Socio-ecological determinants of multiple anthropometric failures among under-five children: A systematic review and meta-analysis of observational studies

Abstract

The composite index of anthropometric failure (CIAF) offers a comprehensive measure of the overall burden of undernutrition in children, extending beyond the traditional anthropometric indices to better capture the co-occurrence of multiple anthropometric deficits. Despite its growing use, evidence on the determinants of CIAF remains fragmented and inconclusive. This systematic review and meta-analysis aimed to identify and synthesize the determinants of CIAF among under five children. A comprehensive search of nine major databases was conducted, including MEDLINE (PubMed), Embase (Ovid), Scopus, CINAHL, ProQuest, ScienceDirect, Global Index Medicus, the Cochrane Library, and Google Scholar. Determinants were categorized using a socio-ecological model across intrapersonal, interpersonal, and community levels. Random-effects meta-analyses were conducted to generate pooled odds ratios (ORs), and heterogeneity was assessed using the I² statistic and Cochran's Q test. Subgroup analyses, sensitivity testing, and publication bias assessment were also performed. Of 6,816 records identified, 56 studies met inclusion criteria (encompassing a total of 1,029,452 under five children). Intrapersonal factors significantly associated with higher odds of CIAF included male sex (OR: 1.17, 95% CI:1.04-1.30), older child age (OR: 1.50, 95% CI: 1.42-1.59), diarrhea (OR: 1.18, 95% CI: 1.08-1.29), fever (OR: 1.08, 95% CI: 1.04-1.13), anemia (OR: 1.22, 95% CI: 1.16-1.29), low birthweight (OR: 2.07, 95% CI: 1.51-2.83), and poor dietary diversity (OR: 1.11, 95% CI: 1.06-1.17). Interpersonal and community-level determinants significantly associated with increased odds of CIAF included low maternal education, maternal unemployment, household poverty, larger family size, food insecurity, and use of unimproved drinking water. We identified key modifiable risk factors associated with CIAF among under five children at different levels, including inadequate dietary intake, childhood morbidity, household food insecurity, limited maternal education, and poor access to safe water. These findings emphasize the need for comprehensive, multi-level interventions that address modifiable risk factors across individual, household, and community levels to reduce childhood multiple anthropometric failures.

Fig 1. A PRISMA flow diagram illustrating the process of systematic review and meta-analysis.

Fig 2. Summary of potential determinants of CIAF among under-five children.

Fig 3. Forest plot showing the association between child’s sex and CIAF.

Fig 4. Forest plots illustrating the association between child’s age and CIAF: (a) 12–23 months vs. < 12 months, (b) 24–35 months vs. < 12 months, (c) 36–48 months vs. < 12 months, (d) 49–59 months vs. < 12 months.

Fig 5. Forest plot showing the associations between child age and CIAF.

Fig 6. Forest plots illustrating the associations between (a, top) low birth weight and CIAF, and (b, bottom) dietary diversity score and CIAF.

Fig 7. Forest plots illustrate the associations between (a, top) maternal education and CIAF, and (b, bottom) maternal employment status and CIAF.

Fig 8. Forest plots illustrate the associations between (a, top) wealth status and CIAF, and (b, bottom) sources of drinking water and CIAF.

Fig 9. Modified socio-ecological model depicting the multilevel factors associated with childhood undernutrition.

Fig 10. Funnel plots for assessing publication bias across studies examining factors associated with CIAF: (a) child’s sex, (b) diarrhea, (c) moderate or severe anemia, (d) birth weight, (e) wealth status, (f) sources of drinking water, (g) place of residency, and (h) maternal employment status.