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Jones R, Haardörfer R, Ramakrishnan U, Yount KM, Miedema S, Girard AW. Women's empowerment and child nutrition: The role of intrinsic agency. SSM Popul Health 2019; 9:100475. [PMID: 31993480 PMCID: PMC6978483 DOI: 10.1016/j.ssmph.2019.100475] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 04/08/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022] Open
Abstract
Women's empowerment is associated with improved child nutrition, and both underpin the achievement of multiple Sustainable Development Goals (SDGs). We examined pathways by which women's empowerment influences child nutritional status. We pooled nationally representative data from Demographic and Health Surveys (2011-2016) collected from married women with children aged 6-24 months in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda (n = 13,780). We operationalized child nutritional status using anemia, height-for-age z-score (HAZ), and weight-for-age z-score (WHZ). We operationalized women's empowerment using a validated measure comprised of three latent domains: social/human assets ("assets"), intrinsic agency (attitudes about intimate partner violence), and instrumental agency (influence in household decision making). We used structural equation models with latent constructs to estimate hypothesized pathways from women's empowerment to child nutritional status with further mediation by maternal body mass index (BMI) and stratification by wealth. Women's empowerment domains were directly and positively associated with maternal BMI (estimate±SE: assets, 0.17 ± 0.03; intrinsic agency, 0.23 ± 0.03; instrumental agency, 0.03 ± 0.01). Maternal BMI was directly and positively associated with child HAZ (0.08 ± 0.04) and child WHZ (0.35 ± 0.03). Assets were indirectly associated with child HAZ and WHZ through intrinsic agency and maternal BMI. In the lowest wealth category, the direct effects from women's empowerment to child nutritional status were significant (assets and instrumental agency were associated with anemia; intrinsic agency associated with HAZ). In the highest wealth category, direct effects from women's empowerment on child nutritional status were significant (intrinsic and instrumental agency associated with WHZ). Improving women's empowerment, especially intrinsic agency, in East Africa could improve child nutrition directly and via improved maternal nutrition. These findings suggest that efforts to realize SDG 5 may have spillover effects on other SDGs. However, strategies to improve nutrition through empowerment approaches may need to also address household resource constraints.
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Affiliation(s)
- Rebecca Jones
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, USA
| | - Regine Haardörfer
- Department of Behavioral Sciences and Health Education, Emory University, USA
| | - Usha Ramakrishnan
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, USA
- Hubert Department of Global Health, Emory University, USA
| | - Kathryn M. Yount
- Hubert Department of Global Health, Emory University, USA
- Department of Sociology, Emory University, USA
| | | | - Amy Webb Girard
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, USA
- Hubert Department of Global Health, Emory University, USA
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Choudhury S, Headey DD, Masters WA. First foods: Diet quality among infants aged 6-23 months in 42 countries. FOOD POLICY 2019; 88:101762. [PMID: 31853163 PMCID: PMC6894322 DOI: 10.1016/j.foodpol.2019.101762] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 05/05/2023]
Abstract
Diet quality is closely linked to child growth and development, especially among infants aged 6-23 months who need to complement breastmilk with the gradual introduction of nutrient-rich solid foods. This paper links Demographic and Health Survey data on infant feeding to household and environmental factors for 76,641 children in 42 low- and middle-income countries surveyed in 2006-2013, providing novel stylized facts about diets in early childhood. Multivariate regressions examine the associations of household socioeconomic characteristics and community level indicators of climate and infrastructure with dietary diversity scores (DDS). Results show strong support for an infant-feeding version of Bennett's Law, as wealthier households introduce more diverse foods at earlier ages, with additional positive effects of parental education, local infrastructure and more temperate agro-climatic conditions. Associations with consumption of specific nutrient-dense foods are less consistent. Our findings imply that while income growth is indeed an important driver of diversification, there are strong grounds to also invest heavily in women's education and food environments to improve diet quality, while addressing the impacts of climate change on livelihoods and food systems. These results reveal systematic patterns in how first foods vary across developing countries, pointing to new opportunities for research towards nutrition-smart policies to improve children's diets.
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Affiliation(s)
- Samira Choudhury
- Centre for Development, Environment and Policy, School of Oriental & African Studies, London WC1H 0XG, UK
| | - Derek D. Headey
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - William A. Masters
- Friedman School of Nutrition Science & Policy, Tufts University, Boston, MA, USA
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Early determinants of linear growth and weight attained in the first year of life in a malaria endemic region. PLoS One 2019; 14:e0220513. [PMID: 31386682 PMCID: PMC6684079 DOI: 10.1371/journal.pone.0220513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/17/2019] [Indexed: 12/25/2022] Open
Abstract
We investigated linear growth and weight attained among 772 children at 10–15 months of age in the first population-based birth cohort in the Brazilian Amazon. Sociodemographic, maternal and birth characteristics were collected in interviews soon after birth at baseline. Anthropometric evaluation was conducted at 10–15 months. Multiple linear regression models were fitted for length-for-age (LAZ) and body mass index (BMI)-for-age Z scores (BAZ), considering a hierarchical conceptual framework with determinants at distal, intermediate and proximal levels, with adjustment for the child’s sex and age. Mean LAZ and BAZ were 0.31 (SD: 1.13) and 0.35 (SD: 1.06), respectively. Overall, 2.2% of children were stunted and 6.6% overweight. Among socioeconomic factors, household wealth index was positively associated with LAZ (p for trend = 0.01), while children whose families received assistance from the Bolsa Família conditional cash transfer program were 0.16 Z score thinner (95% CI: -0.31, -0.00). Maternal height and BMI were positively associated with both LAZ and BAZ at 10–15 months of age (p for trend <0.001). Child’s size at birth was positively related with LAZ (p<0.001 for both birth weight and length). BAZ was 0.34 (95% CI: 0.24, 0.44) higher, but 0.11 lower (95% CI: -0.21, -0.02), for each increase in 1 Z score of birth weight and length, respectively. Children with at least one reported malaria episode within the first year of life were 0.58 (95% CI: -1.05, -0.11) Z score shorter. Socioeconomic and intergenerational factors were consistently associated with LAZ and BAZ at 10–15 months of age. The occurrence of malaria was detrimental to linear growth. In a malaria endemic region, reduction of inequalities and disease burden over the first 1,000 days of life is essential for taking advantage of a critical window of opportunity that can redirect child growth trajectories toward better health and nutrition conditions in the long term.
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Sex effect on growth faltering in an indigenous ethnic minority population of infants in Israel. Public Health Nutr 2019; 22:2747-2755. [PMID: 31274067 DOI: 10.1017/s1368980019001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We examined sex effects on growth faltering in an indigenous population of Bedouin Arab infants born in Israel, an economically developed country. DESIGN Retrospective cohort study. Height-for-age Z-score (HAZ) at age 6, 12, 18 and 24 months was calculated for full-term, normal-birth-weight Bedouin infants born during years 2000-2009 and attending maternal and child health (MCH) clinics. Multivariate linear regression analysis (MLRA) was used to calculate the association between sex and HAZ, controlling for year of birth, birth weight (BW) and residence by type of settlement (established settlement (ES); non-established settlement (NES)). SETTING Bedouin are an indigenous poor community of semi-nomadic Arabs, with the highest infant mortality rate in Israel. Fifty per cent of Bedouin infants live in NES with inadequate access to running water, electricity, and rubbish and sewage disposal. All Bedouin receive free well-baby care in community-based MCH clinics. PARTICIPANTS Full-term, normal Bedouin infants (n 5426) born during 2000-2009 and attending computerized MCH clinics who had growth measurements at age 6, 12, 18 and 24 months. RESULTS At all ages, girls had significantly higher mean HAZ than boys (P < 0·05). Increasing birth year, residence in ES and increasing BW were positively associated with HAZ (P < 0·05) at all ages. In MLRA controlling for birth year, BW and type of settlement, sex still had a significant effect, with lower HAZ among boys at 6, 12, 18 and 24 months of age (P < 0·001 at all ages). CONCLUSIONS Our results indicated that sex effects on growth faltering can occur in an indigenous population with low socio-economic status within an economically developed country.
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Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT, Truong TM, Nguyen DS, Nguyen KT, de Haan S, Jones AD. Child stunting is associated with child, maternal, and environmental factors in Vietnam. MATERNAL AND CHILD NUTRITION 2019; 15:e12826. [PMID: 30958643 DOI: 10.1111/mcn.12826] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 01/02/2023]
Abstract
Child stunting in Vietnam has reduced substantially since the turn of the century but has remained relatively high for several years. We analysed data on children 6-59 months (n = 85,932) from the Vietnam Nutritional Surveillance System, a nationally representative cross-sectional survey. Multivariable Poisson regression models were used to estimate relative risk (RR) of stunting, stratified by child age and ecological region. Covariates at the child, maternal, household, and environmental levels were included based on available data and the World Health Organization conceptual framework on child stunting. Among children 6-23 months, the strongest associations with child stunting were child age in years (RR: 2.49; 95% CI [2.26, 2.73]), maternal height < 145 cm compared with ≥150 cm (RR: 2.04; 95% CI [1.85, 2.26]), living in the Northeast compared with the Southeast (RR: 2.01; 95% CI [1.69, 2.39]), no maternal education compared with a graduate education (RR: 1.77; 95% CI, [1.44, 2.16]), and birthweight < 2,500 g (RR: 1.75; 95% CI [1.55, 1.98]). For children 24-59 months, the strongest associations with child stunting were no maternal education compared with a graduate education (RR: 2.07; 95% CI [1.79, 2.40]), living in the Northeast compared with the Southeast (RR: 1.94; 95% CI [1.74, 2.16]), and maternal height < 145 cm compared with ≥150 cm (RR: 1.81; 95% CI [1.69, 1.94]). Targeted approaches that address the strongest stunting determinants among vulnerable populations are needed and discussed. Multifaceted approaches outside the health sector are also needed to reduce inequalities in socioeconomic status.
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Affiliation(s)
- Ty Beal
- Knowledge Leadership, Global Alliance for Improved Nutrition (GAIN), Washington, District of Columbia.,Department of Environmental Science and Policy, University of California, Davis, California
| | - Danh Tuyen Le
- National Institute of Nutrition (NIN), Hanoi, Vietnam
| | - Thi Huong Trinh
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam.,Department of Mathematics and Statistics, Thuongmai University, Hanoi, Vietnam
| | - Dharani Dhar Burra
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam
| | - Tuyen Huynh
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam
| | - Thanh Thi Duong
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam
| | | | | | - Kien Tri Nguyen
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam
| | - Stef de Haan
- International Center for Tropical Agriculture (CIAT)-Asia Office, Hanoi, Vietnam
| | - Andrew D Jones
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Martin M, Blackwell A, Kaplan H, Gurven M. Differences in Tsimane children's growth outcomes and associated determinants as estimated by WHO standards vs. within-population references. PLoS One 2019; 14:e0214965. [PMID: 30995260 PMCID: PMC6469771 DOI: 10.1371/journal.pone.0214965] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/22/2019] [Indexed: 12/15/2022] Open
Abstract
Anthropometric measures are commonly converted to age stratified z-scores to examine variation in growth outcomes in mixed-age and sex samples. For many study populations, z-scores will differ if calculated from World Health Organization (WHO) growth standards or within-population references. The specific growth reference used may influence statistical estimates of growth outcomes and their determinants, with implications for biological inference. We examined factors associated with growth outcomes in a sample of 152 Tsimane children aged 0-36 months. The Tsimane are a subsistence-scale population in the Bolivian Amazon with high rates of infectious disease and growth faltering. To examine the influence of growth reference on statistical inferences, we constructed multiple plausible models from available infant, maternal, and household attributes. We then ran identical models for height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ), with z-scores alternately calculated from WHO and robust Tsimane Lambda-Mu-Sigma growth curves. The distribution of WHO relative to Tsimane HAZ scores was negatively skewed, reflecting age-related increases in lower HAZ. Standardized coefficients and significance levels generally agreed across WHO and Tsimane models, although the strength and significance of specific terms varied in some models. Age was strongly, negatively associated with HAZ and WAZ in nearly all WHO, but not Tsimane models, resulting in consistently higher R2 estimates. Age and weaning effects were confounded in WHO models. Biased estimates of determinants associated with WHO HAZ may be more extreme in small samples and for variables that are strongly age-patterned. Additional methodological considerations may be warranted when applying WHO standards to within-population studies, particularly for populations with growth patterns known to systematically deviate from those of the WHO reference sample.
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Affiliation(s)
- Melanie Martin
- Department of Anthropology, University of California Santa Barbara, Santa Barbara, CA, United States of America
| | - Aaron Blackwell
- Department of Anthropology, University of California Santa Barbara, Santa Barbara, CA, United States of America
| | - Hillard Kaplan
- Department of Anthropology, University of New Mexico, Albuquerque, NM, United States of America
| | - Michael Gurven
- Department of Anthropology, University of California Santa Barbara, Santa Barbara, CA, United States of America
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Abstract
Water, sanitation, and hygiene (WASH) investments are widely seen as essential for improving health in early childhood. However, the experimental literature on WASH interventions identifies inconsistent impacts on child health outcomes, with relatively robust impacts on diarrhea and other symptoms of infection but weak and varying impacts on child nutrition. In contrast, observational research exploiting cross-sectional variation in water and sanitation access is much more sanguine, finding strong associations with diarrhea prevalence, mortality, and stunting. In practice, both literatures suffer from significant methodological limitations. Experimental WASH evaluations are often subject to poor compliance, rural bias, and short duration of exposure, while cross-sectional observational evidence may be highly vulnerable to omitted variables bias. To overcome some of the limitations of both literatures, we construct a panel of 442 subnational regions in 59 countries with multiple Demographic Health Surveys. Using this large subnational panel, we implement difference-in-difference regressions that allow us to examine whether longer-term changes in water and sanitation at the subnational level predict improvements in child morbidity, mortality, and nutrition. We find results that are partially consistent with both literatures. Improved water access is statistically insignificantly associated with most outcomes, although water piped into the home predicts reductions in child stunting. Improvements in sanitation predict large reductions in diarrhea prevalence and child mortality but are not associated with changes in stunting or wasting. We estimate that sanitation improvements can account for just under 10 % of the decline in child mortality from 1990 to 2015.
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Affiliation(s)
- Derek Headey
- The International Food Policy Research Institute (IFPRI), 1201 Eye Street NW, Washington, DC 20005 USA
| | - Giordano Palloni
- The International Food Policy Research Institute (IFPRI), 1201 Eye Street NW, Washington, DC 20005 USA
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58
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Mother’s Relative Educational Status and Early Childhood Height-for-Age z Scores: A Decomposition of Change Over Time. POPULATION RESEARCH AND POLICY REVIEW 2019. [DOI: 10.1007/s11113-019-09523-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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59
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Bommer C, Vollmer S, Subramanian SV. How socioeconomic status moderates the stunting-age relationship in low-income and middle-income countries. BMJ Glob Health 2019; 4:e001175. [PMID: 30899561 PMCID: PMC6407538 DOI: 10.1136/bmjgh-2018-001175] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 11/05/2022] Open
Abstract
Introduction Reducing stunting is an important part of the global health agenda. Despite likely changes in risk factors as children age, determinants of stunting are typically analysed without taking into account age-related heterogeneity. We aim to fill this gap by providing an in-depth analysis of the role of socioeconomic status (SES) as a moderator for the stunting-age pattern. Methods Epidemiological and socioeconomic data from 72 Demographic and Health Surveys (DHS) were used to calculate stunting-age patterns by SES quartiles, derived from an index of household assets. We further investigated how differences in age-specific stunting rates between children from rich and poor households are explained by determinants that could be modified by nutrition-specific versus nutrition-sensitive interventions. Results While stunting prevalence in the pooled sample of 72 DHS is low in children up to the age of 5 months (maximum prevalence of 17.8% (95% CI 16.4;19.3)), stunting rates in older children tend to exceed those of younger ones in the age bracket of 6–20 months. This pattern is more pronounced in the poorest than in the richest quartile, with large differences in stunting prevalence at 20 months (stunting rates: 40.7% (95% CI 39.5 to 41.8) in the full sample, 50.3% (95% CI 48.2 to 52.4) in the poorest quartile and 29.2% (95% CI 26.8 to 31.5) in the richest quartile). When adjusting for determinants related to nutrition-specific interventions only, SES-related differences decrease by up to 30.1%. Much stronger effects (up to 59.2%) occur when determinants related to nutrition-sensitive interventions are additionally included. Conclusion While differences between children from rich and poor households are small during the first 5 months of life, SES is an important moderator for age-specific stunting rates in older children. Determinants related to nutrition-specific interventions are not sufficient to explain these SES-related differences, which could imply that a multifactorial approach is needed to reduce age-specific stunting rates in the poorest children.
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Affiliation(s)
- Christian Bommer
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Goettingen, Germany
| | - Sebastian Vollmer
- Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Goettingen, Germany
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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60
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Headey D, Hirvonen K, Hoddinott J. Animal Sourced Foods and Child Stunting. AMERICAN JOURNAL OF AGRICULTURAL ECONOMICS 2018; 100:1302-1319. [PMID: 33343003 PMCID: PMC7734193 DOI: 10.1093/ajae/aay053] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 08/31/2019] [Indexed: 05/19/2023]
Abstract
Stunting affects 160 million pre-school children globally with adverse life-long consequences. While work within nutritional science suggests that stunting in early childhood is associated with low intakes of animal-sourced foods (ASFs), this topic has received little attention from economists. We attempt to redress this omission through an analysis of 130,432 children aged 6-23 months from 49 countries. We document distinctive patterns of ASF consumption among children in different regions. We find evidence of strong associations between stunting and a generic ASF consumption indicator, as well as dairy, meat/fish, and egg consumption indicators, and evidence that consuming multiple ASFs is more advantageous than any single ASF. We explore why ASF consumption is low but also so variable across countries. Non-tradable ASFs (fresh milk, eggs) are a very expensive source of calories in low-income countries and caloric prices of these foods are strongly associated with children's consumption patterns. Other demand-side factors are also important, but the strong influence of prices implies an important role for agricultural policies-in production, marketing and trade-to improve the accessibility and affordability of ASFs in poorer countries.
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Affiliation(s)
- Derek Headey
- International Food Policy Research Institute (IFPRI)
| | | | - John Hoddinott
- The authors thank seminar participants at the Allied Social Science Association (ASSA) meetings in Philadelphia
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