Why Is Child Malnutrition Lower in Urban Than in Rural Areas? Evidence from 36 Developing Countries
Introduction
Ample evidence shows that urban children generally have a better nutritional status than their rural counterparts (Hussain and Lundven, 1987, Ruel, 2001, Ruel, von Braun). This is particularly true for linear growth (stunting)1 and for underweight (low weight-for-age). Using data from FAO for 11 countries, most of which were from Africa, Hussain and Lundven (1987) showed that stunting rates in urban areas were 55–78% of those found in rural areas. von Braun et al. (1993) corroborated these findings with UNICEF data sets from 33 countries in Africa, Asia, and the Americas, and showed that, on average, stunting was 1.6 times greater in rural compared to urban areas. Using Demographic and Health Surveys from 28 countries conducted during 1990–98, Ruel (2001) also documented consistently lower prevalences of stunting in urban areas, with wider urban/rural differences in Latin America compared to Africa and Asia.2 For five of the seven Latin American countries studied, stunting prevalence in urban areas was about half that found in rural areas. Although typically wasting is also higher in rural areas, most studies have found very small urban/rural differences and even in a few instances, slightly higher wasting in urban areas has been reported (Hussain and Lundven, 1987, Ruel, 2001, Ruel, von Braun).
In spite of the overall nutritional advantage of children in urban areas, recent evidence suggests that urban poverty and malnutrition have been increasing, both in absolute and in relative terms (Haddad, Ruel, & Garrett, 1999). Data from nine out of 14 countries studied3 show that both the number of underweight preschoolers and the share of urban preschoolers in overall numbers of underweight children have been increasing in the past 10–15 years. These nine countries constitute a large percentage of the developing world, given that they include China, Nigeria, Egypt, and the Philippines.
Thus, although childhood malnutrition has typically been a less severe problem in urban than in rural areas, the accelerated rates of urbanization currently observed in the developing world raise new concerns regarding increasing rates of urban malnutrition. Understanding the relative importance of the various determinants of childhood malnutrition, and whether they differ between urban and rural areas, thus becomes key to designing effective program and policy responses specifically tailored to the needs of different population groups.
The present study uses data sets from the Demographic and Health Surveys for 36 countries from three regions—South Asia, Sub-Saharan Africa, and Latin America and the Caribbean—to address the question of whether the determinants of childhood malnutrition differ between urban and rural areas. The specific objectives of the research are the following:
—to test whether there are urban–rural differences in the strength of association between key socioeconomic determinants and child nutritional status, across and within the three regions; the socioeconomic determinants examined include maternal education, women’s status, household water and latrine use, and socioeconomic status;
—to determine whether the findings differ according to the nutritional status indicator used (i.e., height-for-age or weight-for-height);
—to document differences in the levels of the socioeconomic determinants of malnutrition in urban and rural areas;
—to document differences in the levels of the proximal determinants of malnutrition in urban and rural areas. The proximal determinants examined include maternal nutritional status and maternal and childcare practices such as prenatal and birthing care, child feeding practices, health seeking behaviors, and childcare substitute use.
The study follows the approach used by Garrett and Ruel (1999) in a single-country analysis (for Mozambique) of the same issue. As in this previous study, our overall hypothesis is that the factors that affect malnutrition in urban and rural areas are different, due primarily to the unique aspects and circumstances that characterize life in urban areas. Among these are the greater dependence on cash income and the lower reliance on agriculture and natural resources; the higher percentage of women-headed households; the greater involvement of women in income-generating activities outside the home; the smaller family size and weaker social and family networks; and the resulting limited availability of affordable alternative childcare. On the more positive side, urban areas offer more choices: greater availability of food, housing arrangements, health services and possibility of employment opportunities. Electricity, water, and sanitation services are also, on average, more widely available than in rural areas. Thus, it is possible that the factors that determine nutritional status differ between urban and rural areas, given these differences in environments and in household and individual opportunities and choices.
Understanding differences in the determinants of childhood malnutrition between urban and rural areas is important in order to design appropriate, context-relevant program and policy responses. The present research seeks to generate information that will provide guidance to program planners and policymakers on how to address the increasing problems of urban poverty and malnutrition, and on how to design suitable interventions to reverse these trends.
Section snippets
Data
This research employs data from 36 of the most recent Demographic and Health Surveys (DHS) conducted during 1990–98 in three regions of focus, South Asia, Sub-Saharan Africa (SSA), and Latin American and the Caribbean (LAC). The countries, years of data collection, and sample sizes are listed in Table 1. Eighty percent of all South Asian countries, 58% of SSA countries, and 36% of LAC countries are included. The countries were chosen based on the availability of data on child nutritional
Urban–rural differences in childhood malnutrition
Child nutritional status is undoubtedly better in urban areas in our sample of countries (Table 3), a finding consistent with previous research. Mean HAZ in particular is significantly higher in urban areas, and differences as large or greater than 0.5 of a Z-score are common, especially in countries of South Asia and LAC. WHZ is also generally higher in urban areas, but the differences are of a much smaller magnitude than for HAZ and many are not statistically significant. This is also a
Why is child malnutrition lower in urban than in rural areas?
Our analysis of 36 DHS data sets from three regions of the developing world shows little evidence of differences in key socioeconomic determinants of child nutritional status—women’s education and status, access to safe water and sanitation, and household economic status—or in the strength of their association between urban and rural areas. This is true across the three regions and for most of the determinants examined. Where urban–rural differences in the strengths of associations are
Acknowledgement
This research is an extension of a larger project examining the determinants of child malnutrition in developing countries that was generously funded by the Swedish International Development Agency. We thank the other project researchers, Usha Ramakrishnan, Lawrence Haddad, and Reynaldo Martorell, as well as all those who assisted in the construction of the multicountry data set: Denise Zabkiewicz, Sonu Khera, Heather Hustad, Morgan Hickey, Julia Hendrickson, Raymond Dogore, and Yasmin Ali. We
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