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.

Determinants of stunting reduction in Ethiopia 2000 - 2011.

The prevalence of stunting in Ethiopia declined from 57% in 2000 to 44% in 2011, yet the factors producing this change are not fully understood. Data on 23,999 children 0-59 months of age from three Demographic and Health Surveys (DHS) from 2000, 2005, and 2011 were analyzed to assess the trends in stunting prevalence, mean height-for-age z-scores (HAZ) and the associations between potential factors and HAZ. Associations were determined separately using three separate generalized linear models for children age less than 6 months, 6-23 months, and 24-59 months of age. Significant variables were then analyzed to determine if they showed an overall trend between the 2000 and 2011 surveys. In children < 6 months of age, only mother's height was both a significant predictor of HAZ and showed a progressive, albeit non-significant, increase from 2000 to 2011. In children 6-23 months of age, only mother's use of modern contraception showed substantial changes in a direction consistent with improving HAZ, but improvements in maternal nutrition status were observed from 2000 to 2005. For children 24-59 months of age a consistent and progressive change is seen in child's diarrhea, fever, mother's education, and the occurrence of open defecation. Our analysis demonstrated that factors associated with HAZ vary by child's age and the dominant livelihood practice in the community. Variables that could have contributed to the decline of stunting in Ethiopia in children less than 5 years of age include markers of child health, mother's nutritional status, mother's educational level, and environmental hygiene.

Impact of drought and HIV on child nutrition in Eastern and Southern Africa.

BACKGROUND: Intermittent food insecurity due to drought and the effects of HIV/AIDS affect child nutritional status in sub-Saharan Africa. In Southern Africa in 2001-3 drought and HIV were previously shown to interact to cause substantial deterioration in child nutrition. With additional data available from Southern and Eastern Africa, the size of the effects of drought and HIV on child underweight up to 2006 were estimated. OBJECTIVE: To determine short- and long-term trends in child malnutrition in Eastern and Southern Africa and how these are affected by drought and HIV. METHODS: A secondary epidemiologic analysis was conducted of area-level data derived from national surveys, generally from the mid-1990s to the mid-2000s. Data from countries in the Horn of Africa (Ethiopia, Kenya, and Uganda) and Southern Africa (Lesotho, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe) were compiled from available survey results. Secondary data were obtained on weight-for-age for preschool children, HIV prevalence data were derived from antenatal clinic surveillance, and food security data were obtained from United Nations sources (Food and Agriculture Organization, International Labour Office, and others). RESULTS: Overall trends in child nutrition are improving as national averages; the improvement is slowed but not stopped by the effects of intermittent droughts. In Southern Africa, the prevalence rates of underweight showed signs of recovery from the 2001-03 crisis. As expected, food production and price indicators were related (although weakly) to changes in malnutrition prevalence; the association was strongest between changes in food production and price indicators and changes in malnutrition prevalence in the following year. Areas of higher HIV prevalence had better nutrition (in both country groups), but this counterintuitive association is removed after controlling for socioeconomic status. In low-HIV areas in Eastern Africa, nutrition deteriorates during drought, with prevalence rates of underweight 5 to 12 percentage points higher than in nondrought periods; less difference was seen in high-HIV areas, in contrast to Southern Africa, where drought and HIV together interact to produce higher prevalence rates of underweight. CONCLUSIONS: Despite severe intermittent droughts and the HIV/AIDS epidemic (now declining but still with very high prevalence rates), underlying trends in child underweight are improving when drought is absent: resilience may be better than feared. Preventing effects of drought and HIV could release potential for improvement and, when supported by national nutrition programs, help to accelerate the rates of improvement, now generally averaging around 0.3 percentage points per year, to those needed to meet Millennium Development Goals (0.4 to 0.9 percentage points per year).

AIDS, drought, and child malnutrition in southern Africa.

OBJECTIVE: To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. DESIGN: Epidemiological analysis of sub-national and national surveys with related data. SETTING: Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. SUBJECTS: Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. RESULTS: Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. CONCLUSIONS: First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.