Reaching the global target to reduce stunting: an investment framework

Growth monitoring and promotion service utilization and its associated factors among mothers of children under two years in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Growth monitoring and promotion (GMP) is a nutritional intervention designed to identify and address growth faltering before a child's nutritional status deteriorates into severe malnutrition. Despite GMP being recognized as a priority in Ethiopia's national nutrition program, there is no national aggregated figure to show the extent of GMP service utilization. Therefore, this systematic review and meta-analysis aimed to assess GMP service utilization and associated factors in Ethiopia.

METHODS

A systematic literature search was conducted using PubMed/MEDLINE, CINAHL, Hinari, EMBASE, Scopus, and grey literature sources like Google Scholar, WorldCat, and Institutional repository. The Joanna Briggs Institution (JBI) quality assessment tool was used to appraise the quality of the articles, and articles scoring > 50% were included in the analysis. The pooled prevalence and odds ratio of associated factors with 95%CI was computed using STATA version 16. A random-effect model was employed to estimate the effect size, and I-squared statistics and Egger's test were used to assess heterogeneity and identify potential publication bias, respectively. Subgroup analysis was conducted with publication year, sample size, and region to identify the source of heterogeneity.

RESULTS

Nine studies with 4,768 study participants were included in this meta-analysis. The overall pooled utilization of GMP service among children under two years of age in Ethiopia was 23.21% (95% CI: 16.02, 30.41, I2 = 97.27% & P = 0.0001). Mothers who received counselling on GMP service (OR = 3.16 (95%CI: 2.49-4.00), parents who use family health card (FHC) (OR = 3.29 (95%CI: 1.49-7.28), and mother who use postnatal care (OR = 3.93 (95%CI: 2.40-6.42), and Anti natal care (OR = 3.15 (95%CI: 1.29-7.69) were the factors associated with GMP service utilization among children under two years of age.

CONCLUSIONS

The utilization of GMP services among children under the age of two in Ethiopia remains inadequate. Therefore, it is crucial to provide health education and counselling focusing on GMP to the mothers/caregivers of the child and encourage utilization of FHC. In addition, integrating GMP with other maternal health services should be promoted.

The burden and trends of child and maternal malnutrition across the regions in Ethiopia, 1990-2019: The Global Burden of Disease Study 2019

INTRODUCTION

Child malnutrition is the main contributor to the disease burden in Ethiopia. The objective of this study was to determine the prevalence and trends of child malnutrition and maternal anemia in Ethiopia at the national and regional state levels between 1990 and 2019.

METHODS

We used all accessible data sources and analyzed prevalence, death, and years of life lost (YLL) due to child malnutrition and maternal anemia across nine regions and two chartered cities in Ethiopia, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The burden and trends of child and maternal malnutrition and anemia at the national level, across the regions, and in cities were assessed. Point estimates with 95% uncertainty intervals (UI) are presented.

FINDINGS

Of the 190,173 total under-5 deaths in Ethiopia in 2019, 108,864 (95% UI: 83,544-141,718; 57·2%, 51·3-62·7) were attributed to malnutrition. The prevalence of stunting, underweight, and wasting was 37·0%, 27·0%, and 7·0%, respectively, in 2019. The YLL rate attributable to child malnutrition declined from 251,964 per 100,000 population (95% UI: 218,720-287,559) in 1990 to 57,615 (95% UI: 44,190-75,015) in 2019. The YLL rate of wasting, stunting, and underweight in Ethiopia was 18,566 per 100,000 population (95% UI: 12,950-26,123), 3,290 (95% UI: 1,443-5,856), and 5,240 (95% UI: 3,608-7,312) in 2019, respectively. Gambella showed the highest YLL rate reduction among regions, with a 98·2% change for stunting, 95·9% for wasting, and 97·9% for underweight between 1990 and 2019. The prevalence of anemia among under-5 children in Ethiopia was 62·0% (95% UI: 59·1%-65·1%) in 2019. Somali has the highest child anemia prevalence, 84·4% (95% UI: 79·8%-88·8%), compared to others in 2019. The prevalence of anemia in women of reproductive age (15-49 years) in Ethiopia was 20·4% (95% UI: 19·0%-21·8%) in 2019.

INTERPRETATION

The prevalence of child malnutrition and maternal anemia in Ethiopia remains high compared to national, WHO, and UNICEF 2030 targets in all indicators of child malnutrition and anemia despite several interventions in the last three decades. The YLL rate due to child malnutrition was high, with regional variations. In conjunction with other sectors, especially agriculture, the National Nutrition Program and other nutrition initiatives must make greater efforts with short-term and long-term interventions to improve access and better nutrition.

Multi-Level Mixed-Effects Analysis of Stunting Among 6 to 59 Months Children in Ethiopia: Evidenced from Analysis of Health and Demographic Survey, 2000 to 2019

Background. Stunting remains a major public health issue in developing countries like Ethiopia. It is termed as a chronic malnutrition which leads to morbidity and mortality among children. This study aimed to assess the prevalence and factors associated with stunting among 6 to 59 months children in Ethiopia. Methods. A total weighted sample of 34 930 children aged 6 to 59 months was included in this study. A Multilevel Mixed-Effect logistic regression was carried out. The Median Odds Ratio (MOR) and the Intra class Correlation Coefficient (ICC) were calculated. An adjusted odds ratio along with a 95% confidence interval was reported and statistical significance was declared at a P-value ≤ .05. Results. The weighted prevalence of stunting in Ethiopia was 48.3% (95% CI: 47.8%, 48.8%). Being male, increased in age, having multiple births (twin), having less than 2 years birth interval, history of diarrhea, anemia, lack of maternal and paternal formal education, having poor and middle-wealth status, and living in rural areas were significantly associated with stunting. Conclusions. The prevalence of stunting is high in Ethiopia. The risk factors mentioned above increase the likely hood of stunting among children. Therefore, we recommend that responsible bodies place a greater emphasis and priority on promoting parental education, awareness on the impact of the birth interval on child nutrition, the prevention of childhood diarrhea and anemia, improving household economic status, and reducing rural-urban disparities.

Trend of risk and correlates of under-five child undernutrition in Bangladesh: an analysis based on Bangladesh Demographic and Health Survey data, 2007-2017/2018

OBJECTIVES

The objectives of this study are to identify the trend of undernutrition risk among under-five children (U5C) in Bangladesh and the trend of its correlates.

DESIGN

Multiple cross-sectional data sets from different time points were used.

SETTING

Nationally representative Bangladesh Demographic and Health Surveys (BDHSs) were conducted in 2007, 2011, 2014 and 2017/2018.

PARTICIPANTS

In the BDHSs, the sample sizes for ever-married women (age: 15-49 years) were 5300 in 2007, 7647 in 2011, 6965 in 2014 and 7902 in 2017/2018.

OUTCOMES

Extant indicators of undernutrition (stunted, wasted and underweight) have been considered as the outcome variables.

MATERIALS AND METHODS

Descriptive statistics, bivariate analysis and factor loadings from factor analysis have been used to determine the prevalence of undernutrition over the years and find the trend of risk and its correlates.

RESULTS

Risks of stunting among the U5C were 41.70%, 40.67%, 36.57% and 31.14%; that of wasting were 16.94%, 15.48%, 14.43% and 8.44%; and that of underweight were 39.79%, 35.80%, 32.45% and 22.46% in 2007, 2011, 2014 and 2017/2018, respectively. From the factor analysis, it has been found that the top five potential correlates of undernutrition are the wealth index, the education of the father and mother, the frequency of antenatal visits during pregnancy, the father's occupation and/or the type of place of residence in the last four consecutive surveys.

CONCLUSION

This study helps us gain a better understanding of the impact of the top correlates on child undernutrition. To accelerate the reduction of child undernutrition more by 2030, Government and non-government organisations should focus on improving education and household income-generating activities among poor households and raising awareness among women about the importance of receiving antenatal care during pregnancy.

Impact of new health care reform on enabling environment for children’s health in China: An interrupted time-series study

Background

Creating an enabling environment (EE) can help foster the development and health of children. The Chinese government implemented a new health care reform (NHR) in 2009 in a move to promote an EE for health. The purpose of this study was to evaluate the impact of the NHR on EE for children’s health.

Methods

An interrupted time-series analysis was used to evaluate the changes in the EE before and after 2009 in China. This study analysed the EE through five quantitative indicators, including policy element coverage rate (PECR), service meeting with children’s needs rate (SMCNR), multisector participation rate (MPR), and accountability mechanism clarity rate (AMCR), based on the content analysis of available public policy documents (updated as of 2019) from 31 provinces in mainland China, and the number of health care personnel of maternity and child care centres per 10 000 population (HP per 10 000 population), based on the 2002–2019 China Health Statistical Yearbook and China Statistical Yearbook.

Results

The average values of PECR, SMCNR, and MPR increased rapidly to 90.96%, 82.46%, and 81.31%, respectively, in 2019, representing a higher value compared to the AMCR (7.38%). The NHR promoted the EE, in which HP per 10 000 population showed the fastest increase (β₁ = 0.03, P < 0.01; β₃ = 0.10, P < 0.01), followed by SMCNR (β₁ = 0.94, P < 0.01; β₃ = 1.83, P < 0.01), AMCR (β₁ = 0.13, P < 0.01; β₃ = 0.24, P = 0.14), MPR (β₁ = 1.35, P < 0.01; β₃ = 2.47, P < 0.01) and PECR (β₁ = 1.43, P < 0.01; β₃ = 1.47, P < 0.01).

Conclusions

The NHR has a positive impact on the EE, especially on the human resources and service provision for children. Efforts should be intensified to improve the clarity of the accountability mechanism of the health-related sectors.

Understanding the role of village fund and administrative capacity in stunting reduction: Empirical evidence from Indonesia

The Indonesian government launched various programs to handle stunting cases, including village funds. This paper examined the effects of village fund programs and village apparatuses’ capacities to combat stunting based on aggregate data at the district level in Indonesia. Using descriptive data analysis and fixed effect panel regression, we observed that village fund programs could significantly reduce Indonesia’s stunting prevalence, especially outside Java. It also revealed that the increasing education of regional leaders does not necessarily positively impact leaders’ skills in handling stunting. At the same time, the number of village officials has a statistically significant influence on reducing stunting prevalence. It advised that the village budget fund can support national priorities in tackling the prevalence of stunting. Furthermore, it is essential to build the capacity of the village head for increasing awareness of health activities, especially early prevention of stunting, in addition to an adequate number of officials.

Rural-urban determinants of vitamin a deficiency among under 5 children in Bangladesh: Evidence from National Survey 2017-18

Background

Vitamin A supplementation reduces child morbidity, mortality, and blindness of people, especially in developing countries like Bangladesh. This study explores significant determinants of vitamin A deficiency among preschool children in rural and urban areas of Bangladesh.

Methods

The data set was extracted from a nationally representative survey based on a cross-sectional study, the BDHS-2017-18. The base survey was conducted using a two-stage stratified sample of households. A sample of 8364 (urban 2911, rural 5453) children under-5 years old was analyzed using bivariate and multivariate statistical techniques.

Results

Results have demonstrated that 73.9 and 73.2% of children have had a vitamin A supplementation from urban and rural areas, respectively. Logistic regression analysis showed that parents’ education plays a vital role in consuming vitamin A supplements in urban and rural areas. Children whose mothers have secondary (OR: 1.17, CI: 0.76–1.81) and higher (OR: 1.21, CI: 0.72–2.04) education were more likely to consume vitamin A supplementation than children whose mothers were illiterate in urban areas. However, in rural areas, children whose mothers have secondary education were about 24% and higher education with 60% more likely to consume vitamin A supplementation than children whose mothers were illiterate. Child’s age, regional variation and wealth index also contributing factors for vitamin A deficiency in Bangladesh.

Conclusions

These findings indicated that the consumption of vitamin A does not cover the target of sustainable development goals. Thus special national and community level efforts are required to ensure the coverage of the national vitamin A program is increased adequately to the most vulnerable groups of children in Bangladesh.

Wasting and Stunting in Infants and Young Children as Risk Factors for Subsequent Stunting or Mortality: Longitudinal Analysis of Data from Malawi, South Africa, and Pakistan

BACKGROUND

Few studies have had sufficient longitudinal data to track how different malnourished states relate to mortality at different ages and interrelate over time.

OBJECTIVES

This study aims to describe the RRs and proportions of mortality associated with wasting and stunting and the pathways into and out of these nutritional states.

METHODS

Longitudinal growth data sets collected for children ages 0-24 months from Malawi, South Africa, and Pakistan were combined (n = 5088). Children were classified as deceased, wasted (weight for height < -2 SD; 1-4%), stunted (length < -2SD; 20-47%), or wasted and stunted (WaSt; 2-5%) at ages 3, 6, 9, 12, 18, and 24 months. Mixed-effects Cox models were used to study the association between nutritional status and mortality.

RESULTS

By age 3 months, 20% of children were already stunted, rising to 49% by 24 months, while wasting (4.2% and 2.2% at 3 months, respectively) and WaSt (0.9% and 3.7% at 24 months, respectively) were less common. The HR for mortality in WaSt was 9.5 (95% CI, 5.9-15), but 60% of WaSt-associated mortality occurred at 3-6 months. Wasting or WaSt was associated with 10-23% of deaths beyond 6 months, but in the second year over half of deaths occurred in stunted, nonwasted children. Stunting persisted in 82% of children and wasting persisted in 44%. Wasted children were more likely than nonwasted, nonstunted children to become stunted (RR, 1.93; 95% CI, 1.7-2.2), but 94% of children who progressed to stunting had not been wasted in the prior period.

CONCLUSIONS

WaSt greatly increased the risk of death, particularly in very young infants, but more deaths overall were associated with stunting. Most stunting appeared to be either intrauterine in origin or arose in children without prior wasting. Either stunting and wasting represent alternative responses to restricted nutrition, or stunting also has other, nonnutritional causes.

Training healthcare workers increases IFA use and adherence: Evidence and cost-effectiveness analysis from Bangladesh

Iron and folic acid (IFA) supplementation programmes are important for preventing and controlling anaemia among pregnant women in low- and middle-income countries. However, frontline health care workers often have limited capacity and knowledge, which can compromise such programmes' effectiveness. Between 2012 and 2014, Nutrition International and the Government of Bangladesh implemented a programme intended to increase IFA supplement consumption during pregnancy. The programme provided frontline health care workers with training on the benefits of IFA supplementation, the use of interpersonal communication and health promotion materials during antenatal care visits and health management information systems to track reported adherence to IFA supplementation. Using a quasi-experimental design, this study investigates the programme's effectiveness and cost-effectiveness at increasing IFA supplement consumption and adherence among pregnant women. The difference-in-differences regression analysis comparing outcomes in an intervention and comparison group concluded that the programme increased IFA consumption by an average of 45.05 supplements (P value = 0.018) and increased the share of women that reported adherence to a regime of at least 90 supplements by 40.35 percentage points (P value = 0.020). Knowledge of IFA supplement dosage and benefits also increased among frontline health care workers and pregnant women. The programme cost $47.11 USD (2018) per disability-adjusted life year averted, which is considered highly cost-effective when evaluated against several cost-effectiveness thresholds. This study suggests that the capacity building of frontline health care workers is an effective and cost-effective method of preventing and controlling anaemia among pregnant women in resource-constrained areas.

Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis

BACKGROUND

Childhood undernutrition is the leading cause of under-five mortality and morbidity in the world particularly in East African countries. Although there are studies on child undernutrition in different East African countries, our search of the literature revealed that there is limited evidence of a pooled analysis of these studies. Therefore, this study aimed to investigate the pooled prevalence and associated factors of chronic undernutrition (i.e. stunting) among under-five children in East Africa.

METHODS

A pooled analysis of the Demographic and Health Surveys (DHSs) in 12 East African countries was conducted. A total weighted sample of 79744 under-five children was included in the study. Mixed-effect logistic regression analysis was used to identify significant factors associated with chronic undernutrition since the DHS data has a hierarchical structure. The intra-class correlation coefficient (ICC), Median Odds Ratio (MOR), Likelihood Ratio (LR)-test, and deviance was used for model comparison. Variables with p-value <0.2 in the bivariable mixed-effect logistic regression analysis were considered for the multivariable analysis. In the multivariable multilevel analysis model, the Adjusted Odds Ratio (AOR) with the 95% Confidence Interval (CI) were reported for significant factors.

RESULTS

The pooled prevalence of chronic undernutrition among underfive children in East Africa was 33.3% (95% CI: 32.9%, 35.6%) ranging from 21.9% in Kenya to 53% in Burundi. Children whose mothers lived in rural area (AOR = 1.11, 95% CI: 1.06, 1.16), born to mother who had no formal education (AOR = 1.42, 95% CI: 1.34, 1.50) and primary education (AOR = 1.37, 95% CI: 1.31, 1.44), being in poor household (AOR = 1.66, 95% CI: 1.58, 1.74), and middle household (AOR = 1.42, 95% CI: 1.35, 1.49), child aged 36-48 months (AOR = 1.09, 95% CI: 1.04, 1.14), being male (AOR = 1.19, 95% CI: 1.15, 1.23), 2nd - 4th birth order (AOR = 1.08, 95% CI: 1.03, 1.13), and above 4th 1.27 (AOR = 1.27, 95% CI: 1.19, 1.35), home delivery 1.09 (AOR = 1.09, 95% CI: 1.05, 1.13), small size at birth (AOR = 1.35, 95% CI: 1.29, 1.40) and being multiple births (AOR = 1.98, 95% CI: 1.81, 2.17) were associated with increased odds of stunting. While, antenatal care visit (AOR = 0.89, 95% CI: 0.86, 0.93), mothers aged 25-34 (AOR = 0.83, 95% CI: 0.79, 0.86) and ≥ 35 years (AOR = 0.76, 95% CI: 0.72, 0.81), large size at birth (AOR = 0.85, 95% CI: 0.81, 0.88), and family size >8 (AOR = 0.92, 95% CI: 0.87, 0.98) were associated with decreased odds of stunting.

CONCLUSION

The study revealed that stunting among under-five children remains a major public health problem in East Africa. Therefore, to improve child nutrition status the governmental and non-governmental organizations should design public health interventions targeting rural residents, and the poorest households. Furthermore, enhancing health facility delivery, ANC visit, and maternal health education is vital for reducing child chronic undernutrition.

Examining the Effect of Geographic Region of Residence on Childhood Malnutrition in Uganda

OBJECTIVES

In our study, we examine how geographic region of residence may predict childhood malnutrition, expressed as stunting, wasting and underweight, among children under the age of 5 years in Uganda.

METHODS

Using data from the 2016 Uganda Demographic and Health Survey, we performed an incremental multivariate multilevel mixed-effect modelling to examine the effect of a child, parental and household factors on the association between region of residence and each indicator of childhood malnutrition.

RESULTS

Approximately 28%, 3% and 9% of children under age 5 suffered from stunting, wasting and underweight, respectively. The bivariate result shows that the proportion of children suffering from stunting and underweight was relatively lower in the Kampala region compared with the other regions. With the exception of the Northern region (6.44%), wasting was higher (4.12%) among children in the Kampala region. Children in the other regions were more likely to experience stunting and underweight. When controlling for child, parent and household factors, children in the other regions were less likely to suffer from underweight and stunting, compared with those in Kampala region. Children in the other regions, except the Northern region, were less likely to be wasted compared with those in Kampala region.

CONCLUSION

Our finding suggests that child, parental and household characteristics have effects on the association between region of residence and childhood malnutrition. Addressing individual and household socioeconomic disparities may be vital in tackling regional differences in childhood malnutrition.

Proximal and contextual correlates of childhood stunting in India: A geo-spatial analysis

BACKGROUND

Globally, India is home to every third child affected by stunting. While numerous studies have examined the correlates of childhood stunting (CS) in India, most of these studies have focused on examining the role of proximal factors, and the role of contextual factors is much less studied. This study presents a comprehensive picture of both proximal and contextual determinants of CS in India, expanding the current evidence base. The present study is guided by the WHO conceptual framework, which outlines the context, causes, and consequences of CS.

DATA AND METHODS

The study used exploratory spatial data analysis tools to analyse the spatial pattern and correlates of CS, using data from the fourth round (2015-16) of the National Family Health Survey (NFHS-4) and the 2011 Census of India.

RESULTS

The study findings reiterate that CS continues to be high in India, with several hot spot states and districts, and that children from the central and eastern region of the nation, namely, Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh are particularly vulnerable. Our analysis has identified six risk factors-maternal short stature, large household size, closely spaced births, prevalence of hypertension among women, household poverty, open defecation, and extreme temperature-and four protective factors-female education, access to improved drinking water, dietary diversity among children, and iron and folic acid (IFA) supplementation during pregnancy.

CONCLUSIONS

The study highlights the need for investing in pre-conception care, addressing both demand- and supply-side barriers to increase the coverage of nutrition-specific interventions, implementing programmes to promote the intake of healthy foods from an early age, providing contraceptive counselling and services to unmarried and married adolescents and young women and men, and universalizing quality primary and secondary education that is inclusive and equitable to avert the burden of childhood stunting in India.

Factors influencing delivery of intersectoral actions to address infant stunting in Bogotá, Colombia - a mixed methods case study

Background

Intersectoral actions (ISA) are a recognized relationship between the health sector and other sectors to improve health outcomes. Although a frequent topic in public health studies, evidence for systematic evaluation of implementation of ISA is scarce. An intersectoral health intervention for infants under one-year-old with, and at risk of, stunting (low height-for-age) was developed by a public-private partnership in Bogotá, Colombia, during 2018 and 2019. Here we report a case study conducted in parallel to the intervention designed to assess factors that influenced implementation of the ISA.

Methods

The case study was developed using a concurrent mixed-methods design, with the qualitative component giving context to the quantitative results. The qualitative component was obtained from four workshops, three focus groups, and 17 semi-structured interviews with actors involved in the intersectoral intervention. The quantitative component was obtained with two questionnaires that evaluated perceptions on improvement and partnership functioning of the ISA.

Results

This study collected information from 122 participants. The intervention demanded intersectoral collaboration. Political will, motivated human resources, and recognition that health improvement results from collaboration, were factors that facilitated intersectoral actions. Intersectoral actions were limited by difficulties in engaging the health sector, communication challenges related to local health service decentralization, and administrative barriers.

Conclusions

Intersectoral actions have recently been discussed in the literature due to challenges in implementation and doubts regarding economic outcomes. The implementation of intersectoral public health interventions can be jeopardized by a lack of coordination and management skills.

Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.

Trends in prevalence and determinants of stunting in Tanzania: an analysis of Tanzania demographic health surveys (1991-2016)

Background

Tanzania has made a significant improvement in wasting and underweight indicators. However, stunting has remained persistently higher and varying between regions. We analyzed Tanzania Demographic and Health Survey (TDHS) datasets to examine (i) the trend of stunting over the period of 25 years in Tanzania and (ii) the remaining challenges and factors associated with stunting in the country.

Methods

This secondary data analysis included six TDHS datasets with data of 37,409 under-five children spreading in 1991–1992(n = 6587), 1996(n = 5437), 1999(n = 2556), 2004–05(n = 7231), 2009–10(n = 6597), and 2015–16(n = 9001) conducted in all regions of Tanzania. Variables specific to children and their caregivers were analyzed using SPSS version 22. The variables considered include child anthropometric variables, caregiver’s demographic characteristics and household’s socio-economic factors. We used frequencies and percentages to compare stunting prevalence across the six surveys and chi-square test and three-level hierarchical logistic regression to examine the factors associated with stunting also applying sample weighting as advised by TDHS.

Results

The prevalence of stunting has declined by 30% over the period of 25 years in Tanzania. However, one in three children aged below five years remains stunted with overweight and obesity more than doubled (from 11 to 25%) in the same period among women of reproductive age. The factors associated with stunting included children living in female-headed households (AOR = 1.16, P = 0.014), aged 24–35 months (AOR = 1.75, P = 0.019), born with low birth weight (AOR = 2.14, P < 0.001) and with inconsistent or without breastfeeding (AOR = 3.46, P < 0.001 and AOR = 4.29, P = 0.001) respectively. The risk of stunting among children living in urban area (AOR = 0.56, P < 0.001), with higher caregiver’s education (AOR = 0.56, P = 0.018), obese mother (AOR = 0.63, P < 0.001), households with highest wealth index (AOR = 0.42, P < 0.001), and among girls (AOR = 0.77, P < 0.001).

Conclusions

The burden of stunting in Tanzania has declined by 30% in the past 25 years, but still affecting one in every three children. Efforts are needed to increase the pace of stunting decline especially among boys, children in rural areas, from poor, uneducated, and female-headed households, and through improving infant and young feeding practices. Effective and tailored nutrition-sensitive and specific interventions using multisectoral approaches should be considered to address these important determinants.

Linear growth following complicated severe malnutrition: 1-year follow-up cohort of Kenyan children

BACKGROUND

Stunting is the most common manifestation of childhood undernutrition worldwide. Children presenting with severe acute malnutrition (SAM) are often also severely stunted. We evaluated linear growth and its determinants after medically complicated SAM.

METHODS

We performed secondary analysis of clinical trial data (NCT00934492) from HIV-uninfected Kenyan children aged 2-59 months hospitalised with SAM. Outcome was change in height/length-for-age z-score (HAZ) between enrolment and 12 months later. Exposures were demographic, clinical, anthropometric characteristics and illness episodes during follow-up.

RESULTS

Among 1169 children with HAZ values at month 12 (66% of those in original trial), median (IQR) age 11 (7-17) months and mean (SD) HAZ -2.87 (1.6) at enrolment, there was no change in mean HAZ between enrolment and month 12: -0.006Z (95% CI -0.07 to 0.05Z). While 262 (23%) children experienced minimal HAZ change (within ±0.25 HAZ), 472 (40%) lost >0.25 and 435 (37%) gained >0.25 HAZ. After adjusting for regression to the mean, inpatient or outpatient episodes of diarrhoea and inpatient severe pneumonia during follow-up were associated with HAZ loss. Premature birth and not being cared by the biological parent were associated with HAZ gain. Increases in mid-upper arm circumference and weight-for-age were associated with HAZ gain and protected against HAZ loss. Increase in weight-for-height was not associated with HAZ gain but protected against HAZ loss. No threshold of weight gain preceding linear catch-up growth was observed.

CONCLUSIONS

Interventions to improve dietary quality and prevent illness over a longer period may provide opportunities to improve linear growth.

Trends and Determinants of Child Growth Indicators in Malawi and Implications for the Sustainable Development Goals

Sustainable development goals (SGD) 2 links malnutrition, morbidity and child mortality to stunting, wasting and overweight among children under-5 years of age. Sub-Saharan Africa still registers high nutritionally insecure people. In particular, Malawi has made modest progress in improving nutritional outcomes; and still experiences a number of structural challenges leading to negative nutritional outcomes. We describe trends of under nutrition and how the effect of selected determinants of child nutrition affect Malawian children under-5 from 1992 to 2015–16; and examine the changing patterns of the effect of selected socio-demographic characteristics on stunting and underweight using data from demographic and health surveys (DHS). The analysis included 31,630 children under-5 years from 1992, 2000, 2004, 2010, and 2015–16 DHS. Our outcome measures are stunting (height/length-for-age) and underweight (weight-for-age) less than -2 SD (Z-score). We perform logistic regression to assess the relationship between selected socio-demographic characteristics with the stunting and underweight variables. Underweight decreased by 14.0% from 24.7% (1992) to 10.7% (2015–16). Stunting decreased by 23.0% from 55.6% (1992) to 32.6% (2015–16). Underweight was more prevalent among children from central and southern regions; among male children; and children above 6 months of age or more. Later surveys were associated with reduced likelihood of underweight than the earliest surveys. Similar trends were observed between socioeconomic factors and stunting. The observed underweight and stunting prevalence is 2.2% and 1.9% lower than expected, respectively. Despite modest declines in underweight and stunting among young children in Malawi, underweight and stunting remain significant public health challenges particularly in southern and central Malawi which constitute about 85% of the total population. Interventions to address the critical malnutrition challenges in Malawi are inevitable within the context of SDG 2 on health.

The investment case for folic acid fortification in developing countries

There is compelling evidence that neural tube defects can be prevented through mandatory folic acid fortification. Why, then, is an investment case needed? At the core of the answer to this question is the notion that governments and individuals have limited resources for which there are many competing claims. An investment case compares the costs and benefits of folic acid fortification relative to alternative life-saving investments and informs estimates of the financing required for implementation. Our best estimate is that the cost per death averted through mandatory folic acid fortification is $957 and the cost per disability-adjusted life year is $14.90. Both compare favorably to recommended life-saving interventions, such as the rotavirus vaccine and insecticide-treated bed nets. Thus, there is a strong economic argument for mandatory folic acid fortification. Further improvements to these estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place.

Exposure to Ambient Fine Particulate Air Pollution in Utero as a Risk Factor for Child Stunting in Bangladesh

Pregnant mothers in Bangladesh are exposed to very high and worsening levels of ambient air pollution. Maternal exposure to fine particulate matter has been associated with low birth weight at much lower levels of exposure, leading us to suspect the potentially large effects of air pollution on stunting in children in Bangladesh. We estimate the relationship between exposure to air pollution in utero and child stunting by pooling outcome data from four waves of the nationally representative Bangladesh Demographic and Health Survey conducted between 2004 and 2014, and calculating children’s exposure to ambient fine particulate matter in utero using high resolution satellite data. We find significant increases in the relative risk of child stunting, wasting, and underweight with higher levels of in utero exposure to air pollution, after controlling for other factors that have been found to contribute to child anthropometric failure. We estimate the relative risk of stunting in the second, third, and fourth quartiles of exposure as 1.074 (95% confidence interval: 1.014–1.138), 1.150 (95% confidence interval: 1.069–1.237, and 1.132 (95% confidence interval: 1.031–1.243), respectively. Over half of all children in Bangladesh in our sample were exposed to an annual ambient fine particulate matter level in excess of 46 µg/m³; these children had a relative risk of stunting over 1.13 times that of children in the lowest quartile of exposure. Reducing air pollution in Bangladesh could significantly contribute to the Sustainable Development Goal of reducing child stunting.