Malaria reduction drives childhood stunting decline in Uganda: a mixed-methods country case study

• Published in: The American journal of clinical nutrition 2022-06, Vol.115 (6), p.1559-1568
• Main Authors: Keats, Emily C, Kajjura, Richard B, Ataullahjan, Anushka, Islam, Muhammad, Cheng, Breagh, Somaskandan, Ahalya, Charbonneau, Kimberly D, Confreda, Erica, Jardine, Rachel, Oh, Christina, Waiswa, Peter, Bhutta, Zulfiqar A
• Format: Article
• Language: English
• Subjects: Body height; Child; Childhood; Children; Data analysis; Data collection; Decomposition; Diet; Dietary intake; Editor's Choice; Education; Empowerment; Female; Food intake; Growth curves; Growth Disorders - epidemiology; Growth Disorders - etiology; Growth Disorders - prevention & control; Health care; Heat affected zone; height; Human nutrition; Humans; Infant; Infant, Newborn; Insecticides; length; linear growth; Literature reviews; Malaria; Mixed methods research; Mothers; Norms; Nutrition; Nutritional Status; Original Research Communications; Policies; Qualitative analysis; Reduction; Rural populations; Sanitation; stunting; Uganda; Uganda - epidemiology; Vector-borne diseases
• ISSN: 0002-9165; 1938-3207; 1938-3207
• DOI: 10.1093/ajcn/nqac038

Uganda has achieved a considerable reduction in childhood stunting over the past 2 decades, although accelerated action will be needed to achieve 2030 targets. This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda. This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca–Blinder decomposition and difference-in-difference multivariable hierarchical modeling; 3) national- and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives. Stunting prevalence declined by 14% points from 2000 to 2016, although geographical, wealth, urban/rural, and education-based inequalities persist. Child growth curves demonstrated substantial improvements in child height-for-age z-scores (HAZs) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women’s empowerment, cultural norms, water and sanitation, dietary intake/diversity, and reduced childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multisectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors. Uganda’s success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated, and rural populations along with high-burden districts. ▪