An investigation of factors associated with child stunting in northwest Rwanda : the role of care practices related to child feeding and health : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Nutritional Science, College of Sciences, Massey University, Palmerston North, New Zealand
Background: Stunting (height-for-age z-score < - 2 SD from the median of the WHO growth standards and a marker of chronic undernutrition) among children under 5 years is a public health challenge particularly in low- and middle-income countries, including Rwanda. Understanding the contributing factors is key for guiding future interventions and policies to address stunting.
Objective: This thesis aimed to investigate the factors associated with stunting among children aged 6–23 months of age in Rutsiro district, Rwanda, including the relationship between stunting and care practices related to child feeding and health.
Methods: A mixed-methods approach was used, consisting of an initial qualitative study followed by a cross-sectional survey. In the qualitative study, in-depth interviews with mothers (n= 24) were conducted to explore infant and young child feeding (IYCF) practices - [Study 1]. The qualitative study informed the development of a questionnaire which was used to collected data in a cross-sectional survey. In the survey, quantitative data at child-, maternal-, and household-level were obtained from 400 mother-child pairs. Child’s anthropometric measurements were collected and used to determine child height-for-age z-scores (HAZ), which were used to define stunting. Data on infant and young child feeding (IYCF) and health practices were collected and used to construct an infant and child feeding practices index (ICFI) and a health practices index (HPI), respectively. Qualitative data on the use of multiple micronutrients powder (MNP) during complementary feeding were also collected during the survey. Multiple linear regression analysis was used to examine the association between HAZ and factors, including demographics, ICFI and HPI - [Study 2]. Content analysis and logistic regression analysis were carried out on qualitative and quantitative data, respectively, to examine factors related to access and use of multiple micronutrients powder (MNP) - [Study 3].
Results: Mothers described two different food classification systems, based on modern nutrition knowledge about foods and on traditional beliefs about appropriateness of foods for young children. The traditional beliefs about foods, and the inability to recognize undernutrition/stunting, coupled with limited economic access to foods determines what foods children consume, and result in suboptimal IYCF practices, including limited diversity and amount of foods, and limited use of MNP. Results from the cross-sectional survey showed that 38% of the children were stunted (HAZ < ‒ 2 SD). Maternal height, infant birth weight, and ICFI were positively associated with child HAZ. Conversely, child’s age, sex (male), altitude, diarrhoea and upper respiratory infections in the previous 4 weeks were negatively associated with HAZ. No significant relationship was observed between HPI, household wealth index and child HAZ. Results also indicated that, compared with mothers of young children (6–11 months), mothers of older children (12–24 months) had significantly higher odds of using of MNP during complementary feeding. Similarly, mothers whose children participated in the food supplemental programme had significantly higher odds of using MNP, whereas increasing household hunger score was significantly associated with lower odds of using MNP.
Conclusions: In this setting, IYCF practices are suboptimal, and are associated with stunting. A tailored educational intervention designed to address existing beliefs and perceptions related to child feeding is required. Findings also indicate the need to facilitate mothers’ implementation of appropriate practices through (child-sensitive) programmes that can enhance mothers’ economic conditions and access to foods. The range of factors found to be associated with child HAZ suggests that a multi-sectoral approach is required to address stunting. Such approach should include interventions to improve health and nutrition of women before and during pregnancy to prevent prenatal growth restriction. Postnatally, interventions to promote optimal IYCF practices, particularly breast-feeding practices and dietary diversity should be coupled with measures to control infections.