Health & Place 10 (2004) 183–199 A tale of two continents: a multilevel comparison of the determinants of child nutritional status from selected African and Indian regions Paula Griffiths a, *, Nyovani Madise b , Alison Whitworth c , Zo . e Matthews b a Department of Human Sciences, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK b Division of Social Statistics, University of Southampton, Highfield, Southampton SO17 1BJ, UK c Office for National Statistics, Methodology Division (Rm D212), 1 Drummond Gate, London SW1V 2QQ, UK Received 25 November 2001; received in revised form 10 December 2002; accepted 29 July 2003 Abstract This paper compares individual and household predictors of underweight among young children in sub-Saharan Africa and India, while also assessing the impact of clustering of weight for age z-scores at the household, community and regional levels. Multilevel statistical models are employed to compare the strength of the correlates of underweight (using weight-for-age z-scores) in six sub-Saharan African countries and four Indian states. The multilevel approach controls for correlation among children resulting from clustering within families, communities, or regions and in addition enables tests for differences in the regional, community and household effects for children from families of different socio-economic characteristics. Findings demonstrate the importance of individual and household level predictors such as age, the size of child at birth, prolonged breast-feeding, recent diarrhoea episodes, and maternal education as predictors of low weight-for-age z-scores across regions. Strong family effects are observed as well as significant community and regional random effects on variation in weight for age z-scores. In some regions, socio-economic characteristics of the household result in significant differences in the household or community level variance in weight for age z-scores, suggesting that the impact of the geographical context varies by socio-economic status of the household. r 2003 Elsevier Ltd. All rights reserved. Keywords: Developing countries; Children; Underweight; Multilevel modelling Introduction The study of nationally representative, anthropo- metric indices for children has become possible in many developing countries owing to the availability of nutrition data collected by the Demographic and Health Surveys (DHS) program. The wide-scale achievement in data collection has facilitated comparisons of anthro- pometric data in a diversity of contexts across continents and has provided the basis for greatly improved under- standing of the factors that influence child health. The comparison of sub-Saharan Africa and India is particu- larly interesting in this respect. Malnutrition affects more than half of Indian children (International Institute of Population Sciences, 1994a-e). Malnutrition is less prevalent in Africa, but child mortality is higher. It is well established that health outcomes are affected by factors operating both at the individual level and within the compositional and contextual situation in which individuals reside (Duncan et al., 1998; Diez- Roux, 1998; Macintyre and Ellaway 2000; Pickett and Pearl, 2001; Subramanian et al., 2001). Sastry (1997) proposed a framework for interpreting the effect of different levels of clustering of cases within families and ARTICLE IN PRESS *Corresponding author. Tel.: +44-1509-228486; fax: +44- 1509-233940. E-mail address: p.griffiths@lboro.ac.uk (P. Griffiths). 1353-8292/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2003.07.001