title: Malnutrition among children under the age of five in the Democratic Republic of Congo (DRC): does geographic location matter?
abstract: BACKGROUND
  Although there are inequalities in child health and survival in the Democratic Republic of Congo (DRC), the influence of distal determinants such as geographic location on children's nutritional status is still unclear. We investigate the impact of geographic location on child nutritional status by mapping the residual net effect of malnutrition while accounting for important risk factors.
  
  
  METHODS
  We examine spatial variation in under-five malnutrition with flexible geo-additive semi-parametric mixed model while simultaneously controlling for spatial dependence and possibly nonlinear effects of covariates within a simultaneous, coherent regression framework based on Markov Chain Monte Carlo techniques. Individual data records were constructed for children. Each record represents a child and consists of nutritional status information and a list of covariates. For the 8,992 children born within the last five years before the survey, 3,663 children have information on anthropometric measures.Our novel empirical approach is able to flexibly determine to what extent the substantial spatial pattern of malnutrition is driven by detectable factors such as socioeconomic factors and can be attributable to unmeasured factors such as conflicts, political, environmental and cultural factors.
  
  
  RESULTS
  Although childhood malnutrition was more pronounced in all provinces of the DRC, after accounting for the location's effects, geographic differences were significant: malnutrition was significantly higher in rural areas compared to urban centres and this difference persisted after multiple adjustments. The findings suggest that models of nutritional intervention must be carefully specified with regard to residential location.
  
  
  CONCLUSIONS
  Childhood malnutrition is spatially structured and rates remain very high in the provinces that rely on the mining industry and comparable to the level seen in Eastern provinces under conflicts. Even in provinces such as Bas-Congo that produce foods, childhood malnutrition is higher probably because of the economic decision to sell more than the population consumes. Improving maternal and child nutritional status is a prerequisite for achieving MDG 4, to reduce child mortality rate in the DRC.
authors.affiliation: University of Warwick, Warwick Medical School, Health Sciences Research Institute, Warwick Evidence, Gibbet Hill, CV4 7AL, Coventry, UK. N-B.Kandala@warwick.ac.uk
authors.forename: Ngianga-Bakwin
authors.initials: NB
authors.lastname: Kandala
authors.forename: Tumwaka P
authors.initials: TP
authors.lastname: Madungu
authors.forename: Jacques B O
authors.initials: JB
authors.lastname: Emina
authors.forename: Kikhela P D
authors.initials: KP
authors.lastname: Nzita
authors.forename: Francesco P
authors.initials: FP
authors.lastname: Cappuccio
mesh_terms: D002669:Child Welfare; D002675:Child, Preschool; D015023:Democratic Republic of the Congo / Q000453:epidemiology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D044342:Malnutrition / Q000175:diagnosis / Q000453:epidemiology*; D008499:Medical Records; D009010:Monte Carlo Method