Assessment of the WHO Stunting Framework using Ethiopia as a case study

Statistical modelling of determinants of child stunting using secondary data and Bayesian networks: a UKRI Global Challenges Research Fund (GCRF) Action Against Stunting Hub protocol paper

INTRODUCTION

Several factors have been implicated in child stunting, but the precise determinants, mechanisms of action and causal pathways remain poorly understood. The objective of this study is to explore causal relationships between the various determinants of child stunting.

METHODS AND ANALYSIS

The study will use data compiled from national health surveys in India, Indonesia and Senegal, and reviews of published evidence on determinants of child stunting. The data will be analysed using a causal Bayesian network (BN)-an approach suitable for modelling interdependent networks of causal relationships. The model's structure will be defined in a directed acyclic graph and illustrate causal relationship between the variables (determinants) and outcome (child stunting). Conditional probability distributions will be generated to show the strength of direct causality between variables and outcome. BN will provide evidence of the causal role of the various determinants of child stunning, identify evidence gaps and support in-depth interrogation of the evidence base. Furthermore, the method will support integration of expert opinion/assumptions, allowing for inclusion of the many factors implicated in child stunting. The development of the BN model and its outputs will represent an ideal opportunity for transdisciplinary research on the determinants of stunting.

ETHICS AND DISSEMINATION

Not applicable/no human participants included.

Impact of indoor Air Pollution on the Linear growth of children in Jimma, Ethiopia

BACKGROUND

Stunting in children is the term for reduced linear growth and development, which is frequently brought on by a persistently inadequate diet, recurrent infections and chronic diseases or poor health conditions. Apart from the classic covariates of stunting, which include diet and illness, the relative contribution of household air pollution to chronic nutrition conditions is least studied. Hence, this study is conducted to investigate the impact of household air pollution on the linear growth of under-five children in Jimma town, Ethiopia.

METHODS

A prospective cohort study was employed to collect data from 280 under-five children who lived in households using solid fuel (exposed group, n = 140) and clean fuel (unexposed group, n = 140). Height-for-age Z scores were compared in both groups over a 12-month follow-up period. The difference in differences estimators were used for comparison of changes in the height-for-age Z scores from baseline to end line in exposed and non-exposed groups. The independent effect of the use of solid fuels on height-for-age Z scores was analyzed through a multivariable linear regression model. Statistical Significances were declared at P < 0.05 and 95% CI level.

RESULTS

In an unadjusted model (Model 1), compared with the clean fuel type, the mean difference in the height-for-age Z score of children in households using solid fuel was lower by 0.54 (-0.54, 95% CI -0.97, -0.12, P = 0.011). The beta coefficient remained negative after adjusting for age and sex (Model 2 -0.543, 95% CI -1.373, -0.563) and sociodemographic variables (Model 3: -0.543, 95% CI -1.362, -0.575). In the final model (Model 4), which adjusted for wealth quantile, dietary practice, water, sanitation and hygiene status and household food insecurity access scale, the beta coefficient held the same and significant (beta: -0.543, 95% CI -1.357, -0.579, P < 0.001). Higher HAZ scores were observed among female child (β: = 0.48, 95%CI: 0.28, 0.69), Child with father attended higher education (β: = 0.304 95%CI: 0.304, 95% CI 0.19, 0.41) as compared to male gender and those who did not attend a formal education, respectively. In contrast, child living in households with poor hygiene practices had lower HAZ score (β: -0.226, 95% CI: -0.449, -0.003), P < 0.001.

CONCLUSIONS

Exposure to indoor air pollution was inversely related to linear growth. Furthermore, sex, educational status and hygiene were found relevant predictors of linear growth. In such a setting, there is a need to step up efforts to design and implement public education campaigns regarding the health risks associated with exposure to household air pollution. Promoting improvements to kitchen ventilation and the use of improved cooking stoves, which will help to mitigate the detrimental effects of indoor air pollution on child growth impairment and its long-term effects.

Leveraging multisectoral approach to understand the determinants of childhood stunting in Rwanda: a systematic review and meta-analysis

BACKGROUND

Addressing childhood stunting is a priority and an important step in the attainment of Global Nutrition Targets for 2025 and Sustainable Development Goals (SDGs). In Rwanda, the prevalence of child stunting remains high despite concerted efforts to reduce it.

METHODS

Utilizing the United Nations International Children's Emergency Fund (UNICEF) framework on maternal and child nutrition, this study systematically evaluated the determinants of child stunting in Rwanda and identified available gaps. Twenty-five peer-reviewed papers and five Demographic and Health Surveys (DHS) reports were included in the final selection of our review, which allowed us to identify determinants such as governance and norms including wealth index, marital status, and maternal education, while underlying determinants were maternal health and nutrition factors, early initiation of breastfeeding, water treatment and sanitation, and immediate factors included infections.

RESULTS

A total of 75% of the overall inequality in stunting was due to the difference in the social determinants of stunting between poor and nonpoor households. Maternal education (17%) and intergenerational transfer (31%) accounted for most of the inequalities in stunting, and an increase in gross domestic product per capita contributed to a reduction in its prevalence. There is a paucity of information on the impact of sociocultural norms, early life exposures, maternal health and nutrition, and Rwandan topography.

CONCLUSION

The findings of this study suggest that improving women's status, particularly maternal education and health; access to improved water, sanitation, and hygiene-related factors; and the socioeconomic status of communities, especially those in rural areas, will lay a sound foundation for reducing stunting among under-5 children.

Local contextual factors of child stunting found via shared values of stakeholder groups: an exploratory case study in Kaffrine, Senegal

OBJECTIVE

This work aims to demonstrate an original approach to identify links between locally situated shared values and contextual factors of stunting. Stunting results from multi-factorial and multi-sectoral determinants, but interventions typically neglect locally situated lived experiences, which contributes to problematic designs that are not meaningful for those concerned and/or relatively ineffective.

DESIGN

This case study investigates relevant contextual factors in two steps: by first facilitating local stakeholder groups (n 11) to crystallise their shared-values-in-action using a specialised method from sustainability studies (WeValue_InSitu (WVIS)). Secondly, participants (n 44) have focus group discussions (FGD) about everyday practices around child feeding/food systems, education and/or family life. Because the first step strongly grounds participants in local shared values, the FGD can reveal deep links between contextual factors and potential influences on stunting.

SETTING

Kaffrine, Senegal, an 'Action Against Stunting Hub' site. December 2020.

PARTICIPANTS

Eleven stakeholder groups of mothers, fathers, grandmothers, pre-school teachers, community health workers, farmers, market traders and public administrators.

RESULTS

Local contextual factors of stunting were identified, including traditional beliefs concerning eating and growing practices; fathers as decision-makers; health worker trust; financial non-autonomy for women; insufficient water for preferred crops; merchants' non-access to quality produce; religious teachings and social structures affecting children's food environment.

CONCLUSIONS

Local contextual factors were identified. Pre-knowledge of these could significantly improve effectiveness of intervention designs locally, with possible applicability at other sites. The WVIS approach proved efficient and useful for making tangible contextual factors and their potential links to stunting, via a lens of local shared values, showing general promise for intervention research.

Analysis of the Determinants of Stunting among Children Aged below Five Years in Stunting Locus Villages in Indonesia

Determinants of stunting are a concern in stunting locus villages, especially in East Nusa Tenggara, the province with the highest prevalence of stunting in Indonesia. This study aims to analyze the determinants of stunting in such villages. A cross-sectional research design was conducted on a sample of 166 mothers of children aged 24–59 months selected using a proportional random sampling method in four stunting locus villages in East Nusa Tenggara province, from January to March 2022. Chi-square and binary logistic regression were used to analyze the determinants of stunting with a significance level of p < 0.05. The prevalence of stunting among children aged below five years in the villages was 22.3%. Lack of maternal knowledge (AOR: 5.310; 95% CI: 0.671–41.997) and negative parenting (AOR: 3.026; 95% CI: 1.191–7.871) were associated with higher risk of stunting. Meanwhile, children aged below five years with close birth spacing (AOR: 0.304; 95% CI: 0.087–1.063) had a low risk of stunting. The prevalence of stunting in stunting locus villages needs special attention from the Indonesian government. Maternal knowledge should be enhanced by distributing information related to stunting through formal and non-formal education and teaching good parenting to reduce the prevalence of stunting among children aged below five years in stunting locus villages.

Family Household Characteristics and Stunting: An Update Scoping Review

Stunting remains a public health concern in developing countries. Factors related to stunting have been categorized using various frameworks. Family plays an important role in providing nutrients for children; however, no review specifies this aspect for identifying family characteristics related to stunting. This study aimed to identify family household characteristics related to stunting among children aged less than 5 years. A scoping review was undertaken with sources from PubMed, CINAHL, and Scopus, using the keywords "family characteristics" AND "growth". Inclusion criteria were (1) correlational study; (2) published between 2018 and 31 July 2022; (3) families with children under the age of 5 years; and (4) independent variable any measure of stunting factors from family and household factors. Of 376 articles, only 20 met the inclusion criteria of the study. The family household characteristics included individual factors (sex age, history of diarrhea, and birthplace), family factors (family headship, primary caregiver/mother, social-cultural orientation, and family system factors), and environmental factors. Various child variables, family factors, and environmental factors (the type of home, floor type, water access, source of drinking water, and household electricity) were identified as being associated with stunting. Therefore, these factors should be evaluated to prevent and control stunting, and they should be incorporated into health programs targeting stunting.

Child stunting and associated risk factors in selected food-insecure areas in Rwanda: an analytical cross-sectional study

Introduction

stunting rates among the under-five children are generally high in Rwanda. They are unexpectedly lower than the national average stunting rate in some districts where poverty rates are the highest in the country. This study aimed to ascertain the key factors that protect children from stunting in these poorest areas, where stunting rates are lower than expected.

Methods

we analysed cross-sectional data from 2019/2020 Rwanda Demographic and Health Survey (RDHS) for 477 under-five children from Karongi, Rulindo, Nyanza, and Gisagara districts. Univariate and bivariate statistical analyses were used to find out the factors to retain for multivariable analysis. We obtained the key risk factors of child stunting through a multivariable binary logistic regression analysis.

Results

the child stunting rate in the study districts was 30 percent, which is three percent lower than the national average rate. Child stunting was negatively associated with a birth weight of at least 2.5 kg (AOR = 0.393, 95% CI: 0.180 - 0.856), a high household economic status (AOR = 0.506, 95%CI: 0.273 - 0.937), urban residence (AOR = 0.467; 95% CI: 0.222 - 0.984), and health insurance coverage (AOR = 0.418; 95% CI: 0.228 -0.767). Children aged one year and above, as well as female-headed households, were associated with at least three times and two times greater odds of child stunting than children aged below 12 months and those from male-headed households respectively.

Conclusion

the nutritional performance of children in the study districts is substantially driven by the high uptake of health insurance, which fosters increased access to healthcare services. To address child-stunting gaps in low-income areas in Rwanda, child nutrition programs should improve the utilization of healthcare services, and leverage the potential high effect of nutrition education, especially during pregnancy and lactation.

Spatial analysis of stunting determinants in 514 Indonesian districts/cities: Implications for intervention and setting of priority

While the national prevalence of stunting in Indonesia has decreased, the level remains high in many districts/cities and there is significant variation. This ecological study employed aggregated data from the Basic Health Research Report and the District/City Poverty Data from 2018. We investigated the determinants of stunting prevalence at the district/city level, including autocorrelation applying the spatial autoregressive (SAR) model. The analyses revealed stunting prevalence above the national average in 282 districts/cities (54.9%), i.e. ≥30% in 297 districts/cities (57.8%) and ≥40% in 91 districts/cities (17.7%). Autocorrelation was found between Sumatra, Java, Sulawesi as well as Bali, East Nusa Tenggara and West Nusa Tenggara (Bali NTT NTB). The SAR modelling revealed the following variables with significant impact on the stunting prevalence in various parts of the country: closet defecation, hand washing, at least four antenatal care visits during pregnancy, poverty, immunisation and supplementary food for children under 5 years.

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.

Spatiotemporal clustering and correlates of childhood stunting in Ghana: Analysis of the fixed and nonlinear associative effects of socio-demographic and socio-ecological factors

Childhood stunting remains a major public health issue in many low- and middle-income countries. In Ghana, the progress made is insufficient to reach the targets set by the 2025 World Health Assembly and the 2030 United Nations Sustainable Development Goals. Although studies have examined the socio-demographic determinants of childhood stunting, there has not been any systematic study to examine the spatial associative effects of the socio-demographic and socio-ecological factors at the district level, where health programmes are implemented and monitored. Bayesian geo-additive semiparametric regression technique was used to analyse five conservative rounds of Demographic and Health Surveys in Ghana, with socio-ecological covariates derived from the Demographic and Health Survey Program Geospatial Covariate datasets to examine the temporal trends in childhood stunting, the extent of geospatial clustering at the district level and their associative relationships with socio-demographic and socio-ecological factors. The findings show that childhood stunting in Ghana is not spatially randomly distributed but clustered. Clustering of high childhood stunting was observed amongst districts in the Upper West, Upper East, Northern, North East, Savannah, and Western North regions, whilst clustering of low childhood stunting was observed in districts in the Greater Accra, Volta, Bono and the Eastern regions. Whist socio-demographic factors were predominantly associated with clustering of districts with high childhood stunting, the socio-ecological factors were mainly associated with clustering of districts with low childhood stunting. The socio-ecological factors identified to have a nonlinear associative effect with childhood stunting were Insecticide Treated Net (ITN) coverage, nightlight composite, travel time to a main settlement and population density. The findings suggest that targeted interventions at the district level are essential to reducing childhood stunting in Ghana.

Socio-economic inequalities in children's nutritional status in Democratic Republic of the Congo in 2017-2018: an analysis of data from a nationally representative survey

OBJECTIVE

The Democratic Republic of the Congo (DRC) has one of the highest levels of child undernutrition globally; however, little information exists on the underlying socio-economic inequalities resulting in undernutrition. This study aims to examine the differences in the nutritional statuses of children across different wealth quintiles and explores the association between malnutrition in children and related factors.

DESIGN

We utilised the 2018 Multiple Indicator Cluster Survey data. We estimated the prevalence of malnutrition across all twenty-six provinces. The study used the WHO 2006 child growth standards to measure stunting, underweight and wasting. We employed a mixed-effect linear model to analyse the association between nutritional status and healthcare accessibility, domestic sanitation, and socio-demographic factors.

SETTING

Twenty-six provinces in the DRC.

PARTICIPANTS

21 477 children under 5 years of age and 21 828 women of childbearing age in the DRC.

RESULTS

The national prevalence of underweight, stunting and wasting was found to be 23·33 %, 42·05 % and 5·66 %, respectively. Household wealth and mother's education level were significantly positively associated with the nutritional statuses of children. Among households in the lowest wealth quintile, residence in urban areas was a protective factor against undernutrition.

CONCLUSION

The findings of this study indicate considerable socio-economic inequalities in the nutritional statuses of children under 5 years of age in the DRC, highlighting the need for nutrition promotion as part of maternal and child healthcare. Interventions and policies should include improving nutrition education for less-educated mothers, in particular, in the central provinces of the DRC.

Factors associated with stunting among children 0 to 59 months of age in Angola: A cross-sectional study using the 2015-2016 Demographic and Health Survey

Stunting among children under five years of age is a serious public health problem globally, with life-long consequences to health, well-being, and productivity. Stunted growth has complex and multifactorial causes, reflecting the interaction of a broad range of conditions that determine child health. The Angola 2015-2016 Demographic and Health Survey (DHS) collected nationally representative anthropometry for 6,359 children 0 to 59 months of age in Angola, and ascertained exposure to a wide range of child, parental, socio-economic, and geographic variables. This study used a cross-sectional design to identify exposures associated with stunting among children 0 to 59 months of age in Angola, while considering the multifactorial and multi-level causes of stunting. Main outcome was prevalence of stunting, defined as proportion of children with height-for-age Z-score (HAZ) two or more standard deviations below the median. Prevalence of stunting was associated with individual, household, and area-level exposure variables, including child age and sex, birth order, birthweight, diarrhea, maternal and paternal age and education, source of water, sanitary system, and province. In conclusion, prevalence of stunting in Angola is associated with several factors previously described in the literature. Stunting is associated with exposures at the distal, intermediate, and proximal levels, in line with the framework on the causes of childhood malnutrition. This study identifies opportunities for interventions at multiple levels to decrease prevalence of stunting among children in Angola. Main limitations of this study are the potential for survival bias and residual confounding.

Rural and Urban Correlates of Stunting Among Under-Five Children in Sierra Leone: A 2019 Nationwide Cross-Sectional Survey

BACKGROUND

Undernutrition accounts for at least 50% of the annual global under-five mortality burden. Although disparities in the childhood stunting between urban and rural areas in Sierra Leone have been documented, information on factors associated with these differences is lacking. We aimed to determine rural-urban correlates of stunting among children under the age of 5 in Sierra Leone.

METHODS

We analyzed data from 2019 Sierra Leone demographic and health survey (SLDHS) focusing on under-five children. We conducted multivariable logistic regression to examine rural-urban factors associated with childhood stunting.

RESULTS

Prevalence of stunting was 31.6% (95% CI 29.8-33.2) in rural areas and 24.0% (95% CI 21.6-26.1) in urban areas. Within the rural areas, children of stunted mothers (aOR = 2.37; 95% CI 1.07-5.24, P < .05), younger mothers aged 15 to 19 years (aOR = 2.08; 95% CI 1.17-3.69, P < .05), uneducated mothers (aOR = 1.87; 95% CI 1.28-2.71, P < .01), as well as older children (24-59 months) (aOR = 1.83; 95% CI 1.48-2.27, P < .001), and boys (aOR = 1.37; 95% CI 1.12-1.66, P < .01) were more likely to be stunted compared to those of non-stunted, older, post-primary education mothers and those who were less than 24 months and girls respectively. While urban children whose fathers had lower education (aOR = 1.94; 95% CI 1.10-3.42, P < .05), whose mothers were more parous (para 2-4) (aOR = 1.74; 95% CI 1.03-2.95, P < .05), and boys (aOR = 1.48; 95% CI 1.06-2.08, P < .05) were more likely to be stunted compared to their counterparts with fathers that had tertiary education, mothers of low parity and girls, respectively.

CONCLUSIONS

Stunting is more prevalent in the rural areas compared to the urban areas. Sex of the child was the only significant factor in both rural and urban areas. Our study findings suggest that programs designed to reduce stunting should aim for integrated yet context specific interventions in rural and urban areas.

Drivers of stunting reduction in Ethiopia: a country case study

BACKGROUND

Chronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y.

OBJECTIVES

The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level.

METHODS

This study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000-2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken.

RESULTS

National stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child height-for-age z score (HAZ) decomposition explained >100% of predicted change in mean HAZ between 2000 and 2016, with key factors including increases in total consumable crop yield (32% of change), increased number of health workers (28%), reduction in open defecation (13%), parental education (10%), maternal nutrition (5%), economic improvement (4%), and reduced diarrhea incidence (4%). Policies and programs that were key to stunting decline focused on promoting rural agriculture to improve food security; decentralization of the health system, incorporating health extension workers to improve rural access to health services and reduce open defecation; multisectoral poverty reduction strategies; and a commitment to improving girls' education. Interviews with national and regional stakeholders and mothers in communities presented improvements in health service access, women and girls' education, improved agricultural production, and improved sanitation and child care practices as drivers of stunting reduction.

CONCLUSIONS

Ethiopia's stunting decline was driven by both nutrition-specific and -sensitive sectors, with particular focus on the agriculture sector, health care access, sanitation, and education.

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.

Maternal stature, maternal education and child growth in Pakistan: a cross-sectional study

Pakistan has a significantly higher prevalence of stunted children under five years old compared with other countries with a similar income level. Given maternal education is a modifiable factor, we analyzed whether education has a larger marginal effect on improving children's growth for shorter stature mothers. Pakistan Demographic and Health Survey of 2012–13 was analyzed, with a total of 3,883 of children under five years of age (belonged to 2,327 mothers). The results showed that the overall prevalence of stunting, underweight, wasting, and overweight in our sample was 45%, 26.2%, 9.9%, and 9.5%, respectively. Short stature mothers have a higher number of malnourished children as compared to taller mothers. Compared to tall stature mothers, short stature mothers at all education levels have a higher number of stunted and underweight children. Maternal education has a significant positive effect on children's growth. However, we did not find significant differences in the marginal effect of maternal education among mothers with different statures. Policies providing specialized care to children born to short stature mothers are crucial, along with emphasizing mothers' education. Moreover, a poverty elevation program is necessary as a significant fraction of childhood malnutrition is attributed to the wealth index.

Environmental Health Research in Africa: Important Progress and Promising Opportunities

The World Health Organization in 2016 estimated that over 20% of the global disease burden and deaths were attributed to modifiable environmental factors. However, data clearly characterizing the impact of environmental exposures and health endpoints in African populations is limited. To describe recent progress and identify important research gaps, we reviewed literature on environmental health research in African populations over the last decade, as well as research incorporating both genomic and environmental factors. We queried PubMed for peer-reviewed research articles, reviews, or books examining environmental exposures and health outcomes in human populations in Africa. Searches utilized medical subheading (MeSH) terms for environmental exposure categories listed in the March 2018 US National Report on Human Exposure to Environmental Chemicals, which includes chemicals with worldwide distributions. Our search strategy retrieved 540 relevant publications, with studies evaluating health impacts of ambient air pollution (n=105), indoor air pollution (n = 166), heavy metals (n = 130), pesticides (n = 95), dietary mold (n = 61), indoor mold (n = 9), per- and polyfluoroalkyl substances (PFASs, n = 0), electronic waste (n = 9), environmental phenols (n = 4), flame retardants (n = 8), and phthalates (n = 3), where publications could belong to more than one exposure category. Only 23 publications characterized both environmental and genomic risk factors. Cardiovascular and respiratory health endpoints impacted by air pollution were comparable to observations in other countries. Air pollution exposures unique to Africa and some other resource limited settings were dust and specific occupational exposures. Literature describing harmful health effects of metals, pesticides, and dietary mold represented a context unique to Africa. Studies of exposures to phthalates, PFASs, phenols, and flame retardants were very limited. These results underscore the need for further focus on current and emerging environmental and chemical health risks as well as better integration of genomic and environmental factors in African research studies. Environmental exposures with distinct routes of exposure, unique co-exposures and co-morbidities, combined with the extensive genomic diversity in Africa may lead to the identification of novel mechanisms underlying complex disease and promising potential for translation to global public health.

Trends and factors associated with complementary feeding practices in Ethiopia from 2005 to 2016

Introducing appropriate complementary feeding at 6 months of age is crucial for the optimal growth and development of an infant. In Ethiopia, however, no previous national‐level studies have examined the trends and associated factors of complementary feeding practices. The aim of this study is to investigate the trends and determinants of complementary feeding practices in Ethiopia from 2005 to 2016. The study was conducted using the Ethiopia Demographic and Health Survey (EDHS) data for 2005 (N = 2,520), 2011 (N = 2,850), and 2016 (N = 2,864). Percentage point changes in complementary feeding indicators were estimated to examine the trends over the EDHS years. Multivariate logistic regression was used to examine the association between socioeconomic, demographic, health service, and community‐level factors and (a) the introduction of complementary foods, (b) minimum dietary diversity (MDD), (c) minimum meal frequency (MMF), and (d) minimum acceptable diet (MAD). The proportion of mothers who met MDD increased from 6.3% to 13.5% (p < .001), and MAD increased from 4.1% to 7.1% (p = .003) from 2005 to 2016. Improvements in the introduction of complementary foods (from 50.3% to 59.5%, p = .051) and MMF (from 41.3% to 43.6%, p = .288) were not statistically significant. Maternal education and occupation were associated with the introduction of complementary foods, MDD, MMF, and MAD. Higher partner education and frequent antenatal visits were associated with MDD and MAD. Children whose mothers listened to the radio had higher odds of MDD, MMF, and MAD. Our analysis of the EDHS suggests that the proportion of MDD and MAD were unacceptably low. Interventions aiming to improve complementary feeding practices in Ethiopia should also target mothers with low education, antenatal service usage, and media exposure.

Methodology for developing and evaluating food-based dietary guidelines and a Healthy Eating Index for Ethiopia: a study protocol

INTRODUCTION

Food-based dietary guidelines (FBDGs) are used to promote and maintain healthy eating in a population, by providing country-specific guidance. However, many African countries like Ethiopia do not have FBDGs. This paper describes the methodology for the development of Ethiopian FBDGs and for creating and evaluating a Healthy Eating Index and a scoring tool that can be used to monitor the adherence of the population to FBDGs.

METHODS AND ANALYSIS

A multidisciplinary technical working group will be tasked to develop FBDGs for the general population above 2 years of age based on identification of priority diet-related public health problems and risk factors, and a systematic review of dietary patterns in relation to the identified priority health outcomes, following a multistep process. FBDGs will be translated into daily food choices for specific subpopulations by applying linear programming using data from the National Food Consumption Survey (NFCS) of 2011. FBDGs will be evaluated for cultural appropriateness, acceptability, consumer understanding and practicality. A dietary gap assessment will be conducted by comparing the national food supply with the country's food demand. In addition an Ethiopian Healthy Eating Index (EHEI) will be developed based on the FBDGs using the NFCS data. The EHEI will be evaluated by comparing the EHEI Score based on 24 hours diet recall with that of the EHEI Score based on a Food Frequency Questionnaire, by analysing the association of the EHEI Score with population characteristics and micronutrient intake with or without additional adjustment for energy intake. Finally, a brief Food Quality Screening tool scoring for the important EHEI components will be developed to enable evaluation for counselling.

ETHICS AND DISSEMINATION

Ethical approval is received from the Scientific and Ethical Review Office of the Ethiopian Public Health Institute. The findings will be disseminated through peer-reviewed publications.A dissemination workshop will be organised with key implementing sectors of the food system for a healthier diet (http://a4nh.cgiar.org/our-research/research-flagships/) and with key public and private partners. The findings from this study will be translated into FBDGs and shared through conferences, reports and the mass media (TV and radio).

TRIAL REGISTRATION NUMBER

NCT03394963; Pre-results.

Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey

BACKGROUND

Child growth stunting remains a challenge in sub-Saharan Africa, where 34% of children under 5 years are stunted, and causing detrimental impact at individual and societal levels. Identifying risk factors to stunting is key to developing proper interventions. This study aimed at identifying risk factors of stunting in Rwanda.

METHODS

We used data from the Rwanda Demographic and Health Survey (DHS) 2014-2015. Association between children's characteristics and stunting was assessed using logistic regression analysis.

RESULTS

A total of 3594 under 5 years were included; where 51% of them were boys. The prevalence of stunting was 38% (95% CI: 35.92-39.52) for all children. In adjusted analysis, the following factors were significant: boys (OR 1.51; 95% CI 1.25-1.82), children ages 6-23 months (OR 4.91; 95% CI 3.16-7.62) and children ages 24-59 months (OR 6.34; 95% CI 4.07-9.89) compared to ages 0-6 months, low birth weight (OR 2.12; 95% CI 1.39-3.23), low maternal height (OR 3.27; 95% CI 1.89-5.64), primary education for mothers (OR 1.71; 95% CI 1.25-2.34), illiterate mothers (OR 2.00; 95% CI 1.37-2.92), history of not taking deworming medicine during pregnancy (OR 1.29; 95%CI 1.09-1.53), poorest households (OR 1.45; 95% CI 1.12-1.86; and OR 1.82; 95%CI 1.45-2.29 respectively).

CONCLUSION

Family-level factors are major drivers of children's growth stunting in Rwanda. Interventions to improve the nutrition of pregnant and lactating women so as to prevent low birth weight babies, reduce poverty, promote girls' education and intervene early in cases of malnutrition are needed.

A review of child stunting determinants in Indonesia

Child stunting reduction is the first of 6 goals in the Global Nutrition Targets for 2025 and a key indicator in the second Sustainable Development Goal of Zero Hunger. The prevalence of child stunting in Indonesia has remained high over the past decade, and at the national level is approximately 37%. It is unclear whether current approaches to reduce child stunting align with the scientific evidence in Indonesia. We use the World Health Organization conceptual framework on child stunting to review the available literature and identify what has been studied and can be concluded about the determinants of child stunting in Indonesia and where data gaps remain. Consistent evidence suggests nonexclusive breastfeeding for the first 6 months, low household socio-economic status, premature birth, short birth length, and low maternal height and education are particularly important child stunting determinants in Indonesia. Children from households with both unimproved latrines and untreated drinking water are also at increased risk. Community and societal factors-particularly, poor access to health care and living in rural areas-have been repeatedly associated with child stunting. Published studies are lacking on how education; society and culture; agriculture and food systems; and water, sanitation, and the environment contribute to child stunting. This comprehensive synthesis of the available evidence on child stunting determinants in Indonesia outlines who are the most vulnerable to stunting, which interventions have been most successful, and what new research is needed to fill knowledge gaps.

Assessment of the WHO Stunting Framework using Ethiopia as a case study

Poor linear growth in children <5 years old, or stunting, is a serious public health problem particularly in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) released a conceptual framework on the Context, Causes and Consequences of Childhood Stunting (the 'WHO framework') that identifies specific and general factors associated with stunting. The framework is based upon a global review of data, and we have applied it to a country-level analysis where health and nutrition policies are made and public health and nutrition data are collected. We reviewed the literature related to sub-optimal linear growth, stunting and birth outcomes in Ethiopia as a case study. We found consistent associations between poor linear growth and indicators of birth size, recent illness (e.g. diarrhoea and fever), maternal height and education. Other factors listed as causes in the framework such as inflammation, exposure to mycotoxins and inadequate feeding during and after illness have not been examined in Ethiopia, and the existing literature suggests that these are clear data gaps. Some factors associated with poor linear growth in Ethiopia are missing in the framework, such as household characteristics (e.g. exposure to indoor smoke). Examination of the factors included in the WHO framework in a country setting helps identifying data gaps helping to target further data collection and research efforts. © 2016 John Wiley & Sons Ltd.