Individual, Maternal, Household, and Community Level Variability in Determining Inequalities in Childhood Anaemia within Ethiopia: Four-Level Multilevel Analysis Approach
Abstract
:1. Introduction
2. Methodology
2.1. Data Source and Study Design
2.2. Study Procedure
2.3. Study Variables
2.3.1. Dependent Variable
2.3.2. Independent Variables
2.3.3. Individual-Level Factors
2.3.4. Maternal-Level Factors
2.3.5. Household-Level Factors
2.3.6. Community-Level Factors
2.4. Statistical Model
2.4.1. Ordinal Logistic Regression
Assumptions of the Ordinal Logistic Regression Model
- 1.
- The dependent variable is ordered.
- 2.
- One or more of the independent variables are either continuous, categorical or ordinal.
- 3.
- No multicollinearity.
- 4.
- Proportional odds.
The Proportional Odds Model (POM)
2.4.2. Bivariate Analysis
2.4.3. Multilevel Ordinal Logistic Regression Model
Four-Level Multilevel Model
Multilevel Empty Ordinal Logistic Regression Model
Random Intercept Multilevel Ordinal Logistic Regression Model
Random Coefficient Multilevel Ordinal Logistic Regression Model
2.5. Measures of Variation (Random Effects)
2.6. Proportional Change in Variance (PCV)
2.7. Median Odds Ratio (MOR)
2.8. Model Selection Criteria
Akaike Information Criterion (AIC)
3. Results
- The dependent variable or childhood anaemic status was ordered. i.e., mild, moderate, and severe.
- One or more of the independent variables are either continuous, categorical or ordinal, as shown in the table below.
- No multicollinearity: as shown in the table below, the multicollinearity among the individual, household, maternal, and community-level explanatory variables was tested using the variance Inflation Factor (VIF). Table 1 shows that the VIF for each of the explanatory variables was less than five (5). It shows the absence of multicollinearity in the models, i.e., indicating no multicollinearity problem in the data.
- Conducting the Brant test of the parallel regression (proportional odds) assumption for the status of children’s anaemic status. We identified no predictors found to violate the proportional odds assumption (Table 1).
3.1. Descriptive Statistics on Factors Associated with Childhood Anaemia Status
3.2. Inferential Statistical Analysis on Factors Associated with Childhood Anaemia Status
Bivariate Analysis
3.3. Multilevel Ordinal Logistic Regression Analysis of Childhood Anaemic Status among Maternal, Household, and Community Factors
3.3.1. Intercept Model Only
3.3.2. Model Comparison
3.4. Multilevel Ordinal Logistic Regression Model Result on Childhood Anaemia Status
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Ethics Approval and Consent to Participate
References
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Co-Variable | Regression Coefficient | VIF | Brant Test (p-Value) | 95% Confidence Interval | |
---|---|---|---|---|---|
Lower Bound | Upper Bound | ||||
[Mothers occupational status = No] | −0.089 | 1.063 | 0.090 | −0.191 | 0.014 |
[Mothers occupational status = Yes] | 0 a | ||||
[Sex of child = Male] | 0.010 | 2.665 | 0.814 | −0.076 | 0.097 |
[Sex of child = Female] | 0 a | ||||
[Current marital status = Never in Union] | −0.354 | 1.571 | 0.584 | −1.622 | 0.913 |
[Current marital status = Married/living with partner] | −0.253 | 0.203 | −0.643 | 0.137 | |
[Current marital status = separated] | 0 a | ||||
[Age of Mothers = 15–24] | −5.484 | 1.069 | 0.300 | −6.213 | −4.754 |
[Age of Mothers = 25–34] | −2.301 | 0.089 | −3.036 | −1.566 | |
[Age of Mothers = 35–44] | −4.038 | 0.063 | −4.764 | −3.312 | |
[Age of Mothers = 45 and above] | 0 a | ||||
[Wealth index of mothers = Poorest] | −0.225 | 1.923 | 0.078 | −0.437 | −0.013 |
[Wealth index of mothers = Poorer] | −0.186 | 0.085 | −0.399 | 0.026 | |
[Wealth index of mothers = Middle] | −0.252 | 0.091 | −0.467 | −0.037 | |
[Wealth index of mothers = Richer ] | −0.110 | 0.879 | −0.322 | 0.102 | |
[Wealth index of mothers = Richest ] | 0 a | ||||
[Child Age (in Months) = <6] | 0.003 | 1.027 | 0.967 | −0.157 | 0.163 |
[Child Age (in Months = 6–11] | −0.016 | 0.853 | −0.181 | 0.150 | |
[Child Age (in Months = 12–23] | −0.035 | 0.632 | −0.177 | 0.107 | |
[Child Age (in Months = 24–37] | 0.020 | 0.775 | −0.116 | 0.156 | |
[Child Age (in Months = 38–47] | 0.055 | 0.773 | −0.096 | 0.206 | |
[Child Age (in Months = 48–59] | 0 a | ||||
[Region = Tigray] | −0.101 | 1.186 | 0.921 | −0.348 | 0.146 |
[Region = Afar] | 0.099 | 0.749 | −0.157 | ||
[Region = Amhara] | −0.267 | 0.941 | −0.523 | −0.011 | |
[Region = Oromia] | −0.397 | 0.801 | −0.640 | −0.154 | |
[Region = Somalia] | 0.416 | 0.061 | 0.178 | 0.654 | |
[Region = Benishangul-gumuz] | −0.323 | 0.717 | −0.588 | −0.058 | |
[Region = SNNPR] | −0.034 | 0.787 | −0.280 | 0.212 | |
[Region = Gambela] | −0.306 | 0.630 | −0.582 | −0.030 | |
[Region = Harari] | 0.132 | 0.650 | −0.145 | 0.409 | |
[Region = Addis Ababa] | −0.079 | 0.627 | −0.395 | 0.238 | |
[Region = Dire dawa] | 0 a | ||||
[Place of residence = Urban] | −0.239 | 3.140 | 0.816 | −0.433 | −0.045 |
[Place of residence = Rural] | 0 a | ||||
[Mothers Educational level = No education] | 0.176 | 1.875 | 0.654 | −0.126 | 0.477 |
[Mothers Educational level = primary] | 0.246 | 0.902 | −0.049 | 0.541 | |
[Mothers Educational level = secondary] | 0.124 | 0.618 | −0.176 | 0.425 | |
[Mothers Educational level = higher] | 0 a | ||||
[Sex of household head = Male] | −0.012 | 1.134 | 0.845 | −0.130 | 0.107 |
[Sex of household head = Female] | 0 a | ||||
[Size of child at birth = Very large] | −0.221 | 1.045 | 0.615 | −0.373 | −0.068 |
[Size of child at birth = larger than Average] | −0.088 | 0.778 | −0.247 | 0.071 | |
[Size of child at birth = Medium] | −0.072 | 0.663 | −0.199 | 0.054 | |
[Size of child at birth = Smaller than average] | −0.048 | 0.691 | −0.222 | 0.126 | |
[Size of child at birth = Very Small] | 0 a | ||||
[Preceding birth interval (months) = <24] | −0.043 | 1.029 | 0.803 | −0.145 | 0.058 |
[Preceding birth interval (months = ≥24] | 0 a | ||||
[Antenatal care visit = None] | 0.604 | 1.464 | 0.501 | 0.243 | 0.964 |
[Antenatal care visit = 1–7] | 0.254 | 0.558 | −0.055 | 0.563 | |
[Antenatal care visit = ≥8] | 0 a | ||||
[Type of cooking fuels = Modern fuel] | −0.085 | 1.350 | 0.664 | −0.314 | 0.143 |
[Type of cooking fuels = Traditional fuel] | 0 a | ||||
[Type of toilet facility = Improved toilet facility] | −0.034 | 1.522 | 0.656 | −0.184 | 0.116 |
[Type of toilet facility = Un-improved toilet facility] | 0 a | ||||
[Source of drinking water = Improved water] | 0.097 | 1.201 | 0.056 | −0.002 | 0.197 |
[Source of drinking water = Un-improved water] | 0 a |
Variables | Categories | Anaemic Status | |||
---|---|---|---|---|---|
Mild | Moderate | Severe | p-Value | ||
Place of residence | Urban | 430 | 456 | 41 | p < 0.000 * |
Rural | 1520 | 1808 | 138 | ||
Mothers Educational level | No education | 1209 | 1466 | 93 | p < 0.000 * |
Primary | 497 | 552 | 59 | ||
Secondary | 160 | 146 | 20 | ||
Higher | 84 | 100 | 7 | ||
Sex of household head | Male | 1542 | 1771 | 141 | p < 0.000 * |
Female | 408 | 493 | 38 | ||
Wealth index of mothers | Poorest | 660 | 835 | 62 | p < 0.000 * |
Poorer | 363 | 342 | 34 | p < 0.000 * | |
Middle | 253 | 299 | 21 | ||
Richer | 226 | 306 | 10 | ||
Richest | 448 | 482 | 52 | ||
Age of Mothers | 15–24 | 10 | 1023 | 83 | p < 0.000 * |
25–34 | 1939 | 867 | 68 | ||
35–44 | 1 | 367 | 8 | ||
45 and above | 0 | 7 | 20 | ||
Current marital status | Never in Union | 3 | 2 | 1 | |
Married/living with partner | 1871 | 2186 | 176 | 0.987 | |
Separated | 76 | 76 | 2 | ||
Region | Tigray | 215 | 226 | 24 | p < 0.000 * |
Afar | 147 | 250 | 5 | ||
Amhara | 179 | 199 | 5 | ||
Oromia | 298 | 267 | 13 | ||
Somalia | |||||
Benishangul-gumuz | 279 | 359 | 59 | ||
SNNPR | 132 | 170 | 8 | ||
Gambela | 261 | 287 | 31 | ||
Harari | 135 | 125 | 1 | ||
Addis Ababa | 121 | 135 | 7 | ||
Dire dawa | 92 | 133 | 23 | ||
Mothers occupational status | No | 1425 | 1617 | 128 | p < 0.000 * |
Yes | 525 | 647 | 51 | ||
Sex of child | Male | 984 | 1146 | 95 | p < 0.000 * |
Female | 966 | 1118 | 84 | ||
Preceding birth interval (months) | <24 | 535 | 593 | 48 | p < 0.000 * |
≥24 | 1415 | 1671 | 131 | ||
Size of the child at birth | Very large | 321 | 364 | 19 | 0.581 |
larger than Average | 288 | 310 | 33 | ||
Medium | 829 | 968 | 82 | ||
Smaller than average | 185 | 216 | 13 | ||
Very Small | 327 | 406 | 32 | ||
Child Age (in Months) | <6 | 271 | 284 | 22 | p < 0.000 * |
6–11 | 235 | 255 | 18 | ||
12–23 | 373 | 442 | 31 | ||
24–37 | 465 | 512 | 54 | ||
38–47 | 275 | 362 | 28 | ||
48–59 | 331 | 409 | 26 | ||
Antenatal care visit | None | 116 | 89 | 40 | p < 0.000 * |
1–7 | 1728 | 2063 | 131 | ||
≥8 | 106 | 112 | 8 | ||
Source of drinking water | Improved water | 1203 | 1450 | 116 | p < 0.000 * |
Un-improved water | 116 | 814 | 63 | ||
Type of toilet facility | Improved toilet facility | 363 | 426 | 53 | p < 0.000 * |
Un-improved toilet facility | 1587 | 1838 | 126 | ||
Type of cooking fuels | Modern fuel | 147 | 159 | 20 | 0.615 |
Traditional fuel | 1803 | 2105 | 159 |
Model | Coefficient | Standard Error | Z-Value | p-Value |
---|---|---|---|---|
Fixed intercept (β0) | −0.781 | 0.099 | −7.88 | 0.000 |
Random effect | ||||
Variance (community) | 1.425 | 0.213 | ||
Variance (household) | 1.698 | 0.254 | ||
Variance (maternal) | 1.546 | 0.651 | ||
Icc (community) | 0.179 | |||
Icc (household) | 0.213 | |||
Icc (maternal) | 0.194 |
Model Comparison Criteria | Null Model (Model I) | Individual-Level Factors (Model II) | Maternal Level Factors (Model III) | Households Level Factors (Model IV) | Community-Level Factors (Model V) | Individual, Maternal, Household, and Community-Level Factors (Model VI) |
---|---|---|---|---|---|---|
AIC | 19,059.34 | 21,025.69 | 14,191.21 | 15,124.87 | 15,001.54 | 12,368.45 |
Variable | Mild | Moderate | Severe | |||
---|---|---|---|---|---|---|
Fixed Part | OR[95% C.I] | p-Value | OR[95% C.I] | p-Value | OR[95% C.I] | p-Value |
Constant | 2.8[2.0–3.9] | 0.000 | 2.58[2.24–2.96] | 0.000 | 3.09[2.03–4.70] | 0.000 |
Individual-level factors | ||||||
Child Age (in Months) (ref. < 6) | ||||||
6–11 | 0.96[0.73–1.10] | 0.329 | 0.91[0.75–1.11] | 0.397 | 0.91[0.75–1.12] | 0.406 |
12–23 | 0.86[0.72–1.03] | 0.120 | 0.87[0.73–1.04] | 0.130 | 0.82[0.72–1.03] | 0.115 |
24–37 | 0.83[0.70–0.98] | 0.035 | 0.86[0.70–0.99] | 0.000 | 0.84[0.71–1.0] | 0.057 |
38–47 | 0.81[0.67–0.97] | 0.029 | 0.80[0.65–0.94] | 0.000 | 0.79[0.66–0.94] | 0.011 |
48–59 | 0.79[0.66–0.95] | 0.012 | 0.78[0.65–0.93] | 0.000 | 0.87[0.71–0.98] | 0.000 |
Sex of child (ref. Male) | ||||||
Female | 1.54[1.04–1.99] | 0.000 | 1.61[1.24–1.89] | 0.000 | 0.63[0.31–0.99] | 0.000 |
Preceding birth interval (months) (ref. < 24) | ||||||
≥24 | 0.51[0.33–0.87] | 0.004 | 0.89[0.80–0.99] | 0.048 | 0.40[0.14–0.81] | 0.001 |
Maternal level factors | ||||||
Mother’s age (ref. 15–24) | ||||||
25–34 | 1.1[0.97–1.31] | 0.093 | 1.01[0.95–1.19] | 0.229 | 0.73[0.58–1.79] | 0.681 |
35–44 | 1.06[0.91–1.25] | 0.406 | 0.64[0.40–1.68] | 0.129 | 0.41[0.29–1.44] | 0.149 |
45 and above | 1.14[0.97–1.35] | 0.101 | 0.51[0.42–1.58] | 0.409 | 0.26[0.15–1.05] | 0.331 |
Mother’s educational level (ref. No education) | ||||||
Primary | 1.4[0.86–1.99] | 0.000 | 1.56[0.74–1.48] | 0.547 | 1.01[0.91–1.1] | 0.628 |
Secondary | 1.27[0.97–1.34] | 0.000 | 1.27[0.56–1.74] | 0.241 | 1.8[1.45–2.3] | 0.000 |
Higher | 1.2[0.73–1.48] | 0.000 | 1.32[1.09–1.9] | 0.000 | 3.3[2.22–4.96] | 0.000 |
Antenatal care visit (ref. None) | ||||||
1–7 | 0.03[0.008–0.14] | 0.000 | 0.06[0.009–0.15] | 0.000 | 0.01[0.009–0.20] | 0.000 |
≥8 | 0.08[0.019–0.16] | 0.000 | 0.021[0.01–0.12] | 0.000 | 0.05[0.010–0.14] | 0.000 |
Mother’s occupational status (ref. No) | ||||||
Yes | 0.98[0.88–1.10] | 0.781 | 0.92[0.83–1.03] | 0.191 | 0.96[0.86–1.07] | 0.495 |
Wealth index (ref. poorest) | ||||||
Poorer | 1.01[0.90–1.1] | 0.763 | 1.01[0.88–1.17] | 0.778 | 1.02[0.89–1.1] | 0.718 |
Middle | 1.78[1.40–2.2] | 0.000 | 0.94[0.81–1.09] | 0.462 | 0.95[0.82–1.103] | 0.535 |
Richer | 3.11[2.0–4.6] | 0.000 | 0.98[0.84–1.14] | 0.829 | 1.01[0.86–1.1] | 0.870 |
Richest | 1.44[1.15–2.1] | 0.000 | 1.36[1.15–1.59] | 0.000 | 1.4[1.11–1.75] | 0.003 |
Household-level factors | ||||||
Sex of household head (ref. Male) | ||||||
Female | 0.53[0.28–1.34] | 0.065 | 0.65[0.41–1.42] | 0.334 | 0.25[0.18–1.39] | 0.091 |
Source of drinking water (ref. Improved Water) | ||||||
Unimproved Water | 0.57[0.18–0.88] | 0.001 | 0.49[0.29–0.79] | 0.038 | 0.62[0.43–0.91] | 0.022 |
Type of toilet facility (ref. Improved toilet) | ||||||
Unimproved toilet | 0.66[0.57–0.78] | 0.000 | 0.64[0.55–0.75] | 0.000 | 0.65[0.55–0.76] | 0.000 |
Community level factors | ||||||
Place of residence (ref. urban) | ||||||
Rural | 0.70[0.60–0.82] | 0.000 | 0.81[0.65–0.99] | 0.000 | 0.56[0.48–0.64] | 0.000 |
Region (ref. Tigray) | ||||||
Afar | 0.68[0.55–0.85] | 0.001 | 0.72[0.57–0.89] | 0.003 | 0.70[0.56–0.87] | 0.001 |
Amhara | 0.57[0.46–0.71] | 0.000 | 0.42[0.19–0.82] | 0.000 | 0.56[0.41–0.75] | 0.000 |
Oromia | 0.45[0.37–0.55] | 0.000 | 0.47[0.39–0.57] | 0.000 | 0.47[0.39–0.57] | 0.000 |
Somali | 0.98[0.79–1.20] | 0.860 | 1.01[0.82–1.25] | 0.854 | 0.96[0.78–1.19] | 0.772 |
Benishangul-gumuz | 0.70[0.56–0.88] | 0.003 | 0.72[0.58–0.91] | 0.006 | 0.72[0.57–0.91] | 0.005 |
SNNPR | 1.12[0.91–1.39] | 0.268 | 1.14[0.92–1.41] | 0.218 | 1.15[0.93–1.42] | 0.194 |
Gambela | 0.84[0.66–1.07] | 0.174 | 0.76[0.59–0.97] | 0.000 | 0.81[0.64–1.04] | 0.114 |
Harari | 0.87[0.67–1.14] | 0.338 | 0.83[0.64–1.09] | 0.190 | 0.84[0.64–1.09] | 0.201 |
Addis Ababa | 3.65[2.4–5.4] | 0.000 | 2.67[1.75–4.05] | 0.000 | 2.89[1.8–4.44] | 0.000 |
Diredawa | 0.56[0.43–0.72] | 0.000 | 0.54[0.42–0.71] | 0.000 | 0.53[0.39–0.67] | 0.000 |
Random-effect | ||||||
Var (Cons.) Community | 0.849 | |||||
ICC for Community (%) | 14.22% | PCV for Community (%) | 40.42% | |||
Var (Cons.) Household | 0.931 | |||||
ICC for Household(%) | 15.6% | PCV for Household (%) | 45.17% | |||
Var (Cons.) Mothers | 0.899 | |||||
ICC for Mothers(%) | 15.06% | PCV for Maternal (%) | 41.85% |
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Kuse, K.A.; Jima, D.S.; Chikako, T.U.; Hagan, J.E., Jr.; Seidu, A.-A.; Aboagye, R.G.; Ahinkorah, B.O. Individual, Maternal, Household, and Community Level Variability in Determining Inequalities in Childhood Anaemia within Ethiopia: Four-Level Multilevel Analysis Approach. Children 2022, 9, 1415. https://doi.org/10.3390/children9091415
Kuse KA, Jima DS, Chikako TU, Hagan JE Jr., Seidu A-A, Aboagye RG, Ahinkorah BO. Individual, Maternal, Household, and Community Level Variability in Determining Inequalities in Childhood Anaemia within Ethiopia: Four-Level Multilevel Analysis Approach. Children. 2022; 9(9):1415. https://doi.org/10.3390/children9091415
Chicago/Turabian StyleKuse, Kenenisa Abdisa, Demie Seyoum Jima, Teshita Uke Chikako, John Elvis Hagan, Jr., Abdul-Aziz Seidu, Richard Gyan Aboagye, and Bright Opoku Ahinkorah. 2022. "Individual, Maternal, Household, and Community Level Variability in Determining Inequalities in Childhood Anaemia within Ethiopia: Four-Level Multilevel Analysis Approach" Children 9, no. 9: 1415. https://doi.org/10.3390/children9091415