Prevalence and associated factors of overweight and obesity among adult women in Tanzania from the 2022 Tanzania Demographic and Health Survey

Abstract

In Tanzania, the prevalence of overweight and obesity among women is reported to be increasing over a past decade. However, there is paucity of empirical studies that have documented the national prevalence and the factors associated with the burden among women aged 20–49. Therefore, this study intended to fill the gap. Secondary data analysis was conducted on data from the 5,355 Tanzania Demographic and Health Survey. The weighted sample included in this study was 16,716 women aged 20–49 years. Data analysis was performed using Stata 18.0 software. The strength of the association was assessed using the adjusted odds ratio (aOR) along with its corresponding 95% confidence interval (CI). The overall prevalence of overweight and obesity among adult women aged 20–49 years in Tanzania was 36% (95% CI 33.6, 38.0), whereby 22% of women were overweight, while 14% were obese. The results revealed that factors associated with overweight and obesity among women included being aged 40–49 years (aOR = 3.84, 95% CI 3.11, 4.74; p < 0.001), residing in urban areas (aOR = 1.43, 95% CI 1.13, 1.80; p = 0.003), having secondary education and above (aOR = 1.69, 95% CI 1.26, 2.26; p < 0.001),belonging to rich quintile (aOR = 2.06, 95% CI 1.53, 2.77; p < 0.001), using unhealthy foods (aOR = 1.25, 95% CI 1.01, 1.56; p = 0.044), smoking (aOR = 2.90, 95% CI 1.13, 7.45; p = 0.027) and watching television at least once a week (aOR = 1.56, 95% CI 1.25, 1.94; p < 0.001). The Ministry of Health and other health stakeholders should design programs to combat overweight and obesity, targeting older women by incorporating health topics into the educational curriculum in Tanzania.

Background

Globally, overweight and obesity are significant public health concerns associated with lifestyle changes such as diet, low physical activity, and socioeconomic factors^1,2. Overweight and obesity has become one of the major non-communicable diseases risk factors, and this burden as a global pandemic continues to unacceptably rise³. Worldwide, rates of overweight and obesity continue to grow in adults and children. According to the World Health Organization in 2022, worldwide 2.5 billion (43%) adults aged 18 years or older were overweight, and 890 million (16%) of these adults were living with obesity⁴.

The negative impacts of overweight and obesity cannot be underestimated, including body imbalances, difficulty in childbirth among women, hypertension, and more. The burden appears to be more prevalent among women compared to men^5–7. Studies indicate that one reason women of reproductive age start gaining weight is due to taking on caregiving responsibilities, which are linked to increased nutritional needs, resulting in weight gain⁸. In past decades, the burden was reported to be more prevalent in high-income countries compared to low-income countries. However, in recent years, the trend seems to be increasing among populations in low-income countries, including sub-Saharan Africa⁷.

In sub-Saharan Africa (SSA), previous studies report an increasing trend of overweight and obesity among the population over the past decade^7,9,10. There is reported variation in terms of the burden of overweight among sex, zones and countries in the SSA area^5,9,11. The variations in the burden could be due to differences in ethnicity, socio-economic characteristics as well as geographical differences among countries and their populations^11,12.

In Tanzania, the statistics on overweight and obesity among the local population is reported to increase over time^6,13. Overweight and obesity has tripled from about 11 percent in TDHS 1991–1992 to 28 percent in TDHS-MIS 2015–16¹⁴ and 32 percent in Tanzania National Nutrition Survey (TNNS) 2019¹⁵. The government has been taking several measures to address obesity and overweight. In 2023, it established food-based dietary guidelines aimed at promoting food diversity and improving the health and well-being of the Tanzanian population¹⁶. Through the implementation of these guidelines, the government aims to improve nutrient intake with a diversified diet, promote equal distribution of food within households, decrease consumption of sugar, salt, trans fats, and saturated fats, and increase knowledge of nutrition and the relationship between food and health¹⁶.

Studies have documented several factors associated with overweight and obesity, including low physical activity, high consumption of sugary foods, low intake of vegetables and water, and social and cultural influences, particularly the perception of overweight and obesity as symbols of beauty and/or wealth^6,13,17.

Despite these contributing factors, there is a lack of evidence on the prevalence and associated factors among women aged 20–49 years. It is important to understand the overall national prevalence and regional variations in overweight and obesity among adult women. This knowledge will guide the prioritization of intervention strategies for regions with high prevalence and help the country better understand the potential reasons. These estimates are missing because most studies have focused on regional data^6,13,17, but national estimates are necessary to guide policy. Thus, this study aimed to fill this knowledge gap using the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (2022 TDHS-MIS).

Specific objective

• i.To determine the prevalence of overweight and obesity among adult women aged 20–49 years in Tanzania.
• ii.To determine factors associated with overweight and obesity among adult women aged 20–49 years in Tanzania.

Methods

Data source

We used the most recent nationally representative 2022 TDHS data for this analysis. This survey was conducted between from 24 February to 21 July 2022 by the Tanzania National Bureau of Statistics (NBS) and the Office of the Chief Government Statistician (OCGS) in collaboration with the Ministry of Health, Tanzania Mainland and the Ministry of Health, Zanzibar. This study analyzed secondary data and the analysis involved the use of women’s information obtained from the Tanzanian Demographic and Health Survey and Malaria Indicator survey of 2022. The study extracted the 2022 Tanzania Individual Recode (IR) data set (TZIR81FL.DTA).

Study design

This was a national-based cross-sectional study utilizing the 2022 TDHS-MIS dataset, through the Demographic and Health Survey (DHS) Program, which is a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide.

Sampling procedure

The sample design for the 2022 TDHS-MIS was intended to provide estimates for the entire country, for urban and rural areas in Tanzania Mainland, and for Zanzibar. The 2022 TDHS-MIS followed a stratified two-stage sample design. The first stage involved selection of sampling points (clusters) consisting of enumeration areas (EAs) delineated for the 2012 Tanzania Population and Housing Census (2012 PHC). The EAs were selected with a probability proportional to their size within each sampling stratum. A total of 629 clusters were selected. Among the 629 EAs, 211 were from urban areas and 418 were from rural areas. In the second stage, 26 households were selected systematically from each cluster, for a total anticipated sample size of 16,354 households for the 2022 TDHS-MIS. Of the 16,312 households selected, 15,907 were found to be occupied. A household listing operation was carried out in all the selected EAs before the main survey. A household listing operation was carried out in all the selected EAs before the main survey. All women aged 15–49 years who were either usual residents or visitors in the household on the night before the survey interview were included in the 2022 TDHS-MIS and were eligible to be interviewed¹⁸.

Study variables

Outcome variable

Body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared (kg/m²). BMI categories followed the WHO recommendations as 18.50–24.99 kg/m² (normal), overweight, 25.0–29.9 kg/m²; and obese, ≥ 30.0 kg/m². A binary outcome variable was generated by combining overweight and obese, and compared against women who had thin/underweight and normal BMI. Therefore, Overweight and obesity was the outcome variable of this study. Underweight and normal weight was coded as “0” and overweight and obese as “1”.

Exposure variables

The some of the explanatory variables were chosen based on their availability within the data set and have been reported to be significant in other related literature^6,11,13,17. Thus, the independent variables included were age, place of residence, educational level, wealth status, employment status, unhealthy food consumption, minimum dietary diversity, number of children, smoking status, sweet beverages, height, and watching television as demonstrated in Fig. 1 of the conceptual framework.

Fig. 1.

Conceptual framework of the factors associated with overweight and obesity among adult women aged 20–49 years in Tanzania.

Moreover, Unhealthy foods include sweet foods such as chocolates, candies, cakes, sweet biscuits, cookies, vishetti, and ice cream and fried and salty foods such as chips, mandazi, bagiya, French fries, fried cassava, fried sweet potato, and instant noodles¹⁹. Additionally, Sweet beverages include fruit juice and fruit drinks, sodas, chocolate-flavoured drinks, sweetened tea, coffee, herbal drinks, and other sweetened liquids. Furthermore, Minimum dietary diversity for women is defined as consuming foods from five or more of the following 10 food groups: a. grains, white/pale starchy roots, tubers, and plantains; b. pulses (beans, peas, lentils); c. nuts and seeds; d. dairy (milk, cheese, yogurt, other milk products); e. meat, fish, poultry, organ meats; f. eggs; g. dark green leafy vegetables; h. other vitamin A-rich fruits and vegetables; i. other vegetables; j. other fruits¹⁹.

Statistical analysis

We used Stata version 18 to perform data analyses. We performed descriptive analysis by calculating weighted frequencies and percentages, through which we obtained prevalence of overweight and obesity and described the background characteristics of the study participants. We used the “svy” command in STATA for assigning the sample weight and to adjust for the clustering effect and sample stratification. The bivariate analysis was conducted by using the chi-square test to assess the associations dependent variable and all the exposure variables. We checked multicollinearity between the independent variables by using the variance inflation factor (VIF) and no variable had a score of 5 or higher, implying lack of significant collinearity. Then all the independent variables were included in the multivariate logistic regression model. Variables with p-values less than 0.05 were considered to be independently significant associated with the Overweight and obesity. The strength of the association was assessed using the adjusted odds ratio (aOR) along with its corresponding 95% confidence interval (CI).

Results

Background characteristics of the study participants

The analysis for this study included a total sample of 5,355 adult women aged 20–49 years. The majority of the study respondents were aged 20–29 years (41.7%). Most of the participants resided in rural areas (63.3%), and nearly half (48.9%) had their wealth categorized in the rich quintile. Most had primary education and below (57.6%). The majority (70%) reported had married while more than half had employed (71.6%). Other characteristics of the study participants are presented in Table 1.

Table 1.

Background characteristics of the study participants (n = 5,355) (weighted sample).

Variable	Frequency (n)	Percentage (%)
Age group (years)
20–29	2233	41.7
30–39	1736	32.4
40–49	1386	25.9
Place of residence
Urban	1964	36.7
Rural	3391	63.3
Education level
No education	948	17.7
Primary	3085	57.6
Secondary +	1323	24.7
Wealth status
Poor	1704	31.8
Middle	1032	19.3
Rich	2619	48.9
Marital status
Never in union	740	13.8
Married	3749	70
Separated	866	16.2
Employment status
Unemployed	1521	28.4
Employed	3834	71.6
Unhealthy food consumption
No	4648	86.8
Yes	707	13.2
Sweet beverages
No	3840	71.7
Yes	1515	28.3
Minimum dietary diversity
Yes	1366	25.5
No	3989	74.5
Smoking status
No	5326	99.4
Yes	29	0.6
Watching television
Not at all	2890	54
Less than once a week	933	17.4
At least once a week	1532	28.6
Number of children
0	584	10.9
1–2	1778	33.2
3 and above	2993	55.9
Height
< 145 cm	118	2.2
≥ 145 cm	5237	97.8

Chi-square analysis of overweight and obesity among women aged 20–49 years

Table 2 shows the bivariate association between overweight and obesity and independent variables. Age, place of residence, educational level, wealth status, employment status, unhealthy food consumption, minimum dietary diversity, smoking status, sweet beverages and watching television were significantly associated with overweight and obesity. In contrast marital status, number of children, and height were not significantly associated with overweight and obesity.

Table 2.

Chi-square analysis of overweight and obesity among women aged 20–49 years.

Variable	Number (%) overweight and obesity	P-value
Age group (years)
20–29	599 (25.8)	< 0.001
30–39	726 (40.4)
40–49	650 (46.4)
Place of residence
Urban	964 (50.4)	< 0.001
Rural	1011 (27.5)
Education level
No education	242 (24.5)	< 0.001
Primary	1112 (35.2)
Secondary +	621 (45.6)
Wealth status
Poor	363 (20.4)	< 0.001
Middle	309(28.9)
Rich	1303(48.6)
Marital status
Never in union	268 (34.6)	0.7209
Married	1.379 (35.7)
Separated	328 (37.2)
Employment status
Unemployed	494 (31.1)	0.003
Employed	1481 (37.7)
Unhealthy food consumption
No	1611(33.6)	< 0.001
Yes	364(50.1)
Sweet beverages
No	1235 (31.2)	< 0.001
Yes	740 (47.3)
Minimum dietary diversity
Yes	423 (30.1)	< 0.001
No	1552(37.7)
Smoking status
No	1,958 (35.7)	< 0.001
Yes	17 (54.8)
Watching television
Not at all	781 (26.5)	< 0.001
Less than once a week	371 (38.5)
At least once a week	823(51.1)
Number of children
0	225 (37.4)	0.6695
1–2	643 (35)
3 and above	1107 (35.9)
Height
< 145 cm	41 (32.8)	0.5372
≥ 145 cm	1933 (35.8)

The prevalence of overweight and obesity among adult women aged 20–49 years in Tanzania

The overall prevalence of overweight and obesity among adult women aged 20–49 years in Tanzania was 36% (95% CI 33.6, 38.0). Twenty-two percent of women were overweight, while 14% were obese, as shown in Table 3. The prevalence of overweight and obesity among adult women aged 20–49 years varied significantly across regions, ranging from 17.6% in Rukwa to 53.9% in Dar es Salaam and Kusini Unguja (Fig. 2).

Table 3.

The prevalence of overweight and obesity among adult women aged 20–49 years (%).

Variable	Prevalence	95% CI
Overweight (25–29.9 kg/m2	21.8%	20.21–23.68
Obesity (≥ 30.0 kg/m2)	14%	12.57–15.31
Overweight and obesity (≥ 25.0 kg/m2)	36%	33.62–38.0

Fig. 2.

The prevalence of overweight and obesity across regions among adult women (%).

Factors associated with overweight and obesity among adult women aged 20–49 years

As shown in the logistic regression results in Table 4, women aged 40–49 years (aOR = 3.84, 95% CI 3.11, 4.74) had higher odds of having obesity and overweight compared to young women. Women residing in urban areas had higher odds, (aOR = 1.43, 95% CI 1.13, 1.80), of developing overweight and obesity than women residing in rural areas. Women with secondary education and above (aOR = 1.69, 95% CI 1.26, 2.26) had significantly higher odds of overweight and obesity compared to women with no education. Moreover, the odds of being obese and overweight were higher for women in rich quintile (aOR = 2.06, 95% CI 1.53, 2.77), compared to their counterparts in poor quintile. Additionally, women who were using unhealthy foods (aOR = 1.25, 95% CI 1.01, 1.56), smoking (aOR = 2.90, 95% CI 1.13, 7.45) and watching television at least once a week (aOR = 1.56, 95% CI 1.25, 1.94) had higher odds of being overweight and obesity.

Table 4.

Logistic regression results on factors associated with obesity and overweight among adult women aged 20–49 years in Tanzania.

Variable	OR	95% CI	P - value	aOR	95% CI	P - value
Age group
20–29	Ref			Ref
30–39	1.98	1.67–2.34	< 0.001	2.62	2.14–3.20	< 0.001
40–49	2.52	2.13–2.98	< 0.001	3.84	3.11–4.74	< 0.001
Place of residence
Rural	Ref			Ref
Urban	2.66	2.23–3.18	< 0.001	1.43	1.13–1.80	0.003
Education level
No education	Ref			Ref
Primary	1.67	1.37–2.05	< 0.001	1.26	0.98–1.62	0.072
Secondary +	2.55	2.01–3.23	< 0.001	1.69	1.26–2.26	< 0.001
Wealth status
Poor	Ref			Ref
Middle	1.61	1.30–1.99	< 0.001	1.38	1.10–1.74	0.006
Rich	3.68	3.05–4.45	< 0.001	2.06	1.53–2.77	< 0.001
Marital status
Never in union	Ref			Ref
Married	1.05	0.86–1.28	0.640	1.25	0.96–1.63	0.098
Separated	1.12	0.83–1.51	0.458	1.09	0.77–1.55	0.608
Employment status
Unemployed	Ref			Ref
Employed	1.34	1.14–1.57	< 0.001	1.14	0.97–1.34	0.122
Unhealthy food consumption
No	Ref			Ref
Yes	1.98	1.59–2.46	< 0.001	1.25	1.01–1.56	0.044
Sweet beverages
No	Ref
Yes	1.98	1.66–2.37	< 0.001	1.13	0.93–1.38	0.212
Minimum dietary diversity
Yes	Ref			Ref
No	1.41	1.19–1.67	< 0.001	1.09	0.91–1.30	0.372
Smoking status
No	Ref			Ref
Yes	2.19	0.92–5.22	0.077	2.90	1.13–7.45	0.027
Watching television
Not at all	Ref			Ref
Less than once a week	1.74	1.44–2.09	< 0.001	1.21	0.97–1.52	0.091
At least once a week	2.90	2.44–3.45	< 0.001	1.56	1.25–1.94	< 0.001
Number of children
0	Ref			Ref
1–2	0.90	0.72–1.13	0.374	0.86	0.65–1.15	0.314
3 and above	0.94	0.75–1.16	0.553	0.74	0.54–1.01	0.314
Height
< 145 cm	Ref			Ref
≥ 145 cm	1.14	0.75–1.75	0.537	0.94	0.61–1.43	0.767

Discussion

The study aimed to determine the prevalence of overweight and obesity and associated factors among adult women aged 20–49 years in Tanzania.

Prevalence of overweight and obesity among adult women in Tanzania

The study found that the overall prevalence of overweight and obesity among women aged 20–49 years was 36% (95% CI 33.6, 38.0). The prevalence of overweight and obesity among women aged 20–49 years has increased over time in Tanzania²⁰. Studies conducted in Tanzania found that women’s dietary and lifestyle modifications (nutrition transition) were linked to the country’s increasing rates of overweight and obesity^16,21. The prevalence of overweight and obesity among women aged 20–49 years in Tanzania is lower compared to other Sub-Saharan countries such as Kenya was 45%²² and Ghana (50.2%)²³. To effectively address obesity and overweight among adult women in Tanzania, a multisectoral approach is essential. This should include promoting a diversified diet that incorporates more fruits, vegetables, and healthy meals, reducing sweet beverages consumption, and implementing comprehensive nutrition education programs aimed at raising awareness about balanced diets and healthy lifestyle choices.

Factors associated with obesity and overweight among adult women

The study found that older age, urban residency, higher education level, higher wealth economic status, using unhealthy foods, women who were smoking, and those women who were watching television at least once a week were significantly associated with overweight and obesity.

Consistent with studies done in Tanzania, South Africa, Nigeria and Uganda^11,13, our study has demonstrated that women older women have higher odds of being overweight or obese compared to their younger counterparts. Numerous studies indicate that the prevalence of overweight and obesity among women tends to increase with age^24,25. Studies shows that older women tend to shift various household responsibilities to their children, making themselves more sedentary life. This transition result in decreased physical activity levels, contributing to higher rates of overweight and obesity among this demographic^12,26. Previous studies reported that aging in adults is associated with weight gain. Women’s metabolisms tend to slow down as they get older, which makes weight gain easier. Between the ages of 40 years and 66 years , body weight in both men and women increases at an average rate of 0.3 kg to 0.5 kg per year and then remains stable or even continues to increase until the age of 70^27,28. The study findings suggest targeted health campaigns that promote physical activity among older women.

Like in previous studies^5,10–13, women residing in urban settings had higher odds of being overweight and obese compared to those who were from the rural settings. Urbanization has led to significant dietary changes, as city dwellers often opt for convenient²⁹, calorie-dense meals over traditional, healthier options^30,31. Previous study indicates that many urban residents consume street food daily, which is often preferred due to cultural norms but tends to be less nutritious^32,33. Dietary changes has been resulted into rising rates of overweight and obesity among urban women^33–35. Urban areas are associated with inadequate walkways and limited green spaces, which hinder opportunities for exercise^36,37. Additionally, easy access to passive transport options like bodabodas promotes sedentary lifestyles. This has resulted in a gradual decline in physical exercise levels across all age groups, contributing to overweight and obesity^38–40. The study findings highlight the importance of public awareness campaigns promoting healthier dietary choices in urban areas.

Women with higher education level were observed to have higher odds of being overweight and obese compared to those with no education. The study findings contrast with the studies conducted in Sweden and South Korea^41,42. Nonetheless, similar findings have been observed in other Sub-Saharan African countries^43–45. Studies found that adult women with higher education levels often find themselves balancing work and family responsibilities, which limit their time for physical activity and meal preparation. This situation may lead to a reliance on unhealthy food options, contributing to the rising rates of obesity and overweight among educated women^46,47.

The study also found that women from higher wealth economic status had higher odds of being overweight and obesity compared to those who were coming from poorest economic status. The study findings align with previous studies conducted elsewhere^48–50. Being overweight or obese has historically been perceived as a symbol of wealth and privilege in many African nations. Traditionally, a fuller figure has been associated with prosperity, as it suggests access to abundant food resources^51,52. Similar findings were observed by other studies done in Sub-Saharan Africa^10,53. On the contrary, in high-income nations, the prevalence of overweight and obesity is much higher among people living in poverty than among those individuals who are wealthy^54,55.

Unhealthy food consumption is associated with higher odds of being overweight and obese compared to those who consume healthy foods, as observed in previous studies^13,17. Unhealthy food consumption has been a key driver of obesity and overweight among women^38–40. The tendency to consume foods high in sugar, fats, and cholesterol increases the risk of being overweight and obese⁵⁶. Implementing policies to limit the intake of ultra-processed and deep-fried foods is essential for reducing overweight and obesity through regulations on food marketing, public awareness campaigns about health risks, and promoting the availability and affordability of healthier, minimally processed options in local markets.

The study found that women who were smoking cigarettes had higher odds of having overweight and obesity compared to those who were not smoking cigarettes. The study’s finding is consistent with previous studies that reported smoking behavior is associated with weight^57,58. The study conducted in Scotland found that individuals who smoked for over 20 years or more than 20 cigarettes daily were more likely to be overweight compared to those who smoked less or had never smoked⁵⁹. Smoking impacts metabolic processes and fat distribution. Studies reveal that smoking lowers basal metabolic rates and increases appetite following cessation, potentially leading to weight gain. Furthermore, nicotine influences fat distribution and promotes the accumulation of visceral fat^60–62. The study’s finding contradicts previous findings, which showed that smoking was associated with a low BMI^9,63. The study findings underscore the importance of integrated public health strategies that address both smoking cessation and obesity and overweight prevention.

Those women who were watching television less than once a week had higher odds of having overweight compared to those who watch television at least once a week. Studies found that increased TV watching can lead to reduced physical activity, replacing time that could be spent exercising and resulting in lower energy expenditure, which contributes to weight gain. This trend is particularly concerning in low-income countries where women may choose TV as their primary leisure activity, leading to a more sedentary lifestyle^64,65. Additionally, watching TV is associated with higher consumption of unhealthy snacks and high-calorie drinks, which can further contribute to abdominal obesity among women^66,67. Moreover, this can be attributed by education contents that may be covered by some of the TV channels including sessions like cookery (Mapishi) sessions and other sessions on health and diseases aired by Tanzania Broadcasting Corporation (TBC 1) and Independent Television (ITV). The study finding is consistent with the study conducted in Ethiopia^43,65.

Strengths and limitations of the study

The strength of this study lies in its use of nationally representative data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (2022 TDHS-MIS). This large sample size facilitates the generation of national estimates, thereby enhancing the generalizability of the findings and offering a thorough understanding of overweight and obesity prevalence across various socio-demographic groups. Additionally, the application of sample-weighted data ensures that the results accurately represent the broader population, minimizing potential biases that could occur with unweighted analyses. Some variables, such as physical activity and sedentary lifestyle, were not included because the survey did not capture them.

Conclusion

The overall prevalence of overweight and obesity among adult women aged 20–49 years in Tanzania was 36% (95% CI 33.6, 38.0). The factors associated with overweight among women aged 20–49 years in Tanzania include older age, urban residency, higher education levels, greater economic wealth, consumption of unhealthy foods, smoking, and watching television less than once a week. The Ministry of Health and other health stakeholders should design programs to combat overweight, targeting older women by incorporating health topics into the educational curriculum and improving the economic status of women aged 20 years and above in Tanzania. This approach will effectively empower women to combat overweight in the country.

Abbreviations

AGYW

Adolescent Girls and Young Women

BMI

Body Mass index

CI

Confidence Interval

DHS

Demographic and Health Survey

ITV

Independent Television

MIS

Malaria Indicator Survey

NBS

National Bureau of Statistics

NIMR

National Institute of Medical Research

SSA

Sub-Saharan Africa

TBC

Tanzania Broadcasting Corporation

TDHS

Tanzania Demographic and Health Survey

TNNS

Tanzania National Nutrition Survey

VIF

Variance Inflation Factor

WHO

World Health Organization

Author contributions

JA conceptualized the idea, provided technical inputs to improve designing the study, data analysis, read, improved and approved the final manuscript write up. AM& PL inception of the idea, supported data analysis, read and prepared the final manuscript. TN provided technical support and reviewed all versions of the manuscript. All authors approved the final manuscript.

Funding

No funding was secured to undertake this research work.

Data availability

All relevant data used and analyzed during the current study are freely available upon request to DHS custodian via DHS website: https://www.dhsprogram.com.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval and consent to participate

This study used secondary data which are freely available to the public upon request to The DHS program website (https://dhsprogram.com). In this case, we were granted approval to access the data after submitting our concept note to the DHS custodian.