Article Text

A novel development indicator based on population-average height trajectories of children aged 0–5 years modelled using 145 surveys in 64 countries, 2000–2018
  1. Eric O Ohuma1,2,
  2. Diego G Bassani1,3,4,
  3. Huma Qamar1,
  4. Seungmi Yang5,
  5. Daniel E Roth1,3,4,6
  1. 1 Centre for Global Child Health & Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
  2. 2 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK, Oxford, UK
  3. 3 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  4. 4 Department of Pediatrics, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
  5. 5 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada, Montreal, Quebec, Canada
  6. 6 Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Eric O Ohuma; eric.ohuma{at}


Introduction Children’s growth status is an important measure commonly used as a proxy indicator of advancements in a country’s health, human capital and economic development. We aimed to assess the feasibility of using Super-Imposition by Translation And Rotation (SITAR) models for summarising population-based cross-sectional height-by-age data of children under 5 years across 64 countries.

Methods Using 145 publicly available Demographic and Health Surveys of children under 5 years across 64 low-income and middle-income countries from 2000 to 2018, we created a multicountry pseudo-longitudinal dataset of children’s heights.

Results SITAR models including two parameters (size and intensity) explained 81% of the between-survey variation in mean boys’ height and 80% in mean girls’ height. Size parameters for boys and girls (relative to the WHO child growth standards) were distributed non-normally around a mean of −5.2 cm for boys (range: −7.9 cm to −1.6 cm) and −4.9 cm for girls (range: −7.7 cm to −1.2 cm). Boys exhibited 10% slower linear growth compared with the WHO (range: 19.7% slower to 1.6% faster) and girls 11% slower linear growth compared with the WHO (range: 21.4% slower to 1.0% faster). Variation in the SITAR size parameter was ≥90% explained by the combination of average length within the first 60 days of birth (as a proxy for fetal growth) and intensity, regardless of sex, with much greater contribution by postnatal intensity (r≥0.89 between size and intensity).

Conclusions SITAR models with two random effects can be used to model child linear growth using multicountry pseudo-longitudinal data, and thereby provide a feasible alternative approach to summarising early childhood height trajectories based on survey data. The SITAR intensity parameter may be a novel indicator for specifically tracking progress in the determinants of postnatal growth in low-income and middle-income countries.

  • child health
  • epidemiology
  • public health
  • stunting
  • other study design

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Handling editor Sanni Yaya

  • Twitter @ohumaeric

  • Contributors EOO, DER and DGB designed the research. HQ performed data manipulation, cleaning and data curation. EOO conducted the research and analysed the data with input from DER, DGB, HQ and SY. EOO wrote the paper with input from all authors. EOO had primary responsibility for final content. All authors have read and approved the final manuscript.

  • Funding EO was supported by the Sick Kids Centre for Global Child Health Growth and Development Fellowship.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This work is a secondary analysis of publicly available de-identified data which are exempt from ethical review at the Hospital for Sick Children Ethics Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. The data used are DHS and are publicly available at

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.