TWO ESSAYS IN CHILD NUTRITIONAL STATUS AND URBAN POVERTY DYNAMICS IN ETHIOPIA
- Gebreselassie, Tesfayi
- Graduate Program:
- Doctor of Philosophy
- Document Type:
- Date of Defense:
- August 05, 2004
- Committee Members:
- David Shapiro, Committee Chair
- Leif Jensen, Committee Member
- Dr Suet Ling Pong, Committee Member
- David Gerard Abler, Committee Member
- Barbara White Pennypacker, Committee Member
- Maternal education; Child health; Multilevel Analy
- The thesis consists of two essays. In these essays, I try to address two of the most challenging development issues in Ethiopia, poverty and malnutrition. The foci of the two essays are interrelated but will be examined separately. The title of the first essay is “The Role of Maternal Education in Child Nutritional Status and Child Health-Seeking Behavior of Households in Ethiopia: Do Family and Community Matter?” The data used in this study come from two nationally representative cross-sectional sample surveys conducted by the Central Statistical Authority of Ethiopia: (i) The 1995/96 Household Income, Consumption and Expenditure Survey (HICES), and (ii) The 1995/96 Welfare Monitoring Survey (WMS). In this essay I investigate three indicators of child nutrition and health using the following outcome variables: (i) child nutritional status (measured by child’s height for age); (ii) child health-seeking behavior of households; (iii) the determinants of child illness; and (iv) the determinants of immunization for children 12-59 months old. The main results of this study indicate that age of the child, child illness, parental education, household income and distance to primary school are strong predictors of child nutritional status in Ethiopia. Nonetheless, the strong positive effect of mother’s education on child height appears to be limited to post-primary level of education. The results from this study suggest that although the independent effect of maternal employment (working outside the home) is not a statistically significant determinant, it is negatively related to child nutritional status. When location of residence (urban vs. rural) is not controlled for, the results indicate that the children whose homes used water from protected sources (tap water) have better height-for-age relative to children whose homes used water from unprotected sources. In addition, the use of pit latrine or toilet for safe disposal of feces is not associated with better nutritional status. The empirical analysis uses household consumption expenditure (proxy for household income), both as an observed variable and in instrumented form to purge measurement error and transitory fluctuations from the variable. The results reveal significant association of child nutritional status and health to household income. Except for the illness outcome variable, income is a strong and significant determinant of child height-for-age, immunization and treatment-seeking behavior of households in Ethiopia. The results suggest that child health-seeking behavior is strongly affected by household expenditure, distance to the nearest health facility, living in a rural area, parental education, and the mother’s and child’s ages. With respect to mother’s age, children of older mothers are less likely to go for treatment when they are ill, and have less chance of being ill too. In addition, education of the male head of the household is also a significant predictor of child health-seeking behavior. With regard to child immunization and illness the estimates from the probit models indicate mother’s education is strongly associated with increased chance of immunization and reduced chance of child illness. Overall none of the models predicts the presence of a gender difference with respect to child nutritional status and health-seeking behavior. This result is in tandem with most of the findings in sub-Saharan Africa. Household expenditure is a strong and significant determinant of child nutritional status, immunization and treatment seeking-behavior of households. Among community-level correlates, the distance to primary school is a significant predictor of child height-for-age. The results from multilevel analysis indicate the presence of unobserved heterogeneity across families and across communities with respect to child nutritional outcomes. The intra-community correlation ranges from 19.1 per cent in the null model to 13.4 per cent in the full model, showing that membership in a particular family and a particular community is a major determinant of child nutritional outcomes. In summary, the results from both the classical models (OLS and 2SLS) and the multilevel analysis are similar in terms of the sign of the explanatory variables and statistical significance in the models. Factors such as child age and illness, mother’s and adult male household head’s education (in particular post-primary education), income and location of residence (living in rural area) are important in explaining child nutritional status behavior of households in Ethiopia. The title of the second essay is “Poverty Dynamics in Urban Ethiopia.” Poverty is the key cause of most social problems. Understanding the nature, characteristics and dynamics of poverty can help policymakers to target vulnerable groups more effectively. The year 1994 marked the beginning of an IMF/World Bank-assisted structural adjustment program in Ethiopia. The central questions that this essay address are: What factors account for the pattern of long-term poverty? That is, which household demographic variables emerge as determinants of chronic poverty? How important are household characteristics in determining the chance of moving out of poverty and the risk of falling into poverty? I investigate these research questions using data from a three-wave panel survey of households conducted in 1994, 1995 and 1997 in seven urban centers in Ethiopia. The poverty incidence, P0, obtained by anchoring the poverty line to the national poverty line of Birr 89.59 (at 1995 prices), indicates that 41.3 per cent of the urban population lived below the poverty line in 1994. In 1995, the incidence increased to 46.6 per cent of the sampled population. In 1997, the population below the poverty line declined to 43.6 per cent. The ranking of the distributions in order to examine whether one distribution has more or less poor than the other over a range of poverty lines (poverty dominance test) indicates that there was an unambiguous worsening of the poverty gap in 1995 in the lower and upper tails of the distributions compared to the distributions in 1994 and 1997. The proportion of all poor households that are chronically poor is 37 per cent, while the transient poor account for 26 per cent. The average income and the relative variability (using the coefficient of variation) indicate that the non-poor households have about four times as high consumption expenditure as the chronic poor, while the transient poor households have about two and a half times as high consumption expenditure as the chronic poor. Results from multivariate analyses show that education and health status of the household head, family structure, household size and female headship are significant predictors of chronic poverty. A household head with chronic health problem significantly increases the chance of the household being chronically poor. However, the significant effect of health status of the head vanishes once education is included in the model. The results indicate that having a larger household size increases the chance of being chronically poor. The transition matrices of consumption expenditure reflect the movements of households between two consecutive survey rounds in relation to the poverty line. All the transition matrices indicate that a large proportion of households in both the poorest and the richest cells did not change their position across surveys. This shows that most of the movements took place in the middle of the positions. The findings indicate that a large proportion of the poor were stuck in poverty. With respect to exit from poverty, education is a strong predictor of moving out of poverty. For instance, the probability of moving out of poverty for those with secondary and above education is around 26 percentage points higher compared to those with no education. Family structure is also a significant determinant of moving out of poverty (rather hindering moving out of poverty). The results from the multivariate analyses provide evidence that households with 4 or more children have less chance of moving out of poverty. For instance, households with more than 5 children have about a 21 percentage point lower chance of moving out of poverty compared to those households with no child.
Malnutrition in children is common globally and may result in both short and long term irreversible negative health outcomes. The World Health Organization (WHO) estimates that malnutrition accounts for 54 percent of child mortality worldwide, about 1 million children. Another estimate also by WHO states that childhood underweight is the cause for about 35% of all deaths of children under the age of five years worldwide.
The main causes are unsafe water, inadequate sanitation or insufficient hygiene, factors related to society and poverty, diseases, maternal factors, gender issues and – overall – poverty.
Signs and symptoms
There are three commonly used measures for detecting malnutrition in children:
- stunting (extremely low height for age),
- underweight (extremely low weight for age), and
- wasting (extremely low weight for height).
These measures of malnutrition are interrelated, but studies for the World Bank found that only 9 percent of children exhibit stunting, underweight, and wasting.
Children with severe acute malnutrition are very thin, but they often also have swollen hands and feet, making the internal problems more evident to health workers.
Children with severe malnutrition are very susceptible to infection.
Effects later in life
Undernutrition in children causes direct structural damage to the brain and impairs infant motor development and exploratory behavior. Children who are undernourished before age two and gain weight quickly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition.
Studies have found a strong association between undernutrition and child mortality. Once malnutrition is treated, adequate growth is an indication of health and recovery. Even after recovering from severe malnutrition, children often remain stunted for the rest of their lives.
Even mild degrees of malnutrition double the risk of mortality for respiratory and diarrheal disease mortality and malaria. This risk is greatly increased in more severe cases of malnutrition.
Undernourished girls tend to grow into short adults and are more likely to have small children.
Prenatal malnutrition and early life growth patterns can alter metabolism and physiological patterns and have lifelong effects on the risk of cardiovascular disease. Children who are undernourished are more likely to be short in adulthood, have lower educational achievement and economic status, and give birth to smaller infants. Children often face malnutrition during the age of rapid development, which can have long-lasting impacts on health.
Inadequate food intake, infections, psychosocial deprivation, the environment (lack of sanitation and hygiene), social inequality and perhaps genetics contribute to childhood malnutrition.
The World Health Organisation estimated in 2008 that globally, half of all cases of undernutrition in children under five were caused by unsafe water, inadequate sanitation or insufficient hygiene. This link is often due to repeated diarrhoea and intestinal worm infections as a result of inadequate sanitation. However, the relative contribution of diarrhea to undernutrition and in turn stunting remains controversial.
In almost all countries, the poorest quintile of children has the highest rate of malnutrition. However, inequalities in malnutrition between children of poor and rich families vary from country to country, with studies finding large gaps in Peru and very small gaps in Egypt. In 2000, rates of child malnutrition were much higher in low income countries (36 percent) compared to middle income countries (12 percent) and the United States (1 percent).
Studies in Bangladesh in 2009 found that the mother’s literacy, low household income, higher number of siblings, less access to mass media, less supplementation of diets, unhygienic water and sanitation are associated with chronic and severe malnutrition in children.
Diarrhea and other infections can cause malnutrition through decreased nutrient absorption, decreased intake of food, increased metabolic requirements, and direct nutrient loss. Parasite infections, in particular intestinal worm infections (helminthiasis), can also lead to malnutrition. A leading cause of diarrhea and intestinal worm infections in children in developing countries is lack of sanitation and hygiene. Other diseases that cause chronic intestinal inflammation may lead to malnutrition, such as some cases of untreated celiac disease and inflammatory bowel disease.
Children with chronic diseases like HIV have a higher risk of malnutrition, since their bodies cannot absorb nutrients as well. Diseases such as measles are a major cause of malnutrition in children; thus immunizations present a way to relieve the burden.
The nutrition of children 5 years and younger depends strongly on the nutrition level of their mothers during pregnancy and breastfeeding.
Infants born to young mothers who are not fully developed are found to have low birth weights. The level of maternal nutrition during pregnancy can affect newborn baby body size and composition. Iodine-deficiency in mothers usually causes brain damage in their offspring, and some cases cause extreme physical and mental retardation. This affects the children’s ability to achieve their full potential. In 2011 UNICEF reported that thirty percent of households in the developing world were not consuming iodized salt, which accounted for 41 million infants and newborns in whom iodine deficiency could still be prevented. Maternal body size is strongly associated with the size of newborn children.
Short stature of the mother and poor maternal nutrition stores increase the risk of intrauterine growth retardation (IUGR). However, environmental factors can weaken the effect of IUGR on cognitive performance.
A study in Bangladesh in 2008 reported that rates of malnutrition were higher in female children than male children. Other studies show that, at the national level, differences between undernutrition prevalence rates between young boys and girls are generally small. Girls often have a lower nutritional status in South and Southeastern Asia compared to boys. In other developing regions, the nutritional status of girls is slightly higher.
Measurements of a child’s growth provide the key information for the presence of malnutrition, but weight and height measurements alone can lead to failure to recognize kwashiorkor and an underestimation of the severity of malnutrition in children.
Measures have been taken to reduce child malnutrition. Studies for the World Bank found that, from 1970 to 2000, the number of malnourished children decreased by 20 percent in developing countries. Iodine supplement trials in pregnant women have been shown to reduce offspring deaths during infancy and early childhood by 29 percent. However, universal salt iodization has largely replaced this intervention.
The Progresa program in Mexico combined conditional cash transfers with nutritional education and micronutrient-fortified food supplements; this resulted in a 10 percent reduction the prevalence of stunting in children 12–36 months old. Milk fortified with zinc and iron reduced the incidence of diarrhea by 18 percent in a study in India.
Treatment with antibiotics such as amoxicillin or cefdinir improve the response and survival rate of severely malnourished children to an outpatient treatment plan which provided therapeutic food. This confirms the recommendation, "In addition to the provision of RUTF [ready-to-use therapeutic food], children need to receive a short course of basic oral medication to treat infections." contained in "Community-based management of severe acute malnutrition, A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund."
Main article: Breastfeeding
Breastfeeding can reduce rates of malnutrition and dehydration caused by diarrhea, but mothers are sometimes wrongly advised to not breastfeed their children. Breastfeeding has been shown to reduce mortality in infants and young children. Since only 38 percent of children worldwide under 6 months are exclusively breastfed, education programs could have large impacts on children malnutrition rates. However, breastfeeding cannot fully prevent PEM if not enough nutrients are consumed.
The World Health Organization estimates that malnutrition accounts for 54 percent of child mortality worldwide, about 1 million children. Another estimate also by WHO states that childhood underweight is the cause for about 35% of all deaths of children under the age of five years worldwide.
According to a 2008 review an estimated 178 million children under age 5 are stunted, most of whom live in sub-Saharan Africa. A 2008 review of malnutrition found that about 55 million children are wasted, including 19 million who have severe wasting or severe acute malnutrition.
As underweight children are more vulnerable to almost all infectious diseases, the indirect disease burden of malnutrition is estimated to be an order of magnitude higher than the disease burden of the direct effects of malnutrition. The combination of direct and indirect deaths from malnutrition caused by unsafe water, sanitation and hygiene (WASH) practices is estimated to lead to 860,000 deaths per year in children under five years of age.
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