Sunguya et al.

Nutrition Journal (2019) 18:85

https://doi.org/10.1186/s12937-019-0505-8

RESEARCH Open Access

Trends in prevalence and determinants of

stunting in Tanzania: an analysis of
Tanzania demographic health surveys
(1991–2016)
Bruno F. Sunguya1†, Si Zhu2,3†, Rose Mpembeni1* and Jiayan Huang2,3*

Abstract
Background: Tanzania has made a significant improvement in wasting and underweight indicators. However,
stunting has remained persistently higher and varying between regions. We analyzed Tanzania Demographic and
Health Survey (TDHS) datasets to examine (i) the trend of stunting over the period of 25 years in Tanzania and (ii)
the remaining challenges and factors associated with stunting in the country.
Methods: This secondary data analysis included six TDHS datasets with data of 37,409 under-five children
spreading in 1991–1992(n = 6587), 1996(n = 5437), 1999(n = 2556), 2004–05(n = 7231), 2009–10(n = 6597), and 2015–
16(n = 9001) conducted in all regions of Tanzania. Variables specific to children and their caregivers were analyzed
using SPSS version 22. The variables considered include child anthropometric variables, caregiver’s demographic
characteristics and household’s socio-economic factors. We used frequencies and percentages to compare stunting
prevalence across the six surveys and chi-square test and three-level hierarchical logistic regression to examine the
factors associated with stunting also applying sample weighting as advised by TDHS.
Results: The prevalence of stunting has declined by 30% over the period of 25 years in Tanzania. However, one in
three children aged below five years remains stunted with overweight and obesity more than doubled (from 11
to 25%) in the same period among women of reproductive age. The factors associated with stunting included
children living in female-headed households (AOR = 1.16, P = 0.014), aged 24–35 months (AOR = 1.75, P = 0.019),
born with low birth weight (AOR = 2.14, P < 0.001) and with inconsistent or without breastfeeding (AOR = 3.46,
P < 0.001 and AOR = 4.29, P = 0.001) respectively. The risk of stunting among children living in urban area (AOR =
0.56, P < 0.001), with higher caregiver’s education (AOR = 0.56, P = 0.018), obese mother (AOR = 0.63, P < 0.001),
households with highest wealth index (AOR = 0.42, P < 0.001), and among girls (AOR = 0.77, P < 0.001).
Conclusions: The burden of stunting in Tanzania has declined by 30% in the past 25 years, but still affecting one in
every three children. Efforts are needed to increase the pace of stunting decline especially among boys, children in
rural areas, from poor, uneducated, and female-headed households, and through improving infant and young
feeding practices. Effective and tailored nutrition-sensitive and specific interventions using multisectoral approaches
should be considered to address these important determinants.
Keywords: Stunting, Demographic and health survey, Child health, Breastfeeding, Malnutrition

* Correspondence: jiayanhuang@fudan.edu.cn; rcmpembeni@gmail.com

†
Bruno F. Sunguya and Si Zhu contributed equally to this work.
1
School of Public Health and Social Sciences, Muhimbili University of Health
and Allied Sciences, Dar es Salaam, Tanzania
2
School of Public Health, Fudan University, Shanghai, China
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sunguya et al. Nutrition Journal (2019) 18:85 Page 2 of 13

Background their families as breadwinners than in the past [4, 17].

More than 165 million children are stunted globally, Such demographic changes may have impact in nutrition
with low- and middle-income countries bearing the big- and child health. However, data to ascertain this
gest brunt of this burden [1]. Only 14 countries carry phenomenon have not been analyzed nor has the
80% of this burden, with Tanzania ranking tenth [2]. changes in nutrition landscape and characteristics
Efforts and investments in health have resulted to a thereof in Tanzania. This study therefore, aimed to first,
steady decline of stunting globally, however, the speed examine the trend of stunting over the period of 25 years
has been slow in Africa, calling for more tailored inter- in Tanzania. Second, it aimed to examine the remaining
ventions suitable for each country [2]. Such efforts challenges and factors associated with stunting in the
include strengthening health systems and integrated country. We therefore analyzed data collected from six
management of childhood illnesses, immunization and major surveys conducted over the period of 25 years to
vitamin A supplementation, and advocacy for improving explain the changes in nutritional landscape characteris-
infant and young child feeding practices including exclu- tics thereof in relation to stunting among children below
sive breastfeeding [3]. These nutrition specific interven- five years of age.
tions have resulted into a rapid decline in acute forms of
undernutrition with modest decline of stunting and Methods
other chronic undernutrition. In Tanzania for example, Study design
the country was able to meet the millennium develop- This secondary data analysis was conducted on Tanzania
ment target of 14.4% --ahead of deadline in 2015 [4] Demographic and Health Surveys datasets. A total of 14
owing to such interventions. Similar efforts have not re- surveys have been conducted since 1991 in Tanzania.
sulted in similar results for stunting. More efforts are They include the demographic and health surveys
therefore needed to strengthen nutrition sensitive inter- (DHS), AIDS indicator surveys (AIS), Service Provisional
ventions that can also improve livelihoods and therefore Assessment (SPA), Malaria Indicator Surveys (MIS), and
ameliorate determinants of chronic forms of undernutri- Key Indicator Surveys (KIS) [18]. The DHS has variables
tion such as poverty, food insecurity, education, and that can inform panel data for nutritional, maternal, and
other sociodemographic disadvantages [3, 5]. child indicators that can be analyzed to address the two
Determinants of stunting extends from pre-conception, objectives. We therefore used all the 6 Standard DHS
through pregnancy to the child’s second birthday [6, 7]. surveys. This nationally representative surveys are con-
This window of opportunity calls for strengthening mater- ducted every five years in all regions of the country
nal nutrition before and after conception, and within the using similar methods and tools by the National Bureau
next one thousand days [8]. Evidence have shown that of Statistics (NBS) in collaboration with Monitoring and
20% of stunting has its causes originated in the womb [9], Evaluation to Assess and Use Results (MEASURE) DHS.
and last for life [8, 10, 11]. Stunting at younger age is also
linked with poor cognitive development, low IQ, poor TDHS sampling of households
school performance, and early deaths owing to other de- The six TDHS employed the random sampling method
terminants including early onset of non-communicable taking into consideration the population density to col-
diseases [12, 13]. Such causes and consequences repeat in lect data from all administrative regions of the country.
subsequent generations escalating lifelong cost to national Data of 41297 children were available and spread across
economy owing to poor human capital, lost opportunity the years as follows: 1991-92 (7287), 1996 (6080), 1999
of affected individuals to participate in the national econ- (2839), 2004-05 (7852), 2009-10 (7526), and 2015-16
omy, and costing health care [14]. Investing in efforts to (9713). Not all data had nutrition related variables. We
alleviate stunting is therefore an effective as much it is an managed to extract data of total of 37409 children under
economical intervention [15]. five with nutrition variables, spreading across the years
Over the years, Tanzania like other low- and middle- as follows: 1991-92 (6587), 1996 (5437), 1999 (2556),
income countries has made strides in economic trans- 2004-05 (7231), 2009-10 (6597), and 2015-16 (9001).
formation that resulted from and into improvement of
such basic and underlying causes of undernutrition [1, Datasets and variables used for this analysis
16]. With efforts to increase enrollment in primary edu- We chose to analyze data from six Tanzania Demo-
cation and beyond, more people including caregivers are graphic and Health Surveys (TDHS) conducted in 1991–
educated, delaying to have their first children, and taking 92, 1996, 1999, 2004–05, 2009–10, and 2015–16 because
part in formal sectors in the national economy [4, 17]. they had variables needed for analysis. To enable com-
This has positive impact in their own health, nutrition parability of variables, we chose panel variables whose
status, newborn health, food security, and therefore their data were collected in similar the manner. Such variables
family’s wellbeing [4]. More women are now heading included the demographic characteristics of the care
Sunguya et al. Nutrition Journal (2019) 18:85 Page 3 of 13

givers, nutritional status of children, household wealth having significant number of missing variables. For this,
index, and feeding practices. we ran a three-level hierarchical logistic regression
The main outcome of interest was stunting, measured as models to examine factors associated with stunting.
height-for-age below -2sd of the given standard population. Hierarchical logistic regression models are able to avoid
Severe form of stunting was defined as height-for-age below distal factors be improperly adjusted by proximate fac-
-3sd of a standard population. The TDHS surveys con- tors [19, 20]. In the first model, we included place of
ducted before 2006 used the CDC standard growth refer- residence as the only distal factor. In the second model
ences which were derived from the NCHS/FELS/CDC we included underlying factors such as care givers char-
reference population. This was changed in 2006 when acteristics and household characteristics and factors
WHO conducted a study on growth (https://www.who.int/ from the first model which had p-value< 0.2. In the final
childgrowth/en/). To harmonize the survey data, we re- (third) model, we included proximal factors like child
calculated z-scores of the TDHS 1991–1992, 1996, 1999, characteristics and factors from the first and second
and 2004–2005 surveys into the new WHO Child Growth models which had p-value< 0.2. We applied sample
Standards, using a syntax file provided by the WHO weighting generated by the TDHS to adjust for cluster
(http://www.who.int/childgrowth/software/en/). sampling design and sampling probabilities across clus-
The independent variables from the child question- ters and strata. A statistically significant level was set at
naire included child age in months, child’s sex, birth p < 0.05.
weight in grams and duration of breastfeeding (months).
Child birth weight below 2500 g was considered low
Ethical consideration
birth weight while 2500-4000 g was normal and above
The use of this data was approved by MEASURE
which was considered big baby. Independent variables
Tanzania Demographic and Health Surveys after our re-
pertinent to caregivers were extracted from the women’s
quest with the data analysis protocol. During the sur-
questionnaire. They included caregiver’s age (years),
veys, the protocols and data collection procedures were
highest education level (primary, secondary or higher),
approved by relevant authorities in Tanzania mainland
age at first child birth (years), number of children living
and Zanzibar. These include the National Institute of
in their households, and place of residence (urban or
Medical Research (NIMR), Zanzibar Medical Research
rural). Other variables included the sex of the household
Ethical Committee (ZAMREC), the Institutional Review
head, and mother’s own nutrition status. The latter was
Board of ICF International, and the Centers for Disease
measured as body mass index (BMI), using the cut-off
Control and Prevention in Atlanta. In the data collection
point of < 18.5 kg/m2 as underweight, 18.5-25 kg/m2 as
procedures, all participants were asked to provide verbal
normal nutrition status, 25–30 kg/m2 as overweight, and
informed consent after the consent statement was read
above 30 kg/m2 as obese. Wealth index was used as a
to them which emphasized the voluntary nature of the
measure of household economic status by considering
survey. Interviews were conducted under the private
households assets ownership and living conditions. The
conditions afforded by the environments encountered.
dichotomized variables on such assets were reduced
Confidentiality was adhered to by making sure that
using principle component analyses and item weight
names of respondents were not written in the data col-
assigned to give weighted wealth index which was di-
lection tools and hence were anonymous.
vided into quintiles into poorest, poorer, middle, richer
and richest wealth quintile.
Results
Data analysis Characteristics of caregivers
We conducted descriptive and regression analyses using Findings revealed a steady improvement in education at-
SPSS Version 22. For the first objective, the descriptive tainment among caregivers over two and a half decades
analysis using frequency distributions was done to deter- (Table 1). Over this period, the proportion of caregivers
mine the magnitude of stunting across the six surveys. without any formal education had reduced from 35% in
We used the chi-square test to examine the differences 1991–1992 to 21% in 2015–2016 survey. During the
in prevalence of stunting across the years. We also used same period, caregivers with primary level of education
the chi-square test to assess differences on the charac- had not significantly changed (62 to 65%) while those
teristics of the caregivers in relation to child stunting with secondary school education increased 3 to 13%.
across. For the second objective, we used the last survey The proportion of women who had a child by 19 years
(2015–2016 TDHS) to examine the factors associated had declined from 69% in 1991 to 62% in 2015 signifying
with stunting. This was a mitigation to address the an increase in the age at first birth. Evidence show that
differences in measurements and presentation of inde- caregivers with five or more children declined from 31%
pendent variables across the surveys and some datasets in 1991 to 29% in 2015. This is also evidenced by the
Sunguya et al. Nutrition Journal (2019) 18:85 Page 4 of 13

Table 1 Descriptive characteristics of participants in six Tanzania Demographic and Health Surveys (TDHS 1991–2016)
Variables TDHS 1991–1992 TDHS 1996 TDHS 1999 TDHS 2004–2005 TDHS 2009–2010 TDHS 2015–2016
N % N % N % N % N % N %
Highest educational level of mother respondents
No education 2561 35 1812 29 807 28 2085 26 1959 26 2013 21
Primary 4470 62 4155 67 1983 68 5526 69 5219 68 6142 65
Secondary 208 3 207 3 108 4 275 3 468 6 1279 13
Higher 18 0.3 2 0.03 89 1 20 0.3 87 1
Body mass index (kg/m2) of mother respondents
Low (< 18.50) 638 9 517 9 550 7 681 9 637 7
Normal (18.50–24.99) 5729 80 4715 78 6187 78 5580 74 6476 69
Overweight (25.00–30.00) 698 10 696 12 959 12 1018 13 1616 17
Obese (> 30.00) 123 2 140 2 230 3 300 4 724 8
Age at 1st birth of mother respondents
0–19 4972 69 4057 66 1951 67 5197 65 4933 64 5922 62
20–29 2252 31 2102 34 939 32 2719 34 2670 35 3483 37
30 and above 32 0.5 28 0.46 8 0.3 59 1 64 1 115 1
Duration of breastfeeding of mother respondents
<6 882 12 704 11 347 12 877 11 886 12 982 10
6–12 1334 18 1155 19 505 17 1568 20 1466 19 1128 12
13–24 4234 58 3495 56 1633 56 4609 58 4434 58 1304 14
> 24 702 10 638 10 295 10 709 9 596 8 119 1
Inconsistent breastfeeding 21 0.2 26 0.4 10 0.3 20 0.3 38 0.5 5919 62
Never get breastfeeding 35 0.5 96 2 78 3 162 2 133 2 68 1
Number of living children of mother respondents
1 1223 17 1057 17 544 19 1318 17 1139 15 1796 19
2 1520 21 1186 19 642 22 1838 23 1627 21 1993 21
3 1241 17 1155 19 481 17 1517 19 1487 19 1716 18
4 993 14 880 14 429 15 1068 13 1118 15 1240 13
5 786 11 666 11 282 10 774 10 852 11 956 10
6–15(> 5) 1493 21 1244 20 520 18 1461 18 1443 19 1819 19
Sex of head of household
Male 6395 88 5225 84 2415 83 6619 83 6347 83 7875 83
Female 861 12 963 16 484 17 1356 17 1320 17 1645 17
Residence of respondents
Rural 5808 80 5056 82 2353 81 6417 80 6137 80 6980 73
Urban 1449 20 1132 18 546 19 1558 20 1530 20 2541 27

total fertility rate (TFR) which was reduced from 6.2 in population still resides in rural areas, however, there is a
1991 to 5.2 in 2015. notable decline in the proportion from 80% in 1991 to
The magnitude of underweight (measured by low 73% in 2015.
BMI) among caregivers declined from 9% in 1991 to 7% This is evidenced by a decline in proportion of women
in 2015. The proportion of women with overweight and with duration of breastfeeding of less than six months
obesity has more than doubled from 11% in 1991 to 25% from 12% in 1991 to 10% in 2015. However, in 2015 ma-
just two and a half a decade. In addition, proportion of jority of women reported inconsistent breastfeeding
caregivers who are the breadwinners in their households practices where there is a notable proportion who had
from 12% in 1991 to 17% in 2015. Majority of the never breastfed.
Sunguya et al. Nutrition Journal (2019) 18:85 Page 5 of 13

Trend in stunting over two decades With regards to feeding characteristics, children who
Figure 1 shows the trends in stunting over the two and were breastfed immediately had low magnitude of stunt-
half decades (1991–2015) in Tanzania. The findings ing, but the results were significant only in 2004 and
show a significant reduction of stunting among children 2009. Counter intuitively, breastfeeding duration was not
under five. The prevalence of stunting declined from protective for stunting, but those who were never breast-
50% in 1991 to 35% in 2015 (p < 0.001). In 1991 one in fed were more likely to suffer from stunting compared
every two under-fives had stunting compared to one in to even the children who were breastfed for a shorter
three under-fives in 2015. The decline is also seen in se- period of time. Moreover, women who had more than
vere form of stunting which has halved from 22% in one birth in the past five years were less likely to have
1991 to 12% in 2015. their children stunted compared to those with one birth.
However, the more the number of children living in a
household increases the risk of stunting increased as
Descriptive characteristics of children in relation to stunting well.
status Although the proportion of women-headed household
A higher proportion of boys have consistently suc- showed to increase, the findings show that, the female
cumbed to stunting compared to their counterparts lead households were more likely to have a stunted child
(p < 0.001) (Table 2). Moreover, the prevalence of compared to the one led by a male. In two surveys, this
stunting tends to increase as the child grows to its association is statistically significant. Findings further
highest proportion during 24–35 months and declines show that the higher the number of household’s mem-
thereafter. bers the lower the risk of stunting. The prevalence of
Children with low birthweight have consistently high stunting is also consistently higher among children in
prevalence of stunting compared to those born with nor- rural households compared to their urban counterparts
mal or high birthweight. In 1991, about 60% children (p < 0.001).
born with a low birthweight had stunting compared to
46 and 40% of normal and high birth weight respectively Factors associated with stunting in Tanzania
(p < 0.001). In 2015, 48% of low birth weight children Table 3 shows the results of three-level hierarchical lo-
became stunted compared to 31% of those born with gistic regression analyses. Children living in urban areas
normal weight (p < 0.001). Mothers’ nutrition was also were less likely to be stunted compared to their counter-
found to be a predictor of children’s stunting status. parts living in rural area (AOR = 0.56, 95%CI = 0.50–
Children of mothers with low BMI were more likely to 0.62, P < 0.001). There was no statistically significant as-
suffer from stunting compared to their counterparts sociation between mothers’ age at first birth with child
whose mothers had normal BMI, or even those with stunting status. However, mothers’ education was pro-
overweight and obesity (p < 0.001). Mothers’ age at first tective against child’s stunting. Children whose mothers
birth showed mixed results over all surveys with inclin- had higher education were 44% less likely to be stunted
ation to higher magnitude of stunting when the age was compared to those whose mothers had no education
19 years and below in 1991 (p < 0.001), and others but (P = 0.018). Children whose mothers were obese were
with no statistically significant level. less likely to suffer from stunting compared to their

Fig. 1 Trends in prevalence of stunting in Tanzania from 1991–2016, TDHS Surveys. a P < 0.001, X2 = 523.45. b P < 0.001, X2 = 499.11. Blue line: The
proportion of children with stunting Tanzania. Orange line: The proportion of children with severe stunting Tanzania. Figure 1 shows the trends
in stunting over the two and half decades (1991–2015) in Tanzania. And there were similar trends for prevalence of stunting and severe stunting
Table 2 Stunting prevalence among children under 5 according to the descriptive characteristics in TDHS 1991–2016
variables 1991–1992 1996 1999 2004–2005 2009–2010 2015–2016
% 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I.
Sex of child
Male 52 50.69 54.09 52 50.62 54.18 51 48.07 53.59 47 45.29 48.50 41 39.76 43.13 37 35.57 38.39
Female 47 45.00 48.37 46 44.23 47.84 46 42.91 48.46 42 39.93 43.10 43 41.02 44.35 32 30.78 33.57
P-value < 0.001 < 0.001 < 0.001 < 0.001 0.32 < 0.001
Age of child (months)
Sunguya et al. Nutrition Journal

0–11 30 27.71 32.20 27 24.83 29.51 25 21.91 28.93 26 23.55 27.66 42 39.56 44.68 16 14.55 17.81
12–23 51 48.47 53.47 54 51.02 56.32 53 48.28 56.80 48 46.03 50.89 40 37.48 42.76 38 36.31 40.53
24–35 62 59.20 64.50 62 58.75 64.45 59 55.02 63.63 52 49.41 54.51 43 39.86 45.43 46 44.08 48.85
36–47 59 56.08 61.83 60 56.74 62.66 56 51.55 60.95 53 50.22 55.55 43 39.83 45.29 42 39.10 43.97
(2019) 18:85

48–59 52 48.72 54.61 49 46.11 52.30 53 48.83 58.14 46 43.14 48.68 45 41.61 47.42 33 30.71 35.44
P-value < 0.001 < 0.001 < 0.001 < 0.001 0.34 < 0.001
Birthweight (g)
Low 60 54.91 64.25 63 57.16 68.17 73 64.15 81.85 58 51.43 64.05 40 33.48 46.52 48 42.82 53.41
Normal 46 44.11 47.94 43 41.37 45.34 44 41.01 47.47 41 39.46 42.99 41 39.06 42.67 31 30.09 32.77
High 40 33.81 45.88 41 35.49 47.07 27 19.29 35.11 28 23.27 31.93 40 35.00 44.51 26 23.04 29.68
P-value < 0.001 < 0.001 < 0.001 < 0.001 0.84 < 0.001
Body mass index (kg/m2) of mother respondents
Low (< 18.5) 57 52.98 60.88 54 49.85 58.90 49 44.13 52.89 46 41.62 49.44 39 35.29 43.11
Normal (18.5–24.9) 50 48.61 51.31 51 49.40 52.29 46 45.05 47.61 42 40.46 43.23 37 35.39 37.81
Overweight (25–30) 41 37.40 45.00 38 34.43 41.81 32 28.91 35.14 42 38.83 45.41 31 28.93 33.70
Obese (> 30) 41 29.90 49.31 38 29.50 46.47 32 17.12 28.88 42 36.94 49.35 31 16.80 23.01
P-value < 0.001 < 0.001 < 0.001 0.56 < 0.001
Age of mother respondents at 1st birth
0–19 51 50.02 52.92 50 48.52 51.64 48 46.03 50.81 45 43.39 46.19 42 40.03 42.97 35 33.72 36.25
20–29 45 43.10 47.41 48 45.33 49.75 48 44.50 51.35 43 41.22 45.09 43 41.06 45.10 34 32.58 35.86
30 and above 42 23.54 60.33 58 37.34 78.04 57 7.71 106.58 41 27.20 54.28 46 30.70 60.61 28 19.59 37.02
P-value < 0.001 0.33 0.76 0.43 0.53 0.13
Time after the birth at which the mother respondent first breastfed the last child
Immediately 48 46.30 50.65 45 43.08 47.19 42 40.55 43.71 39 37.23 41.17 34 32.85 35.82
Within 1 day 45 43.04 47.58 50 46.92 52.16 46 44.10 47.69 43 41.75 44.93 35 33.05 36.08
Over 1 day 47 42.82 50.26 48 43.22 52.19 48 44.06 52.27 46 41.08 50.22 35 30.25 39.10
0.20 0.14 < 0.001 0.01 0.90
Page 6 of 13

P-value
Table 2 Stunting prevalence among children under 5 according to the descriptive characteristics in TDHS 1991–2016 (Continued)
variables 1991–1992 1996 1999 2004–2005 2009–2010 2015–2016
% 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I.
Duration of breastfeeding (months)
<6 26 22.89 28.84 22 18.98 25.15 23 17.96 27.26 21 18.54 24.07 39 35.59 42.53 13 10.75 15.01
6–12 41 37.80 43.22 40 36.71 42.43 37 32.16 41.24 35 32.89 37.72 43 40.38 45.80 19 16.92 21.54
13–24 55 53.62 56.76 55 53.05 56.43 54 51.55 56.80 50 48.03 51.05 42 40.10 43.22 38 35.28 40.60
> 24 64 60.33 67.83 68 63.97 71.48 66 60.05 71.53 60 55.80 63.20 48 43.38 51.82 52 42.86 61.56
Sunguya et al. Nutrition Journal

Inconsistent 24 1.05 46.01 19 2.86 34.18 33 −20.86 87.53 33 9.21 57.46 39 21.80 56.99 41 39.32 41.97
breastfeeding
Never get breastfeeding 66 49.69 83.64 57 47.27 67.63 42 29.23 53.84 46 38.18 54.78 43 34.61 53.11 34 20.78 47.14
P-value < 0.001 < 0.001 < 0.001 < 0.001 0.13 < 0.001
(2019) 18:85

Number of births in last five years

1 52 49.56 53.63 52 49.84 53.91 47 44.12 50.41 45 42.86 46.52 41 39.46 43.23 33 31.87 34.77
2 49 47.27 50.52 48 46.55 50.16 50 47.21 52.87 45 43.18 46.43 43 40.82 44.21 37 35.11 38.13
3 45 41.07 48.66 44 40.22 47.97 45 39.53 50.37 41 37.76 44.17 43 39.57 46.77 33 29.36 35.94
>3 58 44.68 71.11 48 31.87 63.37 43 −6.58 92.29 35 23.64 46.95 35 20.48 49.08 18 7.66 28.70
P-value 0.01 0.02 0.35 0.10 0.35 0.00
Number of living children
1 48 45.51 51.46 50 47.28 53.39 44 39.36 48.47 45 42.21 47.85 41 37.61 43.85 32 29.99 34.48
2 47 44.69 50.06 49 46.19 52.09 41 36.96 45.24 44 42.01 46.81 41 38.69 43.79 35 32.30 36.71
3 49 45.76 51.59 48 44.65 50.55 48 42.85 52.41 45 42.70 47.91 42 38.87 44.20 31 29.10 33.73
4 50 46.50 52.87 49 45.28 52.01 55 49.49 59.65 43 40.26 46.35 41 38.38 44.58 35 32.19 37.68
5 53 49.38 56.63 50 45.98 53.71 48 41.86 54.46 44 40.05 47.28 43 39.69 46.83 38 34.45 40.83
6–15 51 48.46 53.63 50 47.30 52.95 57 52.18 61.24 43 40.56 45.69 44 41.62 47.11 38 35.87 40.44
P-value 0.21 0.83 < 0.001 0.94 0.77 < 0.01
Highest educational level
No education 51 49.36 53.38 54 52.10 56.83 50 46.54 53.88 47 44.81 49.27 42 39.70 44.34 39 37.25 41.71
Primary 49 47.49 50.54 48 46.44 49.50 48 46.08 50.80 44 42.72 45.41 43 41.08 43.94 35 33.98 36.44
Secondary 34 26.70 41.65 26 18.67 33.51 23 12.56 33.60 33 26.09 39.24 36 30.76 41.05 25 22.49 27.65
Higher 53 27.91 77.36 10 2.75 16.97 53 24.74 81.93 8 1.74 14.48
P-value < 0.001 < 0.001 < 0.001 < 0.001 0.02 < 0.001
Sex of head of household
Male 49 47.78 50.33 49 47.67 50.42 47 45.36 49.62 43 41.84 44.30 42 40.57 43.16 34 32.85 35.02
Female 53 49.54 56.67 51 47.25 53.89 53 47.59 57.46 50 47.12 52.71 43 40.20 46.00 38 35.57 40.51
Page 7 of 13
Table 2 Stunting prevalence among children under 5 according to the descriptive characteristics in TDHS 1991–2016 (Continued)
variables 1991–1992 1996 1999 2004–2005 2009–2010 2015–2016
% 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I. % 95% C.I.
P-value 0.08 0.64 0.07 < 0.001 0.62 0.01
Number of household members
1–5 51 48.88 53.21 50 47.65 51.89 51 47.52 54.00 46 44.11 47.72 42 40.11 43.92 35 33.30 36.48
6–10 51 48.88 52.30 49 47.41 50.96 49 45.70 51.64 45 43.31 46.61 42 40.53 44.02 35 33.79 36.71
> 10 44 41.81 47.16 48 44.64 51.78 43 38.49 47.22 37 33.74 39.67 42 38.56 44.67 32 29.11 34.36
Sunguya et al. Nutrition Journal

P-value < 0.001 1 0.02 < 0.001 0.89 0.13

Residence of household
Rural 50 48.80 51.45 51 49.85 52.65 52 50.01 54.30 46 45.04 47.55 43 41.23 43.87 38 36.65 39.00
Urban 47 43.90 49.54 40 36.99 42.93 29 24.47 33.22 35 32.36 37.43 40 37.43 42.78 25 23.59 27.18
(2019) 18:85

P-value < 0.01 < 0.001 < 0.001 < 0.001 0.10 < 0.001
Page 8 of 13
Sunguya et al. Nutrition Journal (2019) 18:85 Page 9 of 13

Table 3 Factors associated with stunting using TDHS 2015–2016

Variable N (%) Model 1a Model 2b Model 3c
AOR 95% CI p-value AOR 95% CI p-value AOR 95% CI p-value
Residence
Rural 6531 (74) Reference
Urban 2284 (26) 0.56 (0.50, 0.62) < 0.001
Maternal age in years
15–19 596(7) Reference
20–24 2064(23) 1.31 (1.06, 1.62) 0.014
25–29 2205(25) 1.08 (0.84, 1.39) 0.540
30–34 1693(19) 1.07 (0.8, 1.42) 0.662
35–39 1339(15) 1.08 (0.78, 1.49) 0.634
40–44 731(8) 1.23 (0.86, 1.75) 0.248
45–49 186(2) 1.70 (1.09, 2.65) 0.019
Mother’s body mass index (kg/m2)
< 18.5 605(7) 1.09 (0.92, 1.3) 0.328
18.5–24.9 6034(68) Reference
25.0–30.0 1478 (17) 0.85 (0.75, 0.97) 0.015
> 30.0 676 (8) 0.63 (0.51, 0.78) < 0.001
Mother’s age at 1st birth
< 20 5451(62) 0.94 (0.84, 1.05) 0.282
20–29 3256(37) Reference
30> 107(1) 0.99 (0.62, 1.59) 0.976
Number of births in last five years
1 4014(46) Reference
2 3917(44) 0.99 (0.88, 1.11) 0.867
3 820(9) 0.85 (0.7, 1.03) 0.090
>3 64(1) 0.48 (0.26, 0.91) 0.024
Number of living children
1 1637 (19) Reference
2 1793 (20) 1.07 (0.89, 1.28) 0.455
3 1575 (18) 1.00 (0.81, 1.24) 0.993
4 1155(13) 1.11 (0.86, 1.42) 0.429
5 899(10) 1.17 (0.88, 1.56) 0.267
6–15 1755(20) 1.17 (0.86, 1.59) 0.325
Highest educational level
No education 1891 (21) Reference
Primary 5686 (65) 0.99 (0.88, 1.1) 0.830
Secondary 1161(13) 0.83 (0.63, 1.06) 0.305
Higher 76(1) 0.56 (0.16, 0.91) 0.018
Head of household
Male 7348(83) Reference
Female 1467(17) 1.16 (1.03, 1.31) 0.014
Number of household members
1–5 3429 (39) Reference
6–10 4137 (47) 0.88 (0.79, 0.99) 0.027
Sunguya et al. Nutrition Journal (2019) 18:85 Page 10 of 13

Table 3 Factors associated with stunting using TDHS 2015–2016 (Continued)

Variable N (%) Model 1a Model 2b Model 3c
AOR 95% CI p-value AOR 95% CI p-value AOR 95% CI p-value
> 10 1248(14) 0.75 (0.65, 0.87) 0.000
Wealth index
Poorest 2009(23) Reference
Poorer 1932(22) 0.96 (0.85, 1.09) 0.563
Middle 1778(20) 0.98 (0.86, 1.12) 0.758
Richer 1818(21) 0.65 (0.56, 0.76) < 0.001
Richest 1278(14) 0.42 (0.34, 0.52) < 0.001
Age of child (months)
0–11 1970(22) Reference
12–23 2055(23) 1.50 (0.97, 2.32) 0.069
24–35 1688(19) 1.75 (1.09, 2.79) 0.019
36–47 1580(18) 1.38 (0.86, 2.21) 0.181
48–59 1521(17) 0.99 (0.62, 1.59) 0.967
Sex of child
male 4469(51) Reference
female 4345(49) 0.77 (0.68, 0.87) < 0.001
Birthweight (g)
low < 2500 340 (6) 2.14 (1.68, 2.71) < 0.001
4000 > normal> = 2500 4551(82) Reference
high > = 5000 677 (12) 0.65 (0.54, 0.79) < 0.001
Duration of breastfeeding (months)
<6 962 (11) Reference
6–12 1114(13) 1.63 (1.18, 2.24) 0.003
13–24 1281(15) 2.91 (1.73, 4.91) < 0.001
> 24 111(1) 5.44 (2.57, 11.49) < 0.001
Inconsistent breastfeeding 5288(60) 3.46 (2.07, 5.78) < 0.001
Never breastfed 58(1) 4.29 (1.77, 10.37) 0.001
N (%) N frequency; (%) percentage of frequency, AOR Adjusted Odds Ratio, C.I. Confidence interval
a
Model-1: adjusted for residence place
b
Model-2: adjusted for residence place and all variables shown under Model-2
c
Model-3: adjusted for residence place and all variables shown under Model-3

counterparts whose mothers had normal BMI (AOR = weights were twice more likely to be stunted (P < 0.001),
0.63, 95%CI = 0.51–0.78, P < 0.001). After adjusting for while children born with higher birth weight were 35%
possible confounders, children from households lead by less likely to be stunted (P < 0.001).
females (AOR = 1.16, 95% CI = 1.03–1.31, P = 0.014) Compared to children who were breastfed for less than
were more likely to be stunted compared to the male six months, those who were inconsistent breastfeeding
lead households. Wealthier households were less likely or never breastfed were more likely to be stunted
to have stunted children. For example, children in the (AOR = 3.46, 95% CI = 2.07–5.78, P < 0.001 and AOR =
two higher wealth quintiles were 35 and 58% less likely 4.29, 95% CI =1.77–10.37, P < 0.001 respectively).
to be stunted compared to poorest children (P < 0.001).
Children aged 24–35 months had higher risk of stunt- Discussion
ing compared to those of 0–11 months (AOR = 1.75, Evidence from the secondary analyses of Tanzania
95% CI = 1.09–2.79, P = 0.019). Girls were less likely to Demographic Surveys conducted from 1991 to 2016 sug-
be stunted compared to boys (AOR = 0.77, 95%CI = gest a steady decline of stunting among under-five chil-
0.68–0.87, P < 0.001). Compared with under-fives born dren. There is also a notable improvement in women’s
with normal birth weight, those born with lower birth empowerment that could have influenced the changes.
Sunguya et al. Nutrition Journal (2019) 18:85 Page 11 of 13

This is shown through a notably steady improvement in and basic causes of undernutrition that call for nutrition
education attainment among caregivers, increase in the sensitive approaches. As evidenced elsewhere, improve-
age at first child birth, and proportion of female heading ment of population-wide stunting may take longer than
households. Such progress made may have influenced other forms of acute forms of undernutrition whose de-
better nutritional status among mothers and subse- terminants are immediate causes such as poor feeding
quently consistent decline in the burden of low birth- practices and disease conditions and have specific inter-
weight among children as one of the pathways towards ventions that are easily attained [4, 16].
stunting reduction [21]. This study reveals an increase in proportion of women
The magnitude of undernutrition and in particular who lead their households. However, data suggests that
stunting is on a steady decline globally but with slow when a woman leads the household the children’s nutri-
pace among sub Saharan African countries [16, 22]. tion status is not improving. Tanzania is composed of
Tanzania is no exception [4]. This chronic form of mostly patrilineal societies where majority of households
undernutrition was prevalent among 49.5% of chil- are led by male figures. When a woman leads the house-
dren under five in 1991, translated to one in every holds, she may likely be a single mother, widowed, or liv-
two under-fives [4]. Twenty five years later, and with ing alone. These living arrangements translate to low
efforts and investment in health and human capital household income from a single adult compared to
development in the country, the magnitude of stunt- others where both mother and father may be contribut-
ing has declined to 34% in 2015–2016 [4, 16], trans- ing to household wealth. It also is assumed that, the in-
lated to one in every three under-fives. Although this crease in the number of female household leaders may
30% decline is significant over two and a half de- be due to improved education level, self-sufficiency, and
cades, the prevalence of stunting at this level is one engagement in direct economic activities with a results
of the highest globally [16]. Tanzania remains one of of better feeding practices. This may also affect the chil-
the 14 countries with the 80% of global burden of dren as their only parent would be spending more time
stunting. seeking for means to sustain the household than taking
Evidence from this and previous studies suggest that care of the children nutritional needs as in traditional
efforts to ameliorate stunting should also focus in tai- households in Tanzania. Although to an extension, it is a
lored nutrition specific and sensitive interventions product of higher educational attainment, those with the
[23]. Owing to diversity of causes of undernutrition, highest education levels tend to have less advantage in
there is no silver bullet for stunting. To this end, a stunting reduction owing to less time they have for child
combination of such nutritional sensitive and specific caring. Efforts should therefore be streamlined to work-
interventions tailored to the local context can make ing mothers, including those with higher income.
impact [24, 25]. In the context of Tanzania, socio- Results from this analysis further emphasize on the
demographic disadvantaged populations bear a signifi- interventions in the first 1000 days of life [13, 28, 29].
cant brunt of stunting like other forms of undernutri- Both maternal and newborn health are important to
tion [4, 26, 27]. Like in such previous studies, this address future nutrition status of children [30]. This
analysis found that, the risk of stunting increases with study found a declining burden of maternal undernu-
poverty and low educational attainment of caregivers. trition and low birthweight. Nevertheless, such im-
Poverty renders populations into poor health services portant determinants are still persistent and remain
and poor feeding practices. Evidence further suggests behind the current high burden of stunting. Tanzania
a closer link between the mentioned basic and under- is also facing a nutritional transition challenge owing
lying causes or determinants with immediate causes to increased burden of overweight and obesity amid
such as poor feeding practices. Our current analyses persistent burden of undernutrition [4, 16]. Such poor
also confirmed an association between poor IYCF magnitude of overweight and obesity more than dou-
practices with stunting. Moreover, stunting was higher bled between 1991 and 2015 [4]. This call for
among children aged 24 months and above compared renewed efforts to address double edged sword of un-
to those under one year. The peak age (24–35 dernutrition and overweight and obesity that will con-
months) has a significant nutritional milestone where tinue to burden health system in Tanzania through
the child is mostly independent, finished breastfeed- non-communicable diseases.
ing, and fully introduced to normal foods as per a Evidence in this study puts emphasis on importance of
specific place. addressing stunting among boys. This evidence is not
With improvement of the pertinent determinants like strange in the context of sub Saharan Africa [31]. A
in the context of Tanzania, the indicators for stunting number of explanations have been given including bio-
and other forms of undernutrition are improving. The logically, socially, and feeding differences among girls as
slow pace is due to difficulty in addressing underlying compared to boys [31].
Sunguya et al. Nutrition Journal (2019) 18:85 Page 12 of 13

Evidence from this study should be interpreted carefully conceptualized the study and supervised analysis, also provided critical
owing to the following two limitations. First, the analysis review of the manuscript. All authors read and approved the final
manuscript.
was based on cross sectional surveys that does not provide
causal pathways even though a number of serial cross sec- Funding
tional studies were analyzed together. Findings from this Authors were supported by a seed fund provided by the School of Public
Health, Fudan University, Shanghai China.
study, however, are not different from other well-designed
studies and further strengthen the existing strong- Availability of data and materials
designed studies. Second, data were collected across years All datasets are available upon request from DHS website.
with various improvements in the data collection tools
Ethics approval and consent to participate
and methods. In TDHS surveys, while procedures of data The protocol and data collection procedures for the DHS were approved by
collection remained the same, some variables have chan- NIMR, ZAMREC, the Institutional Review Board of ICF International, and the
ged or modified to address the new needs. An example for Centers for Disease Control and Prevention in Atlanta. All participants were
asked to provide verbal informed consent after being read a document
this is dietary diversity scales, and nutritional assessment emphasizing the voluntary nature of the survey.
reference populations. We dropped the dietary diversity
data owing to significant differences between years and we Consent for publication
Consent to use and publish articles emanating from this dataset was
used one standardized population (the WHO standards) obtained along with the dataset from the Demographic and Health Survey
for nutritional status. Despite the two limitations, this is (DHS) and National Bureau of Statistics. The data is owned by the ICF
the first study that analyzed data across all national repre- International, 530 Gaither Road, Suite 500, Rockville, MD 20850.
sentative surveys for the past two and half a decade in
Competing interests
Tanzania. Evidence presented here is based on a big sam- The authors declare that they have no competing interests.
ple size making it easy to generalize the findings for
Author details
Tanzania as well and with power to generate conclusions. 1
School of Public Health and Social Sciences, Muhimbili University of Health
and Allied Sciences, Dar es Salaam, Tanzania. 2School of Public Health, Fudan
Conclusions University, Shanghai, China. 3Key Laboratory of Health Technology
Assessment, National Health Commission, Shanghai, China.
In conclusions, Tanzania is making progress in address-
ing the burden stunting among children under five. This Received: 30 May 2019 Accepted: 18 November 2019
comes about through strides made to improve socio-
demographic challenges including women empower-
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