Here we provide empirical data on nutritional status and associated factors among children (aged 6-59 months) in the Borana community, that is undergoing a process of agro-pastoralism or settlement, and is increasingly engaged in crop cultivation [17, 18]. The magnitude of observed stunting (41.1%), underweight (28.3%), and wasting (9.8%) are in the “very high, high and serious” categories of WHO prevalence thresholds, respectively . Observed high prevalence of malnutrition can be attributed to the observed inadequate dietary intake, in that most of the children (82%) consumed below the WHO minimum dietary diversity of four food groups. Such low dietary diversity (below four food groups) have been also reported in pastoral [24–26] and agrarian communities of Ethiopia [27–31].
Our findings of stunting and wasting is higher than the prevalence of stunting (19%) and wasting (below 5%) that reported by Lindtjorn et al.  from the same study area about two decades ago. Although comparison of two cross-sectional studies has limitations, the observed difference may indicate that the nutritional status of children in the study area is deteriorating over time, and is becoming as high as prevalence reports from mixed farming area of the country [5, 7, 33, 34]. Observed changes in nutritional status over time (between the two studies) may be linked to the noticeable changes in Borana areas; such as increasing crop cultivation , climate variability and rangeland degradation , decreasing herd size per households , and weakening of pastoral lifestyle (e.g. mobility and flexibility) , besides human population growth. These factors in one way or another can influence household level food availability and reduce their economic access to food. In addition to low harvest rates in arid environments , crop cultivation has a substantial impact on livestock production due to high competition for land, and likely reduces intake of animal source foods. In line with this, two case studies comparing settled and mobile pastoral communities in Kenya and Nigeria have also documented the adverse effects of settlement on the nutritional status of children [20, 21].
Occurrence of stunting suggests repeated infections and/or long-term inadequate nutrient intake that often occurs in pastoral areas during dry periods and in droughts years, when dairy production and terms of trading with food grain fall [32, 36]. Thus, such very high prevalence of stunting is of great concern, as it leads to delayed motor development and impaired cognitive development that could be irreversible. Wasting, however, can be caused by acute food shortage and illness such as diarrhea, and is often associated with child mortality. Underweight is composite indicator that combines linear growth impediment and low weight for height as a result of current insufficient dietary intake and illness . In general, recorded high magnitude of malnutrition in the study area calls for urgent attention, as it results in poor school performance, reduced intellectual capacity of children and leads to lower productivity. The socio-economic burden of childhood malnutrition is evidenced by causing 44% of the health costs, 28% of child mortality, 16% of all repetitions in primary school, and 67% of the adults having suffered from childhood stunting in Ethiopia .
Increased prevalence of underweight, stunting, and wasting with age of children is in agreement with previous findings [5, 7, 34, 37, 38]. This could be linked to the introduction of supplemental diets of less nutrient-dense cereals. A literature review by Onyango  showed that stunting in African children occurs at early infancy and gets worse after two years of age, which has been hypothesized to be linked to the introduction of less nutrient-dense supplemental diets. In addition to poor nutrient contents, cereals and tubers also contain anti-nutrient factors (e.g. phytate) which interfere with the absorption of essential micronutrients from consumed food items and reduce their bioavailability. Moreover, in higher ages children start to interact with the environment, and consume contaminated food and water that increase the risk of exposure to infection and diarrhea episodes [4, 13]. Hence, paying more attention to feeding practices, hygienic conditions and health care during at weaning age may contribute to improved nutrition status.
Contrasting results can be found in the literature regarding differences between boys and girls. In several studies boys were found to suffer more from undernourishment compared to girls [5, 7, 40, 41], while others reported no difference [37, 38, 42] or found girls to be at a higher risk of malnourishment . In pastoral communities such as Borana, care for children likely disfavors girls, and greater nutritional investment in girls than boys is unlikely. It is not clear whether mothers or biological differences compensate for such socio-cultural disparities, and favor girls to be better off. Possible reasons are differences in nutritional requirements as well as efficiency of nutrient conversions between girls and boys of the same age.
Dietary diversity and milk frequency emerged as major predictors of the nutritional status of study children, having significant association with lower risk of stunting, underweight, and wasting. The observed protective effects of increased dietary diversity on nutritional status of the study children confirms earlier studies’ findings [7, 44–46]. According to Motbainor et al. , low dietary diversity was significantly associated with higher prevalence of stunting. In another study, Steyn and colleagues  have demonstrated dietary diversity score was a good estimate of nutritional adequacy and nutritional status, in that children who had low DDS were at higher risk of undernutrition. These findings imply that increasing dietary diversity results in improvement of the dietary quality of consumed food items (e.g. animal source foods) and intake of essential micronutrients that have roles in normal growth and immune system [38, 42].
Significant association of dairy intake with improved anthropometric indices is consistent with other studies in which milk consumption was associated with reduced prevalence of malnutrition and health problems, in addition to improving cognitive functions and school performances . Other studies also found milk consumption to be associated with improved nutritional status of children, and to reduce the prevalence of morbidity and mortality [24, 49]. In a case-control studies among school children in Iran  and Vietnam , milk consumption was significantly associated with higher anthropometric measurements of children in intervention groups. Milk is regarded as an ultimate food that provides energy, protein, and several micronutrients and bioactive peptides with growth-promoting abilities, thus vitally enhancing the health and growth of children [51, 52]. In our study, we did not observe significant association between nutritional status and number of meals consumed per day. This could be explained by the limitation of frequency based indicator i.e. the same food group might be frequently consumed. Cereals preparations and to some extent beans have been found to be the most commonly consumed foods in Borana area . Hence, meal frequency does not necessarily correlate with the extent of dietary diversity and nutritional quality.
Other notable findings of our study were the association of nutritional status with health-related factors such as physical access to health services, availability of family toilet, and occurrence of illness during the three weeks before the survey. Households reside nearby health institutions might have better health information, and higher tendency to visit health institution and get health services compared to those living far away. It has been well documented that disease control and prevention activities through sanitation, promotion of breastfeeding, vaccination, and treatments vitally improve the health status of children, thereby contributing to normal growth and development [4, 53]. Another study in Ethiopia also documented improvement of nutritional status following immunization .
Association of latrine ownership with reduced occurrence of stunting points to the role of improved sanitary and hygiene practices on reducing illness and malnutrition. A study in India also reported lower risk of underweight and stunting among children whose households use toilets . In another study, Babatunde and Qaim  also observed a significant association of toilet use with underweight and wasting among children in Nigeria. Toilet use indicates better sanitary conditions that reduce the risk of exposure to infections and consequent effects on nutritional status of children. The Ethiopian health extension services, (encompassing various activities like toilet construction, proper hand washing, improved hygienic practices etc.) have initiated efforts to improve public health, sanitary and hygienic conditions, and child care and nutrition in rural areas. Strengthening the health extension services would enhance disease control and prevention through improved sanitary and hygienic practices, and ultimately contribute to effective micronutrient absorption and utilization.
Association of illness occurrence with higher risk of underweight can be expected as underweight reflects current poor dietary intake and illnesses; typically diarrhea and respiratory infections . Bloss et al.  also reported children having diarrhea, upper respiratory infections or other illnesses in the past few weeks were three folds more likely to be underweight than other groups in Kenya. Another study  in Ethiopia also found a significant contribution of morbidity to the increased prevalence of wasting. Reviewed studies further demonstrated illness episodes to be the most frequently reported determinants of underweight and wasting , . In general, infections can reduce the appetite of children (reduce intake), interfering with absorption, and result in nutrient and fluid losses, so that leading to temporary weight losses.
The adverse effects of remoteness of market on nutritional status of children (increased risk of stunting) can be explained by the large share of the food supply in pastoral areas originates from markets, affecting dietary intake. A study from Mali  reported positive effects of close-proximity to markets on the dietary intake of children, subsequently leading to improvement in anthropometric measures. Stifel and Minten  also found higher consumption expenditures and more diverse diets among households nearer to markets compared to those living far-off in Ethiopia. Besides reducing transition cost, proximity to marketplaces may increase opportunities for household members to be engaged in non-pastoral income generating activities or provide better access to information that may improve their nutrition knowledge. It’s worth noting that physical access to market alone may not ensure availability and access to foods, as dietary intake is mostly rooted in socioeconomic status of the households.
Surprisingly, we observed the associations of non-pastoral income sources and possession of radio with increased risk of underweight and wasting, respectively. A positive nutrition impact of off-farm income sources has been reported for farming households from Nigeria via increased household income that enables better access to food . A negative outcome of off-farm activities was also observed and associated with its competition for family labor and its negative impact on farming activities in Mexico . Our observation could be explained by the dearth of off-farm income opportunities in a pastoral area, which are mainly practiced by resource-poor households in order to stabilize their income and reduce distress selling of livestock. Those households mainly engaged in marginal off-farm income sources (e.g. petty trade, casual labor, and selling bush products), the earnings of which cannot have a significant effect on the nutritional status of children.
Lastly, this work is among the few study reports from pastoral areas and needs to call attention to policymakers in order to address the challenges of malnutrition among children given the changing environmental and socio-economic factors that disfavor pastoral coping mechanisms. The Ethiopian government has already showed its commitment to end childhood malnutrition by 2030, so that has initiated a National Nutrition Program (2016-2020) to improve child nutrition through proven nutrition interventions. Thus, our findings can contribute to the required data in addressing the nutrition interventions under the National Nutrition Program.
Given the cross-sectional design of the study, it was not possible to investigate the temporal as well as causal relationship of dietary intake with nutritional status of children (although an attempt was made to collect monthly dietary diversity and dairy consumption for sub-samples). In pastoral areas, where consumption varies considerably with seasonal food availability, we selected the minor wet season, when food availability and diversity is considered to be average. Helminthes and other health problems also could have significant impact on the nutritional status of the children and must be taken into considerations when interpreting our findings.