Generalized structural equation modeling of direct and indirect determinants of chronic undernutrition among under-five children in Ethiopia: further analysis of the 2019 mini Ethiopian demographic and health survey.

Background: Despite the global efforts and target to improve child nutrition and eliminate all forms of malnutrition by 2030, chronic undernutrition among under-five children is a major public health challenge in Ethiopia and it was 38%. The evidence of direct and indirect determinants based on the United Nations International Children's Emergency Fund (UNICEF) conceptual framework is limited. Therefore, this study aimed to determine the direct, indirect, and total effects of determinants on chronic undernutrition among under-five children in Ethiopia.

Method: The study used the nationally representative weighted samples of 4,917 under-five children from the 2019 rounds of the DHS. A generalized structural equation model was used to determine the direct, indirect, and total effects of determinants on chronic undernutrition. The level of statistical significance was set at a p-value of less than 0.05.

Result: The results indicated that children whose mothers had education have a 14% low odds of chronic undernutrition (AOR = 0.96, 95% CI; 0.7, 0.99). Those in urban residences had a 20% lower odds (AOR = 0.8, 95% CI; 0.49, 0.89), and children from better wealth index had a 10% lower odds (AOR = 0.9, 95% CI; 0.63, 0.98) of chronic undernutrition. In contrast, children with deprived living standards 2.7 (AOR = 2.7, 95% CI; 2.3, 3.1), and those with inadequate minimum dietary diversity (MDD) 1.69 (AOR = 1.69, 95% CI; 1.27, 2.3) times more likely to experience chronic undernutrition. Living standards through inadequate MDD (AOR = 1.04, 95% CI; 1.001, 1.25, residence through inadequate MDD (AOR = 1.04, 95% CI; 1.006, 1.1), wealth index via inadequate MDD (AOR = 1.01, 95% CI; 1.005, 1.02), and maternal education through antenatal care (ANC) (AOR = 0.88, 95%CI; 0.67, 0.99) had indirect effects on chronic undernutrition.

Conclusion: The study found out determinants like maternal education, urban residence, and better wealth index were directly reducing the likelihood of chronic undernutrition. Conversely, deprived living standards and inadequate MDD directly raised the odds of chronic undernutrition. Determinants such as deprived living standards, residence, wealth index, and maternal education indirectly affected chronic undernutrition through inadequate MDD and ANC. Therefore, the finding suggests that interventions should adopt a holistic approach that includes maternal education, wealth index, living standard, dietary diversity, and ANC for reducing chronic undernutrition among under-five children in Ethiopia.