The role of the state government, civil society and programmes across sectors in stunting reduction in Chhattisgarh, India, 2006-2016

Assessing groundwater quality and its association with child undernutrition in India

BACKGROUND AND OBJECTIVES

Groundwater contamination poses a significant health challenge in India, particularly impacting children. Despite its importance, limited research has explored the nexus between groundwater quality and child nutrition outcomes. This study addresses this gap, examining the association between groundwater quality and child undernutrition, offering pertinent insights for policymakers.

DATA AND METHODS

The study uses data from the fifth round of the National Family Health Survey (NFHS) and the Central Groundwater Board (CGWB) to analyze the association between groundwater quality and child nutritional status. The groundwater quality data were collected by nationwide monitoring stations programmed by CGWB, and the child undernutrition data were obtained from the NFHS-5, 2019-21. The analysis included descriptive and logistic regression model. The study also considers various demographic and socio-economic factors as potential moderators of the relationship between groundwater quality and child undernutrition.

FINDINGS

Significant variation in groundwater quality was observed across India, with numerous regions displaying poor performance. Approximately 26.53 % of geographical areas were deemed unfit for consuming groundwater. Environmental factors such as high temperatures, low precipitation, and arid, alluvial, laterite-type soils are linked to poorer groundwater quality. Unfit-for-consumption groundwater quality increased the odds of undernutrition, revealing a 35 %, 38 %, and 11 % higher likelihood of stunting, underweight, and wasting in children, with higher pH, Magnesium, Sulphate, Nitrate, Total Dissolved Solids, and Arsenic, levels associated with increased odds of stunting, underweight, and wasting. Higher temperatures (>25 °C), high elevations (>1000 m), and proximity to cultivated or industrial areas all contribute to heightened risks of child undernutrition. Children consuming groundwater, lacking access to improved toilets, or living in rural areas are more likely to be undernourished, while females, higher-income households, and those consuming dairy, vegetables, and fruits daily exhibit lower odds of undernutrition.

POLICY IMPLICATIONS

Policy implications highlight the urgent need for investment in piped water supply systems. Additionally, focused efforts are required to monitor and improve groundwater quality in regions with poor water quality. Policies should emphasize safe sanitation practices and enhance public awareness about the critical role of safe drinking water in improving child health.

Association between household food insecurity and stunting in children aged 0-59 months: Systematic review and meta-analysis of cohort studies

Household food insecurity (HFI) during childhood is associated with poor dietary diversity and malnutrition, placing children's growth at risk. Children with growth disorders, such as stunting, are more likely to have poor cognition and educational performance, lower economic status, and an increased risk of nutrition-related chronic diseases in adulthood. Our study aimed to systematically review and conduct a meta-analysis of cohort studies investigating the association between HFI and stunting in children aged 0-59 months. Peer-reviewed and grey literature were systematically searched in electronic databases with no language or date restrictions. Two reviewers independently assessed the studies for pre-established eligibility criteria. Data were extracted using a standard protocol. Random-effects meta-analysis models were used, and I2 > 40% indicated high heterogeneity across studies. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of the evidence. Nine cohort studies comprising 46,300 children were included. Approximately 80% (n = 7) of the studies found a positive association between HFI and stunting. Pooled odds ratio was 1.00 (95% confidence interval [CI]: 0.87-1.14; I2: 76.14%). The pooled hazard ratio between moderate and severe HFI and stunting was 1.02 (95% CI: 0.84-1.22; I2: 85.96%). Due to high heterogeneity, the quality of evidence was very low. Individual studies showed an association between HFI and stunting in children aged 0-59 months; however, this association was not sustained in the pooled analysis, possibly because of high heterogeneity across studies.

Comparison of high and low stunting reduction groups using IFE-EFE matrix analysis in Central Java Province, Indonesia

Background

The results of the 2021 Indonesian Nutritional Status Study (Studi Status Gizi Indonesia, SSGI) showed a 6.8% declining prevalence of stunting in Central Java from 2019 to 2021. However, the prevalence decreases in the regency level of Central Java varied from 0.1 to 20.3%. This study aimed to analyze the external and internal factors that influenced the stunting reduction prevalence in Central Java Province, Indonesia.

Methods

This qualitative study was conducted over 2 months, from April to May 2022. In-depth interviews were used to explore the supporting factors (external, internal, and strategies) and the challenges (internal, external, and solutions) in implementing stunting reduction acceleration programs. The supporting factors and challenges were compared between the groups with high Gro, Sra, Kla, and Pek (GSKP) and low Sur, Mag, Teg, and Pat (SMTP) reduction prevalence. Data were analyzed using internal factor evaluation (IFE) and external factor evaluation (EFE).

Results

In quadrant II, the high-reduction group (GSKP) had IFE and EFE scores of 2.61 and 2.76, respectively. In quadrant IV, the low-reduction group (SMTP) had IFE and EFE scores of 1.86 and 1.62, respectively. The high-reduction group (GSKP) was better than the low-reduction group (SMTP) in using external opportunities and internal strengths by avoiding external threats and minimizing the weakness in the stunting reduction acceleration program in each area. The existence of superior programs and innovations were the strengths that differentiated the high and low groups. Conversely, the low-stunting reduction group struggled to overcome major challenges, especially lacking leadership capacity. From the outside, lack of program sustainability at the village level and budget restraint were the threats found in both groups.

Conclusion

Compared with the low-stunting reduction group, the high group could maximize their strengths and use the opportunities to implement stunting reduction programs.

A whole system approach to childhood obesity: how a supportive environment was created in the city of Brighton and Hove, United Kingdom

Childhood obesity is a growing global challenge, and no country has yet reversed the upward trend in prevalence. The causes are multifaceted, spanning individual, societal, environmental, and political spheres. This makes finding solutions complex as traditional linear models of treatment and effect have proven only minimally successful or unfeasible at the population level. There is also a paucity of evidence of what works, and few examples of intervention that operate on a 'whole systems' level. The city of Brighton in the United Kingdom has experienced a downward trend in child obesity rates compared to national figures. The aim of this study was to explore what has led to successful change in the city. This was done through a review of local data, policy and programs, and thirteen key informant interviews with key stakeholders involved in the local food and healthy weight agenda. Our findings highlight key mechanisms that have plausibly contributed to a supportive environment for obesity reduction in Brighton according to key local policy and civil society actors. These mechanisms include; a commitment to early years intervention such as breastfeeding promotion; a supportive local political context; the ability to tailor interventions to community needs; governance structures and capacity that enable cross-sectoral collaboration; and a citywide framing of obesity solutions in the context of a 'whole system' approach. However, substantial inequalities persist in the city. Engaging families in areas of high deprivation and operating in an increasingly difficult context of national austerity are persistent challenges. This case study sheds light on some mechanisms of what a whole systems approach to obesity looks like in practice in a local context. This is of relevance to both policymakers and healthy weight practitioners across a spectrum of sectors who need to be engaged to tackle child obesity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-023-01361-9.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

BACKGROUND

Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

METHODS

We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2.

RESULTS

In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges.

CONCLUSIONS

Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Reducing childhood stunting in India: Insights from four subnational success cases

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

Understanding drivers of stunting reduction in Nigeria from 2003 to 2018: a regression analysis

Nigeria is a high burden country for stunting. Stunting reduction has been slow and characterized by unequal progress across the 36 states and federal capital territory of the country. This study aimed to assess the changes in prevalence of stunting and growth determinants from 2003 to 2018, identify factors that predicted the change in stunting, and project future stunting prevalence if these predicted determinants improve. Trend and linear decomposition analyses of growth outcomes and determinants were conducted using 2003, 2008, 2013, and 2018 Nigeria Demographic and Health Survey data. Pooled data included 57,507 children 0 to 59 months old. Findings show that stunting and severe stunting significantly reduced from 43 to 37% and 23% to 17%, respectively (p < 0.001), between 2003 and 2018. Disturbingly, height-for-age z-scores at birth significantly decreased, indicating risks of potential future stunting increase. Improvements in nine stunting determinants (maternal body mass index, maternal height, ≥ 4 antenatal care visits, health facility delivery, reduced child illnesses, asset index, maternal education, paternal education, and preceding birth interval) predicted stunting reductions in children 0–59 months. Few of these nine determinants improved in subpopulations with limited stunting progress. Intra-sectoral and multisectoral coordination were potentially inadequate; 12% of children had received all of three selected health sector interventions along a continuum of care and 6% had received all of six selected multisector interventions. Forward looking projections suggest that increased efforts to improve the nine predictors of stunting change can reduce under-five stunting in Nigeria to ≤ 27% in the short term.

The Intervention Service Coverage on Convergence Action to Reduce Stunting in Riau Province Priority Districts, Indonesia

BACKGROUND: The prevalence of stunting in Riau, Indonesia based on the Indonesian Toddler Nutrition Status Survey in 2019 was 23.95%. Efforts to reduce the prevalence of stunting remain challenging to achieve the target of 18% by 2024. One of the pillars in efforts to reduce stunting is convergence action involving multi-stakeholders to ensure the service delivery interventions received by targeted 1000 days of early life households.   OBJECTIVE: This study objective was to describe the intervention service coverage on stunting convergence action to reduce stunting in Riau Province, Indonesia.  METHODS: The intervention service coverage was obtained from web monitoring convergence Action and Reporting System in 2020 and nutritional status was from the Electronic Community-Based Nutrition Recording. Data was taken from 10 priority districts. There were 11 specific interventions and 9 sensitive interventions were analyzed. The data were analysed descriptively by districts and type of intervention.   RESULTS: The specific and sensitive interventions implemented in 161 priority villages in 2021.The results of the study were 6.0% of 392,444 under-five aged children indicated stunting. The average coverage of specific interventions was 78.3% and sensitive intervention was 50.3%. In specific intervention, supplementary feeding for wasted child (92.4%) and chronic energy deficiency pregnant women (91.1%) were the only indicator that reached the set target. All sensitive intervention were not reached the target.  Rokan Hulu (89.5%), Pekanbaru (88.0%), Kampar (84.4%), Pelawan (82.6%) districts had a high specific intervention. The highest sensitive intervention was in Rokan Hulu (74.6%). The budget from regional development for specific intervention was 28.2% and sensitive intervention was 71.8%.   CONCLUSION: The coverage service of sensitive intervention was lower than specific intervention. Only 2 out of 11 specific interventions coverage had reach the target and all of sensitive intervention coverage had not reach the target. The specific and sensitive intervention coverage was varied among priority district. The strengthening of interventions is required to increase coverage service delivery to the targeted household. The local government convergence action and increasing the role of the village authorities were the main keys in accelerating stunting reduction. 

Missed opportunities for delivering nutrition interventions in first 1000 days of life in India: insights from the National Family Health Survey, 2006 and 2016

Objectives

Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps.

Methods

We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015–2016 (n=36 850 and 190 898 mother–child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms.

Results

Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9–26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22–57 pp in 2016), higher SES status and living in urban areas (23–57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators.

Conclusions

India’s progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system.