HLTH 3115 Week 8 Equity Analysis Example

Child Stunting by Household Wealth in Kenya, 2014 and 2022: One Gap Measured Absolutely and Relatively, Then Traced Upstream Through Exposure, Access and Measurement

Student Name

Walden University

HLTH 3115: Public and Global Health

Instructor Name

Month Day, Year

Child Stunting by Household Wealth in Kenya, 2014 and 2022: One Gap Measured Absolutely and Relatively, Then Traced Upstream Through Exposure, Access and Measurement

The Gap

Kenya's 2022 Demographic and Health Survey measured stunting at 27.6% among children under five in the lowest-wealth households and 8.7% among those in the highest (Kenya National Bureau of Statistics et al., 2023). Stunting means a child's height for age is more than two standard deviations below the median of the World Health Organization's child growth standards, which were built from healthy children raised in good conditions in six countries (WHO Multicentre Growth Reference Study Group, 2006). This paper measures the gap between the poorest and wealthiest households in two ways, compares it with 2014 and then works upstream through exposure, access and measurement to explain it.

Measuring the Gap Two Ways

The 2014 values come from the earlier survey (Kenya National Bureau of Statistics et al., 2015). The two measures tell different stories. The absolute gap, the difference in percentage points, narrowed from 22.1 to 18.9: fewer children in the poorest households were stunted, and the distance between the groups shrank. The relative gap, the ratio, widened from 2.6 to 3.2: the wealthiest households improved proportionally faster, so a child in the poorest fifth went from about two and a half times to about three times as likely to be stunted as a child in the wealthiest fifth.

Neither measure is the correct one. Harper et al. (2010) show that picking a difference or a ratio carries a value judgment, and that they often move in opposite directions when overall rates are falling, as here. A report that gave only one would answer a question its reader did not know had been chosen. The absolute gap speaks to how many children are affected; the relative gap speaks to how unequal the chances are.

Table 1

Stunting Among Children Under Five by Household Wealth, Kenya

Ratios are the poorest fifth's percentage divided by the wealthiest fifth's.

Working Upstream: Exposure

Stunting reflects growth faltering, usually in the first two years of life, from poor nutrition and repeated infections, beginning in pregnancy (Black et al., 2013). The first upstream question is whether children in poor and wealthy households are exposed to different conditions. The 2022 survey shows they are. Among the poorest fifth of households, 24.1% had an improved sanitation facility, compared with 97.4% of the wealthiest fifth, and 52.8% used an improved water source, compared with 97.5% (Kenya National Bureau of Statistics et al., 2023). Poor sanitation and unsafe water expose young children to repeated diarrheal and intestinal infections, which reduce the absorption of nutrients. These are conditions of the household's environment, not choices made by parents.

Working Upstream: Access

The second upstream question is whether families reach the services that support healthy growth. Again, the 2022 survey shows large differences. Births in health facilities were 65.1% in the poorest fifth and 98.5% in the wealthiest, and the share of women with four or more antenatal visits was 54.4% and 83.4% (Kenya National Bureau of Statistics et al., 2023). Antenatal care and facility births are points at which pregnant women and newborns can receive nutrition counseling, supplements and early treatment of infections. Fewer contacts mean fewer chances to address problems before growth falters.

Working Upstream: Measurement

The third upstream question is whether the gap is partly produced by how it is measured. Two features matter. First, the wealth quintiles are relative. The Demographic and Health Survey wealth index ranks households by their assets and housing within each survey, then divides them into fifths (Rutstein & Johnson, 2004). The poorest fifth in 2022 is not the same group, in absolute terms, as the poorest fifth in 2014; if household conditions improved overall, the 2022 poorest fifth may be better off than its 2014 counterpart. The comparison across years is therefore a comparison of relative positions, not of fixed living standards.

Second, stunting depends on accurate measurement of age and height. Errors in recorded age, which can be larger where birth registration is incomplete, shift children across the stunting threshold. If such errors are more common in poorer households, part of the measured gap could reflect measurement rather than growth. The survey cannot rule this out, though the size of the gap makes it unlikely to be mostly error.

What This Analysis Does Not Claim

It does not attribute the gap to what poorer parents know, believe or prefer about feeding children. No measure in the survey tables used here addresses those questions, and the exposure and access differences found are large enough to require explanation first. Nor does it claim that sanitation or antenatal care caused the gap; it shows that the gap lines up with large differences in both, which is consistent with the causal pathways described by Black et al. (2013).

What Would Strengthen the Analysis

Three additions would make the upstream account firmer. Stunting by wealth could be cross-tabulated with sanitation and water within each wealth group, which would show whether children in poorer households with improved sanitation are less often stunted than their neighbors without it. Regional breakdowns could show whether the gap is concentrated in particular counties, where specific conditions, such as drought in arid areas, might matter more than household wealth. And a measure of absolute living standards, such as household consumption, would allow the 2014 and 2022 poorest groups to be compared on a fixed scale rather than as relative fifths. Each of these is possible with the survey data, though not with the summary tables used here.

Conclusion

Measured absolutely, the stunting gap between Kenya's poorest and wealthiest households narrowed between 2014 and 2022; measured relatively, it widened. Both statements are true, and a report should give both. Upstream, the gap lines up with large differences in sanitation, water, facility births and antenatal care, and part of the change over time reflects how wealth groups are defined. Each of these is a condition or a system feature that policy can act on, which is the reason to look there first.

References

Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., Martorell, R., & Uauy, R. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, 382(9890), 427-451. https://doi.org/10.1016/S0140-6736(13)60937-X

Harper, S., King, N. B., Meersman, S. C., Reichman, M. E., Breen, N., & Lynch, J. (2010). Implicit value judgments in the measurement of health inequalities. The Milbank Quarterly, 88(1), 4-29. https://doi.org/10.1111/j.1468-0009.2010.00587.x

Kenya National Bureau of Statistics, Ministry of Health, & ICF. (2023). Kenya Demographic and Health Survey 2022. Kenya National Bureau of Statistics and ICF. https://dhsprogram.com/

Kenya National Bureau of Statistics, Ministry of Health, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development, & ICF International. (2015). Kenya Demographic and Health Survey 2014. Kenya National Bureau of Statistics and ICF International. https://dhsprogram.com/

Rutstein, S. O., & Johnson, K. (2004). The DHS wealth index (DHS Comparative Reports No. 6). ORC Macro.

WHO Multicentre Growth Reference Study Group. (2006). WHO child growth standards based on length/height, weight and age. Acta Paediatrica, 95(S450), 76-85. https://doi.org/10.1111/j.1651-2227.2006.tb02378.x