Time trends in socio-economic inequalities in stunting prevalence: analyses of repeated national surveys

Pearl Memorial Lecture. Humans at the extremes: Exploring human adaptation to ecological and social stressors

The field of human biology has long explored how human populations have adapted to extreme environmental circumstances. Yet, it has become increasingly clear that conditions of social stress, poverty, and lifestyle change play equally important roles in shaping human biological variation and health. In this paper, I provide a brief background on the foundational human adaptability research of the International Biological Programme (IBP) from the 1960s, highlighting how its successes and critiques have shaped current research directions in the field. I then discuss and reflect on my own field research that has examined the influence of both environmental and social stresses on human populations living in different ecosystems: the Peruvian Andes, the Siberian arctic, and the Bolivian rainforest. Finally, I consider how the papers in this special issue advance our understanding of human adaptability to extreme conditions and offer directions for future research. Drawing on our field's distinctive evolutionary and biocultural perspectives, human biologists are uniquely positioned to examine how the interplay between social and ecological domains influences the human condition.

Socioeconomic inequalities in underweight children: a cross-sectional analysis of trends in West Africa over two decades

OBJECTIVE

To study trends in socioeconomic inequalities in underweight children in West Africa, and specifically to analyse the concentration index of underweight inequalities and measure inequalities in the risk of being malnourished by household wealth index.

DESIGN

Cross-sectional study.

SETTING

The study used 50 Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys conducted between 1999 and 2020 across 14 countries by the DHS and UNICEF.

PARTICIPANTS

The study included 481 349 children under the age of 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The analysis used three variables: weight-for-age index, household wealth index and household residence. The inequality concentration index for underweight children and the relative risk of being underweight between 2000 and 2020 were calculated.

RESULTS

The prevalence of underweight in West Africa showed a downward trend from 2000 to 2020. Nonetheless, the prevalence of underweight children under 5 years of age is still very high in West Africa compared with other sub-Saharan African countries, and the sustainable development objective is yet to be achieved. There was a wide disparity among countries and significant socioeconomic inequalities in underweight children within countries. The proportions of underweight children were concentrated in poor households in all countries in West Africa and over all periods. Socioeconomic inequalities in underweight children were more significant in countries where the prevalence of underweight was low. These inequalities were more pronounced in urban areas in West Africa from 2000 to 2020.

CONCLUSIONS AND RELEVANCE

There is a high concentration of socioeconomic inequalities in underweight children in disadvantaged households in West Africa.

Correlates of Plasma Citrulline, a Potential Marker of Enterocyte Mass, among Children with Stunting: A Cross-Sectional Study in Uganda

BACKGROUND

Environmental enteric dysfunction (EED) is associated with stunting. Citrulline, produced in mature enterocytes, may be a valuable biomarker of small intestinal enterocyte mass in the context of EED.

OBJECTIVES

We aimed to explore the correlates of plasma citrulline (p-cit) in children with stunting.

METHODS

In a cross-sectional study using baseline data from the community-based MAGNUS (milk affecting growth, cognition and the gut in child stunting) trial (ISRCTN13093195), we explored potential correlates of p-cit in Ugandan children with stunting aged 12-59 mo. Using linear regression in univariate and multivariate models, we explored associations with socioeconomics, diet, micronutrient status, and water, sanitation, and hygiene characteristics. The influence of covariates age, fasting, and systemic inflammation were also explored.

RESULTS

In 750 children, the mean ± standard deviation age was 32.0 ± 11.7 mo, and height-for-age z-score was -3.02 ± 0.74. P-cit, available for 730 children, differed according to time fasted and was 20.7 ± 8.9, 22.3 ± 10.6 and 24.2 ± 13.1 μmol/L if fasted <2, 2-5 and >5 h, respectively. Positive correlates of p-cit were age [0.07; 95% confidence interval (CI): 0.001, 0.15 μmol/L] and log10 serum insulin-like growth factor-1 (8.88; 95% CI: 5.09, 12.67 μmol/L). With adjustment for systemic inflammation, the association with serum insulin-like growth factor-1 reduced (4.98; 95% CI: 0.94, 9.03 μmol/L). Negative correlates of p-cit included food insecurity, wet season (-3.12; 95% CI: -4.97, -1.26 μmol/L), serum C-reactive protein (-0.15; 95% CI: -0.20, -0.10 μmol/L), serum α1-acid glycoprotein (-5.34; 95% CI: -6.98, -3.70 μmol/L) and anemia (-1.95; 95% CI: -3.72, -0.18 μmol/L). Among the negatively correlated water, sanitation, and hygiene characteristics was lack of soap for handwashing (-2.53; 95% CI: -4.82, -0.25 μmol/L). Many associations attenuated with adjustment for inflammation.

CONCLUSIONS

Many of the correlates of p-cit are characteristic of populations with a high EED prevalence. Systemic inflammation is strongly associated with p-cit and is implicated in EED and stunting. Adjustment for systemic inflammation attenuates many associations, reflecting either confounding, mediation, or both. This study highlights the complex interplay between p-cit and systemic inflammation.

Determinants of wasting among children aged 6-59 months in North-East Ethiopia: a community-based case-control study

OBJECTIVE

Childhood acute malnutrition, in the form of wasting defined by Weight-for-Height Z-Scores, is a major public health concern. It is one of the main reasons for the death of children in developing countries like Ethiopia. Accordingly, this study aimed to assess determinants of wasting among children aged 6-59 months in Meket district, North Wollo zone, North-East Ethiopia.

SETTING

The study was conducted among communities in Meket district, North Wollo zone, North-East Ethiopia.

PARTICIPANTS

A total of 327 (109 cases and 218 controls) children aged 6-59 months participated in the study. Children from 6 months to 59 months of age who match the definition of case/wasted/ and control/not wasted were eligible for the study. However, children who had physical deformities which make anthropometric measurements inconvenient were excluded from the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome measure was wasting.

RESULT

The mean ages of the cases and controls were 21.77±11.41 months and 20.13±11.39 months, respectively. Factors that were significantly associated with wasting were: maternal decision making on the use of household money (adjusted odd ratio (AOR)=3.04, 95% CI 1.08 to 7.83), complementary feeding started in a month (AOR=3.02, 95% CI 1.097 to 6.97), food diversity score (AOR=2.64, 95% CI 1.64 to 5.23), frequency of complementary feeding (AOR=6.68, 95% CI 3.6 to 11.25) and history of acute respiratory infections (ARIs) 2 weeks preceding the survey (AOR=3.21, 95% CI 1.07 to 7.86).

CONCLUSION

Our result implies that the right time to introduce complementary foods, the frequency of feeding and also the amount of food consumed were some of the crucial factors that needed to be changed in child nutrition to reduce wasting. Furthermore, within the framework of our study, the empowerment of women in the decision-making process and the prevention of ARI should be seen as a necessary benchmark for acute malnutrition.

The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries

OBJECTIVE

Our aim was to describe the reliance on female permanent contraception among women with demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries (LMICs) and to describe socio-economic and demographic patterns of permanent contraception in countries with high use.

METHODS

Using data from the latest national health survey carried out in LMICs we estimated mDFPS and the share of each contraceptive method used. Countries with a share of more than 25% of female permanent contraception were further explored for differences by wealth, number of living children, woman's age, and by the intersection of woman's age and number of living children.

RESULTS

In the 20 countries studied, between 6% and 94% of the contracepting population used modern methods. Female permanent contraception accounted for more than half of women using modern contraceptives in India, Dominican Republic, El Salvador, Mexico, and Colombia. In India and Tonga, more than 20% of women using contraceptives with fewer than two living children were using female permanent contraception. Among women with two living children, countries with the highest reliance on permanent contraception were India (79%), El Salvador (61%), Cuba (55%), Colombia (52%), and Thailand (51%). Dominican Republic, El Salvador, India, and Mexico presented high levels of permanent contraception among younger women, with reliance higher than 30% among women aged 25 to 29 and 50% or more among women aged 30 to 34.

CONCLUSIONS

Reliance on permanent contraception was high in several countries and among women aged less than 35 years.

Inequalities in childhood stunting: evidence from Sudan multiple indicator cluster surveys (2010-2014)

Background

Leaving no one behind has been an important marker of the Sustainable Development Goals. Closing the gap in malnutrition between children of different backgrounds aligns well with the tenet of this international agenda. To this end, high-quality evidence of the magnitude and trends of socioeconomic and geographic related existing inequalities in the childhood stunting among Sudanese children emanate from this study help for policy maker and planners to design and implement effective interventions to narrow down inequality.

Methods

We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) for our analysis of stunting inequality. Following standard equity analysis methods recommended by the WHO, we performed the disaggregated analysis of stunting across five equity stratifiers: Wealth, education, residence, sex, and sub-national regions. Then, we summarized stunting inequality through four measures of inequality: Difference, Ratio, Slope Index of Inequality (SII), and Relative Index of Inequality (RII). The point estimates of stunting were accompanied by 95% confidence intervals to measure the statistical significance of the findings.

Results

In this study, the national average childhood stunting prevalence was increased by 4% from 2010 to 2014. The findings revealed stark inequalities in stunting in all the studied dimensions of inequality. Huge inequality has existed along the wealth quintiles. Simple difference measure for education was increased by four points and simple relative measure decreased by one point for economic status.

Conclusions

Sex, residence and, geographically related inequalities remain unchanged over time, while economic status and educational inequality had seen a change by some inequality measures over the same time period.

Socioeconomic inequalities in child growth failure in Ethiopia: findings from the 2000 and 2016 Demographic and Health Surveys

OBJECTIVE

Socioeconomic inequalities in child growth failure (CGF) remain one of the main challenges in Ethiopia. This study examined socioeconomic inequalities in CGF and determinants that contributed to these inequalities in Ethiopia.

METHODS

The Ethiopia Demographic and Health Surveys 2000 and 2016 data were used in this study. A pooled unweighted sample of the two surveys yielded 21514 mother-child pairs (10873 in 2000 and 10641 in 2016). We assessed socioeconomic inequalities in CGF indicators using the concentration curve and concentration index (CI). We then decomposed the CI to identify percentage contribution of each determinant to inequalities.

RESULTS

Socioeconomic inequalities in CGF have increased in Ethiopia between 2000 and 2016. The CI increased from -0.072 and -0.139 for stunting, -0.088 and -0.131 for underweight and -0.015 and -0.050 for wasting between 2000 and 2016, respectively. Factors that mainly contributed to inequalities in stunting included geographical region (49.43%), number of antenatal care visits (31.40%) and child age in months (22.20%) in 2000. While in 2016, inequality in stunting was contributed mainly by wealth quintile (46.16%) and geographical region (-13.70%). The main contributors to inequality in underweight were geographical regions (82.21%) and wealth quintile (27.21%) in 2000, while in 2016, wealth quintile (29.18%), handwashing (18.59%) and access to improved water facilities (-17.55%) were the main contributors. Inequality in wasting was mainly contributed to by maternal body mass index (-66.07%), wealth quintile (-45.68%), geographical region (36.88%) and paternal education (33.55%) in 2000, while in 2016, wealth quintile (52.87%) and urban areas of residence (-17.81%) were the main driving factors.

CONCLUSIONS

This study identified substantial socioeconomic inequalities in CGF, and factors that relatively contributed to the disparities. A plausible approach to tackling rising disparities may involve developing interventions on the identified predictors and prioritising actions for the most socioeconomically disadvantaged groups.

Spatial Variations and Determinants of Acute Malnutrition Among Under-Five Children in Ethiopia: Evidence from 2019 Ethiopian Demographic Health Survey

Background and aims:

Childhood acute malnutrition, in the form of wasting defined by a severe weight loss as a result of acute food shortage and/or illness. It is a critical public health problem that needs urgent attention in developing countries, like Ethiopia. Despite its variation between localities, the risk factors and its geospatial variation were not addressed enough across the various corner of the country. Therefore, the current study was undertaken to assess spatial variation and factors associated with acute malnutrition among under-five children in Ethiopia.

Methods:

A total weighted sample of 4 955 under-five children were included from the 2019 Demographic and Health Survey. Getis-Ord spatial statistical tool used to identify the hot and cold spot areas of severe and acute malnutrition. A multilevel multivariable logistic regression model using was used to examine predictors of acute malnutrition. In the multivariable multilevel analysis, Adjusted Odds Ratio with 95% CI was used to declare significant determinants of acute malnutrition among children.

Result:

Among 4 955 under-five children, 7% of them were wasted and 1% of them were severely wasted in Ethiopia during the 2019 national demographic survey. The distribution was followed some spatial geo-locations where most parts of Somali were severely affected (RR = 1.46, P37 value <0.001), and the distribution affected few areas of Afar, Gambella, and Benishangul Gumz regions. Factors that significantly associated with childhood wasting were: gender(male)1.9 (1.3–2.7), age (above 36 months) 0.5 (0.2–0.9), wealth index(richest) 0.5 (0.2–0.8), and water source (unimproved source) 1.5 (1.0–2.3).

Conclusions:

Our finding implies, the distribution of childhood wasting was not random. Regions like Afar, Somali, and pocket areas in Gambella and SNNP should be considered as priority areas nutritional interventions for reducing acute malnutrition. The established socio-demographic and economic characteristics can be also used to develop strategies.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Urban-Rural Disparities in the Magnitude and Determinants of Stunting among Children under Five in Tanzania: Based on Tanzania Demographic and Health Surveys 1991-2016

Our study aims to examine the disparity of under-5 child stunting prevalence between urban and rural areas of Tanzania in the past three decades, and to explore factors affecting the rural–urban disparity. Secondary analyses of Tanzania Demographic and Health Surveys (TDHS) data drawn from 1991–1992, 1996, 1999, 2004–2005, 2009–2010, and 2015–2016 surveys were conducted. Under-5 child stunting prevalence was calculated separately for rural and urban children and its decline trends were examined by chi-square tests. Descriptive analyses were used to present the individual-level, household-level, and societal-level characteristics of children, while multivariable logistic regression analyses were performed to examine determinants of stunting in rural and urban areas, respectively. Additive interaction effects were estimated between residence and other covariates. The results showed that total stunting prevalence was declining in Tanzania, but urban–rural disparity has widened since the decline was slower in the rural area. No interaction effect existed between residence and other determinants, and the urban–rural disparity was mainly caused by the discrepancy of the individual-level and household-level factors between rural and urban households. As various types of determinants exist, multisector nutritional intervention strategies are required to address the child stunting problem. Meanwhile, the intervention should focus on targeting vulnerable children, rather than implementing different policies in rural and urban areas.

Malnutrition in all its forms by wealth, education and ethnicity in Latin America: who are more affected?

OBJECTIVE

To summarise the findings from this supplemental issue on the distribution of malnutrition (stunting/short stature, anaemia and overweight) by wealth, education and ethnicity within and between ten Latin American countries.

DESIGN

We retrieved information from each country's article and estimated the average difference in the prevalence of malnutrition between groups. We estimated the associations between countries' malnutrition prevalence and GDP, percentage of women with high education and percentage of non-indigenous ethnicity.

SETTING

Nationally representative surveys from ten Latin American countries conducted between 2005 and 2017.

PARTICIPANTS

Children (<5 years), adolescent women (11-19 years) and adult women (20-49 years).

RESULTS

Socially disadvantaged groups (low wealth, low education and indigenous ethnicity) had on average 15-21 (range across indicators and age groups) percentage points (pp) higher prevalence of stunting/short stature and 3-11 pp higher prevalence of anaemia. For overweight or obesity, adult women with low education had a 17 pp higher prevalence; differences were small among children <5 years, and results varied by country for adolescents by education, and for adults and adolescents by wealth and ethnicity. A moderate and strong correlation (-0·58 and -0·71) was only found between stunting/short stature prevalence and countries' GDP per capita and percentage of non-indigenous households.

CONCLUSIONS

Overweight was equally distributed among children; findings were mixed for ethnicity and wealth, whereas education was a protective factor among adult women. There is an urgent need to address the deep inequalities in undernutrition and prevent the emerging inequalities in excess weight from developing further.

What Were the Drivers of Improving Child Nutritional Status in Bangladesh? An Analysis of National Household Data from 1992 to 2005 Guided by the UNICEF Framework

BACKGROUND

Bangladesh has experienced rapid reductions in child undernutrition and poverty, increases in maternal education, and dietary change over the past 3 decades.

OBJECTIVE

We aimed to quantify the determinants of the improvement in child nutritional status among preschool-aged children in Bangladesh from 1992 to 2005.

METHODS

We utilized data from 4 rounds of 2 linked and seasonally balanced survey systems: the Bangladesh Household [Income and] Expenditure Surveys (H[I]ES) and the Child [and Mother] Nutrition Survey (C[M]NS). We analyzed 10,780 children aged 6-59 mo, divided into 2 age groups (6-23 mo and 24-59 mo). We used Blinder-Oaxaca decomposition to assess the impact of changing determinants on nutritional status over time, guided by the UNICEF conceptual framework for the causes of child malnutrition.

RESULTS

There were significant improvements in child growth over time for all z-score measures-length/height-for-age (LAZ/HAZ), weight-for-length/height (WLZ/WHZ), and weight-for-age (WAZ)-and in many potential determinants of child growth across domains of the UNICEF framework. Among younger children, decomposition explained 67% of the observed change in LAZ, 130% of WLZ, and 73% of WAZ. Among older children, decomposition explained 41% of the observed change in HAZ and 36% of WAZ. Drivers varied, with improvements in care of children as the only driver in both age groups and for all growth measures. Declines in disease prevalence drove improvements in weight-based measures. For younger children, household diets and household environments were significant drivers of improvement in LAZ and WAZ. For older children, increasing income was the largest driver of HAZ and WAZ.

CONCLUSIONS

Increasing income did not independently drive improvements for younger children but drove improved growth among children aged 2-4 y. This points to the need to focus on nutrition-specific and nutrition-sensitive interventions to decrease child undernutrition in the vulnerable first 1000 days of life.

Biomarkers of environmental enteric dysfunction are not consistently associated with linear growth velocity in rural Zimbabwean infants

BACKGROUND

Child stunting remains a poorly understood, prevalent public health problem. Environmental enteric dysfunction (EED) is hypothesized to be an important underlying cause.

OBJECTIVES

Within a subgroup of 1169 children enrolled in the SHINE (Sanitation Hygiene Infant Nutrition Efficacy) trial in rural Zimbabwe, followed longitudinally from birth to 18 mo of age, we evaluated associations between the concentration of 11 EED biomarkers and linear growth velocity.

METHODS

At infant ages 1, 3, 6, 12, and 18 mo, nurses measured child length and collected stool and blood; the lactulose-mannitol urine test was also conducted at all visits except at 1 mo. Stool neopterin, α-1 antitrypsin, myeloperoxidase, and regenerating gene 1β protein; urinary lactulose and mannitol; and plasma kynurenine, tryptophan, C-reactive protein, insulin-like growth factor-1 (IGF-1), soluble CD14, intestinal fatty acid binding protein, and citrulline were measured. We analyzed the change in relative [∆ length-for-age z score (LAZ)/mo] and absolute (∆ length/mo) growth velocity during 4 age intervals (1-3 mo; 3-6 mo; 6-12 mo; and 12-18 mo) per SD increase in biomarker concentration at the start of each age interval.

RESULTS

In fully adjusted models, we observed only 3 small, statistically significant associations: kynurenine:tryptophan ratio at 12 mo was associated with decreased mean LAZ velocity during the 12-18 mo interval (-0.015 LAZ/mo; 95% CI: -0.029, -0.001 LAZ/mo); mannitol excretion at 6 mo was associated with increased LAZ velocity during the 6-12 mo interval (0.013 LAZ/mo; 95% CI: 0.001, 0.025 LAZ/mo), and plasma IGF-1 at 1 mo was associated with increased LAZ velocity during the 1-3 mo interval (0.118 LAZ/mo; 95% CI: 0.024, 0.211 LAZ/mo). Results for absolute growth velocity were similar, except IGF-1 was also associated with growth during the 12-18 mo interval. We found no other associations between any EED biomarker and linear growth velocity.

CONCLUSIONS

None of 11 biomarkers of EED were consistently associated with linear growth among Zimbabwean children.This trial was registered at clinicaltrials.gov as NCT01824940.

Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study

BACKGROUND

Kyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan.

METHODS

For this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths.

FINDINGS

Over the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030.

INTERPRETATION

Kyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability.

FUNDING

US Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.

[An analysis of policy interventions regarding school lunch programs and their role in the healthy nutrition of children in Córdoba, Argentina]

The aim of this article is to analyze school lunch programs and their role in the healthy nutrition of children in Córdoba, Argentina from 2013 to 2018. A descriptive, cross-sectional study was conducted that included a sample of 10 schools in 2013 and 10 different schools in 2018. A survey of school lunch programs and 24-hour nutrition reminders was carried out with 341 children. The nutritional value of school lunch programs decreased over the study period, particularly among schools in contexts of greater social vulnerability. Significant reductions in average calcium and energy intake were also observed. Indicators of chronic malnutrition, overweight, and excess calcium and vitamin A and C intakes worsened among children attending school lunch programs. Regarding the association between school lunch program attendance and low height for age/risk of low height for age, the odds ratio was not statistically significant. We argue for the necessity of promoting policies that seek urgent improvements in child nutritional indicators from a rights-based perspective.

Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

BACKGROUND

Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.

OBJECTIVE

This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.

METHODS

We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.

RESULTS

Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.

CONCLUSIONS

Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

Understanding multifactorial drivers of child stunting reduction in Exemplar countries: a mixed-methods approach

BACKGROUND

Several countries have notably reduced childhood stunting relative to economic growth over the past 15-20 y. The Exemplars in Stunting Reduction project, or "Exemplars," studies success factors among these countries with a lens toward replicability.

OBJECTIVES

This paper details the standardized mixed-methods framework for studying determinants of childhood stunting reduction applied in Exemplars studies.

METHODS

An expert technical advisory group (TAG), criteria for identifying Exemplar countries, evidence-based frameworks, mixed methodologies (quantitative, qualitative, policy, literature review), effective research partnerships, case study process and timeline, and data triangulation and corroboration are presented.

RESULTS

Experts in health, nutrition, and evaluation methods were selected at the study outset to provide technical support to all phases of research (TAG). Exemplar countries were selected by the TAG, who considered quantitative data (e.g., annual rates of stunting change compared with economic growth, country population size) and qualitative insights (e.g., logistics of country work, political stability). Experienced country research partners were selected and an inception meeting with stakeholder consultations was held to launch research and garner support. Evidence-based conceptual frameworks underpinned all Exemplars research activities. A systematic review of published peer-reviewed and grey literature was undertaken, along with in-depth policy and program analysis of nutrition-specific and -sensitive investments. Both descriptive and advanced quantitative analysis was undertaken (e.g., equity analyses, difference-in-difference regression, Oaxaca-Blinder decomposition). Qualitative data collection using in-depth interviews and focus groups was conducted with national and community stakeholders (i.e., child care workers and mothers) to understand country experiences. The case study process was iterative, and all research outputs were triangulated to develop the stunting reduction narrative for each country. Findings were shared with country experts for weigh-in and corroboration through dissemination events.

CONCLUSIONS

Exemplars research uses a mixed-methods framework for studying positive outliers that can be applied across diverse health and development outcomes.

Drivers of stunting reduction in Nepal: a country case study

BACKGROUND

Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability.

OBJECTIVE

This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country.

METHODS

Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses.

RESULTS

Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction.

CONCLUSIONS

Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.

Extent of and trends in inequalities in child stunting in Sierra-Leone from 2005 to 2013: evidence from demographic and health surveys and multiple indicator cluster surveys

BACKGROUND

Comprehensive assessment of stunting disparity in Sierra-Leone has not been done so far. We aimed to document extent and over time dynamics of inequality in stunting in Sierra-Leone using approaches that facilitate implementation of interventions aim to eliminate non-justified stunting disparity in the country.

METHODS

The data for the study were derived from two rounds of the Sierra Leone Demographic and Health Survey conducted in 2008 and 2013, and two rounds of the Sierra Leone Multiple Indicator Cluster Survey done in 2005 and 2010. We used the 2019 update WHO Health Equity Assessment Toolkit (HEAT) to do the analysis. The toolkit makes use of data stored in the WHO Health Equity Monitor database. We analyzed stunting inequality using summary measures: Population Attributable Risk, Population Attributable Fraction, Difference and Ratio. The summary measures were computed for five equity stratifers: wealth, education, child's sex, place of residence and subnational region. We computed 95% Confidence Interval (CI) for each point estimate to show whether or not observed stunting inequalities are statistically significant, and whether or not the disparity changed over time statistically significantly.

RESULTS

The findings demonstrated stark inequalities in stunting in all the studied dimensions of inequality. While residence and subnational regional related inequalities remain unchanged over time, wealth and educational inequality had seen slight improvement during the same time period. Large sex related stunting inequality remained during the first three surveys time points, but it disappeared in 2013.

CONCLUSIONS

Huge stunting disparities occurred in Sierra Leone, and the disparity disproportionately affects disadvantaged subpopulations and male children. Nutrition interventions that specifically target the subgroups which suffer more from the burden of stunting are required.

Ethnic inequalities in child stunting and feeding practices: results from surveys in thirteen countries from Latin America

Background

Although the prevalence of child stunting is falling in Latin America, socioeconomic inequalities persist. However, there is limited evidence on ethnic disparities. We aimed to describe ethnic inequalities of stunting and feeding practices in thirteen Latin American countries using recent nationally representative surveys.

Methods

We analyzed national surveys carried out since 2006. Based on self-reported ethnicity, skin color or language, children were classified into three categories: indigenous/ afrodescendant/reference group (European or mixed ancestry). Stunting was defined as height (length)-for-age < − 2 standard deviations relative to WHO standards. Family wealth was assessed through household asset indices. We compared mean length/height-for-age and prevalence of stunting among the three ethnic groups.

Results

Thirteen surveys had information on indigenous and seven on afrodescendants. In all countries, the average length/height-for-age was significantly lower for indigenous, and in eleven countries there were significant differences in the prevalence of stunting: the pooled crude stunting prevalence ratio between indigenous and the reference group was 1.97 (95% CI 1.89; 2.05); after adjustment for wealth and place of residence, prevalence remained higher among indigenous (PR = 1.34, 95% CI 1.28; 1.39) in eight countries. Indigenous aged 6–23 months were more likely to be breastfed, but with poor complementary feeding, particularly in terms of dietary diversity. Afrodescendants showed few differences in height, and in two countries tended to be taller compared to the reference group.

Conclusions

In all Latin American countries studied, indigenous tended to be shorter and afrodescendants presented few differences with relation to the reference group. In order to reach the SDG’s challenge of leaving no one behind, indigenous need to be prioritized.

Time trends in demand for family planning satisfied: analysis of 73 countries using national health surveys over a 24-year period

Background

Universal access to family planning is key to extend its health and economic benefits worldwide. Our aim was to track progress in demand for family planning satisfied with modern methods (mDFPS) and its inequalities in low- and middle-income countries (LMICs).

Methods

Analyses were based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out between 1993 and 2017 in 73 LMICs, using data for married women aged 15-49 years. We estimated trends in mDFPS coverage by country and world region and evaluated trends in wealth-based inequalities. The analyses pooling all countries together were stratified by wealth quintiles, area of residence and woman’s age. mDFPS coverage in 2030 for each country was predicted using a linear model.

Results

Overall, mDFPS increased and poor-rich gaps narrowed. Eastern & Southern Africa showed an average increase of 1.5 percentage points (p.p.) a year, being the region with the fastest progress. West & Central Africa had an increase in mDFPS of 1 p.p. a year but current coverage is still below 40%. Generally, inequalities were reduced, except for West & Central Africa and Europe & Central Asia where almost no change was observed. The country with the fastest progress in mDFPS was Rwanda, with an increase of 5 p.p./y, while Timor Leste had the fastest reduction in absolute inequality, less 3.8 p.p./y. Inequalities by area of residence were reduced, but large gaps remain. A similar trend was observed for different age groups. If the current trend is not accelerated, 44 countries will not achieve universal coverage in mDFPS by 2030.

Conclusions

Generally, mDFPS is increasing and inequalities are decreasing. However, progress is slow in some regions, especially West & Central Africa, where low coverage is combined with high levels of inequalities. Efforts to increase family planning coverage must be prioritized in countries where progress is slow or inexistent.

Are inequities decreasing? Birth registration for children under five in low-income and middle-income countries, 1999-2016

INTRODUCTION

Although global birth registration coverage has improved from 58% to 71% among children under five globally, inequities in birth registration coverage by wealth, urban/rural location, maternal education and access to a health facility persist. Few studies examine whether inequities in birth registration in low-income and middle-income countries have changed over time.

METHODS

We combined information on caregiver reported birth registration of 1.6 million children in 173 publicly available, nationally representative Demographic Health Surveys and Multiple Indicator Cluster Surveys across 67 low-income and middle-income countries between 1999 and 2016. For each survey, we calculated point estimates and 95% CIs for the percentage of children under 5 years without birth registration on average and stratified by sex, urban/rural location and wealth. For each sociodemographic variable, we estimated absolute measures of inequality. We then examined changes in non-registration and inequities between surveys, and annually.

RESULTS

14 out of 67 countries had achieved complete birth registration. Among the remaining 53 countries, 39 countries successfully decreased the percentage of children without birth registration. However, this reduction occurred alongside statistically significant increases in wealth inequities in 9 countries and statistically significant decreases in 10 countries. At the most recent survey, the percentage of children without birth registration was greater than 50% in 16 out of 67 countries.

CONCLUSION

Although birth registration improved on average, progress in reducing wealth inequities has been limited. Findings highlight the importance of monitoring changes in inequities to improve birth registration, to monitor Sustainable Development Goal 16.9 and to strengthen Civil Registration and Vital Statistics systems.

Trends in socioeconomic inequalities in stunting prevalence in Latin America and the Caribbean countries: differences between quintiles and deciles

BACKGROUND

With the adoption of the Sustainable Development Goals (SDGs), there is a renewed commitment of tackling the varied challenges of undernutrition, particularly stunting (SDG 2.2). Health equity is also a priority in the SDG agenda and there is an urgent need for disaggregated analyses to identify disadvantaged subgroups. We compared time trends in socioeconomic inequalities obtained through stratification by wealth quintiles and deciles for stunting prevalence.

METHODS

We used 37 representative Demographic and Health Surveys and Multiple Indicator Cluster surveys from nine Latin American and Caribbean (LAC) countries conducted between 1996 and 2016. Stunting in children under-5 years was assessed according to the 2006 WHO Child Growth Standards and stratified by wealth quintiles and deciles. Within-country socioeconomic inequalities were measured through concentration index (CIX) and slope index of inequality (SII). We used variance-weighted least squares regression to estimate annual changes.

RESULTS

Eight out of nine countries showed a statistical evidence of reduction in stunting prevalence over time. Differences between extreme deciles were larger than between quintiles in most of countries and at every point in time. However, when using summary measures of inequality, there were no differences in the estimates of SII with the use of deciles and quintiles. In absolute terms, there was a reduction in socioeconomic inequalities in Peru, Honduras, Dominican Republic, Belize, Suriname and Colombia. In relative terms, there was an increase in socioeconomic inequalities in Peru, Bolivia, Haiti, Honduras and Guatemala.

CONCLUSIONS

LAC countries have made substantial progress in terms of reducing stunting,. Nevertheless, renewed actions are needed to improve equity. Particularly in those countries were absolute and relative inequalities did not change over time such Bolivia and Guatemala. Finer breakdowns in wealth distribution are expected to elucidate more differences between subgroups; however, this approach is relevant to cast light on those subgroups that are still lagging behind within populations and inform equity-oriented health programs and practices.

Socio-Ecological Model of Correlates of Double Burden of Malnutrition in Developing Countries: A Narrative Review

(1) Background: The double burden of malnutrition (DBM) is a complex problem involving the coexistence of under- and over-nutrition within the same individual, household or population. This review aimed to discuss the correlates of the double burden of malnutrition through the socio-ecological model (SEM); (2) Methods: The PubMed database was systematically searched for peer-reviewed articles related to the double burden of malnutrition. Information on correlates of the double burden of malnutrition was extracted for analysis and discussion in alignment with the levels of the socio-ecological model.; (3) Results and Discussion: The correlates of the double burden of malnutrition identified from previous literature were: Race/genetics; maternal short stature; breastfeeding status; low maternal education; family size; household food security; household dietary diversity; and rural and urban settings. In the absence of evidence linking factors in a certain level of the SEM and the double burden of malnutrition, we employed correlates of overweight status and obesity to complete this narrative. Potential intervention strategies were proposed in alignment with the targets and settings identified, based on the socio-ecological approach; (4) Conclusions: The double burden of malnutrition is a public health phenomenon associated with a variety of socio-ecological determinants. An integrated approach is needed to address the root causes of malnutrition in all its forms, and at all life stages.

Risk factors for undernutrition among children 0-59 months of age in Myanmar

The prevalence of childhood stunting in Myanmar is one of the highest among the countries of Southeast Asia. Cross-sectional data from the Myanmar Demographic Health Survey 2015-2016 were used to examine risk factors for stunting, wasting, and underweight among children aged 0-59 months. The prevalence of stunting, wasting, and underweight was 29.0%, 7.3%, and 19.2%, respectively. Accounting for sampling design and weights, multivariable logistic regression was conducted with 35 household, maternal, and child characteristics. Current pregnancy and maternal height <145 cm, home delivery, child's small birth size recalled by mother, and older age (ref: 0-5 months) predicted both stunting and underweight. Larger than average birth size was protective for all stunting, wasting, and underweight. Maternal body mass index <18.5 kg m-2 was a common risk factor for wasting and underweight. Lower wealth quintiles, maternal engagement in nonagricultural occupation, and male child predicted stunting only. Younger child age and not receiving vitamin A supplementation in the previous 6 months were risk factors for wasting only. Regional variation was also seen, with a higher odds of stunting in the West-South Region, North-East States, and West States, compared with the Central Regions. In Myanmar, socio-economic and demographic factors, poor maternal nutritional status, and living in certain geographical locations are affecting children's undernutrition. It is recommended that interventions for growth faltering focus on the first 1,000 days of life; optimum maternal nutrition be ensured during and before pregnancy and at adolescence; societal support be provided for mothers in poverty or engaged in nonagriculture; and region-specific undernutrition pathways be understood.

Trends and inequalities in maternal and child health in a Brazilian city: methodology and sociodemographic description of four population-based birth cohort studies, 1982-2015

Background

Few low-middle-income countries have data from comparable birth cohort studies spanning over time. We report on the methods used by the Pelotas cohorts (1982, 1993, 2004 and 2015) and describe time trends in sociodemographic characteristics of the participant families.

Methods

During the four study years, all maternity hospitals in the city were visited daily, and all urban women giving birth were enrolled. Data on socioeconomic and demographic characteristics were collected using standardized questionnaires, including data on maternal and paternal skin colour, age and schooling, maternal marital status, family income and household characteristics. The analyses included comparisons of time trends and of socioeconomic and ethnic group inequalities.

Results

Despite a near 50% increase in the city’s population between 1982 and 2015, the total number of births declined from 6011 to 4387. The proportion of mothers aged ≥35 years increased from 9.9% to 14.8%, and average maternal schooling from 6.5 [standard deviation (SD) 4.2] to 10.1 (SD 4.0) years. Treated water was available in 95.3% of households in 1982 and 99.3% in 2015. Three-quarters of the families had a refrigerator in 1982, compared with 98.3% in 2015. Absolute income-related inequalities in maternal schooling, household crowding, household appliances and access to treated water were markedly reduced between 1982 and 2015. Maternal skin colour was associated with inequalities in age at childbearing and schooling, as well as with household characteristics.

Conclusions

During the 33-year period, there were positive changes in social and environmental determinants of health, including income, education, fertility and characteristics of the home environment. Socioeconomic inequality was also reduced.

Ethnic inequalities and trends in stunting prevalence among Guatemalan children: an analysis using national health surveys 1995-2014

BACKGROUND

Guatemala has the highest prevalence of stunting among under-five children in Latin America. We aimed to compare indigenous and non-indigenous under-five child populations in relation to stunting, as well as to explore the intersectionality of ethnicity by wealth and by place of residence. We also studied how the ethnic inequalities changed over time, using five ENSMI surveys from 1995 to 2014.

METHODS

Five national health surveys carried out between 1995 and 2014 were analysed. World Health Organization (WHO) 2006 growth standards were used to calculate stunting prevalence. Self-reported ethnicity was classified as indigenous or nonindigenous. Wealth was measured through an asset-based index, and households were classified into quintiles (for analyses of the whole populations) or tertiles (for analyses of intersectionality with ethnicity). Area of residence was recorded as urban or rural, according to country definition.

RESULTS

Overall stunting prevalence declined by 9.8 percentage points (95% CI -16.4 to - 3.3) from 1995 to 2014. The slope index for absolute inequalities in stunting - which corresponds to the difference in prevalence between the wealthiest and poorest households - ranged from - 52.9 to - 60.4 percentage points, with no significant change over time. Children in rural areas were consistently more stunted than those in urban areas, but rural indigenous children were significantly worse than any other group. Indigenous children in the poorest tertile of family wealth consistently presented the highest stunting prevalence, compared to all other groups. Time trends in stunting were assessed through the average annual absolute change (AAAC). The fastest decline was observed among indigenous children from the middle wealth tertile (AAAC = - 1.21 percentage points per year (pp/y); 95% CI - 1.45 to - 0.96) followed by nonindigenous children also from the middle tertile (AAAC = - 0.80 pp./y; 95% CI - 0.99 to - 0.60). Stunting prevalence in the two poorest tertiles of indigenous children in 2015 was similar to what nonindigenous children presented in 1995, 20 years earlier. In the wealthiest tertile, indigenous children were far worse off than nonindigenous children 20 years earlier.

CONCLUSIONS

In terms of stunting prevalence, poor and rural indigenous children are twenty years behind nonindigenous children with similar characteristics.

Infant nutrition and growth: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015

BACKGROUND

Levels of child undernutrition have declined in many middle-income countries, whereas overweight and obesity have increased. We describe time trends in nutritional indicators at age 1 year in the 1982, 1993, 2004 and 2015 Pelotas (Brazil) Birth Cohorts.

METHODS

Each study included all children born in the urban area of the city, with over 4 200 births in each cohort. Children were measured at approximately 12 months of age. Anthropometric indicators were calculated according to World Health Organization Growth Standards. Stunting and wasting were defined as <-2 Z scores for length for age and weight for length, and overweight as >2 Z scores for weight for length. Prevalence was stratified by sex, maternal skin colour and family income.

RESULTS

The prevalence of stunting declined by 53% (from 8.3% to 3.9%) from 1982 to 2015. Wasting prevalence remained stable at low levels (1.8% in 1982 and 1.7% in 2015), whereas overweight increased by 88% (6.5% to 12.2%). Undernutrition was more common among boys, those born to mothers with brown or black skin colour and in the poorest quintile of families. Socioeconomic inequalities in undernutrition decreased markedly over time. Overweight was markedly more common among the rich in 1982, but fast increase among the poor eliminated socioeconomic differences by 2015, when all groups showed similar prevalence.

CONCLUSIONS

Our results confirm the rapid nutrition transition in Brazil, with marked reduction in levels and inequalities in undernutrition in parallel with a rapid increase in overweight, which became the main nutritional problem for children.

Trends and predictors of inequality in childhood stunting in Nepal from 1996 to 2016

BACKGROUND

Although decreasing in trend, one-in-three children remain stunted in Nepal and its distribution is unequal among different socioeconomic and geographical subgroups. Thus, it is crucial to assess inequalities in stunting for designing equity focused interventions that target vulnerable groups with higher burden of stunting. This study measures trends and predictors of socioeconomic inequalities in childhood stunting in Nepal.

METHODS

Data from five rounds (1996-2016) of Nepal Demographic and Health Survey, nationally representative cross-sectional surveys, were used. Levels and trends of absolute and relative disparity in stunting between the poorest and the richest wealth quintiles, and among all quintiles were assessed by calculating absolute and relative difference, concentration curve and index. Average marginal effects of predictors on stunting were calculated using probit regression. The concentration index was subsequently decomposed into contributing factors.

RESULTS

Even though stunting consistently declined in all wealth quintiles between 1996 and 2016, reduction was relatively higher among the richer quintiles compared to poorer ones. The absolute difference between the poorest and the richest quintile increased from 24.7 in 1996 (64.5% in poorest - 39.8% in richest) to 32.7 percentage points in 2016 (49.2-16.5%). The relative disparity also increased; the ratio of stunting in the poorest to the richest quintile was 1.6 in 1996 and 3.0 in 2016. The concentration index increased (in absolute value) from - 0.078 in 1996 to - 0.147 in 2016 indicating that stunting was disproportionately concentrated in poorer households and socioeconomic inequalities worsened from 1996 to 2016. Decomposition analysis revealed that in 1996, wealth (61%), caste/ethnicity (12%), mother's education (12%) and birth order (9%) were the major contributors to observed socioeconomic inequalities in stunting; while in 2016, wealth (72%), mother's BMI (12%) and birth order (9%) were the major contributors.

CONCLUSIONS

Despite remarkable improvements in average stunting over the last two decades, substantial socioeconomic inequalities in stunting exists and is determined not only by immediate factors but also by underlying and contextual factors which emphasize the need for coherent actions across different sectors. In addition to reducing inequalities in wealth, nutrition programming should be focused on most disadvantaged subgroups which are prone to both stunting and relative poverty.

Nutritional status and risk factors for stunting in preschool children in Bhutan

Childhood malnutrition remains endemic in South Asia, although the burden varies by country. We examined the anthropometric status and risk factors for malnutrition among children aged 0–59 months through the 2015 National Nutrition Survey in Bhutan. We assessed in 1,506 children nutritional status (by z‐scores of height‐for‐age [HAZ], weight‐for‐height [WHZ], and weight‐for‐age [WAZ]), estimating prevalence, adjusted for survey design, of stunting, wasting, underweight, and overweight (<−2 for HAZ, WHZ, and WAZ and >2 for WHZ). Children were also assessed for pedal oedema. We conducted multivariable linear/logistic regression analysis to identify child, maternal, and household risk factors for childhood undernutrition and overweight, excluding children with oedema (1.7%). Mean (SE) HAZ, WHZ, and WAZ were −0.82 (0.13), 0.10 (0.04), and −0.42 (0.05), respectively. Prevalence of stunting, wasting, underweight, and overweight were 21.2%, 2.6%, 7.4%, and 2.6%, respectively. In multivariable regressions, risk of stunting significantly increased by age: 5.3% at <6 months (reference), 16.8% at 6–23 months (OR = 3.06, 95% CI [0.63, 14.8]), and 25.0% at 24–59 months (OR = 5.07, [1.16, 22.2]). Risk of stunting also decreased in a dose–response manner with improved maternal education. None of the examined variables were significantly associated with wasting or overweight. Despite a WHZ distribution comparable with the World Health Organization reference (with ~2.6% vs. an expected 2.5% of children beyond 2 z in each tail), stunting persists in one fifth of preschool Bhutanese children, suggesting that other nutrient deficits or nonnutritional factors may be constraining linear growth for a substantial proportion of children.

Household Food Insecurity as a Predictor of Stunted Children and Overweight/Obese Mothers (SCOWT) in Urban Indonesia

(1) Background: The double burden of malnutrition has been increasing in countries experiencing the nutrition transition. This study aimed to determine the relationship between household food insecurity and the double burden of malnutrition, defined as within-household stunted child and an overweight/obese mother (SCOWT). (2) Methods: A cross-sectional survey was conducted in the urban city of Surabaya, Indonesia in April and May 2015. (3) Results: The prevalence of child stunting in urban Surabaya was 36.4%, maternal overweight/obesity was 70.2%, and SCOWT was 24.7%. Although many households were food secure (42%), there were high proportions of mild (22.9%), moderate (15.3%) and severe (19.7%) food insecurity. In a multivariate logistic regression, the household food insecurity access scale (HFIAS) category significantly correlated with child stunting and SCOWT. Compared to food secure households, mildly food insecure households had the greatest odds of SCOWT (adjusted odds ratio (aOR) = 2.789; 95% confidence interval (CI) = 1.540⁻5.083), followed by moderately food insecure (aOR = 2.530; 95% CI = 1.286⁻4.980) and severely food insecure households (aOR = 2.045; 95% CI = 1.087⁻3.848). (4) Conclusions: These results support the hypothesis that the double burden of malnutrition is related to food insecurity, and the HFIAS category is a predictor of SCOWT.

Measurement of social inequalities in health: concepts and methodological approaches in the Brazilian context

This study aims to describe methodological approaches to measure and monitor health inequalities and to illustrate their applicability. The measures most frequently used in the literature were reviewed. Data on coverage and quality of pre-natal care in Brazil, from the Demographic and Maternal and Child Health Survey (PNDS-2006) and the National Health Survey (PNS-2013) were used to illustrate their applicability. Absolute and relative measures of inequalities were presented, highlighting their complementary character. Despite the progress achieved in the national indicators of pre-natal care, important inequalities were still identified between population subgroups, with no change in the magnitude of the differences throughout the studied period. Brazil has important social inequalities, whose consequences still lead to health inequalities. Their description and monitoring are highly relevant to support polices focused on those vulnerable population groups who have been left behind.

Socioeconomic Inequalities Persist Despite Declining Stunting Prevalence in Low- and Middle-Income Countries

Background

Global stunting prevalence has been nearly halved between 1990 and 2016, but it remains unclear whether this decline has benefited poor and rural populations within low- and middle-income countries (LMICs).

Objective

We assessed time trends in stunting among children <5 y of age (under-5) according to household wealth and place of residence in 67 LMICs.

Methods

Stunting prevalence was analyzed in 217 nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 67 countries with ≥2 surveys between 1993 and 2014. National estimates were stratified by wealth and area of residence, comparing the poorest 40% with the wealthiest 60%, and those residing in urban and rural areas. Time trends were calculated for LMICs by using multilevel regression models weighted by under-5 population, with stratification by wealth and by residence. Trends in absolute (slope index of inequality; SII) and relative (concentration index; CIX) inequalities were calculated.

Results

Mean prevalences in 1993 were 53.7% in low-income and 48.2% in middle-income countries, with annual average linear declines of 0.76 and 0.72 percentage points (pp), respectively. Although similar slopes of declines were observed for the poorest 40% and wealthiest 60% groups in all countries (0.78 and 0.74 pp, respectively), absolute and relative inequalities increased over time in low-income countries (SII increased from -19.3% in 1993 to -23.7% in 2014 and CIX increased from -6.2% to -10.8% in the same period). In middle-income countries, socioeconomic inequalities remained stable. Overall, stunting prevalence decreased more rapidly among rural than for urban children (0.78 and 0.55 pp, respectively).

Conclusions

The prevalence of stunting is decreasing. Poor-rich gaps are stable in middle-income countries and slightly increasing in low-income countries. Rural-urban inequalities are decreasing over time.

Individual, household, and community level risk factors of stunting in children younger than 5 years: Findings from a national surveillance system in Nepal

Despite substantial reductions in recent years in Nepal, stunting prevalence in children younger than 5 years remains high and represents a leading public health concern. To identify factors contributing to the stunting burden, we report multilevel risk factors associated with stunting in 4,853 children aged 6-59 months in a nationally and agroecologically representative random sample from the first year of the Policy and Science for Health, Agriculture, and Nutrition Community Studies, a community-based observational, mixed-panel study. Mixed effects logistic regressions controlling for multilevel clustering in the study design were used to examine the association of individual-, household-, and community-level factors associated with stunting. Stunting prevalence was 38% in our sample. After adjustment for potential confounding variables, maternal factors, including maternal height and education, were generally the strongest individual-level risk factors for stunting, adjusted odds ratio (AOR) = 2.52, 95% CI [1.96, 3.25], short (<145 cm) versus not short mothers; AOR = 2.09, 95% CI [1.48, 2.96], uneducated mothers versus secondary school graduates. Among the household- and community-level factors, household expenditure and community infrastructure (presence of paved roads, markets, or hospitals) were strongly, inversely associated with increased stunting risk, AOR = 1.68, 95% CI [1.27, 2.24], lowest versus highest household expenditure quintile; AOR = 2.38, 95% CI [1.36, 4.14], less developed (lacking paved roads, markets, or hospitals) versus more developed communities. Although most factors associated with stunting are not rapidly modifiable, areas for future research and possible interventions emerged.

Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: Wealth quintiles or deciles?

BACKGROUND

Wealth quintiles derived from household asset indices are routinely used for measuring socioeconomic inequalities in the health of women and children in low and middle-income countries. We explore whether the use of wealth deciles rather than quintiles may be advantageous.

METHODS

We selected 46 countries with available national surveys carried out between 2003 and 2013 and with a sample size of at least 3000 children. The outcomes were prevalence of under-five stunting and delivery by a skilled birth attendant (SBA). Differences and ratios between extreme groups for deciles (D1 and D10) and quintiles (Q1 and Q5) were calculated, as well as two summary measures: the slope index of inequality (SII) and concentration index (CIX).

RESULTS

In virtually all countries, stunting prevalence was highest among the poor, and there were larger differences between D1 and D10 than between Q1 and Q5. SBA coverage showed pro-rich patterns in all countries; in four countries the gap was greater than 80 pct points. With one exception, differences between extreme deciles were larger than between quintiles. Similar patterns emerged when using ratios instead of differences. The two summary measures provide very similar results for quintiles and deciles. Patterns of top or bottom inequality varied with national coverage levels.

CONCLUSION

Researchers and policymakers should consider breakdowns by wealth deciles, when sample sizes allow. Use of deciles may contribute to advocacy efforts, monitoring inequalities over time, and targeting health interventions. Summary indices of inequalities were unaffected by the use of quintiles or deciles in their calculation.

Social determinants of inequalities in child undernutrition in Bangladesh: A decomposition analysis

Socioeconomic inequalities in child undernutrition remain one of the main challenges in Bangladesh. The social determinants of health are mostly responsible for such inequalities across different population groups. However, no study has examined the relative contribution of different social determinants to the socioeconomic inequality in child undernutrition in Bangladesh. Our objective is to measure the extent of socioeconomic-related inequalities in childhood stunting and identify the key social determinants that potentially explain these inequalities in Bangladesh. We used data for children younger than 5 years of age for this analysis from 2 rounds of Bangladesh Demographic and Health Surveys conducted in 2004 and 2014. We examined the socioeconomic inequality in stunting using the concentration curve and concentration index. We then decomposed the concentration index into the contributions of individual social determinants. We found significant inequality in stunting prevalence. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well-off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, health-seeking behavior of the mothers, sanitation, fertility, and maternal stature were the major contributors to the disparity in stunting prevalence in Bangladesh. Equity is a critical component of sustainable development goals. Health policymakers should work together across sectors and develop strategies for effective intersectoral actions to adequately address the social determinants of equity and reduce inequalities in stunting and other health outcomes.

Trends and determinants of inequities in childhood stunting in Bangladesh from 1996/7 to 2014

BACKGROUND

We explore long-term trends and determinants of socioeconomic inequities in chronic childhood undernutrition measured by stunting among under-five children in Bangladesh. Given that one in three children remain stunted in Bangladesh, the socioeconomic mapping of stunting prevalence may be critical in designing public policies and interventions to eradicate childhood undernutrition.

METHODS

Six rounds of Bangladesh Demographic and Health Survey data are utilized, spanning the period 1996/97 to 2014. Using recognized measures of absolute and relative inequality (namely, absolute and relative difference, concentration curve and index), we quantify trends, and decompose changes in the concentration index to identify factors that best explain observed dynamics.

RESULTS

Despite remarkable improvements in average nutritional status over the last two decades, socio-economic inequalities have persisted, and according to some measures, even worsened. For example, expressed as rate-ratios, the relative inequality in under-five stunting increased by 56% and the concentration index more than doubled between 1996/97 and 2014. Decomposition analyses find that wealth and maternal factors such as mothers' schooling and short stature are major contributors to observed socio-economic inequalities in child undernutrition and their changes over time.

CONCLUSIONS

Reflecting on recent success around socioeconomic and gender equity in child mortality, and the weak legacy of nutrition policy in Bangladesh, we suggest that nutrition programming energies be focused specifically on the most disadvantaged and applied at scale to close socioeconomic gaps in stunting prevalence.