 166, 31, 158, 49, 161, 68, 160,
100, 164, 119, 26, 50, 32, 99, 43, 69, 167, 149, 168,
40, 150, 169, 156, 42, 98, 146
2 125 (9.532762 n, 34.455097 E) / 0 km 27 18 1.88 5.39 0.52
3 250, 248, 249, 255, 247 (9.227458 n, 42.199757 E) / 9.68 km 106 53 1.42 4.69 0.752
4 201 (7.051999 n, 35.653770 E) / 0 km 16 11 1.94 3.63 0.96
5 205 (7.903248 n, 38.362278 E) / 0 km 24 15 1.76 3.59 0.97
6 253 (9.347798 n, 42.124973 E) / 0 km 20 13 1.83 3.57 0.976
7 172, 188, 115, 89, 197, 182, 113, 186 (6.066850 n, 38.154182 E) / 79.87 km 187 84 1.27 3.56 0.976
LLR, log-likelihood ratio.
 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786 7

Fig. 6. Spatial interpolation of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019.

be significant factors of stunting among children aged <55 y in
Ethiopia.
The odds of stunting were higher for children in the of 6 to 11,
12 to 23, 24 to 35, 36 to 47, and 48 to 59 mo age groups compared
with those in 0 the 5 mo old group. This finding was consistent
with a previous study [25]. This demonstrated that starting other
foods along with breastfeeding a child after 6 mo of age, increases
the likelihood of taking polluted foods and minimizes the essential
safety provided by breast milk [25]. Additionally, as children
mature, a high percentage of parents in rural regions fail to achieve
their children’s optimal nutritional needs [26].
Male children are more likely than female children to be stunted.
This result was also reported by previous studies [8,23,27 29]. It
has been suggested that the faster growth with higher dietary
requirements in this stage of life among male children as well as the
hormonal and genetic factors are possible explanations for the sex-
ual variation on the development of stunting [8].
Coherent with previous studies [30,31], stunting was more
prevalent among children born with an interval of <2 y and birth
intervals of 2 y. Such an association between stunting and shorter
birth interval could be due to competition for food within a house-
hold and the mother may fail to take care of two babies together
within a limited household [30].
The odds of stunting were higher for children born as multiples
in comparison with children who were born as singletons. Another
study witnessed a similar result [32]. It was argued and may be
plausible that low birth weight and competition for nutritional
intake, which is common in children of multiple births, could trig-
ger them to stunting [8].
Regarding household wealth status as a significant predictor of
stunting, children belonging to households having the poorest
wealth status are more likely to develop stunting compared with
those in the richest group. This could be because children from
households having less income are more prone to growth failure
8 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786

Table 3
multilevel analysis of determinants of stunting among children aged <5 y in Ethiopia, Ethiopian Demographic and Health Survey 2019

Individual- and community-level factors Null model Model II aOR (95% CI) Model III aOR (95% CI) Model IV aOR (95% CI)

Age 0 5 1 1
6 11 1.52 (1.10 2.09) 1.53 (1.12 2.11)*
12 23 2.93 (2.23 3.84) 2.93 (2.24 3.84)*
24 35 4.61 (3.53 6.01) 4.63 (3.55 6.03)*
36 47 3.81 (2.91 4.97) 3.82 (2.92 4.99)*
48 59 3.42 (2.62 4.46) 3.43 (2.63 4.47)*
Sex Male 1.21 (1.06 1.36) 1.22 (1.08 1.38)*
Female 1 1
Type of birth Single 1 1
Multiple 2.15 (1.42 3.24) 2.19 (1.46 3.29)*
Birth interval (mo) <24 1.22 (1.04 1.43) 1.26 (1.07 1.48)*
24 1 1
Maternal educational status None 1.92 (1.30 2.84) 1.73 (1.17 2.55)*
Primary 1.88 (1.28 2.77) 1.82 (1.24 2.67)*
Secondary 1.18 (0.77 1.82) 1.18 (0.77 1.81)
Higher 1 1
House wealth status Poorest 2.04 (1.59 2.61) 1.69 (1.21 2.36)*
Poorer 1.98 (1.53 2.56) 1.64 (1.18 2.27)*
Middle 2.30 (1.77 2.98) 1.90 (1.38 2.61)*
Richer 1.91 (1.48 2.47) 1.69 (1.25 2.27)*
Richest 1 1
Region Tigray 4.22 (2.59 6.90) 3.85 (2.33 6.38)*
Afar 2.22 (1.35 3.64) 1.76 (1.06 2.93)*
Amhara 2.67 (1.64 4.36) 2.21 (1.33 3.67)*
Oromia 2.21 (1.37 3.56) 1.64 (0.99 2.692)
Somali 1.24 (0.74 2.05) 0.89 (0.53 1.51)
Benishangul 2. 34 (1.43 3.8) 1.79 (1.07 2.99)*
SNNPR 2.27 (1.40 3.68) 1.67 (1.01 2.76)*
Gambela 0.95 (0.57 1.60) 0.75 (0.44 1.29)
Harari 2.21 (1.36 3.59) 1.98 (1.21 3.26)*
Addis Ababa 1 1
Dire Dawa 1.42 (0.86 2.35) 1.31 (0.78 2.19)
Residence Urban 1 1
Rural 1.35 (1.06 1.71) 0.95 (0.73 1.26)
Community illiteracy level Low 1 1
High 1.45 (1.20 1.75) 1.36 (1.11 1.66)*
Community poverty level Low 1 1
High 1.23 (1.02 1.49) 1.14 (0.92 1.42)
ICC 0.11 (0.085 0.15) 0.08 (0.06 0.12) 0.04 (0.02 0.07) 0.04 (0.02 0.07)
Log-likelihood 3263.42 3095.05 3184.97 3044.04
Deviance 6526.84 6190.1 6369.94 6088.08
aOR, adjusted odds ratio; ICC, intracluster correlation coefficient; SNNPR, Southern Nations, Nationalities and Peoples Region,*
a*
p-value <0.05(significantly associated).

due to insufficient food intake and higher risk for infection as well
as difficulty accessing basic health care services [27].
In this study, maternal education was significantly associated
with stunting. This is consistent with other studies [8,27,33 35].
When compared with children born to mothers having a higher level
of education, children of mothers having primary or no education at
all are more likely to develop stunting. Previous studies support this
finding [36,37]. This might be due to mothers with higher education
having good nutritional knowledge and the ability to make better
decisions and healthier choices when caring for their children.
Additionally, the region was a significant predictor of stunting
in our study. This is consistent with a previously conducted study
[23]. Stunting was more likely prevalent in Tigray, Afar, Amhara,
Oromia, Somali, SNNPR, and Harari regions, using Addis Ababa as a
reference. This may be due to Addis Ababa being the country’s cap-
ital city and its citizens having more access to information about
how to feed their children.
According to the result of this finding, children living in a com-
munity with a high level of illiteracy have higher odds of develop-
ing stunting within the first 5 y of their life. This is supported by
another study [38]. This finding emphasizes the relevance of com-
munity education as an alternate technique for combating
childhood stunting and promoting healthy feeding behaviors for
young children. It was documented that illiteracy is one of the
three leading causes of childhood malnutrition, with poverty and
food insecurity being the other two [39]. Moreover, in comparison
to an uneducated society, educated communities are better
informed about optional child-care techniques, have better feeding
and child-care practices, use the health system, and have more
freedom to make decisions [40,41].
The use of multilevel logistic regression analysis, which was
able to identify other factors beyond individual-level factors that
would not have been identified using ordinary logistic regression
analysis, was one significant strength of this work. Another virtue
of this study was that it was a nationally representative popula-
tion-based study with a high response rate, providing good statisti-
cal power to infer the characteristics of the study population.
However, due to the cross-sectional nature of the data, no causal
inferences about individual and community-level factors that con-
tribute to childhood stunting could be formed. The present study
only showed the variation of stunting by area; future studies
should estimate the distribution of stunting through time. Another
limitation was the use of secondary data, which limited the ability
to include other variables in relation to stunting.
 T.T. Tamir et al. / Nutrition 103 104 (2022) 111786
Conclusion
The distribution of stunting among children aged <5 y in Ethio-
pia is no longer random, with the northern section of the country a
high hot spot area for stunting. Older age, poor family wealth,
maternal illiteracy, and community illiteracy level were the signifi-
cant determinants of stunting in children aged <5 y in this study.
Policymakers should design better educational, economic, and
financial strategies to increase food security and access to essential
nutritional interventions for children from uneducated families,
impoverished households, and northern portions of the country.
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