Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Division of Health Sciences, Populations, Evidence and Technologies Group, Warwick Medical School, University of Warwick, Coventry, UK.
BMC Public Health. 2020 Apr 25;20(1):555. doi: 10.1186/s12889-020-08635-3.
Low- and Middle-Income Countries (LMIC) have remained plagued with the burden of severe acute malnutrition (SAM). The decomposition of the educational inequalities in SAM across individual, household and neighbourhood characteristics in LMIC has not been explored. This study aims to decompose educational-related inequalities in the development of SAM among under-five children in LMIC and identify the risk factors that contribute to the inequalities.
We pooled successive secondary data from the Demographic and Health Survey conducted between 2010 and 2018 in 51 LMIC. We analysed data of 532,680 under-five children nested within 55,823 neighbourhoods. Severe acute malnutrition was the outcome variable while the literacy status of mothers was the main exposure variable. The explanatory variables cut across the individual-, household- and neighbourhood-level factors of the mother-child pair. Oaxaca-Blinder decomposition method was used at p = 0.05.
The proportion of children whose mothers were not educated ranged from 0.1% in Armenia and Kyrgyz Republic to as much as 86.1% in Niger. The overall prevalence of SAM in the group of children whose mothers had no education was 5.8% compared with 4.2% among those whose mothers were educated, this varied within each country. Fourteen countries (Cameroon(p < 0.001), Chad(p < 0.001), Comoro(p = 0.047), Burkina Faso(p < 0.001), Ethiopia(p < 0.001), India(p < 0.001), Kenya(p < 0.001), Mozambique(p = 0.012), Namibia(p = 0.001), Nigeria(p < 0.001), Pakistan(p < 0.001), Senegal(p = 0.003), Togo(p = 0.013), and Timor Leste(p < 0.001) had statistically significant pro-illiterate inequality while no country showed statistically significant pro-literate inequality. We found significant differences in SAM prevalence across child's age (p < 0.001), child's sex(p < 0.001), maternal age(p = 0.001), household wealth quintile(p = 0.001), mother's access to media(p = 0.001), birth weight(p < 0.001) and neighbourhood socioeconomic status disadvantage(p < 0.001). On the average, neighbourhood socioeconomic status disadvantage, location of residence were the most important factors in most countries. Other contributors to the explanation of educational inequalities are birth weight, maternal age and toilet type.
SAM is prevalent in most LMIC with wide educational inequalities explained by individual, household and community-level factors. Promotion of women education should be strengthened as better education among women will close the gaps and reduce the burden of SAM generally. We recommend further studies of other determinate causes of inequalities in severe acute malnutrition in LMIC.
中低收入国家（LMIC）仍然深受严重急性营养不良（SAM）的困扰。在 LMIC 中，个体、家庭和社区特征方面 SAM 教育不平等的分解尚未得到探索。本研究旨在分解 LMIC 中五岁以下儿童 SAM 发展过程中的与教育相关的不平等，并确定导致这些不平等的风险因素。
我们汇集了 2010 年至 2018 年期间在 51 个 LMIC 进行的人口与健康调查中的连续二次数据。我们分析了嵌套在 55823 个街区中的 532680 名五岁以下儿童的数据。严重急性营养不良是结果变量，而母亲的文化程度是主要暴露变量。解释变量涵盖了母婴对的个体、家庭和社区层面因素。在 p = 0.05 时使用了 Oaxaca-Blinder 分解方法。
母亲未受教育的儿童比例从亚美尼亚和吉尔吉斯斯坦的 0.1%到尼日尔的 86.1%不等。在没有受过教育的母亲的孩子中，SAM 的总体患病率为 5.8%，而在受过教育的母亲的孩子中为 4.2%，这在每个国家都有所不同。有 14 个国家（喀麦隆（p<0.001）、乍得（p<0.001）、科摩罗（p=0.047）、布基纳法索（p<0.001）、埃塞俄比亚（p<0.001）、印度（p<0.001）、肯尼亚（p<0.001）、莫桑比克（p=0.012）、纳米比亚（p=0.001）、尼日利亚（p<0.001）、巴基斯坦（p<0.001）、塞内加尔（p=0.003）、多哥（p=0.013）和东帝汶（p<0.001）存在统计学上显著的反文盲不平等，而没有一个国家表现出统计学上显著的亲文盲不平等。我们发现儿童年龄（p<0.001）、儿童性别（p<0.001）、母亲年龄（p=0.001）、家庭财富五分位数（p=0.001）、母亲接触媒体（p=0.001）、出生体重（p<0.001）和邻里社会经济地位劣势（p<0.001）方面的 SAM 患病率存在显著差异。平均而言，邻里社会经济地位劣势、居住地是大多数国家中最重要的因素。其他有助于解释教育不平等的因素包括出生体重、母亲年龄和厕所类型。
SAM 在大多数 LMIC 中普遍存在，个体、家庭和社区层面的因素解释了广泛的教育不平等。应该加强妇女教育的推广，因为妇女教育水平的提高将缩小差距，总体上减轻 SAM 的负担。我们建议进一步研究 LMIC 中严重急性营养不良不平等的其他决定因素。
