Determinants of early initiation of breastfeeding in Somalia: A population based study using the 2020 demographic and health survey data

Abstract

Background

Early initiation of breastfeeding (EIBF) within one hour of birth is essential for neonatal survival, yet evidence from Somalia is limited. This study examined determinants of EIBF using nationally representative data.

Methods

A secondary analysis of the 2020 Somali Demographic and Health Survey (SDHS) was conducted among 2,020 women with children aged 0–23 months. Sampling weights were applied. EIBF was analyzed as a binary outcome using bivariate and multivariate logistic regression. Statistical significance was set at p ≤ 0.05. Analyses were performed using SPSS version 27.

Results

Overall, 75% of newborns were breastfed within the first hour after birth. In the multivariate analysis, mothers aged 30–39 years were more likely to initiate breastfeeding early compared with those aged 15–19 years (AOR = 1.65; 95% CI: 1.01–2.70). Urban residence was positively associated with EIBF (AOR = 1.31; 95% CI: 1.02–1.68), while nomadic residence was negatively associated (AOR = 0.52; 95% CI: 0.40–0.68). Mothers without radio exposure (AOR = 0.68; 95% CI: 0.47–1.00), unemployed mothers (AOR = 0.17; 95% CI: 0.04–0.85), and those whose husbands were unemployed (AOR = 0.75; 95% CI: 0.63–0.91) had lower odds of EIBF. Facility delivery significantly increased the likelihood of EIBF (AOR = 1.44; 95% CI: 1.03–2.00).

Conclusion

EIBF in Somalia is influenced by maternal, socioeconomic, and health service related factors. Strengthening facility-based deliveries and expanding health education through mass media may improve EIBF practices.

Keywords

demographic and health survey early initiation of breastfeeding maternal health neonatal nutrition Somalia

Introduction

Breastfeeding is a fundamental primary health care practice for optimal care of a newborn.¹ Early initiation of breastfeeding (EIBF) refers to feeding of a newborn with breast milk within the first hour after birth.² It provides nutritional, developmental, immunological, social, psychological, economic, and environmental benefits for infants, mothers.³ EIBF enables newborns to receive immunoglobulin-rich colostrum that supports immunity, growth, and development.⁴ EIBF Country-specific evidence indicates that breastfeeding within the first hour reduced neonatal deaths by 19% in Nepal⁵ and 22% in Ghana.⁶ Findings from meta-analyses covering more than 63 developing countries demonstrate that EIBF helps prevent neonatal infections, reduces deaths related to sepsis, pneumonia, diarrhea, and hypothermia, and promotes continued breastfeeding practices.⁷ Another study also reported that initiating breastfeeding more than one hour after birth is associated with a twofold increase in the risk of neonatal mortality.⁸ EIBF offers both immediate and long-term maternal benefits, including reduced postpartum hemorrhage, improved birth spacing, and a lower risk of obesity, breast cancer, and ovarian cancer.^9,10

UNICEF and the World Health Organization (WHO) have long promoted EIB as an effective way to reduce perinatal and infant illness and death through programs such as the Baby-Friendly Hospital Initiative, Community-Based Integrated Management of Childhood Illness (C-IMCI), and Infant and Young Child Feeding.^11–13 Despite WHO recommendations and the known benefits of breastfeeding, global practice remains low. Worldwide, only 39% of newborns are breastfed within the first hour after birth, and just 37% of infants receive exclusive breastfeeding. In sub-Saharan Africa, only 20% of women report practicing exclusive breastfeeding.¹⁴

Previous studies indicate that EIBF is influenced by many factors, including the mother’s age, level of education, place of residence, and use of health services such as antenatal care (ANC) visits and the place of delivery.¹⁵

In Somalia, breastfeeding remain low, with noticeable differences across regions and socioeconomic groups.¹⁶ Factors such as cultural beliefs, misinformation, and limited caregiver awareness, combined with poor access to skilled breastfeeding support, contribute to inadequate infant feeding practices.¹⁷ Moreover, Somalia’s prolonged humanitarian challenges often result in reliance on alternative infant feeding options due to food insecurity and perceived insufficient breastmilk supply, further reducing breastfeeding practice.¹⁸

To the best of our knowledge, no previous study has examined the determinants of EIBF in Somalia using nationally representative data. Therefore, this study investigated the factors associated with EIBF in Somalia using data from the 2020 Demographic and Health Survey. The findings are expected to inform policymakers, healthcare providers, and other stakeholders in designing strategies to improve EIBF practices in the country.

Methods

Data source and sampling

This study utilized secondary data from the 2020 Somali Demographic and Health Survey (SDHS), which was conducted by the Ministry of Health of the Federal Government of Somalia and the Somali National Bureau of Statistics. SDHS, used a stratified two-stage cluster sampling design, in which enumeration areas (EAs) served as the primary sampling units in the first stage. During the survey preparation, each administrative region was systematically divided into EAs using the most recent geographic information to support efficient field operations.

The sampling frame included a total of 16,486 EAs, comprising 7,875 urban, 4,235 rural, and 4,376 nomadic areas. In the second stage, households were randomly selected from within these EAs. The survey targeted women aged 15–49 years residing in the selected households for interviews. The study utilized data from married women included in the SDHS 2020. Due to security concerns, certain areas were excluded: three strata from Lower Shabelle, three from Middle Juba, and two other unspecified strata, resulting in 47 sampling strata ultimately being developed.¹⁹ The SDHS is a valuable source of information about the health and population of Somalia. It helps guide the development of programs, shape policies, and monitor progress towards national and international development goals, including the Sustainable Development Goals (SDGs). The data from the SDHS is essential for informed decision-making and effective implementation of development projects by the government and its partners in Somalia.¹⁹ Therefore, this study examined the factors associated with early initiation of breastfeeding in Somalia using data from the 2020 Demographic and Health Survey.

Sample size

The study utilized a sample of 2,020 women from the 2020 SDHS after data cleaning and preparation. The sample was drawn from 16 regions across Somalia and included respondents from urban, rural, and nomadic areas, covering different types of residences.

Study variables

The outcome variable for this study was EIBF, defined as placing the newborn to the breast within one hour after birth, in accordance with WHO recommendations. The outcome variable was coded as “yes” if breastfeeding was initiated within one hour after birth and “No” if breastfeeding was initiated after one hour.

The independent variables included maternal characteristics such as mother’s age, level of education, and maternal employment status in the 12 months preceding the survey. Household and socioeconomic factors included household wealth index, husband’s employment status, and exposure to mass media through radio and television. Geographic and residence-related factors consisted of region and place of residence. Child-related factors included sex of the child, birth order, and child’s age in months. Health service utilization variables included the number of antenatal care visits and place of delivery.

Statistical analysis

Sampling weights were applied to account for the complex survey design of the SDHS and to minimize potential bias resulting from unequal probabilities of selection. Descriptive statistics were used to summarize sociodemographic characteristics, maternal and child factors, household socioeconomic variables, media exposure, and health service utilization. Sampling weights were applied in all analyses, including bivariate and multivariable logistic regression, to account for the complex survey design of the 2020 SDHS and to obtain nationally representative estimates. All relevant independent variables were initially considered for regression analysis. However, two variables number of antenatal care (ANC) visits and sex of the child were excluded prior to regression analysis. The ANC visits variable was excluded due to potential collinearity with other maternal healthcare utilization variables, particularly place of delivery, which may capture overlapping aspects of maternal health service use. Including both variables in the model could compromise the stability of the estimates. The sex of the child was excluded as it has limited theoretical and empirical relevance to EIBF in this context, and previous evidence suggests it is not a consistent predictor of breastfeeding initiation. Therefore, its inclusion was unlikely to contribute meaningfully to the explanatory power of the model.

EIBF was treated as a binary outcome variable. Both bivariate and multivariate logistic regression analyses were conducted simultaneously to examine the associations between EIBF and independent variables. In the bivariate analysis, crude odds ratios (CORs) with 95% confidence intervals (CIs) were estimated. Variables were then included in the multivariate logistic regression model to assess adjusted associations while controlling for potential confounders.

Statistical significance for both bivariate and multivariate analyses was determined using a p-value ≤0.05. Adjusted odds ratios (AORs) with corresponding 95% confidence intervals were reported for the final model. All analyses were performed using SPSS Statistics Version 27.0.

Ethical consideration

This study is a secondary analysis of publicly available data from the Demographic and Health Surveys Program for Somalia. Ethical approval for the original survey was obtained from the Institutional Review Board of ICF International and the National Ethics Committee of Somalia. Informed consent was secured from all participants, with parental or guardian consent for minors. The data are fully anonymized and de-identified prior to public release. Permission to use the dataset was obtained through the DHS Program website. As this study used secondary, anonymized data, no additional ethical approval was required, and all procedures complied with the Declaration of Helsinki. https://dhsprogram.com/data/available-datasets.cfm.

Results

Descriptive characteristics of the study population

Overall, 75% of newborns were initiated on breastfeeding within the first hour after birth.

A total of 2,020 women with children aged 0–23 months were included in this analysis based on the 2020 SDHS. More than half of the mothers were aged 20–29 years (53.6%), followed by adolescents aged 15–19 years (35.6%). Mothers aged 30–39 years and 40–49 years accounted for 9.8% and 1.0%, respectively.

Participants were drawn from all regions of Somalia, with the largest proportion residing in Banadir (19.3%) and Woqooyi Galbeed (15.5%). The majority of respondents lived in urban areas (60.7%), while 26.8% resided in rural areas and 12.5% were from nomadic settings.

Most mothers had no formal education (76.9%), while 16.6% had primary education and 6.5% had secondary education. Exposure to mass media was generally low: only 8.6% of mothers reported exposure to radio and 10.0% to television. Nearly half of households were classified in the low wealth category (48.3%), whereas 15.2% and 36.4% belonged to the middle and high wealth categories, respectively.

Regarding employment, only 0.5% of mothers reported working during the 12 months preceding the survey, while 43.2% of husbands were employed. With respect to maternal and child characteristics, most children were first-born (84.2%), and the sex distribution was nearly equal (51.2% male and 48.8% female). Children aged 12–17 months constituted the largest age group (29.1%).

Utilization of maternal health services was limited. The majority of women (94.6%) attended fewer than four antenatal care visits, and 67.5% delivered at home, while only 32.5% delivered in a health facility (Table 1).

Table 1.

Descriptive characteristics of mothers and children (SDHS 2020).

Variable	Categories	Weighted frequencies	Percent
Mother’s age group	15–19	718.747	35.58
	20–29	1082.880	53.60
	30–39	198.218	9.81
	40–49	20.468	1.01
Region	Awdal	53.270	2.64
	Woqooyi Galbeed	313.553	15.52
	Togdheer	131.623	6.51
	Sool	59.824	2.96
	Sanaag	89.950	4.45
	Bari	109.083	5.40
	Nugaal	60.048	2.97
	Mudug	150.591	7.45
	Galgaduud	132.661	6.57
	Hiraan	101.918	5.04
	Middle Shabelle	121.805	6.03
	Banadir	389.065	19.26
	Bay	92.967	4.60
	Bakool	34.136	1.69
	Gedo	57.538	2.85
	Lower Juba	122.281	6.05
Residence	Rural	541.007	26.78
	Urban	1225.906	60.68
	Nomadic	253.401	12.54
Education	No education	1553.523	76.90
	Primary	334.881	16.58
	Secondary	131.910	6.53
Radio exposure	Yes	174.099	8.62
Radio exposure	No	1846.215	91.38
TV exposure	Yes	201.929	9.99
TV exposure	No	1818.385	90.01
Wealth (3-level)	Low	976.558	48.34
	Middle	307.581	15.22
	High	736.175	36.44
Husband worked (12m)	Yes	871.693	43.15
Husband worked (12m)	No	1148.622	56.85
Mother worked (12m)	Yes	10.899	0.54
Mother worked (12m)	No	2009.415	99.46
Birth order	1	1700.408	84.17
	2–4	313.902	15.54
	5+	6.004	0.30
Sex of child	Male	1034.342	51.20
Sex of child	Female	985.972	48.80
Child age group (months)	0–5	537.888	26.62
	6–11	517.775	25.63
	12–17	588.128	29.11
	18–23	376.523	18.64
ANC visits (Less than 4 vs 4+)	Less than 4 visits	1910.618	94.57
ANC visits (Less than 4 vs 4+)	4 or more visits	109.697	5.43
Place of delivery (Home vs facility)	Home	1364.198	67.52
Place of delivery (Home vs facility)	Health facility	656.116	32.48

Factors associated with early initiation of breastfeeding

Bivariate analysis

In the bivariate logistic regression analysis, several maternal, household, child, and health service–related factors were significantly associated with early initiation of breastfeeding. Maternal age showed a significant association, with mothers aged 20–29 years (COR = 1.29; 95% CI: 1.05–1.60) and 30–39 years (COR = 1.92; 95% CI: 1.35–2.73) having higher odds of early initiation compared with mothers aged 15–19 years.

Geographic variation was observed, with mothers from Hiraan, Middle Shabelle, and Bay regions having higher crude odds of EIBF compared with those from Awdal. Place of residence was also significant at the bivariate level, as nomadic mothers were less likely to initiate breastfeeding early compared with rural residents (COR = 0.47; 95% CI: 0.38–0.58).

Media exposure was significantly associated with EIBF. Mothers without radio exposure had lower odds of early initiation compared with those exposed to radio (COR = 0.51; 95% CI: 0.29–0.89), and similar findings were observed for television exposure. Household wealth showed a positive crude association, with mothers from high-wealth households having higher odds of early initiation compared with those from low-wealth households.

Maternal and paternal employment status were also significant in the bivariate analysis. Unemployed mothers had markedly lower odds of EIBF compared with employed mothers (COR = 0.14; 95% CI: 0.06–0.32). Likewise, mothers whose husbands were unemployed were less likely to initiate breastfeeding early (COR = 0.66; 95% CI: 0.55–0.78). (Table 2).

Table 2.

Factors associated with early initiation of breastfeeding (binary and multivariate logistic regression, SDHS 2020).

Variable	Category (Ref = 1st)	Crude OR (95% CI)	p-value	Adjusted OR (95% CI)	p-value
Maternal age (years)	15–19	Ref
	20–29	1.29 (1.05–1.60)	0.018	1.11 (0.86–1.43)	0.410
	30–39	1.92 (1.35–2.73)	0.000	1.65 (1.01–2.70)	0.047
	40–49	1.61 (0.41–6.30)	0.489	1.34 (0.38–4.75)	0.648
Region	Awdal	Ref
	Hiraan	1.87 (0.84–4.18)	0.123	2.59 (1.13–5.91)	0.025
	Middle Shabelle	3.84 (1.69–8.77)	0.002	4.19 (1.72–10.20)	0.002
	Bay	2.86 (1.25–6.50)	0.013	2.52 (1.08–5.88)	0.033
	Banadir	0.46 (0.21–1.02)	0.057	0.44 (0.19–1.01)	0.053
	Gedo	0.49 (0.23–1.06)	0.070	0.47 (0.21–1.05)	0.065
Residence	Rural	Ref
	Urban	0.76 (0.55–1.06)	0.102	1.31 (1.02–1.68)	0.036
	Nomadic	0.47 (0.38–0.58)	0.000	0.52 (0.40–0.68)	0.000
Education	No education	Ref
	Primary	0.48(0.22–1.04)	0.069	0.46 (0.20–1.03)	0.063
	Secondary	1.59 (0.40–6.1)	0.470	1.33 (0.36–4.65)	0.645
Radio exposure	Yes	Ref
Radio exposure	No	0.51 (0.29–0.89)	0.018	0.68 (0.47–1.00)	0.049
TV exposure	Yes	Ref
TV exposure	No	0.57 (0.38–0.86)	0.008	0.78 (0.47–1.28)	0.320
Wealth	Low	Ref
	Middle	1.63 (0.99–2.69)	0.056	1.15 (0.65–2.06)	0.625
	High	1.84 (1.39–2.42)	0.000	1.10 (0.86–1.40)	0.450
Husband employment	Yes	Ref
Husband employment	No	0.66 (0.55–0.78)	0.000	0.75 (0.63–0.91)	0.003
Maternal employment	Yes	Ref
Maternal employment	No	0.14 (0.06–0.32)	0.000	0.17 (0.04–0.85)	0.032
Birth order	1	Ref
	2–4	0.91 (0.69–1.20)	0.491	0.62 (0.38–1.03)	0.066
	5+	0.07 (0.01–0.44)	0.005	0.05 (0.01–0.24)	0.000
Child’s age group (months)	0–5 (Ref)	Ref
	6–11	0.78 (0.60–1.01)	0.060	0.77 (0.56–1.06)	0.109
	12–17	2.40 (1.64–3.51)	0.000	2.19 (1.40–3.42)	0.001
	18–23	1.93 (1.21–3.07)	0.006	2.27 (1.27–4.09)	0.007
Place of delivery	Home (Ref)	Ref
Place of delivery	Health facility	1.96 (1.35–2.87)	0.001	1.44 (1.03–2.00)	0.033

Child-related factors were also important. Higher birth order and older child age groups were associated with increased odds of EIBF. Additionally, mothers who delivered in a health facility were significantly more likely to initiate breastfeeding early compared with those who delivered at home (COR = 1.96; 95% CI: 1.35–2.87) (Table 2).

Multivariate analysis

After adjusting for potential confounders in the multivariate logistic regression model, several factors remained independently associated with EIBF. Maternal age remained significant, with mothers aged 30–39 years having higher odds of initiating breastfeeding within the first hour compared with those aged 15–19 years (AOR = 1.65; 95% CI: 1.01–2.70).

Regional differences persisted after adjustment. Mothers from Hiraan (AOR = 2.59; 95% CI: 1.13–5.91), Middle Shabelle (AOR = 4.19; 95% CI: 1.72–10.20), and Bay (AOR = 2.52; 95% CI: 1.08–5.88) regions had significantly higher odds of EIBF compared with those from Awdal.

Place of residence was independently associated with EIBF. Urban mothers were more likely to initiate breastfeeding early compared with rural residents (AOR = 1.31; 95% CI: 1.02–1.68), whereas nomadic mothers had significantly lower odds (AOR = 0.52; 95% CI: 0.40–0.68).

Radio exposure remained a significant predictor, as mothers without radio exposure were less likely to initiate breastfeeding early than those with exposure (AOR = 0.68; 95% CI: 0.47–1.00). Maternal employment also remained strongly associated, with unemployed mothers being significantly less likely to practice early initiation of breastfeeding compared with employed mothers (AOR = 0.17; 95% CI: 0.04–0.85). Similarly, mothers whose husbands were unemployed had reduced odds of early initiation (AOR = 0.75; 95% CI: 0.63–0.91).

Child age was an independent determinant of early initiation of breastfeeding. Children aged 12–17 months (AOR = 2.19; 95% CI: 1.40–3.42) and 18–23 months (AOR = 2.27; 95% CI: 1.27–4.09) had higher odds of having been initiated on breastfeeding early compared with infants aged 0–5 months.

Place of delivery remained significant after adjustment. Mothers who delivered in a health facility were more likely to initiate breastfeeding within the first hour compared with those who delivered at home (AOR = 1.44; 95% CI: 1.03–2.00) (Table 2).

Discussion

Somalia, a country in Sub-Saharan Africa affected by over three decades of civil conflict, has the poorest access to maternal health services globally. Despite progress toward universal health coverage in many Sub-Saharan African countries, improvements have largely excluded nomadic pastoralists, with minimal change since 2006.²⁰ The SDHS shows low maternal service utilization: 24% of women complete at least four antenatal care visits, 21% deliver in health facilities, 32% are assisted by skilled birth attendants, and only 11% of mothers and 10% of newborns receive postnatal care within 2 days. Major barriers include lack of money (65%) and long distances to health facilities (over 62%).¹⁹ Additionally Pastoralists are mobile livestock-dependent populations who migrate seasonally in search of pasture and water, and in Somalia, an estimated 2.3 million nomadic pastoralists lack permanent settlements, which significantly limits their access to maternal and reproductive health services.

Using a nationally representative dataset, this study examined the determinants EIBF in Somalia. The overall prevalence of EIBF in Somalia in this study was 75%, indicating that three-quarters of newborns were breastfed within the first hour of birth. This prevalence is higher than that reported in other African countries including Ethiopia (73%),²¹ Gambia (64.3%),²² and Mauritania (57.3%).²³ However, the prevalence of EIBF observed in the present study is lower than that reported in Tanzania (83%),²⁴ Malawi (76.9%),²⁵ and Zimbabwe (78%).²⁶ Limited awareness of the benefits of EIBF, along with breastfeeding-related taboos, prevailing sociocultural norms, and gender preferences, may have contributed to the low prevalence of early initiation of breastfeeding observed in this study.^6,27

In this study, mothers who delivered in a health facility were significantly more likely to initiate breastfeeding within 1 hour of birth compared to those who delivered at home. This finding is consistent with evidence from a similar study conducted in Nigeria, which also reported higher rates of early initiation of breastfeeding among facility-based deliveries.¹⁰ Somalia faces major challenges in achieving health-related SDGs, particularly in maternal and child health, due to a fragmented health system with limited access to services for much of the population.²⁸ Maternal mortality remains high despite some progress in life expectancy and nutrition.²⁹ Access to maternal healthcare is especially limited among pastoralist communities due to systemic constraints. Although exclusive breastfeeding is practiced by a proportion of mothers, significant knowledge gaps about its recommended duration persist.²⁰ This may be associated to the presence of skilled health providers, who are more likely to encourage and support mothers in initiating breastfeeding within the recommended time frame.³⁰ In the current study, a higher birth order was associated with increased odds of EIBF. Similar associations have been reported in previous studies from India³¹ and Mexico,³² where higher birth order was positively associated with EIBF.

Maternal employment status was associated with early initiation of breastfeeding, with unemployed mothers showing lower odds compared with employed mothers. This variation may reflect differences in socioeconomic and contextual characteristics, as reported in other settings. This finding contradicts reports from other studies, which observed that women who were employed and currently working were less likely to practice EIBF than their non-working counterparts.^23,33,34 The discrepancy may be associated to contextual differences such as variations in workplace policies, maternity leave and access to health information. Radio exposure showed a significant association with EIBF. Mothers without radio exposure were less likely to initiate breastfeeding early compared with those who were exposed to radio. A possible relationship between access to mass media and breastfeeding practices. This finding is supported by a previous study conducted in Ghana, which reported that women who listened to the radio at least once a week were more likely to practice EIBF.³⁵

Maternal age was associated with EIBF, with mothers aged 30–39 years showing higher odds compared with younger mothers. A similar association has been reported in a study conducted in Nepal, where older maternal age was positively associated with EIBF.³⁶ Place of residence was associated with EIBF. Compared with mothers living in rural areas, those residing in urban areas had higher odds of initiating breastfeeding early. In contrast, nomadic mothers were significantly less likely to initiate breastfeeding early compared with rural residents. This finding is consistent with previous studies conducted in Nigeria,³⁷ Tanzania,³⁸ and Ethiopia.³⁹ This difference may be associated to the higher likelihood of rural women delivering outside health facilities, particularly at home, where skilled birth attendants are often absent.

This study has limitations. First, the cross-sectional nature of the DHS data limits the ability to establish causal relationships between variables and early initiation of breastfeeding. Second, reliance on self-reported information may introduce recall bias, particularly regarding the timing of breastfeeding initiation. Third, although sampling weights were applied, some insecure and inaccessible areas were excluded from the survey, which may affect generalizability. Finally, the analysis was limited to variables available in the DHS dataset, and unmeasured factors such as cultural practices and maternal knowledge may have influenced the results.

Conclusion

This study identifies key determinants of early initiation of breastfeeding in Somalia using nationally representative data. Maternal age, place of residence, media exposure, parental employment, and place of delivery were significantly associated with timely breastfeeding initiation. Facility-based delivery and access to health information through mass media increased the likelihood of early initiation, while nomadic residence and socioeconomic disadvantage reduced it. In Somalia, improving early initiation may require expanding maternal health services, particularly basic emergency obstetric and newborn care in underserved areas, and strengthening outreach services for nomadic populations through mobile clinics and community health workers. Radio-based breastfeeding education in Somali language could improve access to information across rural and nomadic settings. Efforts should also focus on promoting institutional delivery and targeting disadvantaged and hard-to-reach groups with tailored maternal health education.

Footnotes

Acknowledgment

The authors would like to thank the Faculty of Medicine and Health Sciences, Jamhuriya University of Science and Technology, the Faculty of Health Science, Salaam University, the Jamhuriya Research Center, and the Research and Development Office at Salaam University for their invaluable support and collaboration throughout the course of this study. We also extend our sincere gratitude to the participants and data collectors whose contributions were essential to the success of this research.

ORCID iDs

Nur Rashid Ahmed

Ahmed Mohamed Dirie

Shafie Abdirahman Dirie

Yahye Sheikh Abdulle Hassan

Osman Abubakar Fiidow

Ethical considerations

Ethical approval was not required for this study because the SDHS 2020 dataset is publicly available at . The dataset contains no personal identifiers, and therefore no additional ethical clearance was necessary.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are available upon reasonable request from the corresponding author.*

Open access

This is an open access article distributed under the terms of the Creative Commons

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