EXEMPLAR
Stunting reduction in Ethiopia
From 1992 to 2016, Ethiopia cut its stunting rate from 67 to 38 percent. Not only have stunting and other development-related indicators improved dramatically, but Ethiopia’s economy has been growing ...
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EXEMPLAR
Stunting reduction in Nepal
Nepal reduced its stunting prevalence from nearly 70 percent to 36 percent over the last twenty years through large-scale improvements in health care, education, and sanitation.
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EXEMPLAR
Stunting reduction in Peru
Between 2008 and 2016, the country's stunting rate declined from 28 percent to 13 percent. The gains reflect investments in preventive health care for mothers and children and targeted programs for th...
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EXEMPLAR
Stunting reduction in Senegal
In just over a decade, the proportion of children with stunted growth in Senegal dropped by 42 percent. Senegal is highly regarded in the development community for its multi-sectoral nutrition strateg...
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PARTNER CONTENT
Accounting for nutritional changes in six...
Over the past two decades, many developing countries have made impressive progress in reducing undernutrition. We explore potential explanations of this success by applying consistent statistical meth...
Accounting for nutritional changes in six success stories: A regression-decomposition approach
Over the past two decades, many developing countries have made impressive progress in reducing undernutrition. We explore potential explanations of this success by applying consistent statistical methods to multiple rounds of Demographic Health Surveys for Bangladesh, Nepal, Ethiopia, Odisha, Senegal, and Zambia. We find that changes in household wealth, mother's education and access to antenatal care are the largest drivers of nutritional improvement, except for Zambia where large increases in bednet usage is the single largest factor. Other factors play a smaller role in explaining nutritional improvements with improvements in sanitation only appearing to be important in South Asia. Overall, the results point to the need for multidimensional nutritional strategies involving a broad range of nutrition-sensitive sectors.
Authors
Derek Headey, John Hoddinott and Seollee Park
Institutional Affiliation(s)
IFPRI
PARTNER CONTENT
Using Tools For Allocating Nutrition Budgets
Optima Nutrition is a quantitative tool that can provide practical advice to governments to assist with the allocation of current or projected budgets across nutrition programs. The model contains a g...
Using Tools For Allocating Nutrition Budgets
Optima Nutrition is a quantitative tool that can provide practical advice to governments to assist with the allocation of current or projected budgets across nutrition programs. The model contains a geospatial component to determine funding allocations that minimize stunting, wasting, anaemia or under-five mortality at both the national and regional levels.The model has a flexible intervention set that includes a variety of micronutrient supplementation programs, infant and young child feeding education, treatment of severe acute malnutrition, treatment and prevention of diarrhoea, fortification of foods, family planning and malaria prevention interventions. Learn more here
Authors
Meera Shekar (mshekar@worldbank.org), Jonathan Akuoku (jakuoku@worldbank.org)
Institutional Affiliation(s)
The World Bank Group, Bill and Melinda Gates Foundation, Burnet Institute
PARTNER CONTENT
Understanding multifactorial drivers..
With a lens toward replicability, the Exemplars in Stunting Reduction project studies success factors among countries that have notably reduced childhood stunting relative to economic growth over the ...
Understanding multifactorial drivers of child stunting reduction in Exemplar countries: a mixed-methods approach
With a lens toward replicability, the Exemplars in Stunting Reduction project studies success factors among countries that have notably reduced childhood stunting relative to economic growth over the past 15–20 years. This paper details the standardized mixed-methods framework for studying determinants of childhood stunting reduction applied in Exemplars studies. An expert technical advisory group (TAG), criteria for identifying Exemplar countries, evidence-based frameworks, mixed methodologies (quantitative, qualitative, policy, literature review), effective research partnerships, case study process and timeline, and data triangulation and corroboration are presented in this work. Exemplar countries were selected by the TAG, who considered quantitative data and qualitative insights. Experienced country research partners were selected and an inception meeting with stakeholder consultations was held to launch research and garner support. The case study process was iterative, and all research outputs were triangulated to develop the stunting reduction narrative for each country. Findings were shared with country experts for weigh-in and corroboration through dissemination events.
Authors
Nadia Akseer, Tyler Vaivada, Oliver Rothschild, Kevin Ho, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Gates Ventures, Centre of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
Stunting in childhood...
Population-based surveys collect crucial data on anthropometric measures to track trends in stunting and wasting prevalence among young children globally. However, the quality of the anthropometric da...
Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline
Population-based surveys collect crucial data on anthropometric measures to track trends in stunting and wasting prevalence among young children globally. However, the quality of the anthropometric data varies between surveys, which may affect population-based estimates of malnutrition. This study aimed to develop composite indices of anthropometric data quality for use in multisurvey analysis of child health and nutritional status, using DHS surveys from 2000 onwards. The teams derived 6 indicators of anthropometric data quality at the survey level, and used principal component factor analysis to generate a composite index of anthropometric data quality for each metric. Surveys were ranked in anthropometric quality across countries and over time using the composite indices. There continues to be substantial heterogeneity in the quality of anthropometric data across surveys.
Authors
Tyler Vaivada, Nadia Akseer, Selai Akseer, Ahalya Somaskandan, Marianne Stefopulos, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Center of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
Anthropometric data quality...
Population-based surveys collect crucial data on anthropometric measures to track trends in stunting [height-for-age z score (HAZ) < −2SD] and wasting [weight-for-height z score (WHZ) < &m...
Anthropometric data quality assessment in multisurvey studies of child growth
Population-based surveys collect crucial data on anthropometric measures to track trends in stunting [height-for-age z score (HAZ) < −2SD] and wasting [weight-for-height z score (WHZ) < −2SD] prevalence among young children globally. However, the quality of the anthropometric data varies between surveys, which may affect population-based estimates of malnutrition. This study aimed to develop composite indices of anthropometric data quality for use in multisurvey analysis of child health and nutritional status, using DHS surveys from 2000 onwards. The teams derived 6 indicators of anthropometric data quality at the survey level, and used principal component factor analysis to generate a composite index of anthropometric data quality for HAZ and WHZ separately. Surveys were ranked in anthropometric quality across countries and over time using the composite indices for HAZ and WHZ. There continues to be substantial heterogeneity in the quality of anthropometric data across surveys. A composite index of anthropometric data quality can be used to account for variations in anthropometric data quality in multisurvey epidemiologic analyses of child health.
Authors
Nandita Perumal, Sorrel Namaste, Huma Qamar, Ashley Aimone, Diego G. Bassani, Daniel E. Roth
Institutional Affiliation(s)
Department of Global Health and Population Harvard TH Chan School of Public Health, Centre for Global Child Health Hospital for Sick Children, The DHS Program at ICF, Dalla Lana School of Public Health University of Toronto, Department of Pediatrics Hospital for Sick Children, Department of Pediatric Medicine, Department of Nutritional Sciences, and Institute of Health Policy, Management and Evaluation, University of Toronto
PARTNER CONTENT
A roadmap to reduce stunting
This article synthesizes the methods, results, and next steps from the Exemplars in Stunting research project. It links to five in-depth country case studies for the Exemplar countries, Peru, the Kyrg...
A roadmap to reduce stunting
This article synthesizes the methods, results, and next steps from the Exemplars in Stunting research project. It links to five in-depth country case studies for the Exemplar countries, Peru, the Kyrgyz Republic, Nepal, Senegal, and Ethiopia. These countries were selected due to their rapid decline in stunting relative to their economic growth based on a minimum population threshold of 5 million people and representation of different global regions. A mixed-methods approach with quantitative and qualitative research methods was employed to understand how these countries reduced stunting prevalence. In all countries, factors that were identified in the multivariable analysis as significant contributors to stunting reduction were improvements in poverty, maternal education, maternal nutrition status, good antenatal care, increase in maternal age, and reduction in fertility. By elucidating common factors between all 5 exemplar countries and by highlighting the mixed methods approach, this body of work can serve as a template for ways to reduce stunting burden in other countries.
Authors
Rebecca Roediger, D. Taylor Hendrixson, Mark J. Manary
Institutional Affiliation(s)
Department of Internal Medicine Washington University at St. Louis, Department of Pediatrics Washington University at St. Louis
PARTNER CONTENT
Drivers of stunting reduction in Peru...
This team used a mixed-methods approach to study factors and key enablers of child stunting reduction in Peru. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among ch...
Drivers of stunting reduction in Peru: a country case study
This team used a mixed-methods approach to study factors and key enablers of child stunting reduction in Peru. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions.
Authors
Luis Huicho, Elisa Vidal-Cárdenas, Nadia Akseer, Samanpreet Brar, Kaitlin Conway, Muhammad Islam, Elisa Juarez, Aviva I. Rappaport, Hana Tasic, Tyler Vaivada, Jannah Wigle, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Research Center for Integral and Sustainable Development Cayetano Heredia University, Maternal and Child Health Research Center Cayetano Heredia University, School of Medicine Cayetano Heredia University, Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Center for the Promotion and Defense of Sexual and Reproductive Rights (PROMSEX), Center of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
Drivers of stunting reduction...
This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -s...
Drivers of stunting reduction in the Kyrgyz Republic: A country case study
This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic. Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Key factors in stunting decline included poverty, maternal nutrition, paternal education, fertility, maternal age, and wealth accumulation. Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as other key drivers. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms.
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Institute of Public Policy and Administration University of Central Asia, Center of Excellence in Women and Child Health the Aga Khan University
PARTNER CONTENT
Drivers of stunting reduction...
This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individu...
Drivers of stunting reduction in Nepal: a country case study
This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using DHS from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. Though mean height-for-age z-scores (HAZ) improved, subnational variation and socioeconomic inequalities in stunting outcomes persisted. Decomposition analysis for children highlighted key factors including parental education, maternal nutrition, reduced open defecation, maternal and newborn health care, and economic improvement. Key initiatives focused on decentralizing the health system and mobilizing community health workers; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives.
Authors
Kaitlin Conway, Nadia Akseer, Raj Kumar Subedi, Samanpreet Brar, Basudev Bhattarai, Raja Ram Dhungana, Muhammad Islam, Jannah Wigle, Mahesh Maskey, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Nepal Public Health Foundation, Center of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
Drivers of stunting reduction in Senegal...
The team aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal’s success in reducing ...
Drivers of stunting reduction in Senegal: a country case study
The team aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal’s success in reducing stunting in children <5 y old between 1992/93 and 2017. A mixed methods approach was implemented, comprising quantitative data analysis, a systematic literature review, creation of a timeline of nutrition-related programs, and qualitative interviews with national and regional stakeholders and mothers in communities. Stunting prevalence reduction varied by geographical region and prevalence gaps were reduced slightly between wealth quintiles, maternal education groups, and urban compared with rural residence. Statistical determinants of change included improvements in maternal and newborn health, economic improvement, increases in parental education, and better piped water access. Key effective nutrition programs used a community-based approach, including the Community Nutrition Program and the Nutrition Enhancement Program. Stakeholders felt sustained political will and multisectoral collaboration along with improvements in poverty, women’s education, hygiene practices, and accessibility to health services at the community level reduced the burden of stunting.
Authors
Samanpreet Brar, Nadia Akseer, Mohamadou Sall, Kaitlin Conway, Ibrahima Diouf, Karl Everett, Muhammad Islam, Papa Ibrahima Sylmang Sène, Hana Tasic, Jannah Wigle, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Université Cheikh Anta Diop, Agence Nationale de la Statistique et de la Démographie, Center of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
Drivers of stunting reduction in Ethiopia
The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, househo...
Drivers of stunting reduction in Ethiopia: a country case study
The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level. This study employed both quantitative and qualitative methods: a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000–2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken. National stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Key factors supporting stunting reduction included increases in total consumable crop yield, increased number of health workers, reduction in open defecation, parental education, maternal nutrition, economic improvement, and reduced diarrhea incidence. Policies and programs that were key to stunting decline focused on promoting rural agriculture to improve food security; decentralization of the health system, incorporating health extension workers to improve rural access to health services and reduce open defecation; multisectoral poverty reduction strategies; and a commitment to improving girls’ education.
Authors
Hana Tasic, Nadia Akseer, Seifu H Gebreyesus, Anushka Ataullahjan, Samanpreet Brar, Erica Confreda, Kaitlin Conway, Bilal S. Endris, Muhammad Islam, Emily Keats, Afrah Mohammedsanni, Jannah Wigle, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, School of Public Health Addis Ababa University, Center of Excellence in Women and Child Health at the Aga Khan University
PARTNER CONTENT
How countries can reduce child...
This work synthesizes findings from mixed methods studies of Exemplar countries to provide guidance on how to accelerate reduction in child stunting. The team conducted a qualitative and quantitative ...
How countries can reduce child stunting at scale: lessons from exemplar countries
This work synthesizes findings from mixed methods studies of Exemplar countries to provide guidance on how to accelerate reduction in child stunting. The team conducted a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors and other sectors.
Authors
Zulfiqar A Bhutta, Nadia Akseer, Emily C. Keats, Tyler Vaivada, Shawn Baker, Susan E. Horton, Joanne Katz, Purnima Menon, Ellen Piwoz, Meera Shekar, Cesar Victora, Robert Black
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, Dalla Lana School of Public Health University of Toronto, Center of Excellence in Women and Child Health at the Aga Khan University, United States Agency for International Development, School of Public Health and Health Systems University of Waterloo, Johns Hopkins Bloomberg School of Public Health, International Food Policy Research Institute South Asia Office, Global Development Division Bill & Melinda Gates Foundation, Health, Nutrition & Population at the World Bank, Federal University of Pelotas
PARTNER CONTENT
Mobilising evidence, data, and resources...
This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on materna...
Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action
This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda—now amplified by the COVID-19 crisis.
Authors
Rebecca A. Heidkamp, Ellen Piwoz, Stuart Gillespie, Emily C. Keats, Mary R. D'Alimonte, Purnima Menon, Jai K. Das, Augustin Flory, Jack W. Clift, Marie T. Ruel, Stephen Vosti, Jonathan Kweku Akuoku, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Johns Hopkins Bloomberg School of Public Health, Bill & Melinda Gates Foundation, International Food Policy Research Institute, Centre for Global Child Health The Hospital for Sick Children, Results for Development, Division of Women and Child Health the Aga Khan University, Department of Agricultural and Resource Economics and Institute for Global Nutrition, University of California Davis, World Bank
PARTNER CONTENT
Malaria reduction drives childhood...
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 contribute...
Malaria reduction drives childhood stunting decline in Uganda: a mixed-methods country case study
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. Uganda's success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health such as increased coverage of insecticide-treated mosquito nets, better maternal nutrition, improved maternal education, and improved maternal and newborn healthcare . 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.
Authors
Emily C. Keats, Richard B. Kajjura, Anushka Ataullahjan, Muhammad Islam, Breagh Cheng, Ahalya Somaskandan, Kimberly D. Charbonneau, Erica Confreda, Rachel Jardine, Christina Oh, Peter Waiswa, Zulfiqar A. Bhutta
Institutional Affiliation(s)
Centre for Global Child Health Hospital for Sick Children, School of Public Health Makerere University, Dalla Lana School of Public Health University of Toronto, Centre of Excellence in Women and Child Health at the Aga Khan University