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Geospatial inequalities and determinants of nutritional status among women and children in Afghanistan: an observational study


This study is the first comprehensive analysis of the geospatial distribution and determinants of nutritional status among women and children in Afghanistan. We estimated posterior prevalence of anthropometric outcomes using Bayesian spatial models with covariates for Afghanistan’s 399 districts, and found considerable variability across districts and often within the same province. Malnutrition of mothers and children were at alarming levels throughout the country, and the highest burden districts clustered in the central, east, and northeastern regions. Linear growth and weight of children younger than 5 years old were independently associated with household wealth, maternal literacy, maternal anthropometry, child age, food security, geography, and improved hygiene and sanitation conditions. The mother’s BMI was determined by many of the same factors, in addition to ethnolinguistic status and parity.

Our findings are consistent with the existing literature8x8Johnecheck, WA and Holland, DE. Nutritional status in postconflict Afghanistan: evidence from the national surveillance system pilot and national risk and vulnerability assessment. Food Nutr Bull. 2007; 28: 3–17
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,9x9Mashal, T, Takano, T, Nakamura, K et al. Factors associated with the health and nutritional status of children under 5 years of age in Afghanistan: family behaviour related to women and past experience of war-related hardships. BMC Public Health. 2008; 8: 301
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,10x10Levitt, E, Kostermans, K, Laviolette, L, and Mbuya, N. Malnutrition in Afghanistan: scale, scope, causes, and potential response. World Bank Publications, Washington, DC; 2010
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,11x11Assefa, F, Jabarkhil, MZ, Salama, P, and Spiegel, P. Malnutrition and mortality in Kohistan district, Afghanistan, April 2001. JAMA. 2001; 286: 2723–2728
Google ScholarSee all References
,12x12Ahmed, A, Edward, A, and Burnham, G. Health indicators for mothers and children in rural Herat Province, Afghanistan. Prehosp Disaster Med. 2004; 19: 221–225
Google ScholarSee all References
,13x13Mihora, LD, Jatla, KK, Little, T, Campbell, M, Rahim, A, and Enzenauer, RW. Vitamin A deficiency in Afghanistan. Eye Contact Lens. 2004; 30: 159–162
Google ScholarSee all References
,14x14UNICEF. Anthropometric nutrition survey—children from 6 to 59 months, pregnant–lactating women and infant and young child feeding practices study, children from 0 to 23 months. Final report. Mihtarlam and Qarghayi districts, Laghman province, Afghanistan. https://www.humanitarianresponse.info/system/files/documents/files/Laghman-Nutrition%20survey%20and%20IYCF-May2011-ACF-FV.pdf. ()
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,15x15UNICEF. Anthropometric nutrition survey—children from 6 to 59 months, pregnant–lactating women and infant and young child feeding practices study, children from 0 to 23 months. Final report. Saighan, Yakawlang and Panjab districts, Bamyan province, Afghanistan. https://www.humanitarianresponse.info/system/files/documents/files/ACF-AADA%20Anthropometric%20nutrition%20survey%20and%20IYCF%20study%20-Bamyan%20province-July2011-Final%20report%20VF.pdf. ()
Google ScholarSee all References
,16x16UNICEF. Anthropometric nutrition survey—children from 6 to 59 months, pregnant–lactating women and infant and young child feeding practices study, children from 0 to 23 months. Final report. Chal and Rustaq districts, Takhar province, Afghanistan. https://www.humanitarianresponse.info/system/files/documents/files/Takhar-Nutrition%20survey%20and%20IYCF-July2011-ACF-FV.pdf. ()
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that recognises malnutrition as a geospatial problem in Afghanistan. Our study found that the highest burden of childhood stunting, underweight, and combined stunting and wasting were consistently in districts in the Farah, Nangarhar, Nuristan, Kunar, Paktia, and Badakhshan provinces. Gaps between districts ranged from 4% to 84% for childhood stunting and 5% to 66% for underweight. Underweight and overweight or obesity were comorbid conditions among mothers in districts of north, northeast, and central, and central highlands where levels exceeded 15–20%. Evidently, districts in the Nuristan, Kunar, and Nangarhar province require specialised attention for consistently having the highest burden of maternal and child undernourishment in Afghanistan. Nangarhar is among the most developed and socioeconomically advanced provinces in the country, thus a high prevalence of malnutrition in several districts is striking and warrants further investigation. The government should consider district-specific exploration of key determinants and interventions in all high-burden areas. Districts with alarmingly high wasting prevalence (some exceeded 20%) were in central regions and regions bordering Pakistan, including the east, southeast, and south. The concurrent conflict and insecurity in these regions could be one explanation, particularly since a gradient of child emaciation across wealth status and maternal education was not evident. The at-risk and unsettled migrant populations in these insecure zones should be a key focus for humanitarian agencies and donors to ensure nutrient-dense food aid, vaccines, and sanitation supplies are provided.

Similar to findings in neighbouring Pakistan,21x21Di Cesare, M, Bhatti, Z, Soofi, SB, Fortunato, L, Ezzati, M, and Bhutta, ZA. Geographical and socioeconomic inequalities in women and children’s nutritional status in Pakistan in 2011: an analysis of data from a nationally representative survey. Lancet Glob Health. 2015; 3: e229–e239
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Our data show that adolescent mothers younger than 20 years old are shorter and more underweight than older mothers (aged 20–49 years) in Afghanistan. Consistent with literature,35x35Gibbs, CM, Wendt, A, Peters, S, and Hogue, CJ. The impact of early age at first childbirth on maternal and infant health. Paediatr Perinat Epidemiol. 2012; 26: 259–284
Google ScholarSee all References

Previous reports have highlighted the pervasive conditions that predispose Afghans to varying degrees of food insecurity, poor diet diversity, and infectious disease—each of which can effect child and maternal nutrition. These include differential periods of drought, isolation or remoteness, geographical barriers, insecurity, nutritional practice, and family behaviour and cultural restrictions, among other factors.8x8Johnecheck, WA and Holland, DE. Nutritional status in postconflict Afghanistan: evidence from the national surveillance system pilot and national risk and vulnerability assessment. Food Nutr Bull. 2007; 28: 3–17
Google ScholarSee all References
,9x9Mashal, T, Takano, T, Nakamura, K et al. Factors associated with the health and nutritional status of children under 5 years of age in Afghanistan: family behaviour related to women and past experience of war-related hardships. BMC Public Health. 2008; 8: 301
Google ScholarSee all References
,10x10Levitt, E, Kostermans, K, Laviolette, L, and Mbuya, N. Malnutrition in Afghanistan: scale, scope, causes, and potential response. World Bank Publications, Washington, DC; 2010
Google ScholarSee all References
The substantial variation in growth and weight across geographical regions and ethnolinguistic status in our analysis represents the importance of these factors in the Afghan context. As we expected, our study showed that some of the strongest predictors of increased child and maternal nutritional status in Afghanistan were greater wealth, maternal literacy, food security, and improved hygiene and sanitation conditions. An analysis37x37Trani, JF and Barbou-des-Courieres, C. Measuring equity in disability and healthcare utilization in Afghanistan. Med Confl Surviv. 2012; 28: 219–246
Google ScholarSee all References

We found that more than 70% of women were illiterate in most districts, poverty was extremely high across the country, and access to improved water (<10% in many districts) and sanitation was unacceptably low throughout. Although often more challenging to intervene, these determinants should be further understood and considered in local nutrition policy and programming initiatives. Civil society, government, and development partners should unite collectively to tackle these multidimensional determinants with multisectoral and innovative strategies.

Our analysis of the 2013 Afghanistan NNS is robust because the survey had large sample sizes, widespread population coverage, and the inclusion of extensive nutrition indicators from children and women. Nonetheless, a few limitations of our study must be considered. Sample sizes for few inaccessible or insecure regions might be smaller or missing (appendix), and thus these district estimates are heavily modelled on the basis of information from neighbouring districts. However, we used a range of predictive priors including province, percentage of the district living in urban areas, average household economic status, food security, and female illiteracy, as has been suggested and done in previous work,22x22Golding, N, Burstein, R, Longbottom, J et al. Mapping under-5 and neonatal mortality in Africa, 2000–15: a baseline analysis for the Sustainable Development Goals. Lancet. 2017; 390: 2171–2182
Google ScholarSee all References
,23x23Burke, M, Heft-Neal, S, and Bendavid, E. Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis. Lancet Glob Health. 2016; 4: e936–e945
Google ScholarSee all References
,26x26Dasgupta, P, Cramb, SM, Aitken, JF, Turrell, G, and Baade, PD. Comparing multilevel and Bayesian spatial random effects survival models to assess geographical inequalities in colorectal cancer survival: a case study. Int J Health Geogr. 2014; 13: 36
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and used rigorous statistical cross-validation methods to assess model fit—thus we feel confident in the reliability of these estimates. Nonetheless, because of inherent uncertainty around modelled estimates, district prevalence should be used as guidance rather than a definitive classification of district rank. Estimated district prevalence should be used as point of reference for local level discussions and planning. Uncertainty around food insecurity indicators might be wider since these indicators were only asked about in a smaller subset of the NNS sample. We did not have adequate data to model several proximal determinants of child nutrition, such as infectious disease, breastfeeding, complementary feeding, and care seeking behaviour for children—although these determinants would be clearly important to child nutrition in Afghanistan. Furthermore, information that would have allowed more objective exploration of mother–child linkages, including gestational age, preterm birth, and birthweight, were also not available. Despite these limitations, we believe that the key messages and proposed actions emanating from these results still hold.

Reporting on Afghanistan’s malnutrition crisis in The Lancet Global Health, Varkey and Colleagues4x4Varkey, S, Higgins-Steele, A, Mashal, T, Hamid, BA, and Bhutta, ZA. Afghanistan in transition: call for investment in nutrition. Lancet Glob Health. 2015; 3: e13–e14
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