Mediators of the Association Between Poor Socioeconomic Status and Child Chronic Undernutrition in Rajshahi District, Bangladesh

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Abstract
Objectives: Children from poor socioeconomic status (SES) households in Bangladesh and other developing countries face a heightened risk of chronic undernutrition, yet the underlying mechanisms remain unclear. This study investigates the association between poor SES and chronic undernutrition in children and explores the mediating factors driving this relationship. Methods: A cross‐sectional study was conducted in urban and rural areas of Rajshahi District, Bangladesh. A two‐phase sampling strategy was employed: five wards and five union parishads (UPs) were randomly selected, followed by stratified random sampling of 664 households (332 urban, 332 rural). Chronic undernutrition was assessed using height‐for‐age z ‐scores. SES was the primary exposure, with five mediating variables: inadequate dietary diversity and delayed breastfeeding initiation, insufficient micronutrient supplementation, disease occurrence, inappropriate health‐seeking behaviors, and poor living conditions (e.g., indoor air pollution). Mediation analysis was performed using the Baron and Kenny approach. Results: The prevalence of chronic undernutrition was 23.9%. Multivariate logistic regression revealed that children from middle and high SES households had 0.81 (95% CI: 0.71–0.93) and 0.67 (95% CI: 0.57–0.77) times lower odds of chronic undernutrition, respectively, compared to poor‐SES children. Mediation analysis identified key contributing factors: inadequate dietary diversity (17.3%), the lack of use of iodized salt (8.8%), history of recent acute respiratory infection (11%), incomplete vaccination (11.1%), and use of unclean cooking fuel (13.1%). Conclusions: Poor SES significantly increases the risk of chronic undernutrition in children, mediated by factors such as inadequate diet, disease, incomplete immunization, and poor living conditions. Targeted interventions addressing these mediators could reduce SES‐based disparities in child undernutrition.

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