Explaining rural-urban disparities in child stunting in African least developed countries: a multi-country...

Rural-urban disparities in child stunting persist in African least developed countries (LDCs), undermining progress towards Sustainable Development Goal 2.2. However, multi-country evidence remains limited on which underlying factors account for these disparities. This study examined rural-urban differences in child stunting across 18 African LDCs and assessed the relative contributions of distal socioeconomic resources and proximal household environmental, healthcare-access, and dietary conditions.

We used the most recent Demographic and Health Surveys conducted between 2015 and 2024 in 18 African LDCs. The analytic sample included 88,625 children aged 6-59 months. Child stunting was defined as length/height-for-age z-scores below - 2 standard deviations from the WHO Child Growth Standards median. Explanatory factors included household wealth, maternal education, maternal digital access, water, sanitation and hygiene (WASH) conditions, healthcare access, and dietary diversity. Logistic regression and Karlson-Holm-Breen decomposition models were fitted separately within each country to estimate the rural-urban association in child stunting and the extent to which explanatory factors accounted for this association. Log odds ratios and decomposition estimates were then pooled across countries using random-effects meta-analysis.

Stunting prevalence was higher among rural than urban children in all 18 African LDCs, with rural-urban differences ranging from 4.2 to 33.1 percentage points across countries. In the KHB decomposition analysis, the pooled total odds ratio for child stunting associated with rural residence was 1.904 (95% CI: 1.644-2.205). All explanatory factors jointly accounted for 70.2% of the pooled rural-urban association. Household wealth made the largest contribution, accounting for 29.7% of the total association, followed by maternal digital access (23.6%) and maternal education (9.2%). WASH conditions accounted for 5.7%, whereas healthcare access and dietary diversity made limited contributions.

Rural-urban inequalities in child stunting remain widespread across African LDCs. These inequalities were largely accounted for by unequal socioeconomic resources, especially household wealth, maternal digital access, and maternal education, while proximal household environmental, healthcare-access, and dietary factors made smaller or limited contributions. Narrowing this gap requires multisectoral strategies that address socioeconomic disadvantage, digital exclusion, and basic infrastructure deficits.