This study determined the spatial distribution of stunting and its associated factors among children under the age of five in Ethiopia. The prevalence of childhood stunting is 37%, indicating that stunting remains a serious public health challenge in Ethiopia. This study found that there is considerable spatial variation in childhood stunting in Ethiopia. Independent factors associated with childhood stunting in this study were child sex, child age, birth interval, birth type, wealth index, maternal education, and administrative region.
In this study, the local cluster analysis (Get-Ordi G*) identified childhood stunting hotspots and cold spot areas in the country. Hotspot clusters have been observed in the Amhara region (East Gojam, North and South Gondar, and South Wollo zones) and the SNNP region (Sidama, Wolayta, Hadiya, and Gamo Gofa zones). This finding is consistent with previous studies conducted on 2011 and 2016 EDHS datasets [17, 18]. This indicates that although the country is moving towards reducing childhood stunting, no significant changes have been observed in reducing the problem burden in certain areas. Therefore, identified clusters may be areas of preference for childhood stunting prevention and control interventions .
The Sat scan analysis is used to determine the true geographical location of clusters and to test whether these clusters are statistically significant. The output from this analysis identified one big primary cluster that contains 61 enumeration areas. The primary cluster was located in the Amhara region (North and South Gondar zones and South Wollo zone), South Tigray zone, and Afar region. This finding is similar to the hot spot analysis result of previous studies conducted in the same area [17, 18, 20]. Geographical and climatic factors may have contributed to the high incidence of childhood stunting in these areas. These areas are known for their acidity and are not suitable for crop production. This can lead to food shortages and hunger in a society where children are most affected.
This study found that childhood stunting was significantly associated with child age; as the child gets older, the risk of stunting also increases. This finding is in line with studies in Bangladesh, Madagascar, and Malawi [21–23]. The possible explanation for this could be due to the inappropriate and late introduction of low nutritional quality supplementary food  and a large portion of guardians in rural areas are ignoring to meet their children’s optimal food requirements as the age of the child increases .
The current study also determined that males are more likely to be stunted than females. This result is consistent with previous studies conducted in sub-Saharan Africa [26–28]. This may be due to preferences in feeding methods or other forms of exposure . Nutritional status can be defined as "biological instability" because boys are expected to grow faster than girls and their growth is easily affected by a lack of healthy food or other diseases or risks . Gender differences in stunting are common in areas of stress caused by ongoing infection and exposure to toxins and air pollution . Furthermore, the proportion of male premature births is higher than that of female premature births, which also contributes to childhood stunting [31–33].
Maternal education has been found to be negatively associated with childhood stunting. Consistently, previous studies shows that maternal education has a positive outcome in reducing childhood stunting [34–39]. The knowledge that mothers acquire from formal education can help them to develop important nutrition and hygiene behaviours that prevent childhood stunting. Another reason is that educated mothers have a tendency to seek better health for childhood illnesses than uneducated mothers, which can prevent stunting [40, 41]. Therefore, maternal education is an important strategy to develop intelligent eating habits in young children and to overcome the growing burden of childhood stunting.
The current findings show that children from poorest quintile families are more likely to be stunted than children with richest wealth. This result is consistent with previous studies conducted in various developing countries [34, 42–44]. This might be attributed to the fact that increased income improves food diversity, improving nutrient intake and nutritional status [45, 46]. In addition, providing children with well-nourished, timely medical care from wealthy families reduces their chances of stunting if they have an infection. Therefore, it is necessary to establish an appropriate financial and economic framework that supports the children of disadvantaged families, such as improving child health, improving food security, and accessing basic health care services.
This study found that having a birth interval ≥ 24 months reduce the chance of being stunted. This is consistent with other studies [47, 48]. Short birth intervals can adversely affect child nutrition due to delayed uterine development, and/or reduced childcare quality . The present study alsoconfirmed that children in the Amhara, Benishangul, and Tigray regions are more stunted than children in Addis Ababa. This finding is similar to other research in Ethiopia , Congo , and Nigeria . This difference may be attributed to the socio-economic and education disparities and access to basic Healthcare facilities. This difference is due to socio-economic and educational inequalities and access to basic health care facilities. Therefore, contextualized interventions are essential in the fight against childhood stunting and improved health, especially for developing and rural areas.
This study is important to identify the underlying factors related to childhood stunting to plan public health interventions and contribute to the appropriate allocation of resources and health services. In addition, it helps the Ethiopian government to design and implement appropriate nutrition programs aimed at improving maternal and child nutrition at the individual and community levels, especially in developing and rural areas.
Strengths and limitations
The strength of this study is that it used nationally representative survey data. Another important strength of this study is the use of multilevel logistic regression analysis, which can detect factors other than individual-level factors that cannot be detected using standard logistic regression analysis. Furthermore, the use of a combination of methods (spatial and regression statistics) is a force that allows the validation of identified hotspot areas due to the predictions of statistical methods. On the other hand, the limitation of this study is that we were unable to establish a cause-and-effect relationship due to the cross-sectional nature of the study design. Another limitation is the use of secondary data that limits the ability to include other variables such as behavioral factors and dietary factors related to childhood stunting.