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Research Article
Revised

Concurrent stunting among under-five children in Egypt

[version 3; peer review: 2 approved with reservations]
PUBLISHED 20 May 2025
Author details Author details
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This article is included in the Global Public Health gateway.

Abstract

Background

Globally, stunting remains a significant public health challenge, particularly in low- and middle-income countries. In Egypt, it affects approximately 33% of children under five and contributes to a 2–3% reduction in the country’s gross domestic product. Therefore, this study examined the trends in the prevalence of stunting and its associated factors among children under five and 0-59 months in Egypt.

Methods

This survey used combined data from the 2005, 2008, and 2014 Egypt Demographic and Health Surveys (EDHS), with a total sample of 39,857 children aged 0-59 months. A multilevel logistic regression that adjusts for sampling weights and clustering was performed to analyse the factors associated with stunting among children in Egypt.

Results

The prevalence of stunting was 24.8% in children aged 0-23 months, 24.3% in children aged 24-59 months, and 24.5 % in children aged 0-59 months. After controlling for potential confounders, the common factors associated with stunting in three age groups were mothers with primary education and mothers who did not have an antenatal care (ANC) visit during pregnancy. Maternal short stature (height < 155 cm) was associated with an increased risk of stunting in three age groups compared to mothers taller than 160 cm.

Conclusion

A coordinated approach across health, WASH, education, and social protection is essential to address stunting in Egypt. Interventions should target high-risk groups, particularly those with low socioeconomic status, focusing on healthcare access, parental education, and infant feeding practices. While short maternal height increases risk, interventions must also tackle broader factors like food security and sanitation. A nutrition monitoring framework integrated into health systems will enable data collection, evidence-based actions, and progress tracking. Effective implementation requires cost-effective, scalable solutions, community involvement, and resource prioritisation to ensure sustainability and equity.

Keywords

Undernutrition, childhood, 0-59 months, Growth defect, North Africa

Revised Amendments from Version 2

The most important updates include the identification of inadequate use of vitamin A supplements as a factor associated with stunting, as presented in the results in the final table. Relevant results throughout the manuscript have been reviewed and updated accordingly. Furthermore, additional discussion has been included to explain the rise in stunting observed in Egypt in 2008, as well as the finding that children from middle-income households were less likely to be stunted.

See the authors' detailed response to the review by Godana Arero Dassie
See the authors' detailed response to the review by Arlette Suzy Setiawan

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.46 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.911 In 2013, the economic and social cost of child undernutrition 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.1315

In response to the need for improved undernutrition in Egypt, several initiatives and programs were developed to address 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 Undernutrition problem still prevalent and the 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.1720

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 pre-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

Data source

Analysis utilised data from the EDHS conducted in 2005, 2008, and 2014. The surveys were implemented by El-Zanaty and Associates on behalf of the Ministry of Health and Population and the National Population Council, as part of the global MEASURE DHS project funded by the United States Agency for International Development (USAID). The 2005, 2008, and 2014 EDHS received primary funding from USAID/Cairo, with additional support from UNICEF and the United Nations Population Fund (UNFPA). The datasets were downloaded from www.dhsprogram.com after completing the registration process.

Study area

Administratively, Egypt is divided into 26 governorates and Luxor City. The four Urban Governorates (Cairo, Alexandria, Port Said, and Suez) have no rural population. Each of the other 22 governorates is subdivided into urban and rural areas. Nine of these governorates are located in the Nile Delta (Lower Egypt), eight are located in the Nile Valley (Upper Egypt), and the remaining five Frontier Governorates are located on the eastern and western boundaries of Egypt.24

Sample selection

This study analysed data from the EDHS for 2005 (n=13,599), 2008 (n=10,590), and 2014 (n=15,668), focusing on children aged 0-59 months. The sample design was multistage sampling design enabled the estimation of key population and health indicators, including fertility and mortality rates, for Egypt, six major regions, and individual governorates. The sample size was disproportionately distributed throughout these areas to provide for regional and governorate-level estimates. The EDHS sample was chosen using a three-stage approach. Initially, primary sampling units (PSUs), which included shiakhas/towns in urban areas and villages in rural areas, were chosen from a list drawn from the 1996 census and then updated to August 2004 for the 2005 survey and to 2006 for both the 2008 and 2014 surveys. The units were geographically stratified, with smaller units merging to form larger units with a population of at least 5,000. During the second stage, complete maps of the selected primary sampling units (PSUs) were used to divide them into groups of about 5,000 people. A fast enumeration was used to assess household quantities, followed by a quality assurance verification in 10% of the regions. A systematic random sample of households was eventually selected. The survey covered all ever-married women aged 15 to 49 who lived or were present in the sampling households the night before the interview.

Outcome variable

The outcome variable for this study was stunting, which was determined by the height-for-age Z-score (HAZ). Children whose height-for-age is less than -2 standard deviations from the corresponding reference median (Z score ≤ -2) were categorised as stunted. Stunting is an indicator of linear growth retardation and reflects cumulative growth deficits in a child. The HAZ is calculated based on the 2006 WHO growth reference, which compares a child’s height to the median height of a healthy child in the same age group or reference population.25 It is expressed in terms of the number of standard deviations (SD) above or below the median height.25

Potential covariates

The UNICEF conceptual framework of the determinants of nutritional status for mother and child health26 guided the selection of covariate variables, with adjustments based on a previous study conducted in 35 low- and middle-income countries.27 The covariates were categorised into three major categories.

Basic factors include governance, resources, and norms area of residence (urban/rural), region (Urban governates, Urban (lower Egypt), Rural (Lower Egypt), Urban (Upper Egypt), Rural (Upper Egypt) and Frontier Governates).

Underlying factors include socioeconomic factors (household wealth quantile, child’s sex, child’s age, maternal age, father age, maternal age at childbirth, age at first cohabitation/married, mother and father level of education, mother work in the last 12 months, father occupation, maternal marital status, religion, household members, number of children < 5 and combined birth rank and birth interval), mother’s health (mother height, maternal body mass index (BMI), maternal autonomy (money, care and movement), health care services factors (combined Place of birth and mode of delivery, delivery assistants, number of ANC visits and postnatal checkup, recent vitamin A supplement, ever had vaccination) and household environmental factors (sources of drinking water, stool disposal, and toilet facility and access to media).

Immediate factors include child health (perceived child size at birth, diarrhoea, fever and cough) and breastfeeding practices (early initiation of breastfeeding and duration of breastfeeding).

Multiple previous studies have consistently highlighted the relationship between these factors and child anthropometric failure. Previous studies have identified a significant association between child anthropometric failures and factors such as household wealth index,11,2832 child age and gender,11,31,33 maternal nutritional health,11,21,29,31,32,34 maternal reproductive care,28,35 family desired birth spacing,11,31 and household environment2833

When considering household income and expenses, the “Household Wealth Quantile” serves as a quantitative indicator of a household’s financial status. The Principal Components Analysis (PCA) approach establishes the quantitative representation of household assets. A score was assigned to every authorised household member once this calculation was performed, in order to ascertain their position in the population. This study classified wealth into five categories at the national level: poorest, poorer, middle, fourth, and richest. The lowest 40% of households consisted of the poorest and poorest households, followed by the middle-class households comprising the next 20%, and the top 40% constituted the fourth and richest households.27

Some covariate factors (combined Place of birth and mode of delivery, combined birth rank and birth interval) were grouped together due to the significant associations between them, as identified and applied in previous research studies.36,37

Statistical analysis

In our analysis, we examined factors associated with stunting from each EDHS 2005,2008 and 2014 surveys to determine the strength of the association of each characteristic in relation to the likelihood of stunting in Egypt. The outcome variable for the final logistic regression models is the presence or absence of stunting (Y = 1 = stunted, 0 = not stunted). For each survey, frequency was used to describe the characteristics of the study population and to estimate the prevalence of stunting. The chi-square test was used for categorical variables. Univariate analyses were used to examine distributions and normality of continuous predictors. Bivariate analyses were performed using Pearson’s chi-square, to test differences in frequencies of categorical variables and t-tests for differences in means of continuous variables. Variables found to be significant at the p < 0.05 were included in the final multivariable analysis models.

All statistical analyses were carried out using STATA/MP Version.17.0 (Stata Corp, College Station, TX, USA), (https://blog.stata.com/2021/04/20/stata-17-released/), and adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) obtained from the adjusted multivariate regression were used to measure the factors associated with child stunting. The prevalence of stunting was estimated in each survey. A total prevalence estimate (unweighted by year of the survey) was also generated for each year.

Results

Characteristics of the sample

The current study involved 39,857 children aged under five years: 13,599 from the 2005 EDHS, 10,590 from the 2008 EDHS and 15668 from the 2014 EDHS. The basic characteristics of the samples in three surveys are displayed in Table S1 (Extended Data). More than one half of the children in each survey lived in rural areas (64%, 63% and 69% in 2005 EDHS, 2008 EDHS and 2014 EDHS respectively). Across the three surveys, the minority of children were from the poorest households, and the ratio of males to girls was almost the same. More than one half of the mothers were aged between 25 and 34 years, while the majority of fathers were aged 18-34 years across the three surveys. Other variables which were in the majority across the three surveys included: married mothers, parents with secondary education, non-working mothers, fathers working in non-agricultural sector, mothers who had money, movement and healthcare autonomy, who were Muslim, who had BMI > 25 who listened to the radio, watched the television and never read any newspaper or magazine, who attended more than 8 ANC clinics, who were delivered by health professionals, who put their babies to the breast within one hour of delivery and who breastfed their babies for more than 12 months; households with members between 5 and 10, having between 2 and 3 children being aged under 5 years, having access to protected water source, with safe stool disposal and improved toilet facility; and children who were not given vitamin A supplement medication and who had not contracted diarrhoea, fever and cough in the two weeks prior to the survey.

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.

247deb11-b4d0-4bab-957e-a3d75adad752_figure1.gif

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

247deb11-b4d0-4bab-957e-a3d75adad752_figure2.gif

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

247deb11-b4d0-4bab-957e-a3d75adad752_figure3.gif

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

Prevalence of stunting by factors

Table 1 presents the prevalence of stunting among Egyptian children aged 0-23 months, 24-59 months, and 0-59 months, in relation to the fundamental, underlying, and immediate variables. Stunted children across all three age groups (0-23 months, 24-59 months, and 0-59 months) were more prevalent among those residing in rural upper Egypt, hailing from low-income families, having mothers under 18 years of age, being the fourth child in birth order, having mothers with limited media exposure (minimal listening and viewing), being born at home via non-cesarean delivery, lacking maternal ANC visits, and having mothers who are illiterate. For detailed information regarding the prevalence of stunting within certain age groups (0-23, 24-59, and 0-59 months) based on the three primary categorical factors, refer to supplementary Table S2 (Extended Data).

Table 1. Prevalence of stunting among children (0-23, 24-59 and 0-59 months) in Egypt by the basic, underlying and immediate factors.

VariablesChildren (0-23 months) stunting +ve prevalenceChildren (24-59 months) stunting +ve prevalence Children (0-59 months) stunting +ve prevalence
Basic factors
Area of residence
Urban25.7 [24.1,27.5]22.7 [21.1,24.4]24.0 [22.6,25.3]
Rural24.4 [23.1,25.7]25.1 [23.8,26.5] *24.8 [23.7,25.9]
Region
Urban Governates23.0 [20.6,25.6]19.8 [17.5,22.2]21.1 [19.3,23.1]
Urban (lower Egypt)29.1 [25.5,33.0]23.6 [20.6,26.8]25.8 [23.3,28.6]
Rural (Lower Egypt)21.8 [19.9,23.7]21.7 [19.9,23.7]21.7 [20.1,23.4]
Urban (Upper Egypt)26.0 [23.0,29.2]25.6 [22.7,28.9]25.8[23.1,28.6]
Rural (Upper Egypt)27.3 [25.5,29.1] ***28.9 [27.1,30.8] ***28.2 [26.7,29.9] ***
Frontier Governates25.4 [21.7,29.5]16.7 [13.1,20.9]20.2 [17.2,23.7]
Underlying factors
Socioeconomic factors
Wealth Index
Richest25.1 [23.1,27.2]22.0 [20.1,24.0]23.3 [21.8,24.9]
Fourth24.0 [22.1,26.0]22.4 [20.7,24.3]23.1 [21.7,24.6]
Middle22.1 [20.2,24.1]21.3 [19.5,23.2]21.6 [20.1,23.2]
Second26.3 [24.3,28.5]26.0 [24.0,28.1]26.1 [24.5,27.9]
Poorest27.4 [25.3,29.7] **30.4 [28.6,32.4] ***29.2 [27.8,30.8] ***
Sex of baby
Boy27.9 [26.5,29.3] ***24.9 [23.6,26.1]26.1 [25.1,27.2] ***
Girl21.6 [20.4,22.9]23.7[22.5,24.9]22.8 [21.9,23.8]
Child age (months)
0-521.5 [19.6,23.6]21.5 [19.6,23.6]
6-1122.3 [20.7,24.0]22.3 [20.7,24.0]
12-1724.3 [22.6,26.1]24.3 [22.6,26.1]
18-2331.0 [29.1,32.9] ***31.0 [29.1,32.9] ***
24-2926.9 [25.1,28.7]26.9 [25.1,28.7]
30-3527.8 [25.9,29.7] ***27.8 [25.9,29.7]
36-4125.6 [23.7,27.6]25.6 [23.7,27.6]
42-4724.0 [22.2,25.9]24.0 [22.2,25.9]
48-5318.9 [17.3,20.7]18.9 [17.3,20.7]
54-5921.7 [19.9,23.7]21.7 [19.9,23.7]
Mother's age (years)
15-2426.0 [24.5,27.6] *25.9 [24.1,27.8]26.0 [24.7,27.3] **
25-3423.8 [22.6,25.1]24.1 [22.9,25.3]24.0 [23.0,25.0]
35-4925.5 [23.1,28.0]23.3 [21.7,25.0]23.9 [22.5,25.4]
Father’s age (years)
18-3425.0 [23.8,26.3]25.6 [24.2,27.0] **25.3 [24.3,26.4]
35-4424.2 [22.8,25.7]23.3 [22.1,24.5]23.6 [22.6,24.7]
45+25.8 [22.9,29.0] **22.6 [20.7,24.6]23.5 [21.9,25.2]
Maternal age at childbirth (years)
Less than 2028.2 [25.6,31.0]26.5 [24.2,28.9]27.2 [25.3,29.1] **
20-2924.7 [23.6,25.9]24.1 [22.9,25.3]24.4 [23.4,25.3]
30-3923.2 [21.5,25.0]23.9 [22.4,25.6]23.6 [22.4,24.9]
40+29.8 [23.9,36.6] **22.0 [17.8,27.0]25.0 [21.3,29.1]
Mother's marital status
Married24.7 [23.7,25.7]24.4 [23.3,25.4] *24.5 [23.6,25.4]
Not married38.6 [29.2,49.1] **19.5 [15.5,24.3]25.2 [21.2,29.7]
Age at first cohabitation/married
<18 years26.6 [24.9,28.4] **27.0 [25.6,28.6] ***26.9 [25.6,28.2] ***
>18 years24.2 [23.0,25.3]23.1 [22.0,24.3]23.6 [22.6,24.5]
Maternal education
Higher21.6 [19.4,24.0]22.3 [20.2,24.7]22.0 [20.3,23.8]
Secondary23.7 [22.4,25.0]22.0 [20.8,23.2]22.7 [21.7,23.7]
Primary29.3 [26.4,32.3] ***27.0 [24.5,29.7]27.9 [25.8,30.1]
No education27.6 [25.6,29.6]28.4 [26.7,30.1] ***28.1 [26.6,29.6] ***
Father education
Higher22.3 [20.2,24.5]21.2 [19.3,23.3]21.7 [20.1,23.3]
Secondary24.1 [22.8,25.4]23.1 [21.9,24.4]23.5 [22.5,24.6]
Primary29.0 [26.7,31.3] ***26.8 [24.8,28.9]27.6 [26.1,29.3] ***
No education26.2 [23.9,28.6]28.1 [26.1,30.3] ***27.4 [25.7,29.2]
Worked in the last 12 months
Non-working 24.6 [23.5,25.7]24.1 [23.0,25.2]24.3 [23.4,25.2] *
Working26.5 [24.1,29.1]25.5 [23.5,27.6]25.9 [24.2,27.6]
Husband's occupation
Non agriculture24.7 [23.6,25.8]23.7 [22.6,24.8]24.1 [23.2,25.0]
Agriculture25.4 [23.2,27.7]27.6 [25.6,29.7] ***26.7 [25.0,28.4] **
Not working24.6 [19.5,30.7]25.1 [20.0,31.1]24.9 [21.0,29.4]
Religion
Muslim24.8 [23.8,25.9]24.1 [23.1,25.2]24.4 [23.5,25.3]
Christian25.6 [21.5,30.1]28.0 [24.4,31.9] **27.0 [24.2,30.2]
Household members
2-424.1 [22.7,25.5]22.7 [21.3,24.2]23.3 [22.2,24.5]
5-1025.0 [23.7,26.3]24.7 [23.5,25.9]24.8 [23.8,25.8]
>1027.8 [24.3,31.7]27.7 [24.3,31.5] **27.8 [24.7,31.0] **
Number of children under 5
None23.9 [22.5,25.4]22.6 [21.3,23.9]23.1 [22.1,24.2]
123.0 [19.5,26.9]24.3 [20.4,28.6]23.6 [20.8,26.6]
2-3 children25.5 [24.2,26.9]24.9 [23.7,26.2]25.2 [24.1,26.3]
4+26.2 [22.3,30.6]29.9 [25.5,34.7] ***28.4 [24.9,32.2] **
Combined birth rank and birth interval
1st birth24.5 [23.0,26.0]22.7 [21.3,24.1]23.4 [22.3,24.6]
2nd/3rd/interval >223.7 [22.4,25.0]23.6 [22.4,24.9]23.6 [22.6,24.7]
2nd/3rd/interval <228.4 [26.0,31.0]26.8 [24.7,29.0]27.4 [25.7,29.2]
4th birth/interval >226.8 [24.0,29.7] **27.0 [24.8,29.3] ***26.9 [25.1,28.8]
4th birth/interval <226.6 [20.9,33.2]33.1 [28.6,38.1]30.7 [26.8,34.9] ***
Literacy
Cannot read28.4 [26.5,30.3] ***28.8 [27.2,30.5] ***28.6 [27.3,30.1] ***
Read par23.6 [22.5,24.8]22.3 [21.2,23.5]22.9 [21.9,23.8]
Mother health and autonomy
Mother's height (cm)
>16022.2 [20.9,23.7]21.1 [19.8,22.6]21.6 [20.5,22.7]
155-15924.6 [23.1,26.1]24.8 [23.4,26.3]24.7 [23.6,25.9]
150-15428.2 [26.1,30.3]28.5 [26.7,30.4]28.4 [26.9,29.9]
145-14936.3 [32.2,40.6]32.3 [28.8,36.1]34.0 [31.1,37.0]
<14542.1 [31.2,53.9] ***46.3 [37.1,55.8] ***44.5 [36.9,52.4] ***
Maternal BMI (kg/m 2)
≤18.523.4 [21.9,24.9]24.9 [23.4,26.5]24.3 [23.0,25.6]
19-2526.6 [25.0,28.2] **28.5 [26.8,30.2] ***27.6 [26.3,29.0] ***
25+26.2 [24.2,28.3]20.3 [18.7,22.0]22.6 [21.1,24.1]
Women has money autonomy
Yes24.3 [23.2,25.6]24.5 [23.3,25.7]24.4 [23.4,25.4]
Husband25.5 [24.0,27.2]24.1 [22.5,25.8]24.7 [23.4,26.1]
Women have health care autonomy
Yes24.7 [23.7,25.8]24.5 [23.5,25.7]24.6 [23.7,25.6]
Husband24.6 [22.5,26.7]22.9 [21.1,25.0]23.6 [22.1,25.3]
Women have movement autonomy
Yes24.4 [23.3,25.5]24.5 [23.4,25.7]24.4 [23.5,25.4]
Husband25.7 [23.8,27.7]24.0 [22.3,25.7]24.7 [23.3,26.2]
Environmental factors
Source of drinking water
Protected25.1 [24.0,26.2]24.1 [23.1,25.1]24.5 [23.6,25.4]
Unprotected22.2 [19.6,25.1]26.6 [23.5,29.9]24.6 [22.4,26.9]
Stool disposal
Safe25.5 [24.3,26.7] **25.3 [24.1,26.5] **25.4 [24.4,26.4] ***
Unsafe22.7 [20.9,24.5]22.2 [20.5,23.9]22.3 [20.9,23.8]
Type of toilet
Improved25.5 [24.4,26.6] **24.5 [23.4,25.6]24.9 [24.0,25.9] **
Unimproved21.6 [19.6,23.8]23.1 [20.9,25.4]22.4 [20.7,24.3]
Listening to the radio
At least24.4 [23.0, 25.8]22.6 [21.3,23.9]23.3 [22.3,24.4]
Less than27.0 [23.3,25.8] **29.0 [26.3,32.0] ***28.2 [26.0,30.5] ***
Never24.8 [23.5,26.3]24.9 [23.6,26.4]24.9 [23.7,26.1]
Watching TV
At least24.8 [23.8,25.9]24.0 [23.0,25.1]24.3 [23.5,25.2]
Less than20.9 [15.5,27.5]28.8 [23.7,34.5]25.8 [21.9,30.2]
Never27.2 [22.4,32.7] ***31.0 [26.7,35.7] ***29.5 [25.9,33.3] ***
Frequency of reading magazine or newspaper
At least22.8 [20.3, 25.5]18.7 [16.6,22.9]20.3 [18.6,22.2]
Less than22.8 [20.7,25.0]21.0 [19.2,22.9]21.8 [20.3,23.3]
Never25.4 [24.3,26.6]25.6 [24.5,26.8] ***25.5 [24.6,26.5] ***
Health care services
Place and mode of delivery
Cesarean & health facility22.3 [20.9,23.9]21.6 [20.1,23.2]21.9 [20.7,23.2]
Non-Cesarean &home delivery24.8 [23.4,26.2]24.1 [22.8,25.4]24.4 [23.3,25.5]
Non-Cesarean & health facility29.0 [27.0,31.2] ***27.6 [25.9,29.5] ***28.2 [26.6,29.8] ***
Antenatal clinic visits
8+22.7 [21.3,24.2]22.4 [20.9,23.9]22.5 [21.4,23.7]
4-7 visits24.8 [23.1,26.6]23.0 [21.5,24.6]23.8 [22.5,25.1]
1-3 visits23.2 [20.4,26.3]25.4 [23.0,28.0]24.5 [22.5,26.6]
None30.5 [28.4,32.8] ***29.1 [27.4,30.9] ***29.6 [28.1,31.2] ***
Delivery assistance
Health professional24.0 [23.0,25.1]23.3 [22.2,24.4]23.6 [22.7,24.5]
Traditional29.3 [26.9,31.9] ***28.6 [26.6,30.7]28.9 [27.2,30.6]
Other22.8 [17.9,28.5]24.7 [20.5,29.5]24.0 [20.5,27.7]
No one43.4 [30.1,57.8]29.1 [21.6,38.0] ***33.8 [26.4,42.1] ***
Postnatal checkup
No PNC26.8 [25.4,28.3] ***24.3 [23.1,25.4]25.1 [24.1,26.2] **
0-2 days23.3 [21.8,25.0]25.2 [23.2,27.2]24.2 [22.7,25.6]
Delayed20.6 [18.5,22.8]22.0 [19.5,24.8]21.2 [19.5,23.0]
Recent vitamin A
Yes24.2 [22.1,26.3]22.8 [20.0,25.8]23.7 [21.9,25.5]
No24.9 [23.8,26.0]24.5 [23.4,25.6]24.7 [23.8,25.6]
Ever had vaccination
No24.9 [23.7,26.1]23.9 [22.8,25.1]24.4 [23.4,25.4]
Yes24.7 [23.1,26.3]24.7 [23.3,26.3]24.7 [23.5,26.0]
Immediate factors
Child health
Size of baby
Average27.2 [25.6,28.8] ***23.5 [22.0,25.1]25.0 [23.7,26.3]
Small23.3 [22.1,24.6]24.9 [23.6,26.2]24.2 [23.1,25.3]
Large23.4 [18.9,28.6]22.9 [19.8,26.3]23.0 [20.4,25.8]
Diarrhoea last two weeks
No25.1 [24.0,26.2]23.9 [22.9,25.0]24.4 [23.5,25.3]
Yes23.9 [22.1,25.7]27.9 [25.3,30.6] **25.3 [23.7,27.0]
Fever
No25.0 [23.9,26.1]24.1 [23.1,25.2]24.4 [23.5,25.4]
Yes24.4 [22.7,26.1]25.1 [23.3,27.1]24.8 [23.4,26.2]
Cough
No25.1 [24.0,26.2]23.9 [22.9,25.0]24.4 [23.5,25.3]
Yes23.9 [22.1,25.7]27.9 [25.3,30.6] **25.3 [23.7,27.0]
Breastfeeding practices
Early initiation of breast feeding
After 1 hr24.2 [23.0,25.5]--
Withing 1 hr25.8 [24.3,27.3]--
Duration of breast feeding
Up to 12 months22.3 [21.1,23.6]24.9 [22.4,27.5]22.8 [21.7,24.0]
>12 months27.8 [26.3,29.3] ***24.2 [23.1,25.3]25.1 [24.1,26.2] ***

* P< 0.05;

** p<0.01;

*** p<0.001.

Multivariable analysis

Table S3 (Extended Data) and Table 2 show the univariate and multivariate analyses of stunting determinants among Egyptian children aged 0–23, 24-59, and 0–59 months. For children across the three age groups, the odds of stunting were significantly lower in 2014 compared to 2005, with adjusted odds ratios (aOR) of 0.64 (95% CI: 0.54–0.76) for the 0-23 months group, 0.78 (95% CI: 0.64–1.00) for the 24-59 months group, and 0.71 (95% CI: 0.59–0.84) for the 0-59 months group.

Table 2. Adjusted Odds Ratios for Determinants of Stunting among Children aged (0-23, 24-59 and 0-59 months) in Egypt.

Children 0-23 monthsChildren 24-59 monthsChildren 0-59 months)
Characteristicsa ORP valuea ORP valuea OR P value
Year
2005111
20080.98 [0.95, 1.13]0.7421.22 [1.02, 1.46]0.0301.05 [0.91, 1.21]0.537
20140.64 [0.54, 0.76]<0.0010.78 [0.64, 1.00]0.0470.71 [0.59, 0.84]<0.001
Basic factors
Region
Urban Governates111
Urban (Lower Egypt)1.41 [1.11, 1.78]0.0051.25 [1.00, 1.57]0.0581.31[1.09, 1.58]0.004
Rural (Lower Egypt)1.00 [0.81, 1.24]0.9911.07 [0.87, 1.32]0.5121.05 [0.89, 1.25]0.533
Urban (Upper Egypt)1.09 [0.87, 1.36]0.4651.28 [1.00, 1.63]0.0421.17 [0.96, 1.43]0.112
Rural (Upper Egypt)1.12 [0.91, 1.39]0.2821.30 [1.05, 1.61]0.0181.22 [1.02, 1.44]0.027
Frontier Governates1.01 [0.76, 1.32]0.967.75 [0.53, 1.06]0.0980.82 [0.66, 1.03]0.089
Underlying factors
Socioeconomic factors
Wealth Index
Richest111
Fourth0.86 [0.72, 1.01]0.0690.90 [0.77, 1.03]0.1440.87 [0.78, 0.98]0.022
Middle0.82 [0.67, 1.00]0.0500.80 [0.66, 0.96]0.0140.84 [0.72, 0.97]0.015
Second0.90 [0.72, 1.11]0.3130.91 [0.74, 1.10]0.3290.93 [0.79, 1.09]0.360
Poorest0.80 [0.64, 1.01]0.0590.95 [0.78, 1.17]0.6390.93 [0.79, 1.09]0.364
Sex of baby
Boy11
Girl0.71 [0.64, 0.78]<0.0010.83 [0.78, 0.89]<0.001
Child age (months)
0-511
6-111.10 [0.94, 1.29]0.2381.08 [0.92, 1.26]0.365
12-171.08 [0.88, 1.32]0.4811.25 [1.07, 1.47]0.005
18-231.52 [1.23, 1.90]<0.0011.78 [1.52, 2.09]<0.001
24-2911.44 [1.23, 1.69]<0.001
30-351.06 [0.93, 1.21]0.3691.49[1.26, 1.77]<0.001
36-41.93 [0.82, 1.06]0.2641.30 [1.12, 1.53]0.001
42-47.85[0.75, 0.98]0.0191.20 [1.01, 1.41]0.33
48-53.62 [0.53, 0.71]<0.0010.88 [0.74, 1.05]0.161
54-59.74 [0.63, 0.85]<0.0011.02 [0.85, 1.22]0.838
Mother's age (years)
15-241
25-340.88 [0.79, 0.98]0.017
35-490.90 [0.76, 1.08]0.250
Father’s age (years)
18-341
35-440.88 [0.80, 0.97]0.008
45+0.79 [0.68, 0.92]0.002
Mother's marital status
Married11
Not married1.76 [1.15, 2.70]0.0100.74 [0.54, 1.00]0.047
Age at first cohabitation/married
<18 years
>18 years
Maternal education
Higher111
Secondary1.07 [0.90, 1.26]0.4291.02 [0.90, 1.16]0.7271.02 [0.90, 1.16]0.736
Primary1.37 [1.20, 1.72]0.0051.21 [1.02, 1.44]0.0281.21 [1.02, 1.44]0.029
No education1.12 [0.91, 1.37]0.2891.09 [0.93, 1.28]0.2811.09 [0.93, 1.28]0.282
Father education
Higher11
Secondary1.00 [0.87, 1.14]0.9451.05 [0.93, 1.17]0.442
Primary1.21 [1.02, 1.43]0.0301.24 [1.08, 1.43]0.003
No education1.16 [0.98, 1.37]0.0891.12 [0.96, 1.30]0.140
Worked in the last 12 months
Non-working 11
Working1.19 [1.06, 1.34]0.0031.18 [1.07, 1.29]0.001
Combined birth order and birth interval
1st birth111
2nd/3rd/interval >2097 [0.86, 1.10]0.6811.10 [0.99, 1.22]0.0840.98[0.91, 1.05]0.498
2nd/3rd/interval <21.23 [1.06,1.44]0.0081.18 [1.04, 1.34]0.0101.15 [1.04, 1.27]0.005
4th birth/interval >21.00 [0.81, 1.24]0.9971.19 [1.01, 1.41]0.0350.98 [0.87, 1.11]0.746
4th birth/interval <20.94 [0.65, 1.34]0.7131.52 [1.18, 1.95]0.0011.16 [0.94, 1.42]0.175
Mother health and autonomy
Mother's height (cm)
>160111
155-1591.09 [0.98, 1.21]0.1271.20 [1.09, 1.32]<0.0011.17 [1.08, 1.26]<0.001
150-1541.32 [1.15, 1.51]<0.0011.38[1.22, 1.57]<0.0011.38 [1.26, 1.52]<0.001
145-1491.90 [1.53, 2.35]<0.0011.62 [1.34, 1.97]<0.0011.79 1.54, 2.09]<0.001
<1452.51 [1.59, 3.95]<0.0013.28 [2.10, 5.15]<0.0013.11 [2.24, 4.33]<0.001
Maternal BMI (kg/m2)
≤18.511
19-250.98 [0.86, 1.12]0.7340.98 [0.90, 1.08]0.720
25+0.69 [0.57, 0.84]<0.0010.74 [0.64, 0.86]<0.001
Environmental factors
Source of drinking water
Protected1
Unprotected1.22 [1.03, 1.46]0.025
Listening to the radio
At least111
Less than1.15 [0.96, 1.37]0.1321.27 [1.09, 1.48]0.0021.22 [1.08, 1.38]0.001
Never1.25 [1.12, 1.40]<0.0011.03 [0.93, 1.14]0.6071.14 [1.06, 1.24]0.001
Frequency of reading magazine or newspaper
At least11
Less than1.11 [0.92, 1.34]0.267
Never1.31 [1.09, 1.56]0.004
Health care services
Place and mode of delivery
Caesarean & health facility1
Non-Caesarean &home delivery1.03 [0.91, 1.17]0.593
Non-Caesarean & health facility1.18 [1.02, 1.37]0.029
Antenatal clinic visits
8+111
4-7 visits1.07 [0.94, 1.21]0.3030.97 [0.87, 1.09]0.6051.01 [0.93, 1.10]0.814
1-3 visits0.91 [0.75, 1.10]0.3221.02 [0.88, 1.19]0.7880.98 [0.86, 1.11]0.714
None1.25[1.08, 1.45]0.0031.17 [1.03, 1.32]0.0111.21 [1.10, 1.34]<0.001
Recent vitamin A supplement
Yes11
No1.16 [1.02, 1.31]0.0251.11 [1.00, 1.23]0.040
Immediate factors
Breastfeeding practices
Duration of breastfeeding
Up to 12 months1
>12 months1.24 [1.06, 1.45]0.009

Children living in rural Upper Egypt and urban Lower Egypt were significantly more likely to be stunted than those from other geographical regions, while those from middle-income households were significantly less likely to be stunted than those from the richest households. For the three age categories, children whose mothers only had primary school were considerably more likely to be stunted than those whose mothers had secondary education or above. For all three age groups, children whose mothers were less than 155 cm tall had a significantly higher risk of stunting than those whose mothers were taller than 160 cm. In all age categories, children whose mothers did not visit any ANC clinic had significantly higher odds of stunting than those whose mothers visited at least 8 ANC clinics. For all three age groups, children whose mothers did not listen to radio had a considerably increased risk of stunting.

Among children aged 0-23 months, the likelihood of stunting was significantly less among girls than boys. The odds of stunting were significantly higher among children aged 18-23 months compared to those aged 0-5 months. For 0-23 months groups, the likelihood of a child being stunted was significantly higher among those whose mothers were not married compared to those whose mothers were married. For children aged 0-23 months, the risk of stunting was significantly higher among children who were delivered through a non-caesarean section and at home than children who were delivered through a caesarean section at a health facility. Children who received vitamin A supplements were more likely to be stunted than children who did not. Among children in the 0-23 months age group, the likelihood of stunting was significantly higher in those who were breastfed for more than 12 months compared to children who were breastfed for up to 12 months.

Among children aged 24-59 months, the likelihood of stunting was significantly less among older children. The odds of stunting were significantly lower in children whose fathers were older than 45 years compared to those fathers were aged 18-34 years. Children whose mothers had only primary education were significantly more prone to stunting than those whose mothers were educated to higher levels than secondary. The odds of stunting were significantly higher among those whose fathers were educated to primary level, compared to those whose fathers had higher levels than secondary. Children whose mothers worked were significantly more likely to be stunted than their counterparts whose mothers did not work. children whose mothers had a BMI of more than 25 kg/m2 were significantly less likely to be stunted compared to those whose mothers had a BMI of 18.5 kg/m2 or less. Children who were from households with unprotected source of drinking water were significantly more likely to be stunted compared to their counterparts from households with protected source of drinking water.

Among children aged 0-59 months, the likelihood of stunting was significantly less among girls than boys. The odds of stunting were significantly higher among children aged 6 months until 41 months compared to other ages. The odds of stunting were significantly higher among those whose fathers were educated to primary level, compared to those whose fathers had higher levels than secondary. Children whose mothers worked were significantly more likely to be stunted than their counterparts whose mothers did not work. For the 24-59 months and the 0-59 months groups, children whose mothers had a BMI of more than 25 kg/m2 were significantly less likely to be stunted compared to those whose mothers had a BMI of 18.5 kg/m2 or less. Those who did not receive vitamin A supplements were more likely to be stunted than those who did.

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.

Child gender and those who do not adequately use vitamin A supplements were associated with stunting among children aged 0-23 and 0-59 months.38

Study findings suggest stunting in Egypt has decreased slightly over the last decade, with a significant increase in 2008. The surge in global food prices in 2007 and 2008 led to significant increases in food costs in Egypt. This escalation reduced access to nutritious foods, particularly among low-income families, contributing to higher rates of child malnutrition and stunting.38 This could be one of the key factors behind the increase in undernutrition in Egypt during 2008. However, 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.39 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 2030.40 Although various efforts have been made,39 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.41 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.42 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.18,42

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 undernutrition 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 2018.43 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 undernutrition and poverty.44 Poverty is the main cause of undernutrition, its presence in early life can worsen the cycle of poverty and result in severe and long-lasting health consequences.44

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.29,45 A study in India indicated that the greatest opportunity for reducing stunting was higher among low to middle wealth quintiles than higher wealth quintiles; however, the decline in prevalence associated with wealth was not consistent throughout the nation.46 A sub-analysis by cross-tabulating household income with place of residence revealed that 81% of middle-income households were in rural areas, while only 19% resided in urban areas. These findings could also be attributed to the fact that middle-income families may provide more balanced, home-cooked meals, while affluent households may depend more on processed or convenience foods, which are not always nutritionally optimal. Wealthier families may initiate formula feeding earlier, whereas middle-income households may adhere more closely to recommended breastfeeding practices. Additionally, middle-income parents may be more involved in child-rearing, while affluent families may delegate childcare to carers who may not consistently follow ideal feeding and care practices.46,47

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.48,49 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.49 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.50,51 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.5254 In consonance with findings from several previous studies such as those from Nigeria,55 Pakistan,56 Indonesia and Bangladesh,57 and from systematic review studies.28,29,58 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.59 While some studies suggest that maternal employment can positively impact child health due to increased family income,60 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 commitments61 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.61 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.62 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.63 Several studies conducted in different countries, including Ghana,64,65 Sub-Saharan African countries,66 and rural Senegal,67 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.63 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 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.68 The micronutrients deficiency is especially concerning in children, as it may impair growth, immune function, and overall health, thus increasing the risk of undernutrition.68 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.69

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.70 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.71

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,72 especially in Sub-Saharan Africa and in lower socioeconomic group.73 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.74,75 Additionally, boys tend to experience higher rates of wasting, and underweight,72,76 which suggest that boys are more vulnerable to environmental stressors and have higher rates of infectious morbidity and mortality.7782 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 boys83,84 or reevaluating the focus on girls and women in nutrition research.72,76,85,86

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 months87 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.88 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.89 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.90 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.91 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.68

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.92 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.92,93 This finding was consistent with those of other previous studies from Indonesia,94 south Asia95 and Bangladesh.96 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,34,45,97 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.98 These factors play a critical role in determining the nutritional health and overall well-being of both mother and child.34,98

To address the prevalence of child stunting in Egypt, multisectoral 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 the healthcare, education, WASH, and social protection sectors to address the multifaceted determinants of child stunting; 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. Addressing the root causes of stunting in Egypt requires a multisectoral approach involving collaboration across health, WASH, education, and social protection sectors. Effective interventions should be designed to target vulnerable groups, including children born to mothers with short stature, while also considering broader determinants such as socioeconomic conditions and environmental influences. To reduce stunting rates, interventions must be accessible and tailored to families with low socioeconomic status. These should include expanding access to quality healthcare services, enhancing parental education on child nutrition and early development, and promoting optimal infant and young child feeding practices. Additionally, strengthening food security programs and improving household access to safe water and sanitation can contribute to better nutritional outcomes. A structured nutrition monitoring framework is essential to track progress and guide policy decisions. Implementing routine data collection on key nutritional indicators will enable early detection of at-risk populations, facilitate timely interventions, and support the continuous improvement of child health programs.

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.

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Elmighrabi NF, Fleming CAK and Agho KE. Concurrent stunting among under-five children in Egypt [version 3; peer review: 2 approved with reservations]. F1000Research 2025, 14:15 (https://doi.org/10.12688/f1000research.159168.3)
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
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Reviewer Report 02 Apr 2025
Arlette Suzy Setiawan, Universitas Padjadjaran, Bandung, Indonesia 
Approved with Reservations
VIEWS 8
Dear Authors,

This timely and important study investigates the prevalence and causes of stunting in Egyptian children under five years of age using nationally representative data from the 2005, 2008, and 2014 Egyptian Demographic and Health Surveys ... Continue reading
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Setiawan AS. Reviewer Report For: Concurrent stunting among under-five children in Egypt [version 3; peer review: 2 approved with reservations]. F1000Research 2025, 14:15 (https://doi.org/10.5256/f1000research.178689.r374387)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 21 Apr 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    21 Apr 2025
    Author Response
    Dear Professor Arlette Suzy Setiawan,

    Thank you very much, Professor, for taking the time to review our work. Your valuable feedback and insights have been extremely helpful in improving the quality ... Continue reading
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  • Author Response 21 Apr 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    21 Apr 2025
    Author Response
    Dear Professor Arlette Suzy Setiawan,

    Thank you very much, Professor, for taking the time to review our work. Your valuable feedback and insights have been extremely helpful in improving the quality ... Continue reading
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Reviewer Report 27 Jan 2025
Godana Arero Dassie, Adama Hospital Medical College, Adama, Ethiopia 
Approved with Reservations
VIEWS 13
While emphasizing the importance of sectoral collaboration, risks overgeneralizing the complexity of addressing stunting. It does not adequately acknowledge the potential challenges in implementation, such as resource constraints, political will, and the difficulties of coordinating efforts across multiple sectors.
... Continue reading
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Dassie GA. Reviewer Report For: Concurrent stunting among under-five children in Egypt [version 3; peer review: 2 approved with reservations]. F1000Research 2025, 14:15 (https://doi.org/10.5256/f1000research.174857.r358467)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 26 Feb 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    26 Feb 2025
    Author Response
    Dear Associate Professor Godana Arero Dassie,

    Thank you for your valuable comments and feedback. The F1000Research journal has a 300-word limit for the abstract, which restricts the inclusion of detailed information. ... Continue reading
  • Author Response 26 Apr 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    26 Apr 2025
    Author Response
    Dear Associate Professor Godana Arero Dassie,

    Thank you very much for taking the time to review our work. Your valuable feedback and insights have been extremely helpful in improving the quality ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 26 Feb 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    26 Feb 2025
    Author Response
    Dear Associate Professor Godana Arero Dassie,

    Thank you for your valuable comments and feedback. The F1000Research journal has a 300-word limit for the abstract, which restricts the inclusion of detailed information. ... Continue reading
  • Author Response 26 Apr 2025
    Nelmighrabi Elmighrabi, School of Health sciences, Western Sydney University - Campbelltown Campus, Campbelltown, 2560, Australia
    26 Apr 2025
    Author Response
    Dear Associate Professor Godana Arero Dassie,

    Thank you very much for taking the time to review our work. Your valuable feedback and insights have been extremely helpful in improving the quality ... Continue reading

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 03 Jan 2025
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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