Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study

Comparison of Conditional and Marginal Models in Assessing a Child Nutrition Intervention in Armenia

INTRODUCTION

Child malnutrition is a major issue in conflict zones. Evidence-based interventions and their thorough evaluation could help to eliminate malnutrition. We aimed to assess the causal effect of a community-based multidisciplinary nutrition program for children in a chronic conflict zone near the northeastern border of Armenia on two main outcomes: stunting and anemia. We further compared the interpretations and public health relevance of the obtained effect estimates.

METHODS

In 2016, the study measured hemoglobin and anthropometric measures and collected data from the children's caregivers. We used propensity score matching analyses, inverse probability weighting, and overlap weighting methods to examine the average treatment effects among treated population (ATT), and among population with overlapping weights (ATO).

RESULTS

The ATT for stunting among children who participated in the intervention program estimated by propensity score matching analyses (PSM-ATT) was (1.95; 95%CI 1.15-3.28). Nevertheless, children who took part in the program had a lower risk of anemia (0.28; 95%CI 0.19-0.42). The ATT, estimated by inverse probability weighting (IPTW-ATT), was slightly lower for stunting (1.82; 95%CI 1.16-2.86) while similar for anemia (0.33; 95%CI 0.23-0.46) compared to PSM-ATT. Compared to the IPTW-ATT and PSM-ATT the ATO was lower for stunting (1.75; 95%CI 1.14-2.68) and similar for anemia (0.31; 95%CI 0.22-0.43).

DISCUSSION

Marginal models could be used in similar quasi-experimental settings to identify the causal effect of interventions in specific populations of interest. Nonetheless, these methods do not eliminate threats to internal validity. Thorough study design and accurate data collection are necessary to improve the efficiency of marginal models.

The determinants of under-5 age children malnutrition and the differences in the distribution of stunting-A study from Armenia

Stunting undermines economic growth by perpetuating the vicious cycle of poverty and labour market performance. Studies have captured the trend in stunting and present distributional evidence of policy effects in the country contexts. We identify the determinants of U5 (under 5 years of age) malnutrition for the poor and the Nonpoor and compare the distribution of stunting at four time points (2000, 2005, 2010 and 2015) over a 15-year period between different groups of population. Further, we decompose the gap in malnutrition into causes of differences in stunting between worse-off and better-off socioeconomic groups of the population and estimate the magnitude of distributional differences in stunting between two socioeconomic groups. We also present the inequality trend over time that provides insights into the dynamicity of the effect of different determinants on stunting at different time points. Using 35,490 observations from Armenian Demographic and Health Survey Data [four waves: Year2015,9533; Year2010,8644; Year2005,8919; Year2000,8334], we apply regression-based decomposition method and inequality measures to identify the determinants of malnutrition and distribution of stunting between and within socioeconomic groups. Although the proportional difference in prevalence of stunting between worse-off and better-off children of 13 months and above are reduced by 9.5% in 2015 compared to 2000, the association between socioeconomic position and stunting is statistically significant among children aged 13 months and above in 2000, as well as among children of 36 months and above in 2015. This study demonstrates that the less of socioeconomic distribution of the population, but rather more of the effect from in-country region and settlement of residence are significantly associated with stunting. The approach of our analysis is potentially also a useful tool to generate evidence for decision making towards achieving SDGs 2.2. We conclude that development in childhood is not independent from the distributional effect of region specific development initiatives. Understanding the regional characteristics and resources allocated for the maternal and child health is the necessity to address stunting.

Short-term nutrition and growth indicators in 6-month- to 6-year-old children are improved following implementation of a multidisciplinary community-based programme in a chronic conflict setting

Objective:

We investigated short- and long-term indicators of malnutrition and diet before and after the community-based ‘Breaking the Cycle of Poverty’ multidisciplinary intervention.

Design:

A historically and geographically controlled study using data collected in 2013 and 2016. We compared the prevalence of short-term indicators (anaemia, breast-feeding duration and minimum dietary diversity) and long-term indicators (stunting and wasting) in exposed communities at two time points. We then compared these factors in geographic areas exposed or not exposed to intervention. We conducted logistic regression analyses on the 2016 sample to measure associations between living in intervention communities and child growth indicators.

Setting:

Berd region, a chronic conflict zone near the north-eastern border of Armenia and Azerbaijan.

Participants:

Children aged 6 months to 6 years.

Results:

Analyses included data from 2013 comprising 382 children, and data from 2016 comprising 348 children living in communities where the programme was implemented, and 635 children from unexposed communities. Anaemia prevalence in exposed communities was significantly lower in 2016 v. 2013 (10·9 v. 19·1 %, P < 0·01). Minimum dietary diversity (79·0 v. 68·1 %, P < 0·001) and breast-feeding duration (13·0 v. 11·5 months, P < 0·002) were significantly improved in exposed communities. Prevalences of stunting (11·5 v. 10·2 %, P = 0·57) and wasting (4·8 v. 2·0 %, P = 0·07) were not significantly different. Odds of anaemia were significantly lower (OR = 0·24, 95 % CI 0·16, 0·36) in intervention communities.

Conclusions:

Exposure to a community-based multidisciplinary intervention reduced the rate of anaemia and improved dietary indicators.