Menu
Menu
Menu
Menu
The current study sought to investigate the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. Data in the children’s files of 31 sub-Saharan African countries were pooled from the Demographic and Health Surveys collected between 2010 and 2019. The outcome variables were three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). The joint effect of maternal marital status and type of household cooking fuel on child nutritional status was examined using multilevel regression models. The results were presented as adjusted odds ratios (aORs) at p < 0.05. The percentages of children who were stunted, wasted and underweight in the 31 countries in sub-Saharan Africa were 31%, 8% and 17%, respectively. On the joint effect of maternal marital status and type of household cooking fuel on stunting, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who use unclean household cooking fuel, children born to single women who use clean household cooking fuel, and children born to married women who used unclean household cooking were more likely to be stunted. With wasting, children born to single mothers who used unclean household cooking fuel and children born to married women who used unclean household cooking fuel were more likely to be wasted compared to children born to married mothers who used clean household cooking fuel. With underweight, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who used unclean household cooking fuel, children born to single women who used clean household cooking fuel and children born to married women who used unclean household cooking were more likely to be underweight. It is imperative for the governments of the 31 sub-Saharan African countries to double their efforts to end the use of unclean household cooking fuel. This goal could be achieved by promoting clean household cooking fuel (e.g., electricity, gas, ethanol, solar, etc.) through effective health education, and promotion programmes. The attention of policymakers is drawn to the urgent need for children’s nutritional status policies and programmes (e.g., dietary supplementation, increasing dietary diversity, improving agriculture and food security) to be targeted towards at-risk sub-populations (i.e., single mothered households).
Data for this study were obtained from the Demographic and Health Surveys (DHS) of 31 countries in SSA counducted from 2010 to 2019. The DHS Program has since 1984 assisted in the conduct of over 400 surveys in many low-and middle-income countries around the world. These cross-sectional surveys provide nationally representative household data on various nutrition, population and health indicators in more than 90 countries. Standardized protocols and instruments are employed to gather data of children, women, men and households. For this study, data in the children’s files were pooled from the DHS. The surveys employ a two-stage stratified sampling in selecting participants. The first stage involves the selection of clusters, usually called enumeration areas (EAs), and the second stage consists of the selection of households for the survey. To ensure consistency in data collection across countries, the DHS use a standard questionnaire comparable across countries for data collection, and the questionnaire is often translated into the major local languages of the countries involved. To ensure validity of the translated questionnaires, the DHS reports that the translated questionnaires, together with the version in English, are pretested in English and the local dialect [16,17]. Figure 1 shows the countries included in this study. We followed the Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) statement in writing the manuscript. The dataset is freely accessible for download at: https://dhsprogram.com/data/available-datasets.cfm (accessed on 3 February 2021). Map showing the 31 sub-Saharan African Countries. The outcome variables are three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). These variables were defined and coded using the WHO child growth standard which is followed by the DHS program [18]. The coding was done as follows: The main predictor variables used were generated based on literature and potential contextual implications of findings. They were maternal marital status and type of household cooking fuel. The variable “maternal marital status” was coded to produce two responses as follows: never married, widowed and separated/divorced were coded together as “Single” and married and living with a partner as “Married” [9]. For parsimony, theoretical and contextual relevance, the variable “type of household cooking fuel” was also coded into two response categories “Clean” and “Unclean” following previous studies [19,20]. Clean fuels included electricity, liquefied petroleum gas (LPG) and natural gas while charcoal, firewood, grass/straw, dung, shrubs, agricultural crop waste represented unclean cooking fuels [19,20]. The two variables “maternal marital status” and “type of household cooking fuel” were then combined [19,20] to produce the variable “Maternal marital status-Type of cooking fuel” with four (4) mutually exclusive categories: “Single mother-clean” (single mothers living in a household that uses clean cooking fuel), “Single mother-unclean” (single mothers living in households that uses unclean cooking fuel), “Married -clean” (mothers who are married or living with a partner in a household that uses clean cooking fuel” and “Married -unclean” (mothers who are married or living with a partner in a household that uses unclean cooking fuel). To observe the effect of maternal marital status and the type of household cooking fuel on the nutritional status of children under the age of 5 years, married-clean is used as the reference group. In the analysis of the effect of maternal marital status and household cooking fuel type on the nutritional status of children under age 5, three categories/clusters of variables (individual level factors-child and mother’s characteristics, household characteristics, and contextual factors) were considered ascovariates. The selection of these variables was based on their significant associations with CNS in previous studies (6–8). Variables under individual level factorsconsidered include the age of the child (0, 1, 2 and 4); sex of child (female and male); birth order of child (1, 2 to 4, and 5 and above); and perceived size at birth (small, average and large) (see [21]). Other included maternal age (re-coded into two categories “15–19” years and “20–49” years (see [22]); educational attainment (no formal education, primary, secondary and higher); working status (yes and no); antenatal visits during pregnancy (yes, no, and “Don’t know”); postnatal check within 2 months (yes and no); and place of delivery (home, health facility, other). At the household level, relevant variables included wealth status (recode as “poor”, “middle” and “rich”); the age of household head (recoded as ages below 35 years “young adults”, between 35 and 55 years “middle-aged adults” and those above 55 years “old-aged adults”; sex of household head (male and female); access to electricity (yes and no); type of toilet facility (re-coded into “improved” and unimproved”; source of drinking water (re-coded as “improved” and “unimproved” (see [23]); and access to media (yes, no) which was derived from the three variables “access to television”, “radio” and “newspaper/magazine”. The contextual factors considered are Urbanicity (rural and urban) and geographic region. The variable “Country” was re-coded to generate “Geographic region” following the UN’s list of countries and geographic regions in SSA. Stata SE version 14.2 (StataCorp, College Station, TX, USA) was used for statistical analyses of data. Descriptive statistics, including frequencies, percentages (weighted) and 95% confidence intervals (CIs) of percentages at p < 0.05 were used to summarize and present the data in tables. To enhance visualization and appreciation of the distributions of the outcome variables across the study countries, the data was integrated into a GIS environment and presented in map images. This procedure was then followed with a bivariate chi-square test of independence to determine the associations between the outcome variables and each of the key predictor variables and covariates. Collinearity diagnosis tests, including Variance Inflation Factors (VIF), Square VIF, Tolerance and R-squared were conducted for the key predictor variables and covariates. The joint effect of maternal marital status and type of household cooking fuel on CNS was examined using six multilevel regression models for each of the outcome variables (stunting, wasting, and underweight). The first model (Model 0) showed the variance in nutritional status attributed to the clustering of the primary sampling units (PSUs), without the explanatory variables. Model I contained only the key predictor variable (maternal marital status-type of household cooking fuel). Model II and III controlled for the individual and household level factors, respectively, while Model IV controlled for the contextual level factors. The final model (Model V) controlled for all the the individual, household, and contextual level factors. The Stata command “melogit” was used in fitting these models. We used Akaike’s Information Criterion (AIC) tests for Model comparison. All the results were presented using adjusted odds ratios (aOR) at 95% Confidence Interval (CI). To prevent potential challenges of oversampling or under-sampling and clustering of samples emerging from the multi-stage sampling technique used in the data collection, the weighting, cluster and strata variables were used to adjust the effect sizes. For DHS reports, ethical clearance are sought from the Ethics Committee of ORC Macro Inc. as well as Ethics Boards of partner institutions (e.g., Ministries of Health) of the studied countries. The DHS protocols ensure that standards for the protection of respondents’ privacy and confidentiality are adhered. Inner City Fund International also make sure that the survey conforms with the United States Department of Health and Human Services’ regulations for the respect of human subjects. This study used a secondary data, hence, no further ethical approval was required. The datasets are freely available for download in the public domain. Further information about the DHS data usage and ethical standards is available at http://goo.gl/ny8T6X (accessed on 3 February 2021).
N/A
