Policy Note Determinants of Child Malnutrition in the Lao PDR Policy Note Determinants of Child Malnutrition in the Lao PDR © 2024 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of the staff of the World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Cover design: Janet Pontin, Layout: Paul Bloxham, Photo: World Bank © Bart Verweij Policy Note Determinants of Child Malnutrition in the Lao PDR iii Contents Key Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv 1. Introduction and Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Determinants of Child Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3. Disparities in Stunting Between Ethnic Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 4. Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 iv Key Messages Child malnutrition, particularly stunting, remains stubbornly high in the Lao PDR. Progress in tackling this scourge has stalled amid COVID-19 and its economic difficulties. Despite falling from 44% in 2011 to 33% in 2017, the stunting rate has since remained unchanged, and is far lower in regional peers like Indonesia, Vietnam, and Cambodia. Children are more likely to suffer malnutrition if they live in a poor household, belong to an ethnic community, or live in a northern province. This not only represents a loss of human potential but also undermines economic growth. Evidence from World Bank supported Nutrition Convergence Projects suggests that key determinants of stunting include completion of four antenatal care visits, use of skilled birth attendants, child dietary diversity, caretaker age and education, household economic status, the number of children ages 0-4 years in a household, and village-level improved sanitation coverage. Consumption of meat, dairy, and eggs is linked to lower stunting. Limited protein intake could lie behind higher stunting rates among children from poorer households, who often miss out on these food items even as older siblings or parents consume them. Meanwhile, wealthier households tend to have greater dietary diversity and consume more protein. Although few Lao households consume dairy, among those that do, caregivers and parents have stopped feeding milk and dairy to children much earlier than they used to. Enhancing the diversity and production of various food items, and educating caregivers about nutrition, would all improve dietary diversity among children from poorer households. Finally, village-level toilet coverage is found to have a robust negative relationship with stunting rates among children ages 24 to 59 months. Stunting prevalence varies significantly across ethnic groups, largely stemming from factors such as household wealth, sanitation, use of skilled birth attendants, and the number of young children. While 30% of children ages 6–59 months from Lao-Taï families are stunted, this proportion doubled among Hmong- Iumien families. Among children ages 6–24 months, differences can be explained by variations in the household asset index (14%), the presence of skilled birth attendants (8%), the number of children ages 0–4 years (7%), completion of four antenatal care visits (7%), and caretaker age and education (6%). For children ages 6–59 months, differences can be attributed to variations in household asset index (25%), improved sanitation (12%), children ages 0–4 years (6%), caretaker age and education (5%), and child dietary diversity (3%). Expanding the multisectoral nutrition convergence approach to target critical factors is essential to regaining momentum in reducing child malnutrition and giving all groups a fair start in life. Our analysis highlights key factors behind high stunting levels and disparities among socioeconomic groups. A multisectoral approach—including conditional cash transfers, livelihood support programs, and the expansion of health and nutrition services—has proven effective in mitigating the impact of health and economic shocks on child malnutrition. Moving forward, the following policy actions are imperative: n Restoring macroeconomic stability to curb inflation and create fiscal space for strategic investments, nutrition projects, and health spending targeting low-income households and marginalized groups. n Scaling up conditional cash transfers (CCT), particularly with conditions tied to skilled use of birth attendants, completion of four antenatal care visits, and knowledge sessions for caregivers. n Expanding and improving the quality of healthcare services, as well as enhancing knowledge transfer to mothers during antenatal care sessions to maximize the impact of CCT. n Improving children's dietary intake, particularly of meat, dairy, and eggs, by increasing and diversifying food production and educating caregivers about food groups, food quantities, and meal frequencies. n Providing improved access to water supply, sanitation, and hygiene services by strengthening infrastructure, service delivery, and institutional capacity. Combining these programs with a behavior-change component can make such interventions more sustainable. Policy Note Determinants of Child Malnutrition in the Lao PDR 1 1. Introduction and Background Since the turn of the millennium, Laos has made strides across multiple socioeconomic outcomes. Economic growth has lifted many out of poverty, and access to basic services, health, and education has improved. The poverty rate declined from 39 percent in 1998 to 18 percent in 2018. Life expectancy increased from 58 years in 1998 to 68 years in 2021, while the mortality rate for children under 5 fell from 116 per 1000 live births to 43 over the same period. Additionally, the proportion of the population experiencing multidimensional poverty— i.e., those deprived in health, education and living standards—has almost halved in recent years, falling from 40 percent in 2011 to 23 percent in 2017 (OPHDI, 2022). Despite this progress, the country is still grappling with elevated levels of childhood chronic undernutrition, especially stunting. Progress in reducing stunting has halted in recent years amid the impact of COVID-19 and inflation. While the proportion of children under 5 who are stunted declined sharply from 44 percent in 2011 to 33 percent in 2017, it remained unchanged between 2017 and 2023 (LSB 2012, 2017, 2024). This places Laos well above its peer countries including Cambodia (22 percent in 2021), Indonesia (21.6 percent in 2022) and Vietnam (20 percent in 2020). Other child nutrition indicators worsened during 2017–2023, with the prevalence of underweight among children under 5 rising from 21 percent to 24 percent, and the incidence of wasting among the same age group increasing from 9 percent to 11 percent.1 There are significant disparities in terms of stunting across socio-economic groups. The latest available data show that stunting rates in the poorest households are more than three times greater than in the wealthiest (LSB 2017). Stunting levels tend to be higher in northern provinces, with rates in Phongsaly, Huaphan, and specific districts in four northern provinces designated for the Nutrition Convergence Projects exceeding 40 percent in 2022 (LSB 2022 and World Bank 2022; See Box 1). In these areas, the prevalence of stunting among the Hmong- Iumien ethnic group was particularly high, at over 50 percent, and improvements in undernutrition rates were minimal between 2017 and 2022. Recent macroeconomic instability may have undermined progress in reducing malnutrition and exacerbated stunting disparities. Inflation has soared into double digits since mid-2022, with headline inflation averaging 27.4 percent and food inflation averaging 30.6 percent between 2022 and 2023. Faced with escalating food prices, many households have resorted to consumption-based coping strategies, such as reducing food intake or substituting their usual foods with cheaper, self-produced, or foraged alternatives. This can jeopardize food and nutrition security. Poor and vulnerable groups, who lack financial buffers to cope with rising prices, have borne the brunt of food inflation, exacerbating their precarious situation. Persistently high levels of childhood undernutrition in Laos represent a staggering—yet avoidable—loss of human and economic potential. Stunting is a significant factor in the country’s low level of human capital. In 2020, a child born in Laos was expected to be 54 percent less productive when she grows up than if she completed her education and enjoyed full health. This productivity gap was smaller on average for the East Asia and Pacific World Bank region and for lower-middle-income countries—and the shortfall in Laos is expected to have worsened in recent years. The burden of malnutrition on the economy was estimated to be at least $482 million annually, representing about 2.7 percent of Lao GDP, of which $212 million or 1.2 percent can be attributed to child stunting and anemia (GoL, 2021). 1 Stunting is a reflection of chronic malnutrition as a result of a) failure to receive adequate nutrition over a long period and b) recurrent or chronic illness. It is measured by height-for-age. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. 2 Policy Note Determinants of Child Malnutrition in the Lao PDR Box 1. Nutrition Convergence Projects The Government of the Lao PDR, with support from the World Bank, has implemented a multisectoral convergence approach to address nutrition and food security challenges. This approach aims to enhance social assistance, livelihood options, childcare practices, and access to health services, while also improving clean water, sanitation, and hygiene. These Nutrition Convergence Projects operate through several government programs: Reducing Rural Poverty and Malnutrition (RRPM) I and II; Health and Nutrition Services Access (HANSA) I and II; Scaling-Up Water Supply, Sanitation, and Hygiene (WASH); Learning and Equity Acceleration (LEAP); Poverty Reduction Fund (PRF) III and Community Livelihood Enhancement and Resilience (CLEAR). This multisectoral approach has shown promising results in enhancing child health and development in similar contexts globally. Phase 1—implemented from 2019 to 2024—focused on 882 villages across 12 districts in the four northern provinces with the highest levels of stunting: Huaphan, Oudomxay, Phongsaly, and Xieng Khuang. The multisectoral approach proved effective in mitigating the impacts of COVID-19 and inflation on child nutrition. Baseline and midline impact evaluation surveys were conducted in 2020 and 2022, respectively, to assess the effectiveness of the nutrition convergence approach. During this period, Laos faced the dual challenges of the pandemic and soaring inflation. Conditional cash transfers (RRPM), livelihood support (PRF III), and health and nutrition service expansion (HANSA) nevertheless continued to help ensure access to maternal health services, knowledge about good nutritional and childcare practices for caretakers, and sufficiently varied diets for children. The survey results indicated that if the Nutrition Convergence Projects had not been implemented before COVID-19, the incidences of stunting, wasting, and being underweight among children would have been significantly higher in the project area. Specifically, stunting and wasting among children under two would have been 7.7 percentage points and 3.4 percentage points higher, respectively, and the incidence of underweight children under five would have been 3.7 percent higher. This policy note uses the most recent available data to outline the primary factors contributing to child stunting and malnutrition in Laos. The report draws on data from the baseline round of impact evaluation surveys conducted in 2020 as part of the Nutrition Convergence Projects. By applying a multivariate analytical model developed by the World Bank (2016) and the Blinder–Oaxaca decomposition method to this data, the analysis identifies the most significant correlates of nutrition outcomes, providing insight into proximate determinants. While the analysis does not establish causation, it indicates potential transmission channels. Building on these findings, this note emphasizes the multisectoral nature of child undernutrition in Laos, identifies key determinants of child stunting, and presents policy recommendations to address them. Policy Note Determinants of Child Malnutrition in the Lao PDR 3 2. Determinants of Child Malnutrition Child undernutrition arises from a complex interplay of factors. At its core, an individual's nutritional status improves when essential nutrients are more available, their general health is better, and they are less exposed to severe and long-lasting diseases. These elements are collectively influenced by underlying factors such as food security (including access, availability, and utilization of food), maternal and childcare practices, water and sanitation, and personal hygiene. Anchoring these determinants in turn are fundamental causes, encompassing institutional/ organizational, political, ideological, economic, and social aspects (such as the social status of women), as well as environmental constraints. Additionally, human-made disasters such as conflict and war, along with natural disasters like recurring floods and drought, further exacerbate the challenges associated with undernutrition. Given the multisectoral nature of nutrition, this report employs multivariate analysis to investigate the factors most influential for nutritional wellbeing among children in Laos. A previous World Bank (2016) report developed a multivariate model to examine the primary determinants of stunting in Laos using household survey data from 2010–2013. In this study, we extend that model and use recent household survey data from the 2017 Lao Social Indicator Survey II and the 2020 Nutrition Convergence Projects baseline survey to enhance our understanding of the causes of malnutrition in the country. The model identifies three main determinants of stunting and child nutrition. The primary determinants are adequacy and diversity of diets, assessed through a WHO-guided dietary diversity score (WHO, 2008). The second category relates to the physical environment, specifically unclean water and poor sanitation, which can damage child health through exposure to adverse bacterial environments (Choudhary et al., 2021). The third set of factors involve effective maternal and childcare practices, including suitable home-based care, healthcare accessibility, the education and age of caregivers, and household wealth status. These factors can be considered complimentary to the other two sets of variables, in that they can magnify or attenuate the effects of dietary adequacy/diversity and sanitation. This section provides a comprehensive exploration of the three determinants. The report begins by investigating the correlation between insufficient dietary intake and stunting. It then reviews factors contributing to inadequate dietary intake, including how food is allocated within households and other feeding practices. The analysis then examines the role of disease and identifies child exposure to diarrheal bacteria as one of the main contributors to undernutrition in Laos. The multivariate model also emphasizes the importance of factors determined before a child's birth. Given the significance of these factors, the analysis concludes with a discussion on the role of intergenerational determinants of undernutrition, including the economic status of the child’s household as well as cultural, social, and gender norms. Inadequate diet Adequate quantity and diversity of foods are crucial to providing a child with the necessary nutrients for their growth and development. But the baseline survey conducted in the four nutrition convergence provinces in 2020 shows that only 40 percent of children ages 6 to 59 months were able to achieve minimum levels of dietary diversity: defined as consumption of at least four varieties of food over a 24-hour recall period.2 Dietary diversity among children aged 6 to 23 months was even lower, at 35 percent. This is concerning: previous literature indicates a significant correlation between a child's diet between 6 and 23 months—known as the complementary feeding period—and their subsequent growth and development. The challenge of low dietary diversity is not limited to the four provinces where data were collected at baseline in 2020. Nationally representative estimates, using the same dietary diversity criteria, show that while 79 percent of children ages 6 to 23 months consume eggs or other animal-source foods, only 64 percent consume fruit and vegetables, and only 43 percent of children ages 12 to 23 months receive breast milk (UNICEF 2023). 2 Based on the previous definition of the WHO/UNICEF minimum dietary diversity indicator that excludes breast milk: consumption of any amount of food from at least 4 out of the 7 following food groups: i) grains, root crops and tubers; ii) pulses and nuts; iii) dairy products; iv) flesh foods (meat, fish, poultry, and organ meats); v) eggs; vi) vitamin-A rich fruit and vegetables; and vii) other fruits and vegetables. 4 Policy Note Determinants of Child Malnutrition in the Lao PDR The World Bank’s multivariate analysis, using the 2020 baseline survey, shows that lower dietary diversity, linked to low nutrient intake, is correlated with stunting. For children ages 6–59 months, the likelihood of stunting decreases when they consume food from more groups, although the correlation appears to be weaker for those ages 6–23 months (See Table A1 in the Annex). The analysis also reveals that while the correlation is significant for consumption of between 0–3 food groups, meeting minimum dietary diversity (consumption of 4 or more food groups) is not necessarily associated with additional reduction in stunting. Low levels of dietary diversity among children could indicate low availability of food at the household level or disparities in the allocation of food across household members. To investigate these possibilities, the analysis first examines whether poorer households spend less on food and whether their diet includes enough variety compared to wealthier households. Subsequently, the analysis delves into the intra-household allocation of food items, which—coupled with poor infant and young child feeding (IYCF) practices—could contribute to increased levels of undernutrition among children. Economically disadvantaged households reported difficulties in accessing a well-rounded diet. Ranking households based on consumption across 54 food and 44 non-food items, as depicted in Table 1, reveals that those at the bottom of the distribution allocate almost 80 percent of their monthly per capita expenditure to food—a striking 30 percentage points more than wealthier households.3 A third of the poorest households reported instances where they could not access sufficient food in the past 12 months, contrasting with only 18 percent of the richest households. The large share of poorer households reporting food insecurity—despite spending a substantial share of their expenditure on food—suggests limited diversity of food intake. Indeed, the poorest households reported consuming only 15 different types of items in the week preceding the survey, while wealthier households consumed 30. These findings are consistent with those of the World Bank (2016), which highlighted that the poorest households in Laos can meet their minimum daily caloric intake but struggle to maintain a balanced and healthy diet. Put another way, households may have enough staples to get by but little access to anything beyond that. This may reflect budget constraints, limited access to markets, and a heavy reliance on self-produced food. According to the Lao Expenditure and Consumption Survey 2018/19, self-produced food accounted for two-thirds of total food consumption among poor households (LSB and World Bank 2020). Expenses on cereals, which are rich in carbohydrates and fiber, dominate the expenditure basket of poorer households. The poorest households allocate a third of their household expenses to cereals, starch, and root crops (such as cassava and sweet potatoes), while about 15 percent of their monthly expenditure is spent on fresh vegetables (Figure 1). Approximately one-fifth of their monthly budget is allocated to sources of protein, such as meats, fish, and eggs. In contrast, richer households spend almost 30 percent of their monthly expenditure on protein sources, with only 10 and 5 percent allocated to cereals and fresh vegetables, respectively. Thus, richer households allocate more of their budget on not only a greater variety of food (Table 1) but also enjoy a more protein-rich diet than poorer families.4 Such protein-dominated diets are generally associated with lower odds of stunting among children (Esfarjani et al., 2013). 3 In Laos, low-income households typically allocate a significant portion of their consumption to food. In 2018/19, poor households, representing 18.3 percent of the population, allocated 77 percent of their consumption to food (LSB and World Bank 2020). 4 These findings are in line with those of the Lao Expenditure and Consumption Survey 2018/19. Poor households allocate 45 percent of their food consumption to rice, compared to 29 percent among non-poor households. Additionally, poor households allocate a higher proportion to vegetables and tubers, while non-poor households allocate a larger share to meat, beverages, restaurant meals, and takeaways (LSB and World Bank 2020). Further rises in protein prices may have since put additional pressure on household budget allocations. This can affect nutrition directly by reducing household members’ chances of protein consumption, and indirectly, as they have less money for nutrition- and health-related expenses after buying food. Policy Note Determinants of Child Malnutrition in the Lao PDR 5 Table 1: Food insufficiency, share of food expenditure, and dietary diversity Quintile rank in the Self-reported food Share of food in monthly Varieties of food items consumption distribution insufficiency in the past per capita expenditure consumed (out of 54) 12 months (%) (%) Poorest 32 82 15 Second 32 75 19 Middle 27 73 23 Fourth 24 68 26 Richest 18 54 30 Source: Authors’ calculations based on the 2020 baseline survey data. Figure 1: Share of household expenditure across food items by consumption quintile 0.4 Share of household expenditure 0.3 0.2 0.1 0 Poorest 2 3 4 Richest Consumption quintile  Cereals, starch, and roots  Meat, fish, and eggs  Milk and milk products  Nuts, beans, and legumes  Fresh vegetables  Fruits, oils, and sugar  Cakes, sweets, and restaurants Source: Authors’ calculations based on the 2020 baseline survey data. In households with lower dietary diversity, children generally experience a lack of dietary variety. Figure 2 illustrates the correlation between household dietary diversity (across 13 items) and individual dietary diversity for children under 5 years old (based on 7 items). Households with greater dietary diversity tend to have children with more diverse diets. However, the positive relationship between household and individual dietary diversity is more pronounced in wealthier households. A one-unit increase in household dietary diversity in more affluent families is associated with a larger increase in children's dietary diversity compared to poorer households. This suggests that dietary diversity at the household and child level can often be influenced by socio-economic, demographic, cultural, and intra-household factors.5 These will be explored in the following subsections. 5 Note that this speaks to relative contributions of availability of resources versus norms – increased incidence of home production is unlikely to remedy the challenge with feeding practices, as individual dietary diversity of children under 5 years old is low even among households that consume a variety of items. 6 Policy Note Determinants of Child Malnutrition in the Lao PDR Figure 2: Household and child dietary diversity 6 Individual dietary diversity for 5 children under 5 4 3 2 1 0 5 10 15 Household dietary diversity All households Poorest households Richest households Source: Authors’ calculations based on the 2020 baseline survey data. Children often miss out on essential food items like meat, eggs, fruit, and vegetables, despite other members of the household consuming them. Children ages 6 to 23 months are even less likely to be fed these items compared to those ages 24–59 months (Table 2). The largest disparity between household and child-level consumption is observed for fruits and vegetables, with only 67 percent of children ages 6–23 months being fed these items despite households consuming them. Consumption patterns across cereals, starches, meats, eggs, and pulses also indicate that children 23 months or younger are less likely to receive complementary items compared to those more than 23 months old. This suggests that caregivers and parents wait until the child reaches an older age before initiating complementary feeding practices. However, medical experts recommend that complementary feeding practices begin when the child is about 6 months old. Table 2: Household access to food and child feeding practices by age group Children ages 6–23 months (%) Children ages 24–59 months (%) Consumption Share of Share of Consumption Share of Share of within the children children within the children children household consuming consuming household consuming consuming if household if household consumed consumed Staples 100 91 90 100 100 100 Fruit & Vegetables 97 65 67 98 88 91 Meat 73 59 77 72 66 87 Eggs 35 30 71 36 36 83 Pulses 9 4 39 8 6 50 Dairy 12 14 80 10 10 69 Source: Authors’ calculations based on the 2020 baseline survey data. Policy Note Determinants of Child Malnutrition in the Lao PDR 7 The World Bank’s multivariate analysis suggests that the consumption of meat, dairy, and eggs is associated with lower stunting for children ages 6–59 months. On average, the chances of stunting are 5.9, 4.0, and 2.2 percentage points lower when a child consumes meat, dairy and eggs, respectively. Meat consumption is also linked to lower stunting among children ages 6–23 months, while other food groups appear to be less significant. This indicates that protein intake is vital to childhood growth. The household survey data from 2020 reveals that dairy consumption falls off as children grow up. Dairy items are not generally a major component of Lao diets. Only 12 percent of households with a child below 24 months, and 10 percent of households with children between 24–59 months, consume milk products. But among the few households that do consume dairy, the proportion of children ages 24–59 that are fed dairy items is 11 percentage points lower than those ages 6–23 months. This drop in milk consumption amongst older children was not observed in the World Bank (2016) data, indicating that caregivers and parents have recently stopped feeding milk and dairy products to their children at an earlier age. Shortfalls in children's dietary diversity often arise at an early age due to delayed breastfeeding and inadequate introduction of complementary foods for those below 24 months. While breastfeeding usually continues beyond one year in the four nutrition convergence provinces—where nearly 67 percent of children ages 12–15 months reportedly received breast milk—it is not complemented with solid, semi-solid, or soft food items (Table 3). Only half of all children between the ages of 6 to 23 months receive other food items in combination with breastfeeding. Another instance of poor IYCF practices is the delayed initiation of breastfeeding, with only a third of children below two months reportedly being breastfed within one hour of birth: a critical moment for child growth and development, without which they could grow up stunted. Among the four provinces, households in Xieng Khuang are most likely to demonstrate poor IYCF practices. Children in households exposed to a nutritional awareness program are more likely to consume complementary diets than those without such training. The data presented in Figure 2 and Table 2 indicate that the likelihood of a child consuming a particular item increases when someone else in the household also consumes that item. Moreover, Figure 3 highlights that providing families with an up-to-date growth chart, or nutrition education can strengthen this relationship: as evidenced by the steeper rise in the likelihood of children ages 6–23 months consuming fruit, vegetables, and meat for a one-unit increase in household-level consumption likelihood. Therefore, enhancing both the diversity of production of items (and thereby ensuring that there is sufficient access) and providing nutritional education programs among caregivers could give children a more diverse diet. The need for such programs is borne out by the 2016 World Bank report, which identified a prevalent belief in Laos that young children instinctively know when and how much to eat. Table 3: Breastfeeding and complementary feeding practices in Nutrition Convergence provinces Children <2 Children <6 Children 6–23 Children 12–15 Children 20–23 months months months currently months, still months, still breastfed within exclusively breastfeeding + breastfeeding at breastfeeding at one hour of birth breastfed receiving solid, 1 year (%) 2 years (%) (%) semi-solid, or soft foods (%) Huaphan 37 75 53 66 18 Oudomxay 30 72 57 67 10 Phongsaly 48 75 52 66 27 Xieng Khuang 27 70 48 67 7 Four provinces 36 73 52 67 16 Source: Authors’ calculations based on the 2020 baseline survey data. Note: Numbers are only representative of the Nutrition Convergence Project area, specifically 882 villages across 12 districts in the four northern provinces. 8 Policy Note Determinants of Child Malnutrition in the Lao PDR Figure 3: Impact of nutrition education and growth monitoring on child dietary diversity 0.8 Fruits and vegetables 0.8 Meat Likelihood of consumption Likelihood of consumption among 6–23 month old among 6–23 month old 0.6 0.6 0.4 0.4 0.4 0.4 0 0 0.1 0.2 0.4 0.6 0.8 1.0 0.1 0.2 0.4 0.6 0.8 1.0 Likelihood of consumption at the household level Likelihood of consumption at the household level No growth monitoring/nutrition education No growth monitoring/nutrition education Received growth monitoring/nutrition education Received growth monitoring/nutrition education Source: Authors’ calculations based on the 2020 baseline survey data. Infectious diseases and access to improved sources of water and sanitation By causing diarrhea and rapid loss of bodily fluids, infectious diseases exacerbate stunting and undernutrition among children. Approximately 6.5 percent of children ages 0–59 months reportedly experienced diarrhea in the two weeks preceding the LSIS II survey in 2017 (LSB 2017). This was a notable reduction of around 3.5 percentage points from 2011/12. The most substantial improvement occurred in provinces where diarrhea was most common in 2011/12. For example, Bokeo, which had a child diarrhea rate of 23 percent—one of the highest in the country—registered a 13 percentage point reduction by 2017. These improvements are crucial for addressing child undernutrition, as numerous studies have shown that chronic exposure to diarrheal illnesses can hinder growth and development. While average indicators for diarrhea have improved, disadvantaged children are more at risk of diarrhea, and less likely to recover effectively. Table 4 shows that children born to mothers with no education, those residing in remote rural areas inaccessible by roads, and those in the bottom two quintiles of wealth distribution were more likely to experience diarrheal episodes in the two weeks prior to the LSIS II survey in 2017. Furthermore, children from these backgrounds were less likely to effectively manage diarrhea through the appropriate use of oral rehydration salt solutions, zinc tablets, and other fluids. Consequently, the direct risk of diarrheal diseases and their indirect effects through undernutrition are disproportionately borne by the most disadvantaged children. Limited access to improved water and sanitation facilities contributes to chronic exposure to fecal bacteria, diarrhea, stunted growth and undernutrition. Unsafe drinking water is a common catalyst for various diseases such as trachoma, cholera, typhoid, and schistosomiasis. Additionally, exposure to fecal contamination—resulting from unsafe disposal of infant and child feces, open defecation, contact with soil contaminated by human and animal feces, and poor hand hygiene practices—amplifies the burden of diarrheal diseases. Even in the absence of diarrhea, persistent exposure to fecal content can impede a child's ability to absorb and utilize nutrients, thereby causing stunted growth. Policy Note Determinants of Child Malnutrition in the Lao PDR 9 Table 4: Diarrheal incidence and management Incidence of Management of diarrhea (% of children having diarrhea) diarrhea (%) Children 0–59 Children Children receiving Children months receiving any oral zinc tablets receiving oral having diarrhea in rehydration salt rehydration last two weeks solution therapy with continued feeding Area Urban 5.8 68.7 24.2 74.8 Rural 6.8 52.0 12.3 56.7 Rural with road 7.1 52.5 13.3 57.5 Rural without road 5.3 49.0 5.5 51.2 Mother's education None / Early childhood 8.2 51.6 10.6 54.8 education Primary 6.1 53.0 12.6 58.1 Lower Secondary 6.4 64.8 20.9 71.8 Upper Secondary 6.2 59.6 20.3 62.3 Post-secondary / non- 4.8 na na na tertiary Higher 4.9 60.8 22.9 66.2 Household Wealth Index Poorest 7.9 47.3 8.3 51.0 Second 8.5 55.7 11.9 59.2 Middle 5.4 58.2 17.0 64.7 Fourth 5.1 66.9 20.7 73.4 Richest 4.6 64.4 32.1 73.0 Source: LSIS, 2017. Poor households tend to have lower access to improved sanitation and drinking water sources. Sanitation access improved between 2012 and 2017. Open defecation rates fell from 37.9 percent (LSIS I) to 23.9 percent (LSIS II), and the percentage of households using improved sanitation and drinking water sources rose from 59.2 to 73.8 percent and 69.9 to 83.9 percent. Yet these improvements have primarily benefited better-off households. In the four provinces targeted by Nutrition Convergence Projects, nearly 60 percent of households in the poorest asset quintile still practice open defecation or use shared toilet facilities, compared with less than 3 percent of the wealthiest households. This stark contrast implies that children from economically disadvantaged households are significantly more exposed to fecal bacteria—and consequently more prone to diarrheal infections and undernutrition—than their wealthier counterparts. The multivariate analysis indicates that access to improved sanitation is a crucial predictor of nutrition and stunting rates among children. When other factors are held constant, a 1 percent increase in village-level toilet coverage is associated with a striking 8 percent reduction in the stunting rate among children ages 6 to 59 months. Notably, the impact of village-level toilet coverage on stunting rates is not significant for children ages 6 to 23 months, but yields results for those between 6 to 59 months. The lack of an impact at younger ages aligns with observations in the World Bank 2016 report, which suggested that “catchup growth” experienced by young children between episodes of diarrheal infections could reduce the carry-through between limited toilet access, diarrhea, and stunting (Richard et al. 2014). 10 Policy Note Determinants of Child Malnutrition in the Lao PDR Table 5: Household access to improved water and sanitation Sanitation Drinking water Improved sanitation facilities Improved sources of drinking water (% of households) (% of households) 75.4 88.8 Provinces Huaphan 85.7 95.0 Oudomxay 73.9 86.6 Phongsaly 55.1 81.6 Xieng Khuang 86.6 91.1 Asset index quintile Poorest 42.2 81.3 Second 68.4 86.9 Middle 83.7 89.0 Fourth 91.2 92.1 Richest 97.8 96.2 Source: Authors’ calculations based on the 2020 baseline survey data. Note: Numbers are only representative of the Nutrition Convergence Project area, specifically 882 villages across 12 districts in the four northern provinces. Intergenerational factors The nutritional status and prenatal practices of mothers play a vital role in the long-term growth prospects of children. Previous research has highlighted that up to half of all growth failure among children under 23 months occurs during the prenatal period (Dewey and Huffman 2009). In Laos, approximately 14 percent of women ages 15 to 49 were underweight, thereby increasing the risk of their children being born with low birth weight (LBW) (World Bank 2016). More recent data from the 2020 Nutrition Convergence baseline survey underscores the significance of prenatal practices. Table 6 shows that the prevalence of LBW, stunting, wasting, and being underweight among children ages 6–23 months is lower for those born to mothers who received at least four antenatal care visits and skilled birth attendance. Among children ages 6–59 months, stunting is significantly influenced by the socio-economic characteristics of their caretakers. Children whose caretakers are under 18 and less educated are more likely to be stunted and underweight. The likelihood of stunting and underweight significantly decreases when caretakers have completed upper secondary and higher education. Similarly, children born into households in the top two asset quintiles have significantly lower chances of being stunted and underweight. Wasting appears to be less correlated with parental socioeconomic characteristics. The literature suggests that wasting and stunting do not necessarily move together. Richard et al (2012) concluded that wasting is a seasonal phenomenon resulting from recent infections or food insecurity that led to short-term loss of muscle mass. Once the food insecurity or infection recedes—for example, as crops recover from poor weather—catch-up growth may occur among children. Conversely, stunting is the consequence of long-term undernutrition, produced not by external shocks but the multi-dimensional factors (economic, educational, cultural, etc.) reviewed in this report. This may explain the differences in correlation between stunting and wasting reported in Table 6. Child nutrition levels are strongly influenced by intergenerational factors, even after controlling for other determinants. Results from multivariate analysis show that the likelihood of stunting among children ages 6 to 23 months decreases by 6.4 percent and by 5.5 percent if mothers received four antenatal care visits and skilled birth attendance, respectively.6 Among children ages 6 to 59 months, those born into households in the richest asset 6 Antenatal care visits received by mothers positively affect child nutrition levels in-utero. For this reason, antenatal visits are studied under a broader group of “intergenerational” factors: meaning that the intervention is received by the previous generation, but its impact is seen on the child. Policy Note Determinants of Child Malnutrition in the Lao PDR 11 quintile are 13 percent less likely to be stunted than those born into the poorest asset quintile. Furthermore, the likelihood of stunting decreases with the age and education of caretakers: children ages 6 to 59 months are 4.6 percent less likely to be stunted if cared for by someone with at least upper secondary education. Table 6: Incidences of child stunting, underweight, wasting, and low birth weight by caretaker’s characteristics and mother’s access to healthcare (% of children) Stunted Wasted Underweight Low birth weight Excluding Including unweighted unweighted Caretaker’s age* Less than 18 48.0 3.8 18.6 18 and above 43.8 3.6 12.3 Caretaker’s education* Less than primary 47.2 4.2 20.8 Mother's education 45.8 3.6 20.4 Completed lower secondary 41.4 2.7 17.7 Upper secondary and higher 32.5 4.2 14.6 Asset index quintile* Poorest 55.9 4.9 24.4 Second 52.4 2.5 20.7 Middle 53.1 2.4 21.1 Fourth 47.5 2.8 18.4 Richest 32.9 3.6 15.1 Antenatal care (ANC)** Fewer than 4 times 48.0 4.9 20.8 11.4 52.4 4 times 32.7 3.7 14.2 7.4 14.5 Skilled birth attendance (SBA)** Unskilled birth attendance 46.9 4.9 19.8 9.7 59.1 Delivery at healthcare 32.7 3.7 14.3 7.8 8.8 facilities or birth attended by skilled health personnel Source: Authors’ calculations based on the 2020 baseline survey data. Note: *among children ages 6–59 months. **among children ages 6–24 months. Traditional misconceptions about dieting during the partum and post-partum periods—and about when infants need additional foods alongside breast milk—contribute to stunting among children. Previous literature, including the World Bank 2016 report, has highlighted harmful beliefs that are often promoted and enforced by influential family members. Table 7 reveals that many of these misconceptions remained prevalent in 2020. For instance, while medical practitioners generally recommend starting infants on a complementary diet at 6 months, in the Nutrition Convergence Project area, 38 percent of families were unaware of this or believed otherwise. Similarly, 40 percent of families erroneously believed that if mothers consume extra food during pregnancy, they are more likely to face a difficult delivery. Relatives often reinforce such beliefs: 46 percent of families relied more on advice from influential family members than trained human development staff or medical practitioners. These beliefs can lead to maternal undernourishment and ultimately result in child stunting. Cultural norms related to open defecation and cooking with traditional stoves and ovens can likewise contribute to child undernutrition. In the 2020 baseline survey data, 31 percent of families believed that open defecation has no impact on the spread of infectious diseases, while 45 percent believed that smoke from 12 Policy Note Determinants of Child Malnutrition in the Lao PDR traditional ovens do not pose major health risks to the family. These harmful misconceptions are slightly more prevalent in Huaphan and Xieng Khuang, indicating that children from these regions face a higher risk of stunting. Table 7: Household cultural norms and misperceptions (% of households) Phongsaly Oudomxay Huaphan Xieng Khuang Four provinces “Until what age is it recommended that a mother feeds nothing more than breastmilk?” Until 6 months 53 73 53 58 57 Until 1 year 28 18 26 29 26 Other/Don't know 14 4 15 10 12 “If a woman eats extra during her pregnancy, she will experience difficulties in delivery” Agree 42 37 40 37 39 Disagree 58 63 60 63 61 “I prefer to listen to advice from my mother-in-law, mother, or other friends and family than to human development staff” Agree 60 37 42 40 46 Disagree 40 63 58 60 54 “I agree households practicing open defecation increases the chances of many diseases spreading” Agree 69 80 64 68 69 Disagree 31 20 36 32 31 “Smoke from cooking is a big health problem for my family” Agree 58 58 53 51 55 Disagree 42 42 47 49 45 Source: Authors’ calculations based on the 2020 baseline survey data. Note: Numbers are only representative of the Nutrition Convergence Project area, specifically 882 villages across 12 districts in the four northern provinces. Policy Note Determinants of Child Malnutrition in the Lao PDR 13 3. Disparities in Stunting Between Ethnic Groups In Laos, stunting varies significantly across ethnic groups. According to the baseline survey data, 30 percent of children ages 6–59 months from Lao-Taï families were stunted, but this proportion doubled among Hmong- Iumien families (Figure 4). The Blinder-Oaxaca decomposition method is employed to explain differences between Lao-Taï and other ethnic groups. The variables from the determinant analysis are used in the decomposition analysis to estimate the extent to which differences in these variables explain variations in stunting prevalence between groups. Figure 4: Stunting prevalence by ethnic group (percent) 59.9 49.5 52.0 46.0 38.7 39.7 29.5 22.3 Lao-Taï Mon-Khmer Chinese-Tibetan Hmong-Iumien  6–23 months  6–59 months Source: Authors’ calculations based on the 2020 baseline survey data. Intergenerational factors and maternal health services emerge as pivotal factors in explaining the disparities in stunting prevalence among children ages 6–24 months between Lao-Taï and non Lao-Taï ethnic groups. The decomposition model reveals that 41.7 percent of the observed differences in stunting prevalence can be explained (Figure 5A). This explained share is attributed to disparities in the household asset index (14.0 percent), access to skilled birth attendance (7.9 percent), completion of four antenatal care visits (6.6 percent), the number of children ages 0–4 years in a household (7.1 percent), as well as the age and education level of caretakers (6.1 percent). These findings underscore the importance of improving access to maternal health services, particularly among marginalized ethnic groups. Additionally, addressing adolescent pregnancy is crucial for equitable child health outcomes across ethnic groups, given that young mothers are less likely to complete their education and learn how to give themselves and their children the healthiest possible diet. Among children ages 6–59 months, intergenerational factors, improved sanitation, and dietary diversity play a key role in explaining inter-ethnic differences in stunting prevalence. In total, the decomposition model accounts for 45.6 percent of the observed variances (Figure 5B). This explained share is attributed to differences in asset index (25.0 percent), improved sanitation (11.7 percent), the number of children ages 0–4 years in a household (5.6 percent), caretakers' age and education (4.5 percent), and child dietary diversity (3.4 percent). These findings highlight the need for targeted interventions—such as building or upgrading sanitation systems, ensuring access to clean water, and promoting proper hygiene practices—to address stunting among marginalized ethnic groups. Additionally, programs to increase awareness of and access to diverse and nutritious foods are crucial for equitable child health outcomes. These may include promoting home gardening, providing nutrition education to caregivers, and supporting local food production to ensure children receive a varied and balanced diet. 14 Policy Note Determinants of Child Malnutrition in the Lao PDR Figure 5: Factors contributing to differing stunting prevalence between Lao-Taï and other ethnic groups A. Children ages 6–24 months B. Children ages 6–59 months Height-for-Age Z-score Stunting Height-for-Age Z-score Stunting 60.4 58.3 55.2 54.4 11.8 11.7 6.3 7.2 16.8 14.0 5.2 5.6 24.9 25.0 4.7 3.9 7.9 1.4 3.5 1.8 2.8 3.1 7.3 6.6 4.0 2.0 3.41.4 7.11.3 5.91.3  Child age  Gender  4 antenatal care visits  Skilled birth attendance  IDDS (0-7)  Log caretaker age  IDDS (0-7)  Log caretaker age  Caretaker completed upper secondary education or higher  Caretaker completed upper secondary education or higher  Household asset index disparities  Household asset index disparities  Log number of children ages 0–4 years  Log number of children ages 0–4 years  Unexplained  Village-level improved sanitation  Unexplained Source: Authors’ calculations based on the 2020 baseline survey data. See Table A.3. Note: IDDS is Individual Dietary Diversity Score for children, based on 7 food groups. Policy Note Determinants of Child Malnutrition in the Lao PDR 15 4. Policy Implications Stalled progress in reducing child malnutrition in Laos underscores the urgent need to strengthen policies and regain momentum. COVID-19 and persistent inflation have significantly affected household income and purchasing power. Lao households have reduced their healthcare spending and adjusted their food consumption patterns by opting for cheaper, self-produced, or foraged alternatives, posing potential risks to food and nutrition security. Additionally, macroeconomic challenges have constrained fiscal space for health and nutrition spending, with public healthcare expenditure steadily declining from 1.7 percent of GDP in 2013 to 0.9 percent in 2023. This note has explored the critical factors contributing to persistently high levels of stunting and disparities between socioeconomic groups. At the same time, a multisectoral approach—including conditional cash transfers, livelihood support programs, and the expansion of health and nutrition services—has proven effective in mitigating the impact of health and economic shocks on child malnutrition. Scaling up this approach, with a focus on the factors identified above, would be a cost-effective strategy to regain momentum in reducing child malnutrition and promoting equitable child health outcomes. This requires the following policy actions: Restoring macroeconomic stability. Given the widespread and adverse effects of economic turbulence on household food security and child malnutrition, it is imperative that stabilization strategies are implemented. Inflation in particular disproportionately affects living standards among poorer households. Given that household poverty is one of the strongest predictors of child malnutrition, renewed economic growth can lead to nutritional gains. Measures to increase foreign currency reserves and manage debt repayments effectively— such as expediting debt renegotiations and bolstering governance of public-private partnerships—are essential to alleviating pressure on the exchange rate, a significant driver of inflation. Simultaneously, fiscal policies should be adjusted to enhance spending efficiency, thereby providing fiscal space for strategic investments and targeted interventions to mitigate the impact of inflation on child malnutrition. Expanding the tax base, curbing costly tax exemptions, raising health taxes on tobacco and alcoholic or sugary beverages, and reinstating fuel excise taxes would help generate the revenue required to implement such policies, some of which are outlined below. Scaling up conditional cash transfers, particularly with conditions tied to skilled birth attendance, completion of four antenatal care visits, and knowledge sessions for caregivers. Conditional cash transfer programs have effectively mitigated the impact of COVID-19 and steep inflation on stunting prevalence in the Nutrition Convergence Project area. Further incentivizing the use of maternal healthcare services and providing essential knowledge to caregivers will not only promote maternal and child health, but also reduce the incidence of stunting among vulnerable populations. Expanding and improving healthcare, especially skilled birth attendance and antenatal care. Conditional cash transfers must be accompanied by improved access to high-quality health services to fully realize their impact. Since antenatal care plays a pivotal role in preventing child stunting, it is essential that such sessions are used to transfer nutritional knowledge and dietary practices to mothers. By prioritizing skilled attendance during childbirth and enhancing antenatal care quality, mothers receive the necessary care and information to protect their health and that of their children, thereby boosting their well-being and reducing stunting rates among their offspring. Enhancing children's dietary intake, particularly by encouraging consumption of protein-rich foods. Consumption of meat, dairy, and eggs is linked to lower stunting. Children in poorer households register higher stunting rates as their diets contain less protein, even if other household members consume protein-rich foods. Compounding this, caregivers in Laos have recently stopped giving milk and dairy to children at a much earlier age. Enhancing children's dietary intake requires enhancing both the diversity and production of food items, as well as educating caregivers about nutrition, especially in poorer households. Delving deeper into how diet impacts stunting is crucial when it comes to designing and implementing policy. Rather than relying solely on one indicator such as minimum dietary diversity—which was found to have an insignificant impact on stunting in the Nutrition Convergence Project area— consumption of specific food groups, food quantities, and meal frequencies should all be considered. Providing improved access to water supply, and sanitation and hygiene services. Including water and sanitation interventions within the Nutrition Convergence Projects could interrupt fecal-oral transmissions among 16 Policy Note Determinants of Child Malnutrition in the Lao PDR infants and children, thereby reducing the incidence of diarrhea and resulting undernutrition. Interventions that provide village-level improved sanitation facilities, promote proper waste disposal of child and animal feces, and strengthen water-quality monitoring at the supply level could help stop the spread of bacterial diseases. Combining these infrastructural and technical interventions with behavioral interventions—such as promoting handwashing with soap, and boiling or filtering of water by households before consumption —could magnify their impact on nutrition and overall wellbeing. Policy Note Determinants of Child Malnutrition in the Lao PDR 17 Appendix Table A1: Regression results of stunting among children ages 6 to 23 months Height-for-Age Z-score Stunting (1) (2) (3) (4) (5) (6) Maternal and child healthcare services 4 antenatal care visits 0.171*** 0.170*** 0.176*** -0.169*** -0.167*** -0.174*** (0.056) (0.056) (0.056) (0.063) (0.063) (0.063) Skilled birth attendance 0.056 0.051 0.060 -0.158*** -0.152*** -0.161*** (0.052) (0.052) (0.052) (0.058) (0.059) (0.058) Dietary IDDS (0–7) 0.040** -0.026 (0.017) (0.019) IDDS (4 or more) 0.053 -0.023 (0.046) (0.052) Grains, root crops, tubers 0.062 -0.068 (0.089) (0.107) Pulses, nuts 0.102 -0.006 (0.108) (0.120) Dairy products 0.014 -0.024 (0.063) (0.071) Meat 0.123** -0.118* (0.055) (0.062) Eggs 0.064 -0.063 (0.047) (0.053) Vitamin-A-rich fruits and -0.054 0.096* vegetables (0.047) (0.054) Other fruits and vegetables 0.035 -0.034 (0.048) (0.054) Exclusive breastfeeding 0.027 0.038 0.026 -0.050 -0.064 -0.051 (0.042) (0.042) (0.042) (0.048) (0.048) (0.048) Intergenerational factors Log caretaker age 0.378*** 0.389*** 0.374*** -0.310*** -0.319*** -0.306*** (0.088) (0.088) (0.088) (0.101) (0.101) (0.101) Caretaker completed upper 0.139** 0.146** 0.144** -0.184** -0.187** -0.189** secondary education or higher (0.064) (0.065) (0.064) (0.077) (0.077) (0.077) Asset index 0.063*** 0.063*** 0.065*** -0.057*** -0.056*** -0.059*** (0.015) (0.015) (0.015) (0.017) (0.017) (0.017) Log number of children ages -0.402*** -0.387*** -0.421*** 0.502*** 0.481*** 0.515*** 0-4 years (0.099) (0.099) (0.099) (0.112) (0.113) (0.112) 18 Policy Note Determinants of Child Malnutrition in the Lao PDR Table A1: Regression results of stunting among children ages 6 to 23 months (continued) Access to clean water and sanitation Village-level improved 0.094 0.091 0.095 -0.082 -0.080 -0.081 sanitation (0.077) (0.077) (0.077) (0.086) (0.087) (0.086) Access to clean water -0.087 -0.085 -0.083 0.099 0.094 0.097 (0.069) (0.070) (0.069) (0.079) (0.079) (0.079) Child characteristics Child age -0.133 -0.187 -0.031 -0.515 -0.444 -0.583 (0.454) (0.460) (0.452) (0.537) (0.544) (0.534) Child age^2 0.009 0.014 -0.001 0.068 0.062 0.075 (0.053) (0.053) (0.052) (0.062) (0.062) (0.061) Child age^3 -0.001 -0.001 -0.000 -0.003 -0.003 -0.003 (0.003) (0.003) (0.003) (0.003) (0.003) (0.003) Child age^4 0.000 0.000 0.000 0.000 0.000 0.000 (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) Boy -0.283*** -0.288*** -0.283*** 0.340*** 0.345*** 0.340*** (0.041) (0.042) (0.042) (0.048) (0.048) (0.048) Constant -1.109 -1.001 -1.398 0.739 0.587 0.931 (1.408) (1.420) (1.403) (1.677) (1.693) (1.670) Observations 3,302 3,302 3,302 3,302 3,302 3,302 R-squared 0.176 0.177 0.175 Note: Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1. Regressions are unweighted. IDDS is Individual Dietary Diversity Score for children, based on 7 food groups. Policy Note Determinants of Child Malnutrition in the Lao PDR 19 Table A2: Regression results of stunting among children ages 6 to 59 months Height-for-Age Z-score Stunting (1) (2) (3) (4) (5) (6) Dietary IDDS (0–7) 0.042*** -0.039*** (0.013) (0.015) IDDS (4 or more) 0.052 -0.029 (0.032) (0.036) Grains, root crops, tubers 0.113 -0.121 (0.081) (0.100) Pulses, nuts -0.037 0.048 (0.072) (0.081) Dairy products 0.067 -0.102* (0.047) (0.054) Meat 0.145*** -0.164*** (0.040) (0.046) Eggs 0.082** -0.065* (0.033) (0.037) Vit-A rich fruit and vegetables -0.090** 0.094** (0.035) (0.040) Other fruit and vegetables 0.039 -0.022 (0.033) (0.037) Intergenerational factors Log caretaker age 0.333*** 0.336*** 0.331*** -0.254*** -0.254*** -0.250*** (0.064) (0.064) (0.064) (0.073) (0.073) (0.073) Caretaker completed upper 0.107** 0.106** 0.113** -0.128** -0.122** -0.136** secondary education or higher (0.049) (0.049) (0.049) (0.058) (0.058) (0.058) Asset index 0.081*** 0.076*** 0.085*** -0.087*** -0.080*** -0.091*** (0.010) (0.010) (0.010) (0.012) (0.012) (0.012) Log number of children -0.323** -0.299*** -0.338*** 0.378*** 0.350*** 0.391*** * ages 0-4 years (0.078) (0.078) (0.078) (0.089) (0.090) (0.089) Access to clean water and sanitation Village-level improved sanitation 0.216*** 0.202*** 0.221*** -0.229*** -0.212*** -0.234*** (0.052) (0.052) (0.052) (0.059) (0.059) (0.059) Access to clean water -0.052 -0.050 -0.048 0.052 0.051 0.049 (0.050) (0.050) (0.050) (0.057) (0.057) (0.057) 20 Policy Note Determinants of Child Malnutrition in the Lao PDR Table A2: Regression results of stunting among children ages 6 to 59 months (continued) Child characteristics Child age -0.308*** -0.319*** -0.284*** 0.358*** 0.372*** 0.334*** (0.037) (0.038) (0.036) (0.045) (0.046) (0.044) Child age^2 0.011*** 0.011*** 0.010*** -0.014*** -0.015*** -0.013*** (0.002) (0.002) (0.002) (0.003) (0.003) (0.003) Child age^3 -0.000*** -0.000*** -0.000** 0.000*** 0.000*** 0.000*** (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) Child age^4 0.000 0.000* 0.000 -0.000** -0.000*** -0.000** (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) Boy -0.170*** -0.174*** -0.169** * 0.186*** 0.190*** 0.185*** (0.030) (0.030) (0.030) (0.034) (0.034) (0.034) Constant -0.067 -0.112 -0.105 -2.429*** -2.389*** -2.389*** (0.301) (0.302) (0.301) (0.358) (0.359) (0.358) Observations 5,863 5,863 5,863 5,863 5,863 5,863 R-squared 0.146 0.150 0.145 Note: Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1. Regressions are unweighted. IDDS is Individual Dietary Diversity Score for children, based on 7 food groups. Information on exclusive breastfeeding, antenatal care visits, and childbirth is only available for the youngest child, so they are omitted from the analysis for children ages 6-59 months. Policy Note Determinants of Child Malnutrition in the Lao PDR 21 Table A3: Blinder-Oaxaca decomposition results 6–23 months 6–59 months Height-for-Age Z-score Stunting Height-for-Age Z-score Stunting Overall Lao-Taï -1.184 0.235 -1.423 0.301 Non Lao-Taï -1.711 0.422 -1.894 0.481 Di erence 0.527 -0.187 0.471 -0.180 Explained 0.241 -0.086 0.205 -0.080 Unexplained 0.286 -0.101 0.266 -0.100 Explaining Factors Maternal and child healthcare services 4 antenatal care visits 0.038*** -0.012*** (0.013) (0.005) Skilled birth attendance 0.016 -0.015*** (0.015) (0.005) Dietary IDDS (0–7) 0.018** -0.004 0.019*** -0.006** (0.008) (0.003) (0.006) (0.002) Exclusive breastfeeding 0.000 0.000 (0.000) (0.000) Intergenerational factors Log caretaker age 0.01** -0.003** 0.009*** -0.003*** (0.004) (0.001) (0.003) (0.001) Caretaker completed upper 0.021** -0.009** 0.013** -0.006** secondary education or higher (0.009) (0.004) (0.006) (0.002) Asset index 0.089*** -0.026*** 0.117*** -0.045*** (0.02) (0.008) (0.015) (0.006) Log number of children 0.033*** -0.013*** 0.024*** -0.01*** ages 0–4 years (0.008) (0.003) (0.006) (0.003) Access to clean water and sanitation Village-level improved 0.025 -0.007 0.056*** -0.021*** sanitation (0.022) (0.007) (0.014) (0.005) Access to clean water -0.009 0.003 -0.005 0.002 (0.008) (0.003) (0.006) (0.002) 22 Policy Note Determinants of Child Malnutrition in the Lao PDR Table A3: Blinder-Oaxaca decomposition results (continued) Child characteristics Child age -0.021 -0.027 -0.559*** 0.231*** (0.078) (0.043) (0.14) (0.059) Child age^2 0.048 0.125 1.204*** -0.55*** (0.299) (0.167) (0.358) (0.159) Child age^3 -0.139 -0.15 -0.882** 0.458*** (0.423) (0.199) (0.361) (0.166) Child age^4 0.108 0.054 0.203 -0.128** (0.201) (0.08) (0.132) (0.061) Boy 0.005 -0.002 0.006** -0.002** (0.005) (0.002) (0.003) (0.001) Note: Standard errors in parentheses. *** p<0.01, ** p<0.05, * p<0.1. 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