Concurrent stunting among under-five children in Egypt

Introduction

Undernutrition is a significant predictor of poor growth and morbidity in infants and young children.¹ Globally, stunting (low height for age) affects 150 million children under the age of five, a substantial portion of the world’s young population.¹ Previous studies have shown that stunting can result in delayed cognitive development, poor school performance, and ultimately lower future earning potential, perpetuating poverty.^2,3 The consequences, of stunting particularly in low- and middle-income countries, are far-reaching, leading to impaired growth, reduced educational attainment, delayed school enrolment, and a 20% reduction in adult income.^4–6 Reducing undernutrition among young children is one of the targets of the Sustainable Development Goal aimed at eradicating extreme poverty and zero hunger. It is also an important strategy to reduce child mortality, the fourth SDG.⁷

In Egypt, approximately one-third of children under the age of five are affected by stunting.^8,9 With one in every five children in Egypt stunted, the country ranks among those with the second highest rates of stunting in the North African region.^9–11 In 2013, the economic and social cost of child malnutrition in Egypt was substantial, estimated to be 20.3 billion Egyptian Pounds, equivalent to about 2% of the Egyptian GDP.¹² Therefore, addressing undernutrition is important not only for public health, but also for enhancing the country long-term economic growth and social stability. Economic growth is an effective instrument for poverty alleviation and improving public health.^13–15

In response to the need for improved undernutrition in Egypt, the Egyptian government has developed several initiatives and programs aimed at addressing this issue, especially among vulnerable populations such as children and women.¹⁶ These initiatives include the National Nutrition Strategy (2017-2030), Food Subsidy Programs, akamol and Karama Programs, the Scaling Up Nutrition (SUN) Movement, Micronutrient Supplementation, and collaborations with international organisations.¹⁶ Despite the previous efforts by the Egyptian government, undernutrition still represents a significant problem in Egypt. Challenges are further exacerbated by high unemployment rates, poverty, inequality, civil unrest, and climate change-induced natural disasters, all threatening food security and individuals’ nutritional status.^17–20

There have been several past studies assessing child stunting in Egypt.^10,21,22 For instance, one study examined the prevalence and factors associated with stunting among school children (6-24 months) in Minia city in Upper Egypt and found that low birth weight of children, short stature of the mothers (≤160 cm) and low maternal education were associated with stunting²¹ and similarly, a study conducted in Sohag, Egypt on stunting in schoolchildren found low maternal body mass index and familial short stature was the key drivers of stunting.²² A population based cross-sectional studies conducted in Upper and Lower Egypt found that stunting peaked at 12–23 months.¹⁰

However, these studies were limited in scope as it covered a smaller section in Egypt, children aged, 6-23 months²¹ and 4-12 years (school age) in just two schools in one governorate.²² Another past study assessed a cross-country study by Pritchett and Summers¹³ used time series data and instrumental variables to demonstrate that as national income increases, population health tends to improve, and conversely, wealthier countries tend to have better health outcomes. Despite significant efforts to address the problem of stunting in Egypt, several factors may contribute to the current situation. Factors include the lack of up-to-date nutritional data, inadequate training for healthcare professionals, a focus on treatment over prevention, and limited studies on ecological factors associated with nutritional issues.²³

Therefore, this study aimed to investigate stunting among children aged 0-23, 24-59 and 0-59 months in Egypt and explore associated factors by pooling the 2005, 2008, and 2014 EDHS. The study will contribute to the growing body of evidence that informs national government institutions, public health researchers, and policymakers working to address the underlying factors associated with child stunting in Egypt. It stands out from previous research on stunting among children in Egypt due to its unique focus on combining data sets from 2005 to 2014. The study utilises population-based national representative data and provides age-specific results by examining the prevalence of stunting in three age groups: 0-23 months, 24-59 months, and 0-59 months across the three-survey data.

Method

Results

Prevalence of stunting

The difference in the prevalence of stunting among children aged 0-23 months in Egypt, based on surveys conducted in 2005, 2008, and 2014 is illustrated in Figure 1. Compared to 2005, the prevalence of stunting among young children in Egypt has significantly decreased from 27.6% to 20.8% in 2014 with overall prevalence 24.8 %. For older children 24-59 months, the difference in the stunting rates in Egypt is shown in Figure 2. The prevalence of stunting among children aged 24-59 months in Egypt was a slightly decreased from 22.5% in 2005 to 21.9% in 2014, with an overall prevalence of 24.3%. Nonetheless, the occurrence of stunting in the same age group experienced a substantial rise from 22.5% in 2005 to 30.4% in 2008. The variation in stunting rates among children aged 0-59 months in Egypt, as observed in surveys conducted in 2005, 2008, and 2014, are illustrated in Figure 3. The prevalence of child stunting in Egypt slightly declined from 24.6% in 2005 to 21.5% in 2014 but remained high at 24.5% overall. However, the prevalence of stunting among the same age group significantly increased from 24.6% in 2005 to 28.9% in 2008. Stunting is prevalent among children under five in Egypt with 1 in each 4 children expected to be stunted.

Figure 1. Prevalence and 95% CIs of stunting among children aged (0–23) in Egypt.

Figure 2. Prevalence and 95% CIs of stunting among children aged (24–59) in Egypt.

Figure 3. Prevalence and 95% CIs of stunting among children aged (0–59) in Egypt.

Discussion

The current study determined the prevalence of stunting and associated risk factors with stunting among children aged (0-23, 24-59 and 0-59 months) in Egypt. Findings from the study demonstrate that stunting is a significant concern in Egypt, with a prevalence rate of 24.5%. Although, the EDHS data analysed did show a fluctuating pattern of prevalence for stunting among children under five in Egypt. It was 24.6% in 2005, rose to 28.9% in 2008, and then declined to 21.5% in 2014. The common factors among the three age groups were the survey year, region, wealth index, child age, mother education level and height, birth order, listening to media and ANC. While factors such as mother’s age, marital status, and duration of breastfeeding were associated only with children aged 0-23 months, paternal education level, mother had BMI >25, and mother’s employment in the last 12 months were factors associated with children aged 0-59 months but not with children aged 0-23 months. Chid gender and the Vitamin A supplement were associated with both children aged 0-23 and 0-59 months.

Study findings suggest stunting in Egypt has decreased slightly over the last decade and the declining in stunting can potentially be attributed to the government’s endeavours in addressing undernutrition. The Egyptian government implemented the Agenda for Action Policy Paper (2017-2025) which was prepared for the main purpose of defining a feasible and practical ‘roadmap’ that would transform government-led nutrition policies and programs and mobilise harmonise multi-sector, as well as a multi-stakeholder, support to scaling-up of nutrition actions.³⁸ Central to this process was the formulation of an updated National Nutrition Policy and Strategy which was aligned to important national and global commitments, such as the Egypt Vision 2030, and the Sustainable Development Goals’ “Agenda for action” in 2023, The National Agenda for Sustainable Development Egypt’s Updated Vision 2030 was published with number of strategies, government plans and programs for Egypt to achieve the SDGs by 2030.³⁹ Although various efforts have been made,³⁸ stunting remains a significant issue in Egypt, and several factors may contribute to its persistence. For example, the lack of regular data collection is a critical challenge as the last EDHS was conducted in 2014, nearly a decade ago.⁴⁰ The lack of updated, monitoring and assessment data hampers the ability to clearly understand and detect problems earlier, as well as to assess the effectiveness of existing policies. This makes it challenging to identify issues promptly and implement effective preventive measures. Therefore, it is crucial to advocate for and invest in the comprehensive and consistent collection of nationally representative data as an integral part of new policies.

Furthermore, other factors that can exacerbate undernutrition or hinder Egypt’s efforts to address the issue include the widespread levels of inequality and poverty. Poverty in Egypt affected a substantial portion of the population in 2015, with 27.8% living in poverty and an additional 28.7% at risk of becoming impoverished.¹⁸ In a study carried out in 2020, it was emphasized that Egypt faces deep-rooted inequalities in multiple domains, including income, wealth, education, gender, employment, and health. These disparities have persisted and even worsened over time.⁴¹ Children from lower socioeconomic background have less access to quality healthcare, nutritious food, safe living conditions, and educational opportunities, which leads to poorer health outcomes.¹⁸ Poor child health as a result of poverty and inequality has a lasting impact, including lower educational attainment, lower earning capacity, and an increased risk of chronic health disorders in adulthood, continuing a cycle of poverty and poor health throughout generations.^18,41

Furthermore, the study discovered that stunting is more common among children living in rural areas of Upper Egypt, which represents > 30 % of the population when compared to the other five regions. Poverty plays a major role in this trend as approximately 43 % of the population in rural Upper Egypt live below the poverty line that represents the highest percentage in the country. There are significant challenges in this area, such as a low level of education, especially among individuals whose fathers also had limited education. Limited access to healthcare, diverse foods, and nutritional knowledge, due to educational, economic, geographic, and gender disparities, worsens the risk of malnutrition among vulnerable populations.¹⁸ A recent report states that over half of the population in Egypt’s rural Upper Egypt is currently facing challenges in meeting their basic needs, including both food and non-food essentials. According to the results of the Household Income and Expenditure Survey, there has been a decline in poverty rates in rural Upper Egypt as the percentage dropped from 56.7% in 2015 to 51.94% in 2018.⁴² Despite this, the rural area of Upper Egypt region continues to uphold its reputation as the most economically underdeveloped in Egypt. Presently, the current national poverty rate is recorded at 32.5%. In urban governorates, the percentage stands at 26.73%, whereas in urban Lower Egypt, it amounts to 14.31%. In the rural regions of Lower Egypt, the percentage amounts to 27.29%. The African continent, along with other developing nations, is experiencing the destructive consequences of the interconnected issues of malnutrition and poverty.⁴³ Poverty is the main cause of malnutrition, its presence in early life can worsen the cycle of poverty and result in severe and long-lasting health consequences.⁴³

Analysis of the current study indicated that children from the middle wealth households were less prone to being stunted, compared to their counterparts from the richest households, which does not reflect findings from a systematic review conducted in sub-Saharan Africa and Bangladesh.^29,44 Individuals with a higher wealth index have fewer nutritional health issues because they have greater access to high-quality and variety meals, higher levels of health education and awareness, and better healthcare services.^13,45 Wealth also creates a safer living environment, reduces food insecurity and stress, and promotes cultural norms that favour healthy eating. These elements combine to improve the nutritional well-being of wealthy people.¹³

Furthermore, the study findings explored that the increased odds of stunting were associated with mothers who had a low level of education and who worked in the last 12 months. This finding may be attributed to the fact that mothers with a higher education level are more knowledgeable about the advantages of exclusive breastfeeding during the first six months, as well as appropriate nutrition and early feeding practices.^46,47 Mothers of high education attainment may comprehend the significance of timely, frequent, and diverse complementary nutrition, which allows them to make more informed decisions regarding their child’s health status.⁴⁷ In addition, mothers who are educated are more likely to practise good hygiene and are more aware of the importance of regular check-ups and preventive care for their children, as well as healthcare services.^48,49 Education should be considered as an essential issue regarding child stunting for Egypt, like many other developing countries as several studies have reported a better education level as a strong determinant of better health outcomes.^50–52 In consonance with findings from several previous studies such as those from Nigeria,⁵³ Pakistan,⁵⁴ Indonesia and Bangladesh,⁵⁵ and from systematic review studies.^28,29,56 Mothers who have recently entered the workforce may find it challenging to dedicate sufficient time and energy to their children’s care. The return to work for mothers often has a negative impact on consistent breastfeeding. Exclusive breastfeeding rates are higher among mothers who are not employed than those who are employed.⁵⁷ While some studies suggest that maternal employment can positively impact child health due to increased family income,⁵⁸ this dynamic must be considered within the cultural context. In Arab countries like Egypt, the working mother often faces unique challenges. A mother is typically expected to balance her job with family commitments⁵⁹ such as childcare, cleaning, and cooking, while the partner primarily focuses on providing for the family’s external needs. When a mother works, this often leads to an overwhelming burden on her health, as she must juggle multiple roles simultaneously.⁵⁹ The cultural nuance of this situation underscores the importance of understanding cultural and social factors that influence the well-being of both the mother and child.

The study analysis found that the duration of breastfeeding > 12 months was more prevalent among children aged 0-23 and 0-59 months and more associated with children aged 0-23 months Similarly, in Pakistan, a study by Syeda et al. revealed that three-year-old children had a significantly higher risk of stunting compared to two-year-old children who were breastfed during their second year, even after accounting for other factors related to mother, child and health care services. The study also found that the three-year-old children who received breastfeeding until this age exhibited an elevated susceptibility to severe stunting when compared to their two-year-old counterparts.⁶⁰ Furthermore, a cohort study conducted in Sudan found that stunting and wasting were more common among children who received prolonged breastfeeding compared to their well-nourished peers. The variance in height gains at 6 months was slight between children who were breastfed and those who were fully weaned. However, there was a significant decrease in weight gain observed among children who were breastfed, particularly between the ages of 6 and 12 months.⁶¹ Several studies conducted in different countries, including Ghana,^62,63 Sub-Saharan African countries,⁶⁴ and rural Senegal,⁶⁵ had demonstrated a positive correlation between the duration of breastfeeding and the occurrence of stunting, wasting, and underweight. Furthermore, these studies have observed that this correlation strengthens as children grow older. Various factors mentioned by the forementioned studies that may be accountable for the found association, such as the findings of the study conducted in Sudan by Fawzi et al. which found an association between prolonged breastfeeding and stunting and wasting were greater among children of disadvantaged or illiterate mothers compared to those of educated, wealthier mothers. The inverse association is hypothesized to stem from inadequate complementary feeding in breast-fed children relative to weaned children, particularly in families with low incomes.⁶¹ The interpretation of the findings needs to be done so with caution as both the current study and those mentioned above have not considered the dietary quality and energy intake received from oral intake alongside the measure of breastfeeding duration as dietary diversity was not included in the 2005 DHS data. Further investigation is needed to determine the interplay between diet quality, breastfeeding duration, and anthropometric outcomes for children aged over 12 months in Egypt.

Additionally, the study analysis found that inadequate use of vitamin A supplement was associated with stunting in both children aged 0-23 and 0-59 months. Vitamin A is essential for healthy vision, immune system function, and for child growth and development.⁶⁶ The micronutrients deficiency is especially concerning in children, as it may impair growth, immune function, and overall health, thus increasing the risk of undernutrition.⁶⁶ The lack of knowledge regarding the significance of vitamin A and its sources in low socioeconomic communities is a contributing factor affecting vitamin A consumption.¹⁰ A similar result was found by study conduct in Brazil as it found that the probability of children experiencing stunting and anemia decreased by 8% and 31% due to vitamin A supplementation, the intake of vitamin A supplements reduces the risk of stunting.⁶⁷

The likelihood of a child being stunted was found to be higher in those whose mothers had limited or no ANC visits during pregnancy. This was consistent with findings from Ethiopia³⁵ and Zambia.³⁰ Routine ANC is a vital health service for expectant mothers that aims to identify potential obstetric complications, provide guidance on healthy lifestyle choices, pregnancy, and childbirth.⁶⁸ Through regular ANC visits, healthcare providers can detect high-risk pregnancies early, thereby reducing the risk of maternal mortality and closely monitoring the progress of the fetus. The World Health Organisation (WHO) stated that ANC is crucial in reducing pregnancy and childbirth complications, stillbirths, and perinatal deaths through evidence-based actions. Moreover, WHO stated that ANC provides a significant chance to engage with and support women, their families, and communities during a crucial stage in a woman’s life.⁶⁹

The study analysis also revealed that boys were significantly more prone to being stunted than girls, which is in consonance with findings from past studies that show that overall, boys tend to be at greater risk of stunting than girls,⁷⁰ especially in Sub-Saharan Africa and in lower socioeconomic group.⁷¹ This finding may be attributed to the fact that research has consistently shown that boys are more prone to common childhood illnesses like lower respiratory infections, diarrheal disease, and malaria compared to girls.^72,73 Additionally, boys tend to experience higher rates of wasting, and underweight,^70,74 which suggest that boys are more vulnerable to environmental stressors and have higher rates of infectious morbidity and mortality.^75–80 In some societies or regions, the health and well-being of younger females may be prioritised by social values and practices, which may lead to superior nutrition and care for them in comparison to older girls or boys. As a result, some researchers and policymakers recommend targeting interventions towards boys^81,82 or reevaluating the focus on girls and women in nutrition research.^70,74,83,84

Analysis of the current study corroborates this finding, by showing that the odds of stunting among children 0-59 months were significantly higher among children aged 18-41 months. Past studies have revealed that the odds of stunting were higher in older children than in younger ones. For instance, in Myanmar, older children (24-35 months) are more likely to be stunted than those under 6 months⁸⁵ and South Ari District, Southern Ethiopia: a community-based cross-sectional study found that children in the age group of 24–59 months were more prone to stunting than others.⁸⁶ Another cross sectional study targeted four North African countries found the higher prevalence of stunting was among children aged 24-59 months.¹¹ This is most likely due to the cumulative effect of foetal and early childhood development delays. Children who remain stunted after two years have missed the critical window of opportunity to reverse the impacts of poor growth and development, which occurs within the first 1,000 days following conception until age two.⁸⁷ Stunting after two years raises the probability of poor long-term cognitive, educational, and productive results. In contrast, a cross-sectional study of 94 low- and middle-income countries on patterns in child stunting by age observed that Stunting prevalence was higher for younger children until around age 28 months.⁸⁸ Research indicates that genetics has a more significant impact on growth patterns after the age of two, implying that environmental factors have a greater influence on the growth of younger children compared to older children.⁸⁹ One possible explanation for this phenomenon is that as children mature, their immune system becomes more robust, enabling them to better resist pathogens and reducing the impact of environmental stressors on their growth.⁶⁶

The analysis revealed that shorter mothers were more likely to have stunted children. The finding suggests that a mother’s height is a significant factor in determining her child’s birth length, with taller mothers more likely to have longer children and shorter mothers more likely to have shorter children. This indicates a strong genetic link between maternal height and child length.⁹⁰ However, it is also important to note that external factors, such as adequate nutrition, play a crucial role in a child’s growth and development. Ensuring proper nutritional intake is essential to support healthy growth and prevent delays in development, as highlighted by a past.^90,91 This finding was consistent with those of other previous studies from Indonesia,⁹² south Asia⁹³ and Bangladesh.⁹⁴ Furthermore, Children of mothers with a BMI greater than 25 were found to be less likely to suffer from stunting compared to their counterparts. While some studies have highlighted the prevalent coexistence of stunting and maternal overweight,^34,44,95 the risk of child stunting and overweight in the mother-child pair appear to be strongly related to other specific maternal characteristics rather than her BMI. These include shorter maternal height, younger maternal age at birth, lower levels of education, and the household’s economic status, as indicated by the wealth index and the number of household members.⁹⁶ These factors play a critical role in determining the nutritional health and overall well-being of both mother and child.^34,96

To address the prevalence of child stunting in Egypt, particularly in rural areas of Upper Egypt, the following policy actions are recommended: 1) implement targeted interventions focusing on boys and children born to short mothers, who are at higher risk of stunting; 2) ensure universal access to ANC for all pregnant women, prioritising those with limited or no previous ANC visits; 3) provide nutrition counselling and education to mothers, emphasising the importance of adequate feeding practices during pregnancy and early childhood; 4) rural focused initiatives: develop and implement context-specific initiatives addressing the unique challenges faced by rural populations in Upper Egypt; 5) foster collaboration between healthcare, education, and social protection sectors to address the multifaceted determinants of child stunting and 6) establish a robust monitoring and evaluation system to track progress, identify areas for improvement, and adjust policies accordingly.

Although this study has several strengths, including the use of a large sample size, pooling three large population-based dataset which enhances statistical power and allows for comparisons across different studies, it also provides detailed insights into changes in the prevalence of undernutrition and its associated factors among children under five in Egypt. By focusing on specific geographic areas and age groups (0-23 months, 24-59 months, and 0-59 months), a more comprehensive understanding of the distinct challenges and circumstances that contribute to undernutrition will enable for more impactful interventions.

The utilisation of a population-based design and a significant pooled sample size ensure that the collected data correctly reflect the total population within the designated area. This strategy enhanced the validity and reliability of results by minimising selection bias and facilitating more precise calculations of prevalence and connections. However, this study was not without its limitations. MICS surveys primarily focus on cross-sectional data collection, limiting the ability to establish causal relationships or understand the dynamic factors contributing to undernutrition. Furthermore, cross-sectional statistics rely on self-reported data, which can be influenced by recall or social desirability biases, leading to inaccuracies. Ultimately, it is important to consider the possibility of unaccounted confounding variables affecting the results of the study. As an example, it should be noted that the study findings regarding breastfeeding and Vitamin A supplement could have been clearer if dietary intake variables for the Infant and young child feeding indicators were included. However, due to the unavailability of data about dietary intake in the EDHS 2005, this was not possible.

Conclusions

Child stunting is a significant public health challenge in Egypt, necessitating focused interventions based on critical risk factors. The current study found the length and the lack of ANC visits were significant factors, highlighting the critical role of maternal healthcare and nutrition. Similarly, this study found boys are more impacted, indicating a necessity for gender-sensitive initiatives. Successful stunting reduction necessitates a comprehensive strategy that incorporates maternal healthcare, nutrition, and educational programs. Improved access to and quality of ANC, poverty reduction, and enhanced healthcare in disadvantaged regions are essential. Furthermore, enduring investments in infrastructure, community-oriented nutritional initiatives, and social safety nets are crucial for sustainable growth and development. Ongoing research and systematic national data collecting will facilitate the monitoring and enhancement of these treatments.

Ethical statement

EDHS ethical clearance was obtained from the Inner-City Fund (ICF) International, and permission to use the data was obtained from ICF International for this study. This study used existing EDHS data sets and did not involve interaction with the participants. A re-analysis was performed with the participants’ original consent. Thus, no further consent was obtained from the participants.