Beyond personal factors: Multilevel determinants of childhood stunting in Indonesia

BACKGROUND: Stunting is still a major public health problem in low- and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict- and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model. METHODS: We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household- and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict- and province-level characteristics on the probability of children being stunted. RESULTS: Our findings showed that the odds of childhood stunting vary significantly not only by individual child- and household-level characteristics but also by province- and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene. CONCLUSIONS: Stunting is associated with not only child-level characteristics but also family- and community-level characteristics. Hence, interventions to reduce stunting should also take into account family and community characteristics to achieve effective outcomes.