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Early-life air pollution and green space exposures as determinants of stunting among children under age five in Sub-Saharan Africa



Childhood malnutrition is a major public health issue in Sub-Saharan Africa (SSA) and 61.4 million children under the age of five years in the region are stunted. Although insight from existing studies suggests plausible pathways between ambient air pollution exposure and stunting, there are limited studies on the effect of different ambient air pollutants on stunting among children.


Explore the effect of early-life environmental exposures on stunting among children under the age of five years.


In this study, we used pooled health and population data from 33 countries in SSA between 2006 and 2019 and environmental data from the Atmospheric Composition Analysis Group and NASA’s GIOVANNI platform. We estimated the association between early-life environmental exposures and stunting in three exposure periods – in-utero (during pregnancy), post-utero (after pregnancy to current age) and cumulative (from pregnancy to current age), using Bayesian hierarchical modelling. We also visualise the likelihood of stunting among children based on their region of residence using Bayesian hierarchical modelling.


The findings show that 33.6% of sampled children were stunted. In-utero PM2.5 was associated with a higher likelihood of stunting (OR = 1.038, CrI = 1.002–1.075). Early-life exposures to nitrogen dioxide and sulphate were robustly associated with stunting among children. The findings also show spatial variation in a high and low likelihood of stunting based on a region of residence.

Impact Statement

  • This study explores the effect of early-life environmental exposures on child growth or stunting among sub-Saharan African children. The study focuses on three exposure windows – pregnancy, after birth and cumulative exposure during pregnancy and after birth. The study also employs spatial analysis to assess the spatial burden of stunted growth in relation to environmental exposures and socioeconomic factors. The findings suggest major air pollutants are associated with stunted growth among children in sub-Saharan Africa.

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Fig. 1
Fig. 2: Effect of in-utero environmental exposures on stunting among children aged under five years.
Fig. 3: Effect of post-utero environmental exposures on stunting among children aged under five years.
Fig. 4: Effect of cumulative period environmental exposures on stunting among children aged under five years.
Fig. 5: Region-specific effect on stunting among children under 5 years for in-utero period.
Fig. 6: Region-specific effect on stunting among children under 5 years for post-utero period.
Fig. 7: Region-specific effect on stunting among children under 5 years for cumulative period.

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Data availability

The data used in this study are publicly available. The health and demographic data is accessible via the Demographic and Health Survey program data portal ( Interested parties have to register on the portal for the data. We do not have permission to share this data. The data for air pollutants and enhanced vegetation index are also accessible through NASA’s GIOVANNI platform ( The PM2.5 dataset is available on the website of the Atmospheric Composition Analysis Group (


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Prince M. Amegbor and Clive E. Sabel were supported by Big Data Centre for Environment and Health (BERTHA) funded by the Novo Nordisk Foundation Challenge Programme (grant NNF17OC0027864). Mark W. Rosenberg is the Tier I Canada Research Chair in Aging, Health and Development and supported by funding from the Canada Research Chairs program. We are also grateful to the NASA’s Goddard Earth Sciences Data and Information Services Center (GES DISC), the USAID DHS programme, and Atmospheric Composition Analysis Group at Dalhousie University and Washington University for the data used in this study.


There is no funding for this research; however, the authors wish to acknowledge support from the Big Data Centre for Environment and Health (BERTHA) funded by the Novo Nordisk Foundation Challenge Programme (grant NNF17OC0027864).

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Authors and Affiliations



PMA, CES, AJM, LHM and MWR designed and conceptualised the study. PMA curated data and developed statistical methods. PMA, CES, AJM, LHM and MWR were involve in the analysis and investigation. PMA wrote the original draft with supervision from CES, AJM, LHM and MWR. All authors contributed to reviewing, revising and editing the manuscript. All authors had access to all data used in the study. All authors had final responsibility for the decision to submit for publication.

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Correspondence to Prince M. Amegbor.

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Ethical approval

This is an observational study. The DHS surveys including the procedures and questionnaires were reviewed and approved by the ICF Institutional Review Board (IRB). Additionally, ethical review was conducted by an IRB in the host country for the surveys. ICF IRB ensures that the survey complies with the U.S. Department of Health and Human Services regulations for the protection of human subjects (45 CFR 46), while the host country IRB ensures that the survey complies with laws and norms of the nation. No further ethics approval was needed for this study.

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Amegbor, P.M., Sabel, C.E., Mortensen, L.H. et al. Early-life air pollution and green space exposures as determinants of stunting among children under age five in Sub-Saharan Africa. J Expo Sci Environ Epidemiol (2023).

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