Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

Abstract

Background: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. Methods: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. Results: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Conclusions: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition.

Consumption of Fortified Infant Cereals and Association with Anemia and Growth: Insights from Demographic Health Surveys (DHS) Data Analysis

“…After matching 30% of the infants of the DHS are stunted (under -200 which stands for -2Z) of infants not fed with FICs are stunted. This rate is slightly lower than the estimates of Argaw et al but can be explained by the large weight of India in their study [40] but very similar to the one estimated by De Onis [41]. In the FICs group this percentage is around 28%.…”

Triple trouble: Understanding the burden of child undernutrition, micronutrient deficiencies, and overweight in East Asia and the Pacific

“…Globally, inequity, and deprivation are key drivers of child stunting (Argaw et al, 2019) with research from South Asia finding low levels of maternal education and household poverty to be key drivers of child stunting (Rama, Beteille, Li, Matra, & Newman, 2015). In East…”

Productive simplification in the use of anthropometric nutritional status

“…Various studies across many years have shown that there are many factors associated with the depression of linear growth, including infection, poor diet quality, low socioeconomic status, low birthweight, hypoxia, environmental pollution, deprivation, psychosocial stress, social and economic status, poverty, and structural violence in some countries (Ulijaszek 2006) - Figure 1 illustrates this, incorporating also epigenetics (Ulijaszek in press). A recently published study (Argaw et al 2019) has examined the relationships between change in growth stunting and distal, intermediate, and proximal level factors using multilevel pooled trend analysis of pooled data from 50 Demographic and Health Surveys since 2000 in fourteen countries (Bangladesh, Cambodia, Ethiopia, Haiti, Kenya, Malawi, Mali, Nepal, Nigeria, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe). These authors found that at a distal level, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were each significantly associated with a lower probability of within-country stunting.…”

“…The gini coefficient and urbanisation represent country-level political economic factors, socioeconomic status, social mobility and poverty, while women's decision making reflects cultural and political economic factors. The intermediate-level factors identified by Argaw et al (2019) map onto exposure to infectious disease, while the proximate factors of birthweight and breastfeeding map onto epigenetics, nutrition, and exposure to infection, respectively. The Argaw et al (2019) analysis allows priorities to be set for intervention for reduction in rates of stunting in low and middle income countries.…”

“…The intermediate-level factors identified by Argaw et al (2019) map onto exposure to infectious disease, while the proximate factors of birthweight and breastfeeding map onto epigenetics, nutrition, and exposure to infection, respectively. The Argaw et al (2019) analysis allows priorities to be set for intervention for reduction in rates of stunting in low and middle income countries. In order, they are to decrease the rates of low birth weight, increase rates of vaccination, to improve water and sanitation provision, to further promote early initiation of breastfeeding and to reduce economic inequality, to further promote urbanisation, and to increase levels of female empowerment.…”