Access to this full-text is provided by PLOS.
Content available from PLOS One
This content is subject to copyright.
RESEARCH ARTICLE
Prevalence of stunting and its associated
factors among children 6–59 months of age in
pastoralist community, Northeast Ethiopia: A
community-based cross-sectional study
Mulugeta Gebreayohanes
1
, Awrajaw DessieID
2
*
1Department of Human Nutrition, Institute of Public Health, University of Gondar, Gondar, Ethiopia,
2Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of
Gondar, Gondar, Ethiopia
*awrajawdss@gmail.com
Abstract
Introduction
Globally, stunting is a significant public health concern and it is very critical in Ethiopia. This
research aims to determine the prevalence of stunting and its correlates among children in
the pastoral community.
Methods
A community-based cross-sectional study was conducted in Dubti District, Afar Region,
North East Ethiopia from 2–31 January 2018. A total of 554 children were recruited using a
multi-stage sampling technique and participated in this study. A binary logistic regression
analysis was performed to determine factors linked to stunting. The significance of the asso-
ciations was determined at a p-value <0.05 and the adjusted odds ratio at 95% CI was cal-
culated to evaluate the strength of the associations.
Results
The prevalence of stunting was 39.5% (95% CI: 35.4–43.5%). The odds of stunting were
increased, so does the age of the child increased as compared to 6–11 months of children.
Initiating breastfeeding after 1 hour after birth (AOR = 1.99; 95% CI: 1.22, 3.23), not exclu-
sively breastfeeding for at least 6 months (AOR = 2.57; 95% CI: 1.49, 4.42), poor dietary
diversity (AOR = 1.93; 95% CI: 1.03, 3.62), and using unprotected water for drinking (AOR =
1.68; 95% CI: 1.21, 2.94) were significant factors.
Conclusion
Among children aged 6–59 months, the level of stunting in the pastoral community was sig-
nificantly high. The study found that stunting was associated with multiple nutritional and
non-nutritional factors. To tackle stunting, inter-sectoral cooperation is needed by enhancing
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 1 / 15
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Gebreayohanes M, Dessie A (2022)
Prevalence of stunting and its associated factors
among children 6–59 months of age in pastoralist
community, Northeast Ethiopia: A community-
based cross-sectional study. PLoS ONE 17(2):
e0256722. https://doi.org/10.1371/journal.
pone.0256722
Editor: Srinivas Goli, University of Western
Australia, AUSTRALIA
Received: July 27, 2020
Accepted: August 16, 2021
Published: February 3, 2022
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0256722
Copyright: ©2022 Gebreayohanes, Dessie. This is
an open access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting information
files.
the clean water supply of the community, optimal breastfeeding practice, food diversity, and
economic status.
Background
One of the most important causes of child morbidity and mortality in developing nations is
malnutrition. Sub-Saharan Africa leads by high child morbidity and death rates associated
with malnutrition [1]. It affects a nation’s future economic competitiveness and continues to
be a key concern in developing countries [2]. Stunting is chronic malnutrition that occurs
when children struggle to meet their capacity for linear growth and cause significant physical
and cognitive damage [3]. It will also have irreparable effects on a child’s future growth, which
will increase population vulnerability and weaken its capacity to cope with episodes of food
stress [4].
Over 161 million children under the age of five are affected by stunting worldwide, with an
estimated one million deaths. African and Asian children are hit hard by stunting [3]. Under-
nutrition is one of the major health issues of children under the age of five and results in a
16.5% GDP loss in Ethiopia [5,6]. Stunting can have devastating health and economic costs
that last for a lifetime [7].
With very weak human development metrics, Ethiopia is one of the poorest countries in
the world. Around 23 million Ethiopians live under the poverty line and food insecurity
remains a major problem [8]. Pastoralists (90%) dominate the production system of the Afar
region, from which agro-pastoralists (10%) now emerge after some permanent and temporary
rivers on which small-scale irrigation grows. Strong reminiscences of suffering are due to the
frequent episodes of drought and unseasoned flooding and disease outbreaks in the pastoral
areas of Ethiopia. The reduction of hunger, food security, and pastoral livelihood strategies are
therefore largely dependent on the climate system and vulnerable to seasonal variations.
The prevalence of stunting in Ethiopia has dropped considerably from 58% in 2000 to 38%
in 2016, but in the Afar region, the stunting level is above the national average of 41% [9]. Mal-
nutrition in the Afar region poses a huge problem [10]. While the consequences of stunting
are clear, its causes are more complex [11]. Poor nutritional and health condition of a mother,
insufficient infant and young child feeding practices, micronutrient deficiencies, and infection
are primary factors leading to stunting [12].
The United nation’ sustainable development goals (SDGs) have marked stunting along with
other nutrition indicators as the main focus areas to eradicate global malnutrition [13]. Stunt-
ing is regarded by the Ethiopian government as a major public health issue and an obstacle to
its economic goals. The Health Sector Transformation Plan (HSTP), part of GTP II, aimed at
reducing mortality rates of 30 per 1,000 live births below five years in Ethiopia, reducing stunt-
ing to 26% in less than 5 years [14].
To tackle stunning on a sustainable basis, it is important to understand local geo-cultural
domains such as tradition and community livelihoods. In this context, it is also important to
interpret prevalence and cause factors. Access to seasonal pastures is prioritized by these com-
munities and they are highly mobile between different wet and dry seasons to seek food for
their livestock, their main livelihoods, in a much-dispersed way. In pastoralist groups, how-
ever, there is a lack of evidence regarding the extent of stunting and its correlates. Therefore,
this research in the Dubti district could reflect the effectiveness of a permanent solution for
addressing stunting in the region by pointing out the main determinants of stunting, rather
than relying on targeting short-term food help that would ultimately not overcome stunting.
This study will therefore provide input to local government officials, non-governmental
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 2 / 15
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing exist.
Abbreviations: ANC, Antenatal Care; AOR,
Adjusted Odds Ratio; CI, Confidence Interval; COR,
Crude Odds Ratio; GDP, Gross Domestic Product;
GTP, Growth Transformation Plan; HAZ, Height for
Age Z-score; HSTP, Health Sector Transformation
Plan; IQR, Inter Quartile Range; MDDS, Minimum
Dietary Diversity Score; NGO, Non-Governmental
Organization; PNC, Postnatal Care; SD, Standard
Deviation; SDG, Sustainable Development Goal;
SPSS, Statistical Package for Social Science; TLU,
Tropical Livestock Unit; WHO, World Health
Organization.
organizations (NGOs), policymakers working to reduce the rate of child mortality that con-
tributes to the goal of the Health Sector Transformation Plan (HSTP) and Growth Transfor-
mation Plan (GTP) II of Ethiopia on the prevalence and related factors for children aged 6–59
months.
Materials and methods
Study design and period
A community-based cross-sectional study was conducted from 2–31 January 2018.
Study area
The study was conducted in the Dubti district, Afar region, Northeast Ethiopia. It is one of
the 32 districts in the Afar region. It is located approximately 7 km far from the regional capi-
tal Semera [15] and 600 km northeast of Addis Ababa, the capital of Ethiopia [16]. The study
region is often struck by drought. The community is predominantly pastoralists with a small
plot of land for cultivation and is primarily engaged in the rearing or husbandry of livestock.
They live in a scattered way and many places remain isolated and difficult to enter. Pastorals
are particularly susceptible to extensive droughts. Infrastructure or facilities such as water,
sanitation, basic health, and nutrition are very limited in terms of accessibility [15]. Accord-
ing to the district health center annual report, a total of 8187 under-five children resided in
the area [17].
Source and study population
Children aged 6–59 months living in the district were the source populations of this study and
the study population consisted of children from 4 (3 rural and 1 urban) randomly selected
Kebeles in the district. During the entire data collection season, children who were critically ill
and those affected by spinal curvature (kyphosis, scoliosis, and kyphoscoliosis) were exempted
from the study.
Sample size determination and sampling technique
The sample size was determined by a single population proportion formula using the assump-
tions of 95% confidence level, the proportion of stunting among 6–59 months children in
Afambo district 32.2% [18], 5% margin of error, and a design effect of 1.5. The final sample
size was therefore calculated to be 555, after a 10% non-response rate was added. The study
participants were recruited using a multi-stage sampling technique. In the first stage, from the
two urban kebeles, one kebele was selected by the lottery method, and in the same way, from
the 12 rural kebeles, three kebeles were selected. Second, the total sample size was allocated
proportionally based on the total number of households with children aged 6–59 months and
a simple random sampling technique was used to select children based on the existing sam-
pling frame from health posts. The index child or the youngest child was selected in this study
from households with two or more children aged 6–59 months. The mother or guardians were
interviewed.
Variables measurement
Height and weight. The height of infants aged between 6 months and 23 months was
measured in a recumbent position to the nearest 0.1 cm using a board with an upright wooden
base and a movable headpiece. Children between 24 and 59 months of age were measured in a
standing position of 0.1 cm to the nearest. Besides, the child weight was measured using an
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 3 / 15
electronic digital weight scale for children who were comfortable to measure on their own,
and also for children who were uncomfortable to measure on their own, we used the combined
mother and child weight and the mother’s weight to calculate the child’s weight [19].
Stunting. Height-for-age is a measure of linear growth retardation and cumulative
growth deficits. Children whose height-for-age Z (HAZ) score is below minus two standard
deviations (-2 SD) from the median of the reference population were considered to be
stunted. Children below minus three standard deviations (-3 SD) were considered to have
been severely stunted [9].
The economic status of households. Since the community is pastoral, the economic sta-
tus of households has been measured using the Tropical Livestock Unit (TLU) as a proxy. TLU
is a measure developed by the Food and Agriculture Organization (FAO) that allows the com-
bination of multiple animal species into a weighted measure of total body weight and potential
market value [20]. A single animal weighing 250 kg is a single TLU, which provides a weight-
ing factor of 0.7 for cattle, 0.1 for sheep, 0.1 for goats, and 0.01 for chickens. The economic
status of households was determined by comparing the TLU scores to the standard ranking. A
score below 5 TLU shows the household is poor. A TLU score of 5 to 12.99 showed the house-
hold’s economic status was medium and richer households ranked 13 and above TLU [20].
Minimum Dietary Diversity Score (MDDS). Proxy for the adequacy of dietary micronu-
trient density for infants and young children. Consumption of 4 or more of the 7 food groups
means that the child is likely to consume at least one animal food source and at least one fruit
or vegetable in addition to the staple food (grains, roots, or tubers) in the last 24 hours. Four
food groups should be drawn from the list of seven food groups: grains, roots and tubers,
legumes and nuts; dairy products (milk yogurt, cheese); meat, fish, poultry, and liver / organic
meat; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables [18].
Fully vaccinated: Children who had received a vaccination against tuberculosis (BCG),
three doses each of the DPT and polio vaccines, and a measles vaccination by the age of 12–23
months [21]. Non-vaccinated: Children who had not received a vaccination against tuberculo-
sis (BCG), three doses each of the DPT and polio vaccines, and a measles vaccination by the
age of 12–23 months. Partially vaccinated: Children who had started the vaccination but not
completed all the doses due to forgetfulness, and drop out [21].
Data quality management
The structured questionnaire was prepared in English and translated into the Afar language
and translated back into English by language experts to check its consistency. The pre-test of
the questionnaire was performed on 5% of the sample size in a similar area-Asayita district,
Afar region. The weight measurement scale was checked against zero readings after and before
each child was weighed. A two-day training was given to data collectors and supervisors on
processes, techniques, and methods for collecting data. In addition, a clear introduction was
given to respondents on the intent and objectives of the study before data collection. In paral-
lel, constant and strict monitoring and on-the-spot checks have been carried out throughout
the process.
Data processing and analysis
The data were verified, coded, and entered in version 7.2 of Epi-Info software. Sex, age, and
weight data were transferred to the WHO Anthro software using the WHO standard with par-
ticipant identification numbers to translate the nutritional data into Z scores for the HAZ indi-
ces. The data, including the HAZ, was subsequently exported to SPSS version 20 for analysis.
The bivariate analysis was performed to determine the association of stunting and associated
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 4 / 15
factors and the variables were selected for multivariate analysis by p-value <0.2. A multivari-
able binary logistic regression analysis was employed to control the possible effects of con-
founders. The model goodness of fit test was checked by Hosmer and Lemeshow Test, and it
was found fit (X
2
= 11.57, p-value = 0.17). Finally, variables that showed significant associations
were identified based on the adjusted odds ratios (AOR) with a 95% CI and p-value <0.05.
Ethical statement
This study was approved by the Institutional Review Board of the University of Gondar, Insti-
tute of Public Health, Ethiopia. Informed consent was obtained from all parents/ or legal guard-
ian of children participated in this study after adequate explanations of the study. For illiterate
parents/ or legal guardians and informed consent was obtained from their legally Authorized
Representatives. The study was conducted according to the Declaration of Helsinki, and the
National Research Ethics Review Guideline for Medical and Health Research Involving Human
Subjects, enforced by the Ministry of Science and Technology, Government of Ethiopia.
Results
Demographic and socio-economic characteristics
The study included a total of 554 study participants, giving a response rate of 99.82%. The
majority of households were male-headed (92.1%). Approximately 92.6% of respondents were
Muslim, and more than three-fourth (79.1%) of the participants were Afar by ethnicity. Five
hundred and seven mothers (91.5%) were married and 79.2% were aged between 20–34 years.
More than half of respondents (57.9%) can’t read and write. Nearly three-fourths of households
have been classified as poor based on TLU. The average household family size was 5 (SD±1.81),
and 45.3% of households had fewer than 5 family members. Nearly half (48%) and 46.4% of
households had 1 and 2 children under five years of age, respectively. Most of the mothers were
housewives (62.5%), and 81.6% of the fathers were agro-pastoralists by occupation. The major-
ity of households (92.8%) were not productive safety net program (PSNP) users (Table 1).
Child characteristics and child carrying practice
This study showed that 56.3% of the children were males and 20.0% of them were aged 6–11
months with a median (IQR) age of 31 (IQR = 19) months. More than one-third of children
were second by birth order and 99.1% of the children were singletons. More than half (52.5%)
of the children were born at home, according to this study. The study revealed that 79.2% of
mothers started breastfeeding with colostrum within one hour immediately after birth and the
majority (80.5%) of the children were breastfed exclusively for at least six months. This study
found that 54.7% children had of at least 3 meal frequencies a day and the majority (83.2%) of
children had a minimum dietary diversity score of <4. About 59.8% of children have been
fully vaccinated. Regarding the morbidity status of the children, 65.7% of the children had at
least one disease. More than half (59.9%) of the children encountered acute respiratory infec-
tion in the past two weeks before the data collection. Moreover, 14.4% and 13% of the children
were also affected by diarrhea and stomach illness, respectively. Malaria and measles were also
reported in 3.2% and 4.0% of the children in this study (Table 2).
Maternal characteristics and health service utilization
This study shows that more than half of mothers were aged between 26 and 35 years when
they gave birth to the index child, with a median (IQR) age of 28 (IQR = 6) years. About 50.2%
completed the full ANC schedule and 75.1% received PNC. More than one-third of mothers
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 5 / 15
(65.9%) had no extra meal at all during their pregnancy or lactation. Husbands make decisions
in the majority of households concerning the use of money (71.3%) (Table 3).
Environmental health characteristics of households
The majority (62.3%) of households used a public tap as a source of drinking water, which is
one of the improved sources of drinking water. About 48.2% of households had access to water
Table 1. Demographic and socio-economic characteristics of households in Dubti district, Afar region, northeast Ethiopia, January 2018 (N = 554).
Variables Category Frequency Percent
Head of Household Father of the child 510 92.1
Mother of the child 25 4.5
Others19 3.4
Ethnicity Afar 438 79.1
Amhara 86 15.5
Oromo 15 2.7
Others# 15 2.7
Religion Muslim 513 92.6
Orthodox 24 4.3
Protestant 17 3.1
Marital status Married 507 91.5
Unmarried 13 2.3
Divorced/Widowed/separated 34 6.1
Total number of <5 children 1 266 48.0
2 257 46.4
3 31 5.6
Educational status of mother Can’t read and write 321 57.9
Informal education 21 3.8
Primary education 129 23.3
Secondary education 56 10.1
Higher education 27 4.9
Occupational status of mother Housewife 347 62.6
Agro-pastoralist 150 27.1
Merchant 34 6.1
Others§ 23 4.2
Occupational status of father Agro-pastoralist 452 81.6
Merchant 68 12.3
Government/self-employee 34 6.1
Family size <5 251 45.3
5 303 54.7
Wealth status Poor 412 74.4
Medium 81 14.6
Rich 61 11.0
PSNP user No 514 92.8
Yes 40 7.2
Note: Others:
Caregivers of the targeted child;
#
Tigre, Wolayita, Somali;
§
Private organization employee, government employee, student, NGO employee. PSNP = Productive safety net programme
https://doi.org/10.1371/journal.pone.0256722.t001
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 6 / 15
Table 2. Child characteristics and child carrying practice in Dubti district, Afar region, northeast Ethiopia, January 2018 (N = 554).
Variables Category Frequency Percent
Sex of the child Female 242 43.7
Male 312 56.3
Age of the child in months 6–11 111 20.0
12–23 122 22.0
24–35 177 31.9
36–59 144 26.0
Birth order First 122 22.0
Second 198 35.7
Third 110 19.9
Fourth and above 124 22.4
Type of birth Single 549 99.1
Twin 5 0.9
Place of delivery Home 291 52.5
Health institution 263 47.5
Time of initiation of breastfeeding Within 1 hour 439 79.2
After 1 hour 115 20.8
Exclusive breastfeeding <6 months 108 19.5
6 months 446 80.5
Frequency of feeding <3 times 251 45.3
3 times 303 54.7
Minimum dietary diversity score <4 461 83.2
4 93 16.8
Immunization status (n = 122) Not vaccinated 7 5.7
Partially vaccinated 42 34.4
Fully vaccinated 73 59.8
Morbidity No disease 190 34.3
One disease 253 45.7
Two and more diseases 111 20.0
NB: Children aged 12–23 months were considered to compute the frequency of immunization status.
https://doi.org/10.1371/journal.pone.0256722.t002
Table 3. Maternal characteristics in Dubti district, Afar region, northeast Ethiopia, January 2018 (N = 554).
Variables Category Frequency Percent
Age of mother 25 201 36.3
26–35 279 50.4
36 74 13.3
Number of ANC visit 0 36 6.5
1–3 240 43.3
4 278 50.2
PNC follow up No 138 24.9
Yes 416 75.1
An extra meal is given to the mother during pregnancy or lactation No 189 34.1
Yes 365 65.9
Decision making on the use of money Mainly wife 81 14.6
Mainly husband 395 71.3
Both jointly 78 14.1
https://doi.org/10.1371/journal.pone.0256722.t003
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 7 / 15
for the round trip within less than 15 minutes. More than half of the participants (59.2%) used
the latrine for defecation. From the study, 38.6% of mothers and caregivers washed their hands
with water only (Table 4).
Prevalence of stunting
The prevalence of stunting was found to be 39.5% (95% CI: 35.4–43.5%). Moreover, the preva-
lence of moderate and severe stunting was 29.6% and 9.9%, respectively. The prevalence of
stunting among female and male children was 36.0% and 42.3%, respectively. The highest
prevalence of stunting was 61.1% among children aged 36–59 months, 41.2% among those
aged 24–35 months, and 34.4% among those aged 12–23 months, and the lowest 14.4% was
among children aged 6–11 months. Of stunted children, the majority 41.8% were between the
ages of 36–59 months and the minimum 5.5% were between the ages of 6–11 months.
Factors associated with stunting
Stunting was correlated with economic status, age of the child, breastfeeding initiation, com-
plementary feeding, minimum dietary diversity score, and source of drinking water. Children
from poor households were 5.5 times more likely to be stunted than children from a rich fami-
lies (AOR = 5.50; 95% CI: 2.52, 12.04). Stunting was more common among children aged 12–
23, 24–35, and 36–39 months compared to children aged 6–11 months (AOR = 2.55; 95% CI:
1.27, 5.09), (AOR = 3.02; 95% CI: 1.58, 5.78), and (AOR = 4.12; 95% CI: 2.00, 8.45),
respectively.
The time breastfeeding initiated after birth and exclusive breastfeeding were among the pre-
dictors for stunting in this study. Chances of being stunted have increased by 99% among chil-
dren who started breastfeeding after 1 hour compared with children who started breastfeeding
within 1 hour of birth (AOR = 1.99; 95% CI: 1.22, 3.23). In comparison, infants who exclu-
sively breastfeed for less than 6 months were 2.57 more likely to be stunted than their counter-
parts who had exclusively breastfed for 6 months or longer (AOR = 2.57; 95% CI: 1.49, 4.42).
Minimum dietary diversity score (MDDS) was found to be linked to stunting. Children
from mothers who had 4 and less score were 93% more likely to be stunted than their counter-
parts who had a score of more than 4 (AOR = 1.93; 95% CI: 1.03, 3.62). Households using
unprotected river water were 68% more likely their children to be stunted than households
receiving drinking water from public tabs (AOR = 1.68; 95% CI: 1.21, 2.94) (Table 5).
Table 4. Environmental health characteristics of households in Dubti district, Afar region, northeast Ethiopia,
January 2018 (N = 554).
Variables Category Frequency Percent
Source of drinking water River 150 27.1
Spring 59 10.6
Public tap 345 62.3
Time to obtain drinking water (round trip) <15 minutes 267 48.2
15–30 minutes 160 28.9
>30 minutes 127 22.9
Latrine utilization No 226 40.8
Yes 328 59.2
Materials used for hand washing Water only 214 38.6
Using soap sometimes 227 41.0
Using soap always 113 20.4
https://doi.org/10.1371/journal.pone.0256722.t004
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 8 / 15
Discussion
The level of stunting among children 6–59 months children was 39.5% in the current study.
Moreover, the prevalence of severe and mild stunting was 9.93% and 29.6%, respectively.
Stunting, which is an indicator of chronic malnutrition would result in delayed developmental
milestones, inadequate psychosocial stimulation, poor school performance over the years, and
a compromised life-course potential [22]. These conditions entirely impacted the progress of
all SDG targets. Hence, addressing child nutritional problems is key for national and global
health, education, and economic developmental agendas.
Table 5. Factors affecting stunting among children aged between 6 and 59 months in Dubti district, Afar region, northeast Ethiopia, January 2018 (N = 554).
Variables Stunting COR with 95% CI AOR with 95% CI
Yes No
Economic status
Poor 186 226 4.2 (2.07, 8.49) 5.50 (2.52, 12.00)
Medium 23 58 2.02 (0.88, 4.65) 2.48 (0.96, 6.15)
Rich 10 51 1 1
Sex of the child
Female 87 155 0.76 (0.54, 1.08) 0.68 (0.46, 1.02)
Male 132 180 1 1
Age of the child
6–11 16 95 1 1
12–23 42 80 3.12(1.63,5.96) 2.51 (1.25, 5.04)
24–35 73 104 4.17(2.27,7.66) 2.99 (1.56, 5.73)
36–59 88 56 9.33(4.99,17.46) 4.11 (2.00, 8.45)
Initiation of breastfeeding
After 1 hour 66 49 2.52 (1.66, 3.83) 1.89 (1.17, 3.06)
Within 1 hour 153 286 1 1
Exclusive breastfeeding
6 months 69 39 3.49 (2.25, 5.42) 2.51 (1.47, 4.29)
>6 months 150 296 1 1
Frequency of feeding per day
<3 times 104 147 1.16 (0.82, 1.63) 1.03 (0.69, 1.53)
3 times and more 115 188 1 1
Minimum dietary diversity score
4 202 259 3.49 (1.99, 6.09) 1.94 (1.04, 3.64)
>4 17 76 1 1
Time to obtain drinking water (round trip)
<15 minutes 88 179 1 1
15–30 minutes 67 93 1.46 (0.98, 2.19) 1.59 (0.98, 2.58)
>30 minutes 64 63 2.07 (1.34, 3.18) 1.58 (0.83, 3.00)
Materials used for hand washing
Only water 103 111 1.69 (1.06, 2.71)1.33 (0.76, 2.31)
Using soap sometimes 76 151 0.92 (0.57, 1.48) 1.04 (0.61, 1.80)
Always using soap and water 40 73 1 1
Source of drinking water
River 82 68 2.41 (1.63, 3.57) 1.72 (1.01, 2.98)
Spring 22 37 1.19 (0.67, 2.11) 0.88 (0.41, 1.91)
Public tap 115 230 1 1
https://doi.org/10.1371/journal.pone.0256722.t005
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 9 / 15
The level of stunting found in this study is designated to be very serious or critical in the
study area, according to the WHO classification [23], which implied that stunning is the big
public health challenge in Ethiopia. The result is in line with the national prevalence of stunt-
ing (38%) among under-five children [24]. The prevalence was, however, lower than that of
other studies conducted in the Hadibu Abote district, Oromia region, which reported 47.6%
prevalence [25]; in the district of Bule Hora, South Ethiopia, 47.6% [26]; and 67.8% in the dis-
trict of Asayita district, Eastern Ethiopia [27]; 56.6% in the district of Medebay Zana district,
Northern Ethiopia [28]; 49.1% in the district of Libo-Kemekem, North-west Ethiopia [29].
However, the finding was higher than the prevalence of stunting which was reported in the
Afambo district of Eastern Ethiopia (32.2%) [18]; the study done in Dollo Ado district (34.4%)
[30], another study conducted in eastern Ethiopia (34.4%) [31]; a study conducted in Delanta
district, Ethiopia (22.1%) [32]. The discrepancies in the finding may be due to differences in
the sample size and other socio-economic factors such as feeding habits, policies for infant and
child feeding, differences in education and culture. Milk and milk products consumption in
the study area could help child development and ultimately tackling stunting, as confirmed in
the scientific article [33]. This could be helpful to fight for improving the nutritional status of
children in the nomadic community, where a large population of cattle, sheep, goats, and cam-
els are found.
This research has shown that 65.7% of children were affected by at least one disease such as
diarrhea, respiratory infections, malaria, and measles, etc This finding has been corroborated
by scientific literature [29,34,35]. Reducing co-morbidities may strengthen the battle against
stunning, which would otherwise become a double or triple burden. It is also important to
reinforce the need to incorporate intervention activities of the nutritional problem and dis-
eases like diarrhea, respiratory infections, malaria, etc. [35].
This study shows, as the child’s age increases, so are the likelihood that the child will be
stunted. Scholarly articles in Ethiopia and elsewhere in other parts of the globe supported the
finding [36–38]. As stunting has a constant and cyclical nature, inadequate dietary practice,
weaning, lower and insufficient breast, and complementary feeding strategies have been weak-
ened and become unsuccessful as the child’s age increases, which further causes stunting.
Another possible reason for the higher risk of stunning among older children could be the
unhygienic preparation of additional food that exposes children to frequent infections. The
area being studied is also exposed to the many kinds of infections and diarrheal diseases,
which increase the risk of chronic malnutrition via reducing the access of these children to
drinking water.
Besides, one interesting finding that emerged in this study was the number of livestock
owned by the household became a strong correlate of stunting. The economic status measured
indirectly by TLU implied that stunting can be addressed by considering the cultural and eco-
nomic context of the area. Feeding the livestock products for the children could bring change
in disease prevention. Though it was measured by different contexts in different studies, eco-
nomic status was the major risk factor for stunting in Ethiopia [37,39], and elsewhere in Africa
[38]. It is well understood that poor people are suffering from poor diet, inadequate schooling,
poor clothing, poor hygiene, and health, resulting in the children to suffer from failure in
growth [37]. To tackle malnutrition, initiatives aiming to increase the number of animals in
the nomadic community are therefore critical. It is also crucial to promote animal health by
increasing awareness of animal disease prevention and control, by enhancing access to animal
health facilities, and, most importantly, by piling up animal feed.
This research found that children born to households who obtained drinking water from
unimproved water sources (rivers) were more likely their children to be stunted than their
counterparts who obtained from improved water sources. Similar research in Ethiopia found
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 10 / 15
that households drinking water from an unprotected source were more stunted than their
counterparts, corroborating this result [28,37]. The lack of safe water causes multiple types of
infection and diarrhoeal disease, which in turn raises chronic malnutrition. To tackle the prob-
lem of malnutrition in the area, improving access to better water sources is very necessary.
Hence, this study bold out that to tackle stunting among children, non-nutrition-specific strat-
egies have also paramount importance.
Stunting is found to be associated with the time of initiation of breastfeeding for the inborn
child, in this study. Children who started breastfeeding immediately after birth within an hour
whose mothers began breastfeeding suffered less from stunting. To improve the nutritional
status of the infant, it is commonly recommended that children start breastfeeding immedi-
ately after birth. This may be because early breastfeeding leads to increased secretion and pro-
duction of breast milk that will provide the baby with sufficient nutrients, such as colostrum
[32]. Colostrum provides natural immunity to the infant and thereby decreases hypoglycemia
and hypothermia, which in turn protects the infant’s wellbeing [32,40]. This study supports
the WHO recommendation, which underlines the value of timely breastfeeding to children’s
health [33]. The results are backed by similar studies in Tigray, Northern Ethiopia [28]; in
Indonesia [41]. These findings demonstrate the importance of early breastfeeding initiation as
a means of early maternal care and the best food that can reduce the risk of stunting. Early
breastfeeding is designated as one of the gateways to effective breastfeeding practice and
ensures that infants obtain sufficient food [42]. Hence, health education should also be given
to mothers on the benefits of early breastfeeding in improving the nutritional status of chil-
dren. In providing a close follow-up on the matter, health extension workers and women’s
health development armies are vital [43].
Also, the current study showed that one of the important predictors of stunting was exclu-
sive breastfeeding. Children who were not breastfed for at least 6 months exclusively were
2.57 times more likely to get stunted. A parallel can be drawn with scholarly articles [44–47].
The likely explanation is that for children whose digestive and immune systems are not yet
mature, inappropriate timing for providing complimentary food will affect their nutritional
status. The provision of food supplements may be a significant cause of malnutrition, partic-
ularly under unhygienic conditions [47]. To prevent infections that could hinder the devel-
opment of the infant, exclusive breastfeeding is very necessary, particularly in the region
where the sanitation status is very poor. Therefore, mothers should be advised to benefit
from this and an enabling environment should be developed that promotes optimal
breastfeeding.
This study indicated that one of the correlates of stunting was found to be a lack of adequate
food diversity. It is 93% more likely that children who have eaten less optimal dietary diversity
would be stunted. This finding is confirmed by several similar studies conducted in Ethiopia
and elsewhere [48–50]. Therefore, this study demonstrates that malnutrition can be reduced
by increasing the variety of complementary foods. Households should be educated and
encouraged to provide appropriate and varied foods that can satisfy the need for energy and
nutrients for the infant. Since a large number of cattle are owned by the pastoral group, supply-
ing milk for their children is imperative.
Several projects have been implemented in Ethiopia to tackle malnutrition. One of the strat-
egies was PSNP. However, the wealthier households are more likely to benefit from the PSNP
than poorer households in Afar region [51]. The present finding indicated that PSNP didn’t
help in reducing stunting among children. The possible justification might be, the right target
groups for such kinds of interventions, which are poor households were not sufficiently
addressed in the program. Hence, to bring plausible effects on health and nutrition, addressing
the target groups is very crucial.
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 11 / 15
The research has the limitations set out below. Due to the cross-section design of the
research, we cannot declare a temporal association between stunting and other independent
variables. Standard height/length measurement procedures have been used, but measurement
errors, particularly among evaluators, are unavoidable. Besides, recall bias can occur in chil-
dren who live in rural villages to report the age of the child. Nevertheless, if available, we have
attempted to confirm the age stated in the immunization card.
Conclusion
In conclusion, in the pastoralist community, the stunting situation was critically high, sug-
gesting that stunting is still an issue of public health. The study found that stunting was
linked to various nutrition-specific and non-nutrition-specific factors. Childhood age,
household economic status, early initiation of breastfeeding, exclusive breastfeeding, and
source of water supply. It is recommended to improve the economic status of households by
preserving animal welfare and diversifying sources of income, by supporting optimal feeding
practices for infants and young children, by complying with the WHO and national breast-
feeding and complementary feeding guidelines. Protecting existing sources of water from
potential pollution and increasing the coverage of safe sources of water in the region are also
significant. Findings also suggest the importance of addressing income inequality when
implementing nutrition strategies. According to the findings, comprehensive action on the
underlying factors, such as economic status and access to improved water sources, is needed
to achieve the SDG targets related to child nutrition. Otherwise, Ethiopia will falter to meet
and an economic and health burden in the future generation will be inevitable. Generally,
the findings of this study revealed that the etiologic factors of stunting are multifactorial.
This means that implementing initiatives in a piecemeal fashion will significantly contribute
to the persistence of malnutrition. A systematic and organized approach is thus needed for
addressing the multiple and interconnected determinants of stunting throughout an individ-
ual’s life cycle. The Countermeasures should be optimized according to evidence observed in
the nomadic community, contextually with their way of life and socioeconomic status.
Supporting information
S1 Table. Afar version questionnaire.
(DOCX)
S2 Table. English version questionnaires.
(DOCX)
S1 Dataset.
(SAV)
Acknowledgments
The authors would like to extend their grateful acknowledgments to the University of Gondar,
College of Medicine and Health Sciences, Institute of Public Health for providing ethical clear-
ance. We also would like to appreciate the Afar Regional Health Bureau for facilitating the data
collection process. Finally, we would like to extend our cordial appreciation to all the partici-
pants and data collectors.
Author Contributions
Conceptualization: Mulugeta Gebreayohanes, Awrajaw Dessie.
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 12 / 15
Data curation: Awrajaw Dessie.
Formal analysis: Mulugeta Gebreayohanes, Awrajaw Dessie.
Investigation: Mulugeta Gebreayohanes, Awrajaw Dessie.
Methodology: Mulugeta Gebreayohanes, Awrajaw Dessie.
Project administration: Mulugeta Gebreayohanes, Awrajaw Dessie.
Resources: Mulugeta Gebreayohanes.
Software: Mulugeta Gebreayohanes, Awrajaw Dessie.
Supervision: Awrajaw Dessie.
Visualization: Awrajaw Dessie.
Writing – original draft: Awrajaw Dessie.
Writing – review & editing: Mulugeta Gebreayohanes, Awrajaw Dessie.
References
1. Olack B, et al. (2011) Nutritional Status of Under-five Children Living in an Informal Urban Settlement in
Nairobi, Kenya. Journal of Health, population, and nutrition 29(4): 357–363. https://doi.org/10.3329/
jhpn.v29i4.8451 PMID: 21957674
2. CSA, ICF a (2012) 2011 Ethiopian Demographic and Health Survey Findings. Calverton, Maryland,
USA: CSA and ICF International.
3. Mercedes de Onis FB (2016) Childhood stunting: a global perspective. Matern and Child Nutrition.
4. Mihret J TA (2014) Disaster Risk Management and Sustainable Development Department. Bahirdar
University. Bahirdar, Ethiopia.
5. Yisak H, Gobena T, Mesfin F (2015) Prevalence and risk factors for under nutrition among children
under five at Haramaya district, Eastern Ethiopia. BMC Pediatrics 15: 212. https://doi.org/10.1186/
s12887-015-0535-0 PMID: 26675579
6. Burney T, Martinez M, Nnamdi K (2014) Achieving Food and Nutrition Security in Ethiopia. Findings
from the CARE Learning Tour to Ethiopia. 1825 Street, NW, Suite 301.Washington, DC. pp. 3–15.
7. WHO (2016) Levels and Trends in Child malnutrition. UNICEF / WHO / World Bank Group Joint Child
Malnutrition Estimates Key findings of the 2016 edition; http://www.who.int/nutgrowthdb/estimates.
8. Group ADB (2015) Federal Democratic Republic of Ethiopia Country paper 2016–2020.
9. CSA, ICF a (2017) Ethiopia Demographic and Health Survey 2016.
10. EDHS (2014) Ethiopia Mini Demographic and Health Survey. Addis Ababa, Ethiopia. 52–57 p.
11. IFPRI (2016) Global nutrition report 2016: From promise to impact: Ending malnutrition by 2030. Inter-
national Food Policy Research Institute Washington, DC.
12. Organization WH (2014) Global nutrition targets 2025: policy brief series (WHO/NMH/NHD/14.2).
Geneva: World Health Organization.
13. UN-DESA (2017) The Sustainable Development Goals Report 2017.
14. MoH (2015) Health Sector Transformation Plan (HSTP) 2015/16–2019/20. Addis Ababa,
Ethiopia. pp. 3–40.
15. Sarson M (2013) ECHO Support to Community Management of Malnutrition Vital for Children’s Health
in Ethiopia. 1–2.
16. Udoh EE, Amodu OK (2016) Complementary Feeding Practices among mothers and Nutritional Status
of Infants in Akpabuyo Area Cross River State Nigeria. Springerplus 5: 2073. https://doi.org/10.1186/
s40064-016-3751-7 PMID: 28018781
17. Center DWH (2016) Dubti Woreda Health Center 2016 Annual Report.
18. Legesse M, Abuhay T, Haile Y (2016) Determinants of Child Malnutrition among Agro Pastorals in
Northeastern Ethiopia: A cross—sectional Study. Southern east Ethiopia. Health Science Journal
10: 15.
19. World Health Organization (1995) Physical status: The use of and interpretation of anthropometry,
Report of a WHO Expert Committee: World Health Organization.
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 13 / 15
20. FAO Tropical Livestock Units (TLU). [cited 2019 January 26]; htttp://www.fao.org/ag/againfo/
programmes/en/lead/toolbox/Mixed1/TLU.htm#Exchange.
21. Gualu T, Dilie A (2017) Vaccination coverage and associated factors among children aged 12–23
months in debre markos town, Amhara regional state, Ethiopia. Advances in Public Health 2017.
22. Alam MA, Richard SA, Fahim SM, Mahfuz M, Nahar B, et al. (2020) Impact of early-onset persistent
stunting on cognitive development at 5 years of age: Results from a multi-country cohort study. PloS
one 15: e0227839. https://doi.org/10.1371/journal.pone.0227839 PMID: 31978156
23. De Onis M, Blo
¨ssner M, Borghi E, Frongillo E, Morris R (2003) WHO global database on child growth
and malnutrition. Geneva: WHO.
24. Central Statistical Agency [Ethiopia], ICF International (2016) Ethiopia Demographic and Health Survey
2016. Addis Ababa, Ethiopia and Calverton, Maryland, USA.
25. Mengistu K, Alemu K, Destaw B (2013) Prevalence of malnutrition and associated factors among chil-
dren aged 6–59 months at Hidabu Abote District, North Shewa, Oromia Regional State. J nutr disorders
ther 1: 1–15.
26. Asfaw M, Wondaferash M, Taha M, Dube L (2015) Prevalence of undernutrition and associated factors
among children aged between six to fifty nine months in Bule Hora district, South Ethiopia. BMC Public
Health 15: 41. https://doi.org/10.1186/s12889-015-1370-9 PMID: 25636688
27. Fentaw R, Bogale A, Abebaw D (2013) Prevalence of child malnutrition in agro-pastoral households in
Afar Regional State of Ethiopia. Nutrition Research and Practice 7: 122–131. https://doi.org/10.4162/
nrp.2013.7.2.122 PMID: 23610605
28. Alemayehu M, Tinsae F, Haileslassie K, Seid O, Gebregziabher G, et al. (2014) Nutritional status and
associated factors among under-five children, Tigray, Northern Ethiopia. Int J Nutr Food Sci 3: 579–
586.
29. Geberselassie SB, Abebe SM, Melsew YA, Mutuku SM, Wassie MM (2018) Prevalence of stunting and
its associated factors among children 6–59 months of age in Libo-Kemekem district, Northwest Ethio-
pia; A community based cross sectional study. PloS one 13: e0195361. https://doi.org/10.1371/journal.
pone.0195361 PMID: 29723280
30. Demissie S, Worku A (2013) Magnitude and factors associated with malnutrition in children 6–59
months of age in pastoral community of Dollo Ado district, Somali region, Ethiopia. Science Journal of
Public Health 1: 175–183.
31. Zewdu S (2012) Magnitude and factors associated with malnutrition of children under five years of age
in Rural Kebeles of Haramaya, Ethiopia. Harar Bulletin of Health Sciences 4: 221–232.
32. Tadesse SE, Mekonnen TC (2020) Prevalence and Associated Factors of Stunting Among Children
Aged 6–59 Months in Delanta District; North East Ethiopia. Nutrition and Dietary Supplements 12:
41–48.
33. World Health Organization (2009) Infant and young child feeding: model chapter for textbooks for medi-
cal students and allied health professionals.
34. Huriah T, Fitriami E, Rahman A. The Prevalence and Associated Factors of Stunting Children in Rural
Area, Yogyakarta, Indonesia; 2019. Atlantis Press.
35. Kinyoki DK, Moloney GM, Uthman OA, Odundo EO, Kandala N-B, et al. (2018) Co-morbidity of malnu-
trition with falciparum malaria parasitaemia among children under the aged 6–59 months in Somalia: a
geostatistical analysis. Infectious Diseases of Poverty 7: 72. https://doi.org/10.1186/s40249-018-0449-
9PMID: 29986753
36. Alemayehu M, Tinsae F, Haileslassie K, Seid O, Gebregziabher G, et al. (2015) Undernutrition status
and associated factors in under-5 children, in Tigray, Northern Ethiopia. Nutrition 31: 964–970. https://
doi.org/10.1016/j.nut.2015.01.013 PMID: 26059369
37. Takele K, Zewotir T, Ndanguza D (2019) Understanding correlates of child stunting in Ethiopia using
generalized linear mixed models. BMC Public Health 19: 626. https://doi.org/10.1186/s12889-019-
6984-x PMID: 31118013
38. Kandala NB, Lang S, Klasen S, Fahrmeir L (2001) Semiparametric analysis of the socio-demographic
and spatial determinants of undernutrition in two African countries. Research in Official Statistics: 81–
100.
39. Takele K, Taye A (2014) Bayesian modelling of growth retardation among children under-five years old.
Far East Journal of Theoretical Statistics 48: 87–109.
40. Central Statistical Agency [Ethiopia], ORC Macro (2006) Central Statistical Agency: Ethiopia demo-
graphic and health survey 2005.
41. Muldiasman M, Kusharisupeni K, Laksminingsih E, Besral B (2018) Can early initiation to breastfeeding
prevent stunting in 6–59 months old children? Journal of Health Research 32: 334–341.
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 14 / 15
42. Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, et al. (2008) Maternal and child undernutrition:
global and regional exposures and health consequences. The lancet 371: 243–260. https://doi.org/10.
1016/S0140-6736(07)61690-0 PMID: 18207566
43. Sanghvi T, Martin L, Hajeebhoy N, Abrha TH, Abebe Y, et al. (2013) Strengthening systems to support
mothers in infant and young child feeding at scale. Food and nutrition bulletin 34: S156–S168. https://
doi.org/10.1177/15648265130343S203 PMID: 24261074
44. Gebre A, Reddy PS, Mulugeta A, Sedik Y, Kahssay M (2019) Prevalence of malnutrition and associated
factors among under-five children in pastoral communities of afar regional state, Northeast Ethiopia: A
community-based cross-sectional study. Journal of nutrition and metabolism 2019. https://doi.org/10.
1155/2019/9187609 PMID: 31275645
45. Chirande L, Charwe D, Mbwana H, Victor R, Kimboka S, et al. (2015)Determinants of stunting and
severe stunting among under-fives in Tanzania: evidence from the 2010 cross-sectional household sur-
vey. BMC pediatrics 15: 165. https://doi.org/10.1186/s12887-015-0482-9 PMID: 26489405
46. Giashuddin M, Kabir M, Rahman A, Hannan M (2003) Exclusive breastfeeding and nutritional status in
Bangladesh. The Indian Journal of Pediatrics 70: 471–475. https://doi.org/10.1007/BF02723136 PMID:
12921314
47. Fikadu T, Assegid S, Dube L (2014) Factors associated with stunting among children of age 24 to 59
months in Meskan district, Gurage Zone, South Ethiopia: a case-control study. BMC Public Health 14:
800. https://doi.org/10.1186/1471-2458-14-800 PMID: 25098836
48. Khamis AG, Mwanri AW, Ntwenya JE, Kreppel K (2019) The influence of dietary diversity on the nutri-
tional status of children between 6 and 23 months of age in Tanzania. BMC pediatrics 19: 518. https://
doi.org/10.1186/s12887-019-1897-5 PMID: 31881999
49. Motbainor A, Worku A, Kumie A (2015) Stunting is associated with food diversity while wasting with
food insecurity among underfive children in East and West Gojjam Zones of Amhara Region, Ethiopia.
PLoS one 10: e0133542. https://doi.org/10.1371/journal.pone.0133542 PMID: 26285047
50. Arimond M, Ruel MT (2004) Dietary diversity is associated with child nutritional status: evidence from
11 demographic and health surveys. The Journal of nutrition 134: 2579–2585. https://doi.org/10.1093/
jn/134.10.2579 PMID: 15465751
51. Lind J, Sabates-Wheeler R, Hoddinott JF, Taffesse AS (2018) Targeting social transfers in pastoralist
societies: Ethiopia’s productive safety net programme revisited: Intl Food Policy Res Inst.
PLOS ONE
Stunting and its determinants in pastoral community
PLOS ONE | https://doi.org/10.1371/journal.pone.0256722 February 3, 2022 15 / 15
Available via license: CC BY
Content may be subject to copyright.
