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Handwashing, sanitation and family planning practices are the strongest underlying determinants of child stunting in rural indigenous communities of Jharkhand and Odisha, Eastern India: a cross-sectional study: Child stunting in Jharkhand and Odisha

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The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of the world's stunted children live in India, and children belonging to rural indigenous communities are the worst affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand and Odisha, India, to highlight key areas for intervention. We analysed data from 1227 children aged 6-23.99 months and their mothers, collected in 2010 from 18 clusters of villages with a high proportion of people from indigenous groups in three districts. We measured height and weight of mothers and children, and captured data on various basic, underlying and immediate determinants of undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with children's height-for-age z-score (HAZ; p < 0.10); we included these in a multivariable model to identify the strongest HAZ determinants using backwards stepwise methods. In the adjusted model, the strongest protective factors for linear growth included cooking outdoors rather than indoors (HAZ +0.66), birth spacing ≥24 months (HAZ +0.40), and handwashing with a cleansing agent (HAZ +0.32). The strongest risk factors were later birth order (HAZ -0.38) and repeated diarrhoeal infection (HAZ -0.23). Our results suggest multiple risk factors for linear growth faltering in indigenous communities in Jharkhand and Odisha. Interventions that could improve children's growth include reducing exposure to indoor air pollution, increasing access to family planning, reducing diarrhoeal infections, improving handwashing practices, increasing access to income and strengthening health and sanitation infrastructure.
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Handwashing, sanitation and family planning practices are
the strongest underlying determinants of child stunting in
rural indigenous communities of Jharkhand and Odisha,
Eastern India: a cross-sectional study
Jennifer Saxton
*
, Shibanand Rath
, Nirmala Nair
, Rajkumar Gope
, Rajendra Mahapatra
,
Prasanta Tripathy
and Audrey Prost
*
*
UCL Institute for Global Health, London, UK, and
Ekjut, Chakradharpur, Jharkhand, India
Abstract
The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of
the worlds stunted children live in India, and children belonging to rural indigenous communities are the worst
affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand
and Odisha, India, to highlight key areas for intervention.
We analysed data from 1227 children aged 623.99months and their mothers, collected in 2010 from 18 clusters of
villages with a high proportion of people from indigenous groups in three districts. We measured height and weight
of mothers and children, and captured data on various basic, underlying and immediate determinants of
undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with
childrens height-for-age z-score (HAZ; p<0.10); we included these in a multivariable model to identify the
strongest HAZ determinants using backwards stepwise methods.
In the adjusted model, the strongest protective factors for linear growth included cooking outdoors rather than in-
doors (HAZ +0.66), birth spacing 24months (HAZ +0.40), and handwashing with a cleansing agent (HAZ +0.32).
The strongest risk factors were later birth order (HAZ 0.38) and repeated diarrhoeal infection (HAZ 0.23).
Our results suggest multiple risk factors for linear growth faltering in indigenous communities in Jharkhand and
Odisha. Interventions that could improve childrens growth include reducing exposure to indoor air pollution,
increasing access to family planning, reducing diarrhoeal infections, improving handwashing practices, increasing
access to income and strengthening health and sanitation infrastructure.
Keywords: child stunting, indigenous communities, Eastern India.
Correspondence: Jennifer Saxton, UCL Institute for Global Health, 30 Guilford Street, London, UK. E-mail: jenny.c.saxton@gmail.com.
Introduction
The World Health Organisation has called for global
action to reduce child stunting by 40% by 2025 (de
Onis et al. 2013). The Lancets 2013 Maternal and
Child Undernutrition Series identied 10 nutrition-
specic interventions that could reduce stunting by
20% if they reached 90% of children in 34 countries
(Bhutta et al. 2013). These included strengthening in-
fant and young child feeding practices, providing
periconceptional folic acid, energy protein, multiple
micronutrients and calcium supplementation to
mothers, Vitamin A to children and scaling up the
management of moderate and severe acute malnutri-
tion. Improving adolescent nutrition and access to fam-
ily planning would further contribute to stunting
reduction, as would handwashing promotion, and ac-
cess to safe water and sanitation (Sachdev et al. 2013,
Humphrey, 2009, Sachdev, 2012, Spears et al. 2013,
Dangour et al. 2013). Nutrition-sensitive interventions
to support womens empowerment, agriculture, food
systems, education, employment, social protection
and safety nets would provide additional leverage
against the underlying and basic causes of
undernutrition (Ruel and Alderman, 2013). Scaling
up nutrition-specic and sensitive interventions will
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884 869
DOI: 10.1111/mcn.12323
Original Article
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduc-
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improve childrens development, schooling attainment
and later adult health (Adair et al. 2013).
Approximately one third of the 165 million children
affected by stunting in low and middle-income coun-
tries live in India (Black et al. 2013b). A recent analy-
sis of nationally representative data conrmed that
inuences on growth in this context are multiple, in-
cluding socio-economic characteristics and factors re-
lated to the environment, nutrition, infections and
access to healthcare (Fenske et al. 2013). Further anal-
ysis of data from over 26000 children in the nationally
representative NFHS-3 by Corsi et al. (2015) found
that maternal stature, education, household wealth, di-
etary diversity and maternal BMI were the ve most
important risk factors for stunting, and accounted for
67.2% of the Population Attributable Risk for
stunting. Children from the poorest families and from
Scheduled Caste and Scheduled Tribe (indigenous)
communities are the worst affected by stunting (IIPS
and Macro International, 2007, HUNGaMA Survey
Report, 2011). In Indias20132014 nationally repre-
sentative rapid survey of children, 42.3% of children
under-ve from Scheduled Tribes were stunted, rising
to 64.1% and 53.4% in Jharkhand and Odisha, two
states with a high proportion of Scheduled Tribe
households (Ministry of Women and Child Develop-
ment, Government Of India, 2015). Unfortunately,
most studies on undernutrition among Scheduled
Tribe communities use national data from 2005/6 or
small sample sizes, and often do not investigate
stunting determinants systematically (Arnold et al.
2009, Debnath and Bhattacharjee, 2014, UNICEF,
2014). Determinants research could help prioritise
interventions for scaling up stunting reduction in areas
with indigenous populations.
We conducted an analysis of determinants of stunting
in over one thousand children in three rural districts of
Jharkhand and Odisha with a large proportion of indig-
enous people, to understand what actions could accel-
erate stunting reduction in those areas.
Participants and methods
Study area and participants
We conducted a cross-sectional nutrition survey in 18
geographic clusters within three districts of Jharkhand
and Odisha, two states of eastern India. Both states
are largely rural, and many of the village clusters in this
survey were in remote, hilly, forested areas. The largest
indigenous groups in the study districts are the Ho,
Santhal, Munda and Oraon.
Participants were children aged eight weeks to three
years and their mothers. We rst conducted a census to
identify all children under three years of age and
women who were more than six months pregnant
(who would have delivered by the time we conducted
the nutrition survey) to generate the sampling list. If
women had more than one eligible child, both siblings
were eligible to take part. We excluded multiple births,
and children whose mothers had died.
Data collection
Locally recruited growth monitors and helpers col-
lected data between January and June 2010. Each
Key messages
We identied potentially modiable stunting determinants to inform a context-specic stunting reductionstrategy for
indigenous areas of eastern India.
There is a clear role for interventions to promote handwashing and reduce diarrhoea. Community-wide sanitation
programmes to promote safe faeces disposal could be valuable, in conjunction with investments in health and sani-
tation infrastructure.
Cooking outdoors was positively associated with height-for-age. Reducing indoor air pollution from burning biomass
fuels could reduce stunting.
Adequate birth spacing and interventions to minimise unintended pregnancy could reduce stunting.
Income-generation and social protection schemes could help households increase dietary diversity.
870 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
growth monitor and their helper worked as a pair in the
cluster they resided in. All growthmonitors took part in
a six-day residential training course, including an an-
thropometry standardisation exercise recommended
for SMART emergency nutrition surveys (ENA for
SMART, 2007).
We interviewed mothers in Hindi, Ho or Oriya using
a questionnaire capturing the following information:
maternal and household socio-demographic character-
istics; household environment, standard of living, water
source, sanitation; maternal dietary adequacy and
diversity; pregnancy history, antenatal, perinatal and
postnatal information; maternal physical and mental
health; current childhood illness symptoms (diar-
rhoea/fever/cough); healthcare seeking for childhood
illnesses; breastfeeding and complementary feeding;
and contact with health workers. Maternal psychologi-
cal distress (none/mild, moderate and severe) was
measured with the Kessler-10 (Kessler et al. 2002).
The K10 is a validated screening tool and was used lo-
cally in a previous study (Tripathy et al. 2010). Mater-
nal and child anthropometry was measured using:
SECA 874 weighing scales with taring button (gradua-
tion weight: 50 g <150 kg >100 g), Leicester height
measures (nearest 1 mm), SECA measuring mat for
children under two years or unable to stand (nearest
5 mm); Mid-to-Upper-Arm-Circumference (MUAC)
was measured using UNICEF colour-banded tapes
(nearest 1 mm).
Sample size
The survey from which our data are drawn was part of
an evaluation of an intervention to improve maternal
and child health and nutrition through participatory
womens group meetings. The evaluation involved 36
clusters, 18 of which were control areas. The sample
size was calculated to enable detection of 0.2 difference
in weight-for-height z-scores between the intervention
and control clusters, and also took into account poten-
tial clustering using two published intraclass correlation
coefcients (ICC) for weight-for-height from similar
studies: 0.017 and 0.054 (Patel et al. 2003, Rahman
et al. 2008). We used an intermediary ICC of
0.0320.034, at the 5% signicance level, 80% power
and a standard deviation of 1 for both intervention
and control groups. We increased the planned sample
size by 20% to account for attrition because of seasonal
migration. The overall required sample size was
n= 5184, so we randomly sampled 144 children from
the sampling lists in each cluster. For the analysis
reported here, we only used data from the 18 control
clusters in order not to bias estimates through any
potential effects of the intervention. We only included
children aged 623.99months, which is a commonly
used age group for analysing linear growth determi-
nants, enabling comparison of our results with other
studies.
Data management and analysis
We collected data on paper forms and entered them
twice into an Access database. Discrepancies between
the rst and second entries were resolved by returning
to the original record. We examined anthropometric
data for completeness and plausibility using ENA for
SMART software before generating z-scores, then used
SPSS version 21 for all subsequent analyses.
Statistical analysis
The analysis of potential stunting determinants was
carried out in three steps. First, we identied potential
determinants of child undernutrition using the
UNICEF conceptual framework to test in the models
(UNICEF, 1990). The framework maps determinants
hierarchically as distal basic causes (e.g. poverty, gover-
nance), underlying causes (e.g. food security, child
caring practices, health services and environment) and
immediate causes (breastfeeding , disease). The
questionnaire was designed to mainly capture informa-
tion on determinants at the immediate and underlying
level, and less on determinants at the basic level.
Table 1 shows all potential determinants for which data
were collected. We used Generalised Estimation
Equation (GEE) analysis to assess the univariable
association between each potential determinant with
HAZ, retaining those with signicance values of
p<0.1 (see Additional File 1).
We assessed candidate variables for multi-
collinearity using correlations, and by assessing toler-
ance and variance ination factors. Most variables
were not collinear, with the exception of fathers age
Child stunting in Jharkhand and Odisha 871
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
Table 1. Potential determinants of undernutrition and corresponding study variables, classied according to the UNICEF conceptual framework
Determinant category Variables
Basic causes Socioeconomic quintile
a
Income group
b
Maternal education
Fathers education
Social group (Scheduled Tribe, Scheduled Caste, Other Backward Class)
Religion
District
Relationship to household head
Underlying causes
Household shocks Household shocks in the last 12months
c
Maternal health Parity/Birth spacing
Self-reported anaemia and malaria in pregnancy
Self-reported food intake during pregnancy
Iron tablet consumption during pregnancy
Maternal BMI/Maternal height
Non-pregnancy related illness/injury in the last three months
Psychological distress (last four weeks)
Child health and feeding practices Early initiation of breastfeeding
Pre-lacteal feeds
Bottle-feeding
Colostrum discarding/BCG, DPTand Polio immunisations
Feeding and treatment seeking during childhood illness
Use of oral rehydration solution for child diarrhoea
Birth order
Underlying child health issues Repeated attacks of diarrhoea, fever and cough
Health environment and services Place of delivery
Antenatal and postnatal visits
Growth monitoring and food ration provision through the Anganwadi Centre
Sufcient living area (3 people per sleeping room)
Cooking location (main living area, separate room or outdoors)
Season of birth
Treatmentofdrinkingwater
Source of drinking water
Accessibility of drinking water (30 min)
Disposal of childrensfaeces
Use of a handwashing agent (soap/ash/mud)
Occasions when cleansing agent is used for handwashing (before
preparing food/feeding a child/eating, after defecation/cleaning up a child
who has defecated)
Immediate causes
Dietary intake/breastfeeding (previous 24 h) Predominant breastfeeding
Age-appropriate breastfeeding
Minimum dietary diversity (4foodgroups)
Minimum meal frequency
d
Consumption of iron-rich foods
Child morbidity (last 14 days) Symptoms of fever, cough or diarrhoea
Cough severity
e
Diarrhoea severity
f
a
We created socio-economic quintiles using a principal components analysis (PCA). Component variables were based on the Multi-dimensional Poverty Index
(Alkire & Santos 2010) and two similar principal components analyses provided there was sufcient variability in the data (Menon et al. 2000;Vyas and
Kumaranayake 2006). The PCA was set to extract a single component and several iterations were run to achieve the best possible t to the data (Field
2009). Variables in the nal PCA included: household assets (fan, electricity,bicycle, moto rcycle), womensliteracy, fuel type (dung, wood, charcoal = most poor,
gas/coal/kerosene/oil = least poor) and Land ownership (no land, <2 bighas/land mortgaged, 24 bighas, 4 or more bighas; one Bigha is equivalent to approx-
imately half an acre in the study areas).
b
The majority of participant households were working in the inform al sector, often as daily wage labourers, and reliable
income data was challenging to collect. Instead, we allocated women to three in come groups (low, middle or high) based on the occupation providing the house-
holds main source of income to reect how lucrative these occupations would be.
c
Household shocks included: a major health problem, disease epidemic, crop
failure/drought/drop in production, damage to houses or crops.
d
Breastfed children twice/day if 68 months, thrice/day if 923 months, non-breastfed ch ildren
four times/day.
e
No cough, uncomplicated cough, cough with atypical breathing.
f
No diarrhoea, uncomplicated diarrhoea, bloody diarrhoea.
872 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
(collinear with mothersage);mothers age was
retained given they are the main caregivers of children
in the study context. In the case of variables con-
structed using common information (e.g. advice and
treatment seeking during child illness) we retained the
variable with the strongest relationship with HAZ.
All remaining variables were entered simultaneously
into GEE multiple linear regression models. We elimi-
nated the least signicant exposure variables (p>0.1)
in turn using backwards step-wise exclusion. We
included additional forward steps after each elimina-
tion to check whether previously eliminated variables
had become signicant (p0.1) in later models.
Ethics, consent and permissions
UK ethical approval was given for the survey by the
UCL Research Ethics Committee (Application num-
ber 2163/001). At the time of survey there were no lo-
cal university partners or independent research ethics
committees in the study area, so local ethical approval
was not possible. Informed verbal consent to partici-
pate in the survey was sought from each respondent
and recorded in writing or by thumbprint.
Results
Participant characteristics
A total of 5184 mothers were invited to participate in
the study. Of these mothers, 2619 resided in the control
areas (i.e. where the data reported here originate
from); 2267 (86.6%) agreed to take part.
We used data from the census conducted prior to the
nutrition survey to assess non-respondent bias.
Maternal literacy was slightly higher among respon-
dents (29.9%) compared with non-respondents
(25.3%): χ
2
(1) = 2.940, p= 0.086. There was no differ-
ence in the proportion of different social or ethnic
groups by responder status (χ2 (3) = 3.251, p=0.354),
or in the proportion of women with a Below Poverty
Line (BPL) card (65.1%): χ
2
(1) = 1.311, p= 0.252 (a
state government issued card that enables households
meeting certain poverty-related criteria to access
subsidised items such as grain).
We made additional exclusions based on eligibility
criteria and data validation checks. Figure 1 describes
the number of motherchild pairs available at
each assessment stage, with reasons given for
exclusions. The nal sample available for analysis was
Fig. 1. Flowchart describing the recruitment of participants and data exclusions prior to analysis.
Child stunting in Jharkhand and Odisha 873
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
1227 mothers and children; Table 2 shows their
characteristics.
55.7% (683/1227) of children were stunted
(HAZ <2.00). A higher proportion of boys were
stunted compared with girls (57.7% and 53.7%, respec-
tively); 30.6% (375/1227) of children were severely
stunted (HAZ <3.00): 32.7% of boys and 28.4% of
girls. Stunting varied by age group: it decreased from
33% to 26.5% between 6 and 7 months but tended to in-
crease with child age thereafter, peaking at 75.6%
among children aged 22 months. A scatterplot and
Pearsons correlation indicated minimal association
Table 2. Socio-demographic characteristics of mothers and their households (n= 1227)
Characteristic %(n)
Marital status Married 99.7 (1223)
Co-habiting/widowed 0.3 (4)
Age at marriage Mean (SD) 18.4 (2.41)
Unknown/missing % (n) 3.4 (42)
Status within household Household head 0.7 (8)
Wife 72.2 (886)
Daughter in law 26.2 (321)
Other relative 1.0 (12)
Maternal age (years) Mean (SD) 26.4 (5.23)
Unknown/missing % (n) 7.7 (95)
Paternal age (years) Mean (SD) 31.1 (6.35)
Unknown/missing % (n) 8.8 (108)
Religion Sarna 44.4 (545)
Hindu 52.9 (649)
Christian 1.8 (22)
Muslim 0.4 (5)
Other 0.5 (6)
Social group Scheduled Tribe 77.6 (952)
Scheduled Caste 2.4 (29)
Other Backward Class 17.4 (213)
Other/missing 2.6 (33)
Maternal literacy No schooling 68.4 (839)
Primary school (rstfth year) 3.9 (48)
Secondary school (sixtheighth year) 24.9 (306)
Higher secondary (ninth year) 2.8 (34)
Land ownership
a
No land 13.2 (163)
<2bighas
2
/land mortgaged 33.4 (410)
24 bighas 33.9 (416)
>4 bighas 19.3 (237)
Missing 0.1 (1)
Cooking fuel as poverty indicator
b
Least poor 12.1 (149)
Most poor 87.7 (1076)
Missing 0.2 (2)
Below poverty line card No/Applied for 37.4 (458)
Yes 59.9 (735)
Missing 2.7 (34)
Income category Lowest 82.7 (1015)
Middle 12.9 (158)
Highest 4.4 (54)
Socio-economic quintile Lowest SES group 19.5 (239)
Second lowest SES group 11.7 (144)
Middle SES group 21.3 (261)
Second highest SES group 19.5 (239)
Highest SES group 25.3 (310)
Missing 2.7 (34)
a
Bighas are a measure of land area, and vary by region: 1 bigha is about 0.5 acres in Jharkhand and Odisha.
b
Wood/leaves/dung/
charcoal = poorest, coal/oil/kerosene/gas = least poor Alkire & Santos, 2010).
874 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
between HAZ and weight-for-height z-score (r= 0.02,
p= 0.49).
Most women in the sample were married. Approxi-
mately three quarters were wives of the household
head, and a quarter were daughters-in-law. More than
three-quarters (77.5%) were from indigenous groups,
and nearly one-fth identied as Other Backward
Class. Most women (68.0%) were unable to read and
just over one-fth could read easily (21.9%). Mean
maternal body mass index (BMI, weight in kg/height
in m
2
) was 18.5 and ranged from 10.9 to 29.5. The
BMI variable was normally distributed, but 55.7% of
women were classed as underweight (BMI <18.5) (data
reported in text only).
Half of households had electricity. Land ownership
was variable, with 12.8% of mothers reporting that
their household owned no land, and one-fth reporting
>4 bighas (around two acres) of land. 59.5% of
Table 3. Final model estimates for determinants of height-for-age z-score in children 6.0023.99 months (n= 1227)
Determinant
%(n)ormean
(SD) Unadjusted β(95%CI)
P-
value
a
Adjusted β(95%CI)
P-
value
a
Basic causes Income group 0.007 0.065
Lowest 82.7 (1015) 1 1
Middle 12.9 (158) 0.343 (0.0730.612) 0.013 0.237 (0.0330.441) 0.023
Highest 4.4 (54) 0.547 (0.1630.931) 0.005 0.253 (0.1430.649) 0.210
Underlying causes Birth order <0.001 0.001
First born 28.0 (344) 1 1
Second born 23.6 (289) 0.057 (0.1550.269) 0.599 0.001 (0.2430.240) 0.992
Third born 17.8 (219) 0.103 (0.4280.223) 0.537 0.097 (0.4300.235) 0.566
Fourth born 30.6 (375) 0.446 (0.6680.224) <0.001 0.379 (0.6510.107) 0.006
Birth spacing 0.005 0.035
<24 months 14.8 (181) 1 1
24 months 39.8 (488) 0.464 (0.1010.826) 0.012 0.395 (0.0860.705) 0.012
First child/dont know 45.5 (558) 0.452 (0.1720.731) 0.002 0.262 (0.260.551) 0.075
Maternal body mass
index
18.45 (1.84) 0.070 (0.0200.120) 0.006 0.088 (0.0390.137) <0.001
Maternal height (cm) 149.3 (5.76) 0.058 (0.0350.080) <0.0001 0.057 (0.0360.078) <0.001
Cooking location <0.001 <0.001
In the house/main
living area
62.6 (768) 1 1
In a separate room 31.4 (385) 0.268 (0.0150.521) 0.038 0.065 (0.1560.287) 0.565
Outdoors 6.0 (74) 0.823 (0.4761.171) <0.001 0.663 (0.3480.977) <0.001
Season of birth 0.026 0.072
Winter 20.9 (257) 1 1
Summer 37.2 (457) 0.043 (0.2060.292) 0.733 0.047 (0.2190.314) 0.727
Rainy 41.8 (513) 0.285 (0.0350.535) 0.025 0.281 (0.0060.568) 0.055
Hand washing agent
None 80.2 (984) 1 1
Ash/mud/soap 19.8 (243) 0.438 (0.1970.678) <0.001 0.317 (0.1060.528) 0.003
Repeated diarrhoea
No 70.2 (861) 1 1 0.003
Yes 2 8 . 4 (34 8 ) 0.343 (0.5510.135) 0.001 0.233 (0.3870.079)
Immediate causes Minimum dietary
diversity
No 94.6 (1161) 1 1
Yes 5.4 (66) 0.496 (0.1260.865) 0.009 0.333 (0.0650.732) 0.101
Other xed
demographics
Sex of child
Male 50.0 (614) 1 1
Female 50.0 (613) 0.225 (0.0630.386) 0.006 0.271 (0.1330.408) <0.001
a
P-values are shown for the predictor variable overall, and for each category of the variable relative to the baseline category.
Child stunting in Jharkhand and Odisha 875
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
mothers had a BPL card, and most belonged to the
lowest income category based on occupation (82.3%).
Univariable associations
A range of basic, underlying and immediate causes
of undernutrition were associated with HAZ in
univariable GEE regression models. Univariable
associations between all candidate predictor vari-
ables and height-for-age z-score are presented in
Additional File 1.
The variables eligible for inclusion in the multi-
variable models (backwards stepwise regression
using GEE) were: socio-economic quintile, income
group, mothers and fathers education, maternal
BMI (included as a continuous variable), maternal
height (included as a continuous variable), mater-
nal age, district, social group, sex; self-reported
anaemia in pregnancy, womens non-pregnancy ill-
ness or injury (previous 3 months), birth order,
birth spacing, parity, season of birth, delivery loca-
tion, BCG and DPT vaccinations, treatment of
diarrhoea/fever/cough (last 14 days); cooking loca-
tion, household overcrowding, treatment of drink-
ing water, use of a handwashing agent,
handwashing score; child minimum dietary
diversity (4 food groups consumed in the last
24 hours), repeated bouts of diarrhoea, diarrhoea
(last 14 days).
Multivariable analysis
Results for the nal model after elimination of
variables with p>0.10 are shown in Table 3.
Income was the only basic determinant of HAZ
remaining in the nal adjusted model. Children from
the middle income group had HAZ scores 0.237 SD
units higher than those in the lower group (95%
Condence Interval/CI 0.0330.441, p= 0.023). Sex
remained signicant: girls had higher HAZ scores
than boys (β= 0.271, 95%CI 0.1330.408, p<0.001).
Birth order remained a strong underlying determi-
nant of HAZ: children born fourth in the family or later
had HAZ-scores 0.379 units lower than rst-born chil-
dren (95%CI 0.6510.107; p= 0.006). Several un-
derlying predictors related to care of mothers were
positively associated with child HAZ, including birth
spacing 24 months (β= 0.395 95%CI 0.0860.705,
p= 0.012). A one unit change in maternal BMI was as-
sociated with a small increase in HAZ-score (β= 0.088,
95%CI 0.0390.137, p<0.001), as was maternal height
(β= 0.057, 95%CI 0.0360.078, p<0.001).
Cooking outdoors as opposed to in the main living
area was associated with 0.663 increase in HAZ (95%
CI 0.3480.977, p<0.001). Use of a handwashing agent
(soap/ash/mud) compared with water alone was
strongly and positively related to HAZ (β= 0.317,
95%CI 0.1060.528, p= 0.001). Being born in the rainy
season as opposed to winter had a modest positive asso-
ciation (β= 0.281, 95%CI 0.0060.568, p= 0.055). Re-
peated diarrhoea was strongly and negatively
associated with HAZ (β=0.233, 95%CI 0.387
0.079, p=0.003). The single remaining immediate di-
etary determinant of HAZ was minimum dietary diver-
sity (β=0.333, 95%CI 0.0650.732; p=0.010).
Missing data and multiple imputation
A small proportion of the sample had missing data for
variables entered into the rst backward stepwise
model. Maternal age had the most missing (7.7%,
n= 95), followed by socio-economic quintile (2.8%,
n= 34). The remaining variables with missing data col-
lectively accounted for 3.2% of the dataset (n=39).
We used multiple imputation to impute socioeco-
nomic quintile and maternal age (constrained to be
1355years as per the original data range) and created
20 imputed datasets in line with published guidance
(Sterne et al. 2009).
We re-ran the backwards step-wise process using the
pooled estimates and p-values from the imputed
datasets. We obtained the same nal model as reported
in Table 3 and estimates were unchanged.
The effect of siblings
Seventeen families (1.4% of the sample) had multiple
children participating in the study. Although our model
did not account for clustering at the family level, we
repeated the analysis with all children, and then with
one sibling randomly removed. There was no differ-
ence in the results.
876 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
Interactions
We explored reasons for sex differences in HAZ, focus-
ing on dietary diversity and repeated diarrhoea.
The interaction between sex and dietary diversity
was signicant (p<0.001). Girls who did not meet die-
tary diversity criteria had signicantly higher HAZ-
scores than male counterparts with equally poor diets
(β= 0.190, p= 0.018). We also observed a l ack of associ-
ation in the sub-group of boys consuming adequately
diverse diets and HAZ.
The interaction between sex and repeated diarrhoeal
episodes was signicant (p<0.001). Girls who did not
experience repeated diarrhoea had signicantly higher
HAZ-scores than male counterparts (β= 0.202,
p= 0.028). Boys with repeated diarrhoea had signi-
cantly worse HAZ scores than boys who did not expe-
rience repeated diarrhoea (β=0.446, p= 0.002), but
this difference was not observed in girls.
Discussion
Our study provides the most recent data on stunting
determinants among Scheduled Tribe communities in
rural eastern India. We adopted a holistic approach to
understanding determinants by classifying them
according to the UNICEF conceptual framework. The
data indicate high levels of stunting with a range of
potential drivers. The strongest protective factors were
cooking outdoors, adequate birth spacing(24 months)
and handwashing with a cleansing agent. The strongest
risk factors were later birth order and repeated
diarrhoeal infection.
We discuss results for each level of the UNICEF con-
ceptual framework below; results are also presented
pictorially in Fig. 2.
Demographic and basic determinants: higher
income groups and girls were more resilient against
stunting
The interaction effects between sex and HAZ sug-
gested that girlslinear growth is less affected by inade-
quately diverse diets and repeated diarrhoea than
boys, and that adequate dietary diversity was only sig-
nicantly protective for girls. Other literature from In-
dia has suggested that girls suffer disproportionately
from undernutrition because of preferential treatment
of male children (Borooah, 2004), but differential
Fig. 2. The signicance of nal model variables and their associations with height-for-age z-score, mapped onto the UNICEF conceptual framework.
Child stunting in Jharkhand and Odisha 877
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
feeding wasnot evident in our sample. It is important to
reiterate that our study included predominantly indige-
nous participants, where females from some communi-
ties may have a higher social status than women from
other social groups in India (Mitra, 2008).
Income was the only basic determinant to be
retained in the nal model. In this study, income may
have been a proxy for disposable income to buy food
and other essentials. Undernutrition is often associated
with low income and a cross-sectional survey of chil-
dren under three in Andhra Pradesh also identied
low wealth as a risk factor for undernutrition
(Meshram et al. 2011). Another study from Eastern In-
dia observed a weaker income gradient in undernutri-
tion, with only children from the richest wealth group
deriving signicant benets. The authors noted that
small increases in income may not lead to substantial
reductions in undernutrition without additional gains
in health and education (Bhagowalia et al. 2012).
The lack of signicant associations between stunting,
having no education or belonging to lower socio-
economic quintiles was surprising. National-level analy-
ses by Corsi et al. (2015) found that having no educa-
tion and belonging to the poorest wealth quintile were
two of the strongest risk factors for stunting, and these
associations have long been documented in ecological
studies (Black et al., 2013). We included many more
variables related to underlying determinants of
stunting compared with Corsi et al.s (2015) analysis.
It is possible that these washed outthe effects of
some basic determinants, or that our sample was too
small to detect their effects.
Underlying health environmentdeterminants:
handwashing, cooking outdoors and being born
during the rainy season were protective against
stunting
Handwashing with a cleansing agent was strongly pro-
tective against stunting. Systematic reviews have
highlighted the potential of handwashing to reduce diar-
rhoea by 4048% (Cairncross et al. 2010, Fewtrell et al.
2005, WHO & UNICEF, 2009). Another review sug-
gested that handwashing also reduces the risk of viral
and bacterial pneumonia (Luby et al. 2005). Intestinal
worms are highly prevalent in our study areas, and there
is a link between helminth infections and child undernu-
trition (Awasthi et al. 2008, Hall et al. 2008). Worms can
be transferred through the faecaloral route, which
would be disrupted by good handwashing practices. A
cross-sectional survey in rural Andhra Pradesh identied
not using soap for handwashing as one of the strongest
predictors of young child stunting (Meshram et al. 2011).
Cooking outdoors rather than the main living area
appeared to be strongly protective against stunting. A
likely explanation is that cooking outdoors reduces
exposure to harmful indoor air pollutants from the
burning of biomass fuels. The use of biomass fuels
for cooking was high (>87%), and most people
cooked over an open re (>85%). Cooking tasks
are usually performed by women in the study areas,
thereby exposing them, unborn and young children
to biomass fuel smoke more than other family mem-
bers (Bruce et al. 2000, Duo et al. 2008). National
data (19989) showed that severe stunting was 84%
higher in biofuel burning households and child anae-
mia prevalence was higher compared with households
using cleaner fuels, after adjusting for tobacco smoke,
maternal education, nutrition and recent illness
(Mishra and Retherford, 2007). Demographic and
health surveys from seven developing countries found
biofuel exposure was associated with a 0.13 lower
HAZ-score than for non-biofuel households, after
confounder adjustment (Kyu et al. 2009). One known
mechanism is that indoor air pollution increases the
risk of acute respiratory infections, which can lead
to stunting (Bruce et al. 2000). There is also consis-
tent epidemiological evidence that indoor air pollu-
tion can cause low birth weight (LBW) (Bruce et al.
2000). A cohort study from South India measured
children from birth to 6months at two-week intervals
and identied a 49% increased risk of LBW and a
30% higher risk of stunting at 6months in households
using wood and/or dung as their main fuel compared
with cleaner fuels (Tielsch et al. 2008). Much of this
LBW may be attributable to intrauterine growth re-
striction: exposure to particulate matter and other
noxious substances in pregnancy can increase the risk
or exacerbate the problem in already vulnerable pop-
ulations with high levels of maternal underweight and
anaemia (Tielsch et al. 2008). Although there appears
878 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
to be a strong protective inuence of cooking out-
doors on height-for-age, our explanation that this is
because of lowered exposure to indoor air pollution
remains speculative. We do not have data on other
important aspects of indoor air pollution (e.g. expo-
sure time, use of res/stoves inside for other reasons,
tobacco use or air quality measurements) which could
partially account for this nding. Paternal smoking
has been linked to stunting in previous studies, al-
though the effect seems to be weaker than for burn-
ing biofuels (Duoetal.2008).
Being born in the rainy season was protective against
stunting compared with being born in the winter. The
relative disadvantage to winter-born children could be
because of worsened intrauterine growth restriction
and stunting in early life from extra exposure to biofuel
smoke to keep warm in the winter (Bruce et al. 2000).
There are also seasonal peaks in respiratory infections
in winter that could contribute to stunting (Luby et al.
2005).
Underlying maternal care determinants: taller
mothers, mothers with higher BMIs and those who
spaced births by 24months had children with
signicantly higher height-for-age
Maternal BMI and height were modestly and positively
related to HAZ. More than half of women (55.7%)
were underweight in this sample (BMI <18.5), while
44.1% were in the healthy BMI range (BMI 18.5
24.9), and 0.2% were overweight (BMI 25.029.9);
none of the women were obese (BMI 30). Low mater-
nal BMI is a known risk factor for intrauterine growth
restriction and subsequent growth faltering (Black
et al. 2013b). Maternal underweight can also affect
child growth through reduced micronutrient content
of breast milk, in particular vitamin A, which is impor-
tant because infants have low stores at birth (Black
et al. 2013b, Black et al. 2013a). Low maternal BMI
may also reect poor dietary intake and adequacy,
and low food availability, which could partly explain
this association. Corsi et al.s analysis of NFHS-3 data
also found strong associations between stunting and
low maternal stature (<145 cm) (OR: 4.2, 95% CI:
3.55.0) as well as maternal BMI (OR: 1.4, 95% CI:
1.21.6).
Adequate birth spacing (24 months) appeared
strongly benecial for HAZ. This corresponds with
NFHS-2 and NFHS-3 analyses that identied birth
spacing <24months as a risk factor for stunting (Som
et al. 2007, Debnath and Bhattacharjee, 2014). In a re-
cent analysis of NFHS-3 data focusing on Scheduled
Tribe children, those whose mothers had short preg-
nancy intervals (<2 years) had a twofold increase in
the odds of stunting (adjusted OR 2.0, 95%CI 11.2
3.6) (Debnath and Bhattacharjee, 2014). Mechanisms
include compromised nutrition for the rst-born child
through early interruption of breastfeeding, and, for
the second child, a greater risk of LBW (Dewey and
Cohen, 2007, Wendt et al. 2012). One review found that
the association between birth spacing and child growth
was inconsistent: about half of the studies found a pos-
itive association where intervals of 36months equated
to reduced stunting risks of 1050% (Dewey and Co-
hen, 2007). The risks associated with maternal under-
nutrition and anaemia were also mixed, and not all
studies adjusted for obvious confounders, such as
breastfeeding. We were unable to collect objective
measures of anaemia during pregnancy and relied on
self-report, which was univariably associated with
HAZ despite probably being an underestimate. In the
NFHS-3 survey prevalence of any anaemia was 61.2%
in Orissa, and 69.5% in Jharkhand (Debnath and
Bhattacharjee, 2014). Dewey and Cohen (2007) con-
sider the recuperativeinterval (when women are nei-
ther pregnant or breastfeeding) as potentially more
relevant to maternal health than pregnancy or birth in-
tervals (Dewey and Cohen, 2007). A more recent meta-
analysis relating inter-pregnancy interval to birth out-
comes found that intervals of <12 months signicantly
increased the risks of prematurity, LBW, stillbirths
and early neonatal deaths (Wendt et al. 2012). Inade-
quate birth spacing could be a sign of unmet need for
family planning, and this highly nutrition-sensitive as-
pect of health provision should be a priority in under-
served areas.
Underlying child care determinants: later birth
order is a signicant risk factor for stunting
Children born later in large families were at greater
risk of stunting in this sample, particularly children
Child stunting in Jharkhand and Odisha 879
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
born fourth compared with rst-borns. This is con-
sistent with NFHS data: in the NFHS-1, third born
children had a 1.261.56 greater risk of severe
stunting (Mishra and Retherford, 2007) and in the
NFHS-3, there was an elevated risk for sixth born
compared with rst-born children from Scheduled
Tribes (Debnath and Bhattacharjee, 2014). Later
birth order (and greater parity) is likely to stretch
household resources and undermine the effectiveness
of caring practices. In addition to addressing unmet
need for family planning in the study areas, interven-
tions to counteract the negative effects of later birth
order could address sibling-to-sibling care. Not only
does this increase the likelihood of infections and
sub-optimal feeding, as children may be less likely
to understand these issues than adults, but child care
responsibilities are a common reason for female sib-
lings leaving education prematurely (Sengupta and
Jaba, 2002). There has been a recent attempt to in-
crease the availability of crèches to counteract this
problem, and they may be incorporated into Inte-
grated Child Development Service reforms (Indian
Planning Commission, 2011).
Underlying child health status: repeated diarrhoeal
infection was associated with lower height-for-age
Repeated diarrhoea infection was negatively related to
HAZ, consistent with previous studies. A multi-country
longitudinal study identied a doseresponse relation-
ship between each day of diarrhoea in the rst two
years of life and stunting at 24 months, accounting for
18% of stunting (Checkley et al. 2008). A Brazilian co-
hort study from birth to 24 months also found the dura-
tion of diarrhoeal episodes was important: 713 days
signicantly worsened HAZ-scores relative to acute
episodes (<7 days) and prolonged episodes doubled
the risk of developing persistent diarrhoea (14 days)
in later childhood (Moore et al. 2010). Each day of diar-
rhoea amounted to a day of missed opportunity for lin-
ear growth, and if prolonged, minimised the possibility
for catch-up growth.
Diarrhoea may have indirect effects on child growth
in areas with pre-existing high mortality and prevalent
undernutrition. One study attributed 26% of acute
lower respiratory infections to recent diarrhoea in a
Ghanaian cohort with high baseline levels of undernu-
trition and mortality, but they did not observe this effect
in a better-nourished Brazilian cohort with low
mortality. In other words, for particularly vulnerable
populations there may be an additional pathway to un-
dernutrition and death from diarrhoea via elevated re-
spiratory infection risk (Schmidt et al. 2009). The
authors suggest that the mechanism could operate
through acute micronutrient loss because of diarrhoea
and subsequent immune system impairment, dehydra-
tion and immobilisation that creates a window for
opportunistic infections. Extra efforts dedicated to
diarrhoea reduction could thus also reduce incidence
of acute respiratory infections in malnourished
populations.
Immediate determinants: dietary diversity was
protective against stunting in girls but not boys
Minimum child dietary diversity was protective against
stunting for girls, but not boys. Only 5.4% of children
had adequately diverse diets (4 food groups the previ-
ous day) which is lower than the 15.2% reported in the
NFHS-3 (Schmidt et al. 2009). Micronutrients are es-
sential for growth and development in the rst two
years of life. From 6 months the majority of iron, zinc
and Vitamin B6 are required from food, even with con-
tinued breastfeeding, and the proportion of energy,
protein and essential fatty acids also increases. Animal
source foodsare important because they are rich in pro-
tein and micronutrients; a lack of these foods is a risk
factor for stunting and iron-deciency anaemia. The
very low dietary diversity and iron-intake among indig-
enous children is worrying and probably reects the
late introduction of complementary foods as well as
poor diet among those who have been introduced to
those foods. The low consumption of iron-rich foods
in our sample may be because of prohibitive cost or
cultural inappropriateness. Recent NFHS-3 analyses
found minimum dietary diversity was the infant and
young child feeding indicator that was most strongly
associated with stunting and underweight (p<0.05)
(Menon et al. 2015), and was also in the top ve risk
factors for stunting (Corsi et al. 2015).
Late introduction of complementary foods probably
contributed to the low percentage of children
880 J. Saxton et al.
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12, pp. 869884
624 months consuming an adequately diverse diet.
There are many reasons for late introduction, including
seasonal factors relating to food availability, postponing
the celebration associated with children taking their
rst food (because of the high costs of hosting),
caregivers being unaware their child has reached six
months, and increasing food prices (Meshram et al.
2011, Dewey and Brown, 2003). One NFHS-3 analysis
identied stunting as a determinant of late introduction
of complementary foods, and suggested that mothers of
stunted children may not have felt their child was
readyfor food because they were small (Patel et al.
2012).
Limitations
Key limitations of our study include lack of variability
or data for other potential stunting determinants, the
cross-sectional design, potential residual confounding
and limited generalizability to other indigenous com-
munities in India.
There was insufcient variability in many water,
sanitation and hygiene measures, and these could not
be included in the analyses. For example, most respon-
dents practiced unsafe disposal of childrens faeces
(97.3% throw faeces outside), just 0.9% reported
handwashing before preparing food and 99.2% of care-
givers reported open defecation. These are probably
important determinants of undernutrition but could
not be fully examined. One study from Peru (Checkley
et al. 2004) and a multi-country analysis of DHS data
from eight low-income countries (Esrey, 1996) have
highlighted that improved sanitation has a greater im-
pact on childrens linear growth than improved drink-
ing water and safe water storage alone. The authors
of the Peruvian study found that the health benets of
improved water supplies were not fully realised unless
safe water storage practices and improved sanitation
were in place. The DHS analysis indicated that im-
proved water supplies did not signicantly increase
child height unless improved sanitation was available,
but also identied a synergistic effect between im-
proved water and sanitation on child height that was
greater than if only one of the services was present. It
is likely that improved coverage of sanitation in the
study areas would strengthen the effectiveness of water
treatment and hand washing as stunting reduction
interventions.
We did not measure water storage, which is an im-
portant dimension of drinking water safety; it will be
useful to consider this in future work. A common causal
factor in undernutrition is environmental enteropathy,
for which only invasive biomarker measures are
currently available. This would not have been appropri-
ate for our survey, but other researchers are developing
urinary, faecal and blood-based markers which may be
more acceptable (Prendergast and Kelly, 2012).
The question asking whether children suffered from
repeated attacks of diarrhoea did not quantify the
duration or severity of episodes, and only captured
mothersperceptions of whether the problem was re-
curring. In the case of recurrent diarrhoea, longitudinal
studies have shown that the duration of previous
diarrhoeal episodes is important, and that prolonged
episodes have more serious implications for linear
growth than shorter, acute episodes (Moore et al.
2010). It was not possible to collect detailed informa-
tion about recurrent diarrhoea episodes in this cross-
sectional survey.
The cross-sectional design of our study means that
we are unable to infer causal associations between the
determinants and HAZ. There may be causality in both
directions for particular variables: for example, positive
feedback between undernutrition and morbidities such
as diarrhoea would be expected. Some of the associa-
tions found in our analyses may also be accounted for
or modied by unmeasured confounding.
Finally, our sample was drawn from purposively se-
lected clusters in two states of eastern India, which
limits the generalizability of our ndings. However a re-
cent NFHS-3 analysis focusing on stunting determi-
nants among of 1606 Scheduled Tribe children
623 months identied stunting determinants that are
aligned with those we found, including child age, mater-
nal stunting and short pregnancy intervals (<2 years)
(Debnath and Bhattacharjee, 2014).
Acknowledgements
We extend our thanks to The women and children of
Jharkhand and Odisha who gave their time to partici-
pate in the study.
Child stunting in Jharkhand and Odisha 881
© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd. Maternal & Child Nutrition (2016), 12,pp.869884
Source of funding
The research was supported by the Big Lottery Fund,
grant reference number: IS/2/010281409, and by a UK
Medical Research Council doctoral fellowship to JC
Saxton. The funder had no role in designing the study,
data collection and analysis, the decision to publish or
the preparation of this manuscript.
Conicts of interest
The authors declare that they have no conicts of
interest.
Contributor statement
JS, AP, NN and PT designed the study. All authors con-
tributed to the design of the questionnaire. JS, SR, RM
and RG carried out the anthropometry and question-
naire training, and supervised data collection. JS
carried out the analyses and wrote the rst draft of
the article, with help from AP. All authors contributed
to subsequent manuscript revisions.
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... In addition, a higher percentage of mothers/caretakers for the controls used soap for hand washing (90.0%) than the cases (73.0%), and the difference between the two groups was statistically significant (p < 0.001). A similar finding in India [20], also reported that use of a hand washing agent (soap/ash/mud) compared with water alone was strongly and positively associated with normal nutrition status (height for age) (p = 0.001). The 2013 UNICEF report on "Improving child nutrition: The achievable imperative for global progress" states that proper hand washing with soap can prevent nearly half of all cases of childhood diarrhea which in turn reduces the risk of malnutrition [21]. ...
... A similar finding in India [20] reported that use of a hand washing agent (soap/ash/mud) compared with water alone was strongly and positively associated with normal nutrition status (HAZ) (β = 0.317, 95% CI. 0.106-0.528, p = 0.001). ...
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The feeding and caring practices of infants and young children are critical to children’s nutrition status and development milestones. Most nutrition studies have focused on unfavorable factors that contribute to malnutrition rather than favorable factors that promote good nutrition status among children. This study aimed at identifying predictors of normal nutrition status among children aged 6–24 months in Gulu District, Northern Uganda. A matched case-control study was conducted on a sample of 300 (i.e., 100 cases and 200 controls) purposively selected children during October–December 2021. Controls were children that had normal nutrition status, whereas cases with undernourished children had at least one type of undernutrition. Logistic regression was used to determine the predictors of good nutrition status using odds ratios (ORs). The mean age of the cases and controls was 15 months (SD ± 6) and 13 months (SD ± 5), respectively. At multivariable analysis, breastfeeding in the first hour of the child’s life (AOR = 3.31 95% CI. 1.52–7.23), use of family planning (AOR = 2.21 95% CI. 1.25–3.90), number of under-fives in the household (AOR = 0.31 95% CI. 0.13–0.73) and hand washing with soap (AOR = 3.63 95% CI. 1.76–7.49) were significantly independently associated with a child’s good nutrition status. Interventions that can improve children’s nutrition status include breastfeeding in the first hour of child’s life, use of family planning methods, child spacing and hand washing with soap.
... In this study, improved water supply and sanitation did not show a significant reduction in child stunting, however, hand washing practice with soap was one of the significant factors associated with a reduction in child stunting. Inconsistent findings on benefits of improved water supply and sanitation and hygiene in child stunting reduction were reported [34,46,47]. Some studies showed a strong association between the level of environmental WASH (Water, Sanitation and Hygiene) and child linear growth [36,48]. ...
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Background: Stunting is a critical public health problem of developing countries like Ethiopia. Different interventions like irrigation activity have been carried out by the government of Ethiopia to improve the nutritional status of the community. However, there is scanty of data on childhood stunting and its associated factors between irrigation user and non-irrigation user. Objective: To assess the magnitude of childhood stunting and its associated factors between irrigation and non-irrigation user in North Mecha District, Northwest Ethiopia. Methods: A community-based comparative cross-sectional study design was employed from October to November 2019. A systematic sampling was used to draw mothers with children age 6-59 months (582 irrigated and 582 non- irrigated household users). Data were collected using questionnaire and anthropometric measurement tools. Multivariable logistic regression was used to identify the predictors of stunting. Adjusted odds ratios with 95% CI were used to determine the degree of association between independent and outcome variable. A-p-value < 0.05 was used as cutoff point to declare statistically significant variables with the outcome variable. Results: The prevalence of childhood stunting (6-59 months) among irrigation users [32.8% at 95%CI [29.1%-36.7%]] was slightly lower than non-users [40.2% at 95%CI [[36.3%-44.2%]]]. However, the difference did not show significant variation. The odds of childhood stunting were higher among a child from a mother had no antenatal visit, a child whose age was between 12 and 47 months, a child from a mother who did not use water and soap always for washing hands, and a child who had fever. Conclusion: The prevalence of childhood stunting was high and did not show significant variation between irrigation and non-irrigation users. A child from mother had no antenatal visit, whose age was between 12 and 47 months, a mother who did not use water and soap always for washing hands, and who had fever were factors associated with higher child stunting. Thus, the identified modifiable factors should be strengthened to reduce stunting.
... Research on handwashing continued to draw researchers' interest owing to its public health importance and significance in the reduction of infectious diseases, including the current COVID-19 pandemic. Handwashing is the act of cleaning one's hands to remove microorganisms or other unwanted substances, and has health benefits such as minimising the spread of coronavirus, influenza and other infectious diseases (Cowling et al., 2009;World Health Organization [WHO], 2020a), preventing infectious causes of diarrhoea (Luby et al., 2006), decreasing respiratory infections (Scott et al., 2003), averting child stunting (Saxton et al., 2016) and reducing infant mortality rate at home birth deliveries (Rhee et al., 2008). Handwashing also prevents diarrheal diseases, which limit the body's ability to absorb nutrition from food (Gilmartin and Petri, 2015). ...
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Background Research on handwashing continues to draw researchers’ interest owing to its public health importance and significance in the reduction of infectious diseases. The aims of this study are to: (1) understand the pattern and predictors of handwashing using soap/detergent and water; and (2) assess the spatial clustering of handwashing through soap/detergent and water at the district level in India. Methods Data of households where the place for handwashing was observed by the research investigators (n = 582,064), gathered through the National Family Health Survey-4 (2015–2016), were used for this analysis. The availability of soap/detergent and water at the usual place of handwashing was assumed to be used for handwashing. Binary logistic regression was carried out to examine the adjusted effect of socioeconomic characteristics on the use of soap/detergent and water for handwashing. The univariate local indicator of spatial association (LISA) cluster map and Moran’s I statistics were applied for assessing spatial autocorrelations at the district level. Analyses were carried out with IBM-SPSS Software. Results Two-fifths of Indian households do not use both soap/detergent and water for handwashing. Households using both the cleansing elements vary considerably by socioeconomic characteristics— worse for the socioeconomically disadvantaged groups. There is spatial clustering in the use of soap/detergent and water for handwashing: lower in a cluster of districts in eastern India. Conclusion Results suggest the need to generate awareness, particularly among the socioeconomically weaker populations, about advantages of hand hygiene, which will reduce the prevalence of infectious diseases like COVID-19 and be helpful to achieve many Sustainable Development Goals.
... In this study, improved water supply and sanitation did not show a signi cant reduction in child stunting, however, hand washing practice with soap was one of the signi cant factors associated with a reduction in child stunting. Inconsistent ndings on bene ts of improved water supply and sanitation and hygiene in child stunting reduction were reported (35,47,48). Some studies showed a strong association between the level of environmental WASH (Water, Sanitation and Hygiene) and child linear growth (37,49). ...
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Full-text available
Background: Stunting is a critical public health problem of developing countries like Ethiopia. Different interventions like irrigation activity have been carried out by the government of Ethiopia to improve the nutritional status of the community. However, there is scanty of data on childhood stunting and its associated factors between irrigation user and non-irrigation user. Objective: To assess the magnitude of childhood stunting and its associated factors between irrigation and non-irrigation user in North Mecha District, Northwest Ethiopia. Methods: A community-based comparative cross-sectional study design was employed from October to November 2019. A systematic sampling was used to draw mothers with children age 6-59 months (582 irrigated and 582 non- irrigated household users). Data were collected using questionnaire and anthropometric measurement tools. Multivariable logistic regression was used to identify the predictors of stunting. Adjusted odds ratios with 95% CI were used to determine the degree of association between independent and outcome variable. A-p-value <0.05 was used as cutoff point to declare statistically significant variables with the outcome variable. Results: The prevalence of childhood stunting (6-59 months) among irrigation users [32.8% at 95%CI (29-37)] was slightly higher than non-usurers [40.2% at 95%CI (36-44)]. However, the difference did not show significant variation. The odds of childhood stunting were higher among a child from a mother had no antenatal visit, a child whose age was between 12 and 47 months, a child from a mother who did not use water and soap always for washing hands, and a child who had fever. Conclusion: The prevalence of childhood stunting was high and did not show significant variation between irrigation and non-irrigation users. A child from mother had no antenatal visit, whose age was between 12 and 47 months, a mother who did not use water and soap always for washing hands, and who had fever were factors associated with higher child stunting. Thus, the identified modifiable factors should be strengthened to reduce stunting.
... In this study, improved water supply and sanitation did not show a signi cant reduction in child stunting, however, hand washing practice with soap was one of the signi cant factors associated with a reduction in child stunting. Inconsistent ndings on bene ts of improved water supply and sanitation and hygiene in child stunting reduction were reported (33,44,45). Some studies showed a strong association between the level of environmental WASH (Water, Sanitation and Hygiene) and child linear growth (46,47). ...
Preprint
Full-text available
Background Stunting is a critical public health problem of developing countries like Ethiopia. Different interventions like irrigation activity have been carried out by the government of Ethiopia to improve the nutritional status of the community. However, there is scanty of data on childhood stunting and its associated factors between irrigation user and non-irrigation user. Objective To assess the magnitude of childhood stunting and its associated factors between irrigation and non-irrigation user in north Mecha District, Northwest Ethiopia. Methods A community-based comparative cross-sectional study design was employed from October to November 2019. A systematic sampling was used to draw mothers with children age 6–59 months (582 irrigated and 582 non- irrigated household users). Data were collected using questionnaire and anthropometric measurement tools. Multivariable logistic regression was used to identify the predictors of stunting. Adjusted odds ratios with 95% CI were used to determine the degree of association between independent and outcome variable. A-p-value < 0.05 was used as cutoff point to declare statistically significant variables with the outcome variable. Results The prevalence of childhood stunting among age 6–59 months children did not show significant variation between Irrigation user 32.8% at 95%CI (29–37) and non-irrigation user 40.2% at 95%CI (36–44). The odds of childhood stunting were higher among children from mother had no antenatal visit, children whose age was between 12 and 47 months, children from mothers who did not use water and soap always for washing hands, and children who had fever. Conclusion The prevalence of childhood stunting was high and did not show significant variation between irrigation and non-irrigation users. Children from mother had no antenatal visit, children whose age was between 12 and 47 months, children from mothers who did not use water and soap always for washing hands, and children who had fever were factors associated with higher child stunting. Thus, the identified modifiable factors are the area of intervention in reduce stunting.
... Maternal short stature emerged as the strongest risk factor for CS even after adjusting for a range of proximal and contextual factors, with the risk of CS higher by 0.57 with one unit increase in the proportion of short-statured mothers. This finding is consistent with observations from studies from India and multi-country studies [12,18,[34][35][36][37] and reflects the intergenerational transmission of disadvantage. ...
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The purpose of this study is to identify the determinants of malnutrition among the tribal children in India. The investigation is based on secondary data compiled from the National Family Health Survey-3. We used a classification and regression tree model, a non-parametric approach, to address the objective. Our analysis shows that breastfeeding practice, economic status, antenatal care of mother and women’s decision-making autonomy are negatively associated with malnutrition among tribal children. We identify maternal malnutrition and urban concentration of household as the two risk factors for child malnutrition. The identified associated factors may be used for designing and targeting preventive programmes for malnourished tribal children.
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In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under-five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country-specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition-sensitive development and encourage development of evidence-based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.
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Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in substantial increases in mortality and overall disease burden. In this paper, we present new analyses to estimate the effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on mortality and disease. We estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2·2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. Deficiencies of vitamin A and zinc were estimated to be responsible for 0·6 million and 0·4 million deaths, respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths, and combined were responsible for about 0·2% of global childhood DALYs. Iron deficiency as a risk factor for maternal mortality added 115 000 deaths and 0·4% of global total DALYs. Suboptimum breastfeeding was estimated to be responsible for 1·4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years). In an analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35% of child deaths and 11% of the total global disease burden. The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their occurrence or ameliorate their consequences.
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This paper studies the impact of household demand factors on the school participation and performance in four villages and two urban wards of West Bengal. The aim of the study was to assess the relative importance of these factors on the schooling choices made for girl children. The results indicated that some of the strongest enabling factors with regard to girls' school participation and grade attainment were household resource factors such as parental, especially maternal schooling, father's occupation, and family income. Urban residence, as expected, had a strong positive association, and significant cohort effects were observed with regard to the schooling outcomes. A girl child's labour force participation significantly reduced the demand for schooling, and the amount of schooling obtained. Religion and caste factors emerged as important determinants of schooling, as well.
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Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?. By - Prof Zulfiqar A Bhutta PhD, Jai K Das MBA, Arjumand Rizvi MSc, Michelle F Gaff...