Introduction
Child undernutrition is a major public health problem in developing countries, including Bangladesh (Alom et al., Reference Alom, Quddus and Islam2012; Hasan et al., Reference Hasan, Soares Magalhaes, Williams and Mamun2016). Almost 45% of the 10–11 million under-5 children who die each year die from undernutrition (Pelletier & Frongillo, Reference Pelletier and Frongillo2003; Collins et al., Reference Collins, Dent, Binns, Bahwere, Sadler and Hallam2006; Das & Rahman, Reference Das and Rahman2011; Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013; Demissie & Worku, Reference Demissie and Worku2013; Rahman, Reference Rahman2015; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017). Consequently, undernutrition is considered the paramount leading cause of morbidity and mortality among under-5 children (Groenewold & Tilahun, Reference Groenewold and Tilahun1990; Rajaram et al., Reference Rajaram, Sunil and Zottarelli2003; Rahman & Chowdhury, Reference Rahman and Chowdhury2007; Amsalu & Tigabu, Reference Amsalu and Tigabu2008; Das & Rahman, Reference Das and Rahman2011; Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017). Its consequences are severe and wide-ranging, including an enduring negative impact on children’s physical and mental growth (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Das & Rahman, Reference Das and Rahman2011; Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013) and the poor development of children’s social skills (Pelletier & Frongillo, Reference Pelletier and Frongillo2003; Rahman et al., Reference Rahman, Chowdhury and Hossain2009). In addition, it has been found to be correlated with poor academic performance (Khanam et al., Reference Khanam, Nghiem and Rahman2011; Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013) and lower survival capacity during childhood (Pasricha & Biggs, Reference Pasricha and Biggs2010). Childhood undernutrition is also responsible for various chronic diseases and low productivity in adulthood (Pelletier & Frongillo, Reference Pelletier and Frongillo2003; Rahman et al., Reference Rahman, Chowdhury and Hossain2009).
Three anthropometric parameters are widely used to determine child nutritional status: height-for-age (stunting), weight-for-height (wasting) and weight-for-age (underweight) (Shetty, Reference Shetty2003; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017). Black et al. (Reference Black, Allen, Bhutta, Caulfield, De Onis and Ezzati2008) reported that of these, stunting and wasting are still global health concerns. Stunting is caused by chronic undernutrition, which encumbers the linear growth of the child, whereas acute undernutrition is the key cause of wasting, which is associated with recent weight loss or failure to gain weight (WHO, 2006). As a significant indicator of acute undernutrition, wasting is considered a better predictor of mortality among children during the first five years of life (WHO, 2006; Black et al., Reference Black, Allen, Bhutta, Caulfield, De Onis and Ezzati2008, Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013). For instance, children with severe acute undernutrition have been found to be almost nine times more likely to die than nourished children (UNICEF, 2009). In 1990, an estimated 58 million under-5 children were wasted, but in 2011 this number declined to 52 million (an 11% decrease) (de Onis et al., Reference de Onis, Brown, Blossner and Borghi2015). Although 8% of under-5 children were wasted globally in 2011, the average rate of wasting remained high in south–central Asia (15%) (de Onis et al., Reference de Onis, Brown, Blossner and Borghi2015). Black et al. (Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013) revealed that wasting accounts for 12.6% of total child deaths.
In 2017, globally almost 51 million under-5 children were wasted, and nearly 53% of these (27 million) were living in South Asia (UNICEF et al., 2018). Previous studies have established that maternal education (Phengxay et al., Reference Phengxay, Ali, Yagyu, Soulivanh, Kuroiwa and Ushijima2007; Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Demissie & Worku, Reference Demissie and Worku2013; Mishra et al., Reference Mishra, Kumar, Basu, Rai and Aneja2014; Olita’a et al., Reference Olita’a, Vince, Ripa and Tefuarani2014; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017), paternal education (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Olita’a et al., Reference Olita’a, Vince, Ripa and Tefuarani2014; Musa et al., Reference Musa, Muhammad, Lawal, Chowdhury and Hossain2017; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017), urban/rural place of residence (Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Rahman, Reference Rahman2015), sex (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Demissie & Worku, Reference Demissie and Worku2013; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017), age (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Alom et al., Reference Alom, Islam and Quddus2009; Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Aheto et al., Reference Aheto, Keegan, Taylor and Diggle2015; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Das & Gulshan, Reference Das and Gulshan2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017), measles vaccination (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017), fever (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Dabale & Sharma, Reference Dabale and Sharma2014; Ayana et al., Reference Ayana, Hailemariam and Melke2015; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017), maternal BMI (Rayhan & Khan, Reference Rayhan and Khan2006; Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Demissie & Worku, Reference Demissie and Worku2013; Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Rahman, Reference Rahman2015; Chowdhury et al., Reference Chowdhury, Rahman, Khan, Mondal, Rahman and Billah2016; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Das & Gulshan, Reference Das and Gulshan2017), birth weight (Rayhan & Khan, Reference Rayhan and Khan2006; Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Demissie & Worku, Reference Demissie and Worku2013; Rahman, Reference Rahman2015; Aheto et al., Reference Aheto, Keegan, Taylor and Diggle2015; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017), maternal age (Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Rahman, Reference Rahman2015), mass media exposure (Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Rahman, Reference Rahman2015) and household wealth status (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Habyarimana, Reference Habyarimana2016; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017) are significantly associated with acute undernutrition among under-5 children.
Despite commendable progress in reducing child and maternal mortality in accordance with the Millennium Development Goals (MDGs), child wasting remains a persistent problem in Bangladesh (Mohsena et al., Reference Mohsena, Goto and Mascie-Taylor2017). Recently, the World Bank found that Bangladesh has outperformed its neighbouring countries in Human Capital Index improvements and productivity. However, Bangladeshi children are endangered as a consequence of inadequate nutrition and lack of proper facilities (Musa et al., Reference Musa, Muhammad, Lawal, Chowdhury and Hossain2017; Munirul Islam et al., Reference Munirul Islam, Arafat, Connell, Mothabbir, McGrath and Berkley2019). Inadequate maternal and child nutrition is a prime public health problem in Bangladesh, and the reduction of child undernutrition through appropriate initiatives would be an important step towards reducing childhood morbidity and mortality in the country (Chowdhury et al., Reference Chowdhury, Banu, Chowdhury, Rubayet and Khatoon2011). This present study was undertaken to determine the factors relating to wasting of children in Bangladesh.
Methods
Data sources
The datasets used in the study were derived from Bangladesh Demographic and Health Survey (BDHS) 2014. This was a cross-sectional study, conducted by the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare of Bangladesh using a two-stage stratified sampling method (NIPORT et al., 2016). From the expected 18,000 households, 1,7863 ever-married women aged 15–49 were interviewed with a response rate of 98%. A total of 7886 under-5 children’s information was available in the BDHS 2014 dataset. Among the 7886 children, 755 subjects were excluded due to a huge number of missing cases and finally 7131 children were included in this study. The children’s information was collected from their mother.
Outcome variables
The outcome variable was wasting, measured by the weight-for-height (WHZ) Z-score, which is widely used to measure acute undernutrition. This was classified into three categories: adequately nourished (Z-score≥−2.0), moderately wasted (−3.0≤Z-score < −2.0) and severely wasted (Z-score < −3.0). The Z-scores were calculated from the ages, heights and weights of the children using WHO AnthroPlus Software version 3.2.2, 2011 (WHO, 2010).
Predictor variables
Based on an extensive literature review on acute undernutrition (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Rahman, Reference Rahman2015; Aheto et al., Reference Aheto, Keegan, Taylor and Diggle2015; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017; Das & Gulshan, Reference Das and Gulshan2017; van Cooten et al., Reference van Cooten, Bilal, Gebremedhin and Spigt2019), the considered covariates were: geographical division (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur and Sylhet); place of residence (urban, rural); sex (male, female); place of delivery (respondent’s home, other); child age (< 1 year, ≥1 year); respiratory illness (no, yes); size at birth (< average, ≥average); measles vaccination (no, yes); fever within 2 weeks of survey (no, yes); diarrhoea within 2 weeks of survey (no, yes); maternal age at first birth (< 20 years, ≥20 years); maternal BMI (≤18.50, 18.51–25.00 and >25.00 kg/m2); maternal and paternal education (none, primary, secondary and higher), maternal occupation (housewife, agricultural sector, non-agricultural sector and service sector); paternal occupation (agricultural sector, non-agricultural sector, business and service sector); wealth index (poor, middle, rich); source of drinking water (open source, piped and tube well); toilet facilities (no facilities, hanging toilet, pit toilet, flush toilet); number of under-5 children (1, 2, ≥3); and birth order (first birth, second, third or above).
Statistical analysis
Descriptive statistics were calculated to determine the frequency and percentage of the selected characteristics. Pearson’s Chi-squared test was applied to determine the relationship between acute undernutrition and the selected predictor risk factors. Multinomial multiple logistic regression analysis was conducted to identify the high risk factors for acute undernutrition. Significance was based on p< 0.05 and odds ratios (OR) and 95% confidence intervals (CIs). SPSS version 23.00 was used for the analysis.
Results
A total of 7131 under-5 children were selected to determine the risk factors associated with acute undernutrition. Table 1 shows the background characteristics of the under-5 children and the prevalence of moderate and severe wasting due to acute undernutrition. More than two-thirds (68.4%) of the children were from rural areas. More than a third (36.6%) were delivered at home and most (98.9%) were a single birth. Around one-fifth were less than 1 year old. Most of children were average or above-average size at birth. More than a quarter of the children had not received a measles vaccination. Almost 37% had suffered from recent fever and a few (5%) had suffered from diarrhoea. About 15% had respiratory problems at the time of the survey. A large percentage (73%) were born to mothers who had given birth to their first child before the age of 20 years. More than a quarter of mothers had a BMI of ≤18.5. Moreover, almost 15% of mothers and a quarter of fathers had never received any kind of formal education. Most of the mothers defined their work status as housewife, while a majority of the fathers were working in the service sector. More than 40% of households were categorized as poor. More than 60% of respondents were not exposed to television. Furthermore, most of the respondent households used a tube-well for their drinking water and more than 77% of families had pit toilets.
Table 1. Prevalence of moderate and severe wasting among under-5 children by background characteristics, Bangladesh, 2014
a p-value obtained from Chi-squared test.
Table 1 shows the prevalence of moderate and severe wasting by the selected characteristics of the under-5 children. It also shows that 11.1% of Bangladeshi children were moderately wasted and 4.6% were severely wasted in 2014. Overall, 15.7% were suffering from acute undernutrition. Apart from birth status, maternal age at first birth, paternal education and source of drinking water, all other covariates were significantly associated with wasting in under-5 children. The percentage of children with moderate wasting was the highest in Rajshahi (13.5%) whereas the rate of severe wasting was highest in Barisal division (6.2%). Moderate wasting was significantly higher in rural areas (12.2%) compared with urban areas (8.7%), but severe wasting was lower in rural than in urban children. Boys were more susceptible to both moderate and severe wasting (11.3% and 5.4% respectively) than girls (10.9% and 3.8% respectively). Children who were delivered at home had a higher likelihood of being moderately or severely wasted (11.7% and 5.6% respectively) compared with those who were not born at home. The prevalence of moderate and severe wasting was the highest among children aged below 1 year (12.1% and 7.5%, respectively).
Children who were smaller than average at birth had a higher likelihood of being moderately or severely wasted than other children. Both moderate and severe wasting rates were higher in children suffering from respiratory problems than their counterparts who were not. Fever was also shown to be related to higher moderate and severe wasting (12.7% and 5.0% respectively). Additionally, the prevalence of moderate and severe wasting was the highest (14.2% and 6.2%, respectively) among children suffering from diarrhoea. Compared with children who were not vaccinated for measles, vaccinated children had a lower percentage of both moderate and severe wasting. Children whose mothers had a low BMI (≤18.50) had the highest percentages of moderate and severe wasting (15.1% and 6.0% respectively) compared with those whose mothers had a BMI greater than 25.00 (6.7% and 3.9%, respectively). Children in poor families had a higher percentage of moderate and severe wasting than those in rich or middle-income families. The prevalence of moderate wasting decreased with an increase in maternal education. Also, the rate of severe wasting was higher in children whose fathers and mothers worked in the agricultural sector. Moderate and severe wasting were the highest (18.3% and 6.2% respectively) for children whose families did not have proper toilet facilities.
A multinomial multiple logistic regression analysis was performed to identify the high risk factors for acute undernutrition (Table 2). The children of Barisal, Chittagong, Rajshahi and Rangpur divisions had 1.57, 1.38, 1.64 and 1.33, respectively, times greater odds of being moderately wasted compared with children of Sylhet division. Also, the odds of being severely wasted were 2.11, 1.62 and 1.52 times higher among children in Barisal, Chittagong and Khulna divisions, respectively, than among those in Sylhet division. Furthermore, children from rural areas had 1.23 times greater odds of being moderately wasted than their urban counterparts. Boys possessed 1.48 times greater odds of becoming severely wasted than girls.
Table 2. Multinomial logistic regression analysis of moderate and severe wasting among under-5 children in Bangladesh, 2014
The analysis reference category was ‘nourished’.
Ref.: reference category; OR: Odds Ratio; CI: Confidence Interval.
Children who were smaller than average at birth were respectively 1.65 and 1.74 times more likely to be moderately and severely wasted compared with those who were average or larger than average at birth. Moreover, children who did not receive measles vaccinations were 1.58 times more likely to be severely wasted than their counterparts who did. In addition, children free of fever were almost 15% less likely to be moderately wasted than children who had a fever. The children of mothers with BMI ≤ 18.50 were 2.22 and 1.45 times more likely to be moderately and severely wasted than the children whose mothers have a BMI >25.00. The children of mothers with BMIs of 18.51–25.00 had a 1.58 times higher risk of becoming moderately wasted compared with those whose mothers with a BMI > 25.00 kg/m2. Also, the children of poor families were 1.51 times more vulnerable to being severely wasted than those of rich families (Table 2).
Discussion
The pattern of change in prevalence of overall wasting among under-5 children in Bangladesh over the period 2000 to 2014, using BDHS data, is shown in Figure 1. The percentage of acutely undernourished under-5 children increased from 10.0% in 2000 to 17.0% in 2007, and thereafter remained relatively constant at around 15–16%. This is a troubling indication of Bangladesh’s public health status, particularly for under-5 children.
Figure 1. Trends in overall prevalence of acutely malnourished children in Bangladesh, 2000–2014.
The present study was undertaken to investigate the determinants of undernutrition among under-5 children in Bangladesh using public domain survey data. The data used (BDHS-2014) pertained to both individuals and households. They therefore contain information on individual risk factors and those that stem from shared exposures. The explanatory variables found to be significantly associated with acute undernutrition were geographic division, urban/rural place of residence, sex of the child, place of delivery, child’s age, respiratory illness, size at birth, measles vaccination, fever, diarrhoea, maternal BMI, maternal education, paternal occupation, paternal occupation, wealth index of household and household toilet facilities. In the multivariate analysis, variables showing a significant association with moderate wasting were geographic division, urban/rural place of residence, size at birth, fever and maternal BMI, while those correlated with severe wasting were geographic division, sex of the child, size at birth, measles vaccination, maternal BMI and wealth index. The study also found that, overall, 15.7% of under-5 children in Bangladesh suffered from acute undernutrition in 2014. This proportion is very high compared with the global wasting rate of 8.0% (de Onis et al., Reference de Onis, Brown, Blossner and Borghi2015). Thus, acute child undernutrition is a serious problem for public health in Bangladesh.
The study explored some divisional differences in the nutritional status of children. Children living in Barisal and Chittagong divisions were found to be at higher risk of moderate and severe wasting than those living in Sylhet. Bangladesh region has been shown to be a significant determinant of wasting in previous studies (Chowdhury et al., Reference Chowdhury, Rahman, Khan, Mondal, Rahman and Billah2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Das & Gulshan, Reference Das and Gulshan2017). Furthermore, this study found that rural children had a higher risk of being wasted than those from urban areas, probably due to lower access to adequate education, poorer household socioeconomic circumstances, poorer quality medical facilities, lack of transportation and individuals’ poor knowledge about nutrition. This finding corroborates those of previous studies (Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Rahman, Reference Rahman2015; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Rahman & Rahman, Reference Rahman and Rahman2019). The study also found that sex of the child was an important indicator of wasting, with male children being at 1.48 times higher risk of suffering from severe acute undernutrition than female children. This finding is consistent with previous studies conducted in Bangladesh (Rabbi & Karmaker, Reference Rabbi and Karmaker2015), Ethopia (Demissie & Worku, Reference Demissie and Worku2013), Nigeria (Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017) and India (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012). Although traditionally male children received more attention from parents in Bangladesh, this situation has been changing recently. The Government of Bangladesh has implemented policies and programmes aimed at enhancing female education, with the provision of stipends and free education for female students and has encouraged female participation in every job sector. This has resulted in an upgrade of the economic conditions of women in Bangladesh, which has helped them participate in decision-making in almost all sectors where they are involved, especially within their own families. Consequently, parents now value the intelligence of their female children. Therefore, female children no longer face discrimination in attention, adequate food provision, care and support.
Child’s size at birth was a significant indicator of acute undernutrition. The results of this study suggest that children who were perceived to be of smaller than average size at birth had a higher risk of being wasted, which fits with the findings of previous research in Bangladesh (Rayhan & Khan, Reference Rayhan and Khan2006; Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Rahman, Reference Rahman2015), Nigeria (Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017), Ethiopia (Demissie & Worku, Reference Demissie and Worku2013) and Ghana (Aheto et al., Reference Aheto, Keegan, Taylor and Diggle2015). Since lower birth size is a salient predictor of wasting, reducing the factors influencing this, such as poor maternal nutritional and inadequate prenatal care, might lead to a reduction in the prevalence of wasting (Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013). In addition, acute undernutrition was more prevalent in the children who suffered from fever, which is also a result consistent with those of previous studies (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Dabale & Sharma, Reference Dabale and Sharma2014, Ayana et al., Reference Ayana, Hailemariam and Melke2015; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017). Ayana et al. (Reference Ayana, Hailemariam and Melke2015) demonstrated that febrile illness is positively correlated with reduced food intake and increased loss of fluids, which might lead to acute childhood undernutrition.
Black et al. (Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013) pointed out that children suffering from measles were more vulnerable to acute undernutrition and death. This study also found an increased risk of wasting among children who did not receive a measles vaccination, confirming previous research (Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Black et al., Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017). As measles is preventable with vaccination, the result implies that in addition to offering protection from the disease, measles vaccination can substantially reduce the proportion of wasted children.
A mother of good nutritional status is likely to have healthier babies (Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Torlesse & Aguayo, Reference Torlesse and Aguayo2018). Poor nutritional status was found to be a significant predictor for childhood acute malnutrition. Maternal nutritional status must therefore always be included in the formulation of child undernutrition policies and programmes. Black et al. (Reference Black, Victora, Walker, Bhutta, Christian and De Onis2013) found that, in Asia, the prevalence of low BMI (< 18.50) had decreased since 1980, but the rate was almost 10% higher than the worldwide average rate. This study observed that the prevalence of wasting in Bangladesh had increased as a consequence of the decline in mothers’ average BMI. Several similar studies have illustrated that low maternal BMI is related to acute undernutrition in children (Rayhan & Khan, Reference Rayhan and Khan2006; Rahman et al., Reference Rahman, Chowdhury and Hossain2009; Demissie & Worku, Reference Demissie and Worku2013; Rahman, Reference Rahman2015; Chowdhury et al., Reference Chowdhury, Rahman, Khan, Mondal, Rahman and Billah2016; Habyarimana, Reference Habyarimana2016; Akombi et al., Reference Akombi, Agho, Merom, Hall and Renzaho2017; Das & Gulshan, Reference Das and Gulshan2017). Das and Gulshan (Reference Das and Gulshan2017) found that the children of mothers with a BMI < 18.50 were at 2.14 times higher risk of being wasted than those of mothers with BMI > 25.50. Rayhan and Khan (Reference Rayhan and Khan2006) estimated that the children of mothers with a BMI > 18.50 were 40% less likely to be wasted than those of mothers with BMI < 18.50. Chowdhury et al. (Reference Chowdhury, Rahman, Khan, Mondal, Rahman and Billah2016) found similar results.
This study was designed to identify whether there was a relationship between mother’s education and the likeliness of children being wasted. The findings suggest that maternal education is not an underlying factor for wasting among under-5 children in the study context. This is consistent with the findings of some previous studies (Rayhan & Khan, Reference Rayhan and Khan2006; Souza et al., Reference Souza, Benício, Castro, Muniz and Cardoso2012; Alom et al., Reference Alom, Quddus and Islam2012; Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Mohsena et al., Reference Mohsena, Goto and Mascie-Taylor2017; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017; Musa et al., Reference Musa, Muhammad, Lawal, Chowdhury and Hossain2017) but inconsistent with others (Phengxay et al., Reference Phengxay, Ali, Yagyu, Soulivanh, Kuroiwa and Ushijima2007; Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Demissie & Worku, Reference Demissie and Worku2013; Mishra et al., Reference Mishra, Kumar, Basu, Rai and Aneja2014; Olita’a et al., Reference Olita’a, Vince, Ripa and Tefuarani2014; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017). Also, paternal education was not found to be a significant risk factor for acute undernutrition in children, which is consistent with some previous studies (Phengxay et al., Reference Phengxay, Ali, Yagyu, Soulivanh, Kuroiwa and Ushijima2007; Souza et al., Reference Souza, Benício, Castro, Muniz and Cardoso2012; Mishra et al., Reference Mishra, Kumar, Basu, Rai and Aneja2014; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017) but inconsistent with others (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Olita’a et al., Reference Olita’a, Vince, Ripa and Tefuarani2014; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017; Musa et al., Reference Musa, Muhammad, Lawal, Chowdhury and Hossain2017).
This study has also demonstrated that wealth index, as expected, plays a notable role in child undernutrition. This is consistent with previous research, which has found that the odds of being wasted are higher among the children of poor families than those of rich families (Meshram et al., Reference Meshram, Arlappa, Balakrishna, Rao, Laxmaiah and Brahmam2012; Rabbi & Karmaker, Reference Rabbi and Karmaker2015; Mishra et al., Reference Mishra, Kumar, Basu, Rai and Aneja2014; Fuchs et al., Reference Fuchs, Sultana, Ahmed and Hossain2014; Habyarimana, Reference Habyarimana2016; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017; Pravana et al., Reference Pravana, Piryani, Chaurasiya, Kawan, Thapa and Shrestha2017; Khan et al., Reference Khan, Ariff, Khan, Habib, Umer and Suhag2017). The results of this study have established that, in 2014, children from poor families were at about 1.50 times higher risk of being severely wasted than children from rich families. Lower economic status is undoubtedly related to some issues closely linked to wealth index that would enhance acute undernutrition among under-5 children, because inadequacy of wealth means inadequacy of basic amenities, such as education, health services, food and shelter (Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017). Diseases such as fever and diarrhoea frequently occur in poor families and lead to childhood undernutrition (Ortiz et al., Reference Ortiz, Van Camp, Wijaya, Donoso and Huybregts2014; Ambadekar & Zodpey, Reference Ambadekar and Zodpey2017). Ortiz et al. (Reference Ortiz, Van Camp, Wijaya, Donoso and Huybregts2014) and Musa et al. (Reference Musa, Muhammad, Lawal, Chowdhury and Hossain2017) have argued that poor access to health services can be related to acute undernutrition.
Study strengths and limitations
The main strength of this study is that the data were of national level. Given this, the findings will help the Bangladeshi authorities formulate appropriate national-level policies and programmes to reduce wasting among under-5 children. At the same time, it assessed divisional differences in child nutritional, so immediate action can be taken at a divisional level and where needs are most pressing. However, the study has its limitations. First, although this was a cross-sectional study, due to a lack of recent data it was not possible to compare the 2014 data with the prevailing situation in Bangladesh. Second, only certain covariates were considered. Third, there were missing values in some covariates, which might have affected the results. Finally, some relevant variables, such as breastfeeding practice and antenatal visits, were not included in the study.
Conclusions and policy implications
This study of acute undernutrition among under-5 children in Bangladesh offers insight into the broader state of child health in Bangladesh. Because nutritional status is considered a measure of quality of life and freedom from disease, although Bangladesh outperformed the relevant MDGs, the persistent widespread prevalence of child wasting is deeply troubling. To succeed in reducing acute child undernutrition, organized long-term and short-term efforts must be undertaken in the country. Interventions must target economic empowerment and short-term nutrition supplements for people of disadvantaged economic status. In addition, the government should collaborate with different international or national-level non-profit organizations to carry out programmes alongside ongoing government programmes. Furthermore, parents need better access to health information and education, and to this end community-based health service facilities should be promoted at the grassroots level.
This study puts forward some of the leading risk factors for acute child undernutrition in Bangladesh. Policies and programmes aimed at eradicating acute child undernutrition need to address these determinants. The findings of this research may be used to inform other countries where child undernutrition exists.
Acknowledgments
The authors wish to acknowledge to the authority of the National Institute of Population Research and Training (NIPORT), Bangladesh, for providing the data used in this study. They are also grateful to Dr Rebecca Kippen (Associate Professor, Demography in the School of Rural Health, Monash University, Australia) and Katie Rainwater (PhD fellow, Department of Development Sociology, Cornell University, USA) for their assistance in reviewing the manuscript.
Funding
This research received no funding.
Conflicts of Interest
The authors have no conflicts of interest to declare.
Ethical Approval
This study was based on an analysis of existing public domain survey datasets that are freely available online with all identifier information removed. The survey was approved by the Ethics Committee in Bangladesh. The authors were granted permission to use of the data for independent research purposes.
