Health impacts of macroeconomic crises and policies: determinants of variation in childhood malnutrition trends in Cameroon

BACKGROUND: It is generally hypothesized that macro economic shocks worsen child health by lowering household economic status and limiting access to health care, but this proposition seldom has been tested empirically. We examined the effects of economic crises and adjustment programmes during the 1990s in Cameroon on childhood malnutrition in population subgroups and evaluated the household and health system mediators of these effects. METHODS: We used pooled cross-sectional data from two Demographic and Health Surveys conducted in 1991 and 1998. In multivariate analysis, we stratified data on child sex and age, maternal education, and place and region of residence. We used a linear regression model to estimate the net effects of changes in average household economic status and maternal health seeking behaviour (MHSB) on changes in the prevalence of malnutrition for each stratum, adjusting for all other variables. RESULTS: The prevalence of malnutrition in children younger than 3 years increased from 16 to 23% (P < 0.001) between 1991 and 1998. The increase in urban areas, from 13 to 15% (P = 0.391), mostly occurred in children of low-educated mothers. The increase in rural areas, from 19 to 25% (P < 0.001), mostly occurred in boys, children older than 6 months of age, those born to low-educated mothers, and those of low economic status. In urban areas, the advantage associated with higher maternal education was robust to all controls, and declines in economic status and MHSB were the mediators of increasing malnutrition. In rural areas, increase in malnutrition was higher in children with lower baseline economic status; decline in MHSB was a significant mediator of worsening nutritional status. CONCLUSIONS: The negative nutritional effects during economic crises and adjustment programmes of the 1990s in Cameroon were largest among children of low socioeconomic status. Declines in household economic status and access to health care were the mediators of increasing malnutrition.     

Can mothers identify malnutrition in their children?

To assess mothers' perceptions about malnutrition and theirability to identify malnutrition in their own children, 339children aged 3–35 months and their mothers were studiedin two urban hospitals in Dhaka, Bangladesh, and in a communityclinic. The weight, height, and mid-upper arm circumferenceof the children were measured, and their mothers were interviewed.Child nutritional status according to their mother's statementand anthropometrically assessed nutritional status were compared.Sixty per cent of the mothers correctly identified better nutritionalstatus (weight/age >75% of NCHS median) and 67% mothers correctlyidentified malnutrition (weight/age < 75% of NCHS median)in their children. Sixty-one per cent of mothers with less than5 years of formal education correctly identified better nutrition(weight/age >75%) whereas 38% mothers with more than 5 yearsof education correctly identified better nutrition. Correctidentification of malnutrition was made by 70% of mothers withless than 5 years of formal education, and 74% of educated mothersdid the same. As regards causes of malnutrition, 33% of mothers stated thatlack of food at home resulted in undernutri-tion in their children(mean weight-for-age of these children was 65% of the NCHS median).Mothers' suggestions for improving child health were: betterfood in 31% cases; treatment of illnesses in 22% cases; andboth in 42% cases. The results suggest that most of the mothersare able to identify malnutrition in their children, and 95%of them are aware of ways to improve it, and that the provisionof adequate food and health care may improve child nutritionalstatus.     

Risk factors for acute respiratory infections in underfives in a rural community

The risk factors for acute respiratory infection (ARI) were investigated in a 6-month study of 366 children under 5 years of age from a rural zone of Delhi, India. Home visits were made to each child enrolled in the study every 2 weeks. 242 children (65.9%) had adequate nutritional status, 95 (26%) had mild malnutrition, and 30 (8.1%) had moderate to severe malnutrition. The annual ARI incidence was 3.27 episodes per child in the moderate to severely malnourished children, 2.82 episodes in mildly malnourished children, and 2.26 episodes in adequately nourished children. Lower respiratory infection was more affected by adverse nutritional status than upper respiratory infection. ARI incidence was also significantly lower among children living in well-ventilated homes (1.79 episodes/child/year) than those living in poorly ventilated homes (2.87 episodes/child/year). Since none of the mothers smoked and adequate breast feeding was practiced by 95% of mothers, the influence of these two risk factors on ARI was not relevant in this study.     

The ecology of nutritional status and development in young children in Kingston, Jamaica

A survey of two poor neighborhoods in Kingston, Jamaica is reported. The nutritional status in children under 48 months (309) and the developmental levels of children between six and thirty months (168) were assessed. Characteristics of children with poor nutritional status and development were identified. Thirty-one percent of the children had Gomez grade 1 malnutrition, 9% had Gomez grade 2, and 1.6% had Gomez grade 3. There was somewhat more stunting than wasting. Nutritional indicators, weight for age and weight for height, as well as developmental levels declined with the children's age. Children with poor nutritional status tended to be girls, have poor housing, mothers with low levels of education, and mothers who worked. Children with low developmental quotients (DQs) tended to be boys and have mothers who worked. Multiple regression analysis showed that stunting (ht/age) and weight for age had significant effects on DQ, whereas wasting (wt/ht) did not.     

Household and community HIV/AIDS status and child malnutrition in sub-Saharan Africa: evidence from the demographic and health surveys

This paper examines the extent to which under five children in households or communities adversely affected by HIV/AIDS are disadvantaged, in comparison with other children in less affected households/communities. The study is based on secondary analysis of the Demographic and Health Survey (DHS) data collected during 2003-2008 from 18 countries in sub-Saharan Africa, where the DHS has included HIV test data for adults of reproductive age. We apply multilevel logistic regression models that take into account the effect of contextual community/country level HIV/AIDS factors on child malnutrition. The outcome variable of interest is child undernutrition: stunting, wasting and underweight. The results suggest that across countries in sub-Saharan Africa, children whose mothers are infected with HIV are significantly more likely to be stunted, wasted or underweight compared to their counterparts of similar demographic and socio-economic background whose mothers are not infected. However, the nutritional status of children who are paternal orphans or in households where other adults are HIV positive are not significantly different from non-orphaned children or those in households where no adult is infected with HIV. Other adult household members being HIV positive is, however, associated with higher malnutrition among younger children below the age of one. Further analysis reveals that the effect of mothers' HIV status on child nutritional status (underweight) varies significantly across communities within countries, the effect being lower in communities with generally higher levels of malnutrition. Overall, the findings have important implications for policy and programme efforts towards improved integration of HIV/AIDS and child nutrition services in affected communities and other sub-groups of the population made vulnerable by HIV/AIDS. In particular, children whose mothers are infected with HIV deserve special attention.     

Familial and socioeconomic influences on children''s well-being: An examination of preschool children in Kenya

As patterns of family formation change, it is important to know how children's lives are affected by their parents' marital and socioeconomic circumstances. Using data from the 1993 Kenya Demographic and Health Survey, this study shows that children of never married and formerly married mothers have significantly higher probabilities of polio dropout and acute undernutrition than those of monogamously married mothers. The number of male household members of working age greatly enhances the chances of full immunization and the nutritional status of children whose mothers were previously married. For children of never married mothers, the benefits of residing with males of working age are largely a function of ethnicity. The results also show that, although children are not disadvantaged nutritionally when their fathers have more than one wife, polygyny is associated with a higher probability of polio dropout and lower probability of full immunization than monogamy. Higher socioeconomic status is associated with a greater probability of full immunization and a lower probability of malnutrition but socioeconomic factors do not explain the effects of mothers' marital status. The findings underscore the complex realities of family interaction and the importance of the broader social context in accounting for variations in child welfare across diverse marital situations.     

The deterioration in children's nutritional status in rural Chad: the effect of mothers' influence on feeding.

OBJECTIVES: This study examined how maternal influence on child feeding modified the deterioration of child nutritional status in Chad. METHODS: The pattern of height with age was examined in 98 rural Chadian children aged 12 through 71 months from 64 households randomly chosen. RESULTS: Younger children were more stunted than older ones, probably reflecting secular deterioration in weanlings' nutritional status from 1982 to 1987. Children of mothers with influence over child feeding were taller than children of mothers with less influence, but this held only for the youngest children. CONCLUSIONS: Height-for-age can be a useful indicator of recent changes in social and environmental effects on child health. The mother's influence may have buffered the negative impact of socioeconomic conditions on child growth.     

Impact of sociomedical factors on pre-school malnutrition -- an appraisal in an urban setting

The nutritional status of 584 preschool children in an urban slum of Srinagar district was assessed through interviews of mothers conducted in a house-to-house survey, the clinical assessment of child nutritional status, and the anthropometric measurement of the children using accepted standard techniques. The anthropometric measurements of the children were compared to the 50th percentile of the Harvard Standard, while the classification recommended by the Indian Academy of Pediatrics was adopted for the categorization and grading of protein energy malnutrition. 60.45% of the children were malnourished, comprised of 33.22%, 20.89%, and 6.34% of children with grade I, II, and III degrees of malnutrition, respectively. Higher prevalence of malnutrition is associated with higher age, female sex, lower per capita income, higher birth order, and lower parental literacy. Parental literacy status followed by birth order and per capita income were the most important factors associated with preschool child malnutrition.     

Maternal education and child nutritional status in Bolivia: finding the links

This study models various pathways linking maternal education and child nutritional status in Bolivia, using a national sample of children. Pathways examined include socioeconomic status, health knowledge, modern attitudes towards health care, female autonomy, and reproductive behavior. The data come from the 1998 Bolivia Demographic and Health Survey. Logistic regression results suggest that socioeconomic factors are the most important pathways linking maternal education and child nutritional status, and that modern attitudes about health care also explain the impact of education. Health care knowledge accounts for less of the effect of maternal education on child nutritional status, with autonomy being the weakest pathway. Other pathways, such as reproductive behaviors, appear to influence nutritional status independent of maternal education. Overall, the pathways examined accounted for 60 percent of the effect of maternal education on child nutritional status.     

Nutritional status of Naporuna children under five in the Amazon region of Ecuador]

OBJECTIVES: To assess the nutritional status of Naporuna children under five years of age from the Amazon region of Ecuador, and to identify risk factors for developing malnutrition in this population group. METHODS: A survey-based cross-sectional study was carried out in Orellana, a province in northeastern Ecuador, between June 2001 and February 2002. Household interviews were conducted in 30 communities chosen at random, and a questionnaire was used to record the following: the social and demographic characteristics and parity of mothers having children under five years of age, and the children's demographic and anthropometric characteristics, history of breastfeeding, and medical conditions suffered over the two-week period just prior to the survey. Each child was also subjected to a physical examination. Anemia was diagnosed clinically by conjunctival exam. The statistical association among variables was determined by means of the chi-square test, with use of Yates' correction and Fisher's exact test (two-tailed) when there were 5 observations or less. Risk factors for chronic malnutrition and underweight were determined by means of logistic regression. RESULTS: Overall, 189 mothers of 347 children under five were interviewed. Of these 347 children, 307 (88.5%) participated in the study. Chronic malnutrition was found in 22.8% of the children; 26.4% were underweight, and 9.8% had acute malnutrition. Moreover, 7.5% had severe chronic malnutrition; 4.9% were severely underweight, and 1.6% had severe acute malnutrition. A total of 5 children (1.6%) showed signs of both chronic and acute malnutrition. The largest prevalence of chronic malnutrition was found in the 12-23 month age group. Risk factors for chronic malnutrition that were statistically significant included living in an area without access to a road, the total number of children in the family (> or =7), and the presence of an acute respiratory infection or abdominal distension on the day the physical examination was performed. Abdominal distension and pale conjunctiva on physical examination were predictive for underweight. CONCLUSIONS: Among the Naporuna children under 5 years of age included in this study, the prevalences of acute malnutrition and underweight appeared to be higher than had been previously detected among other populations in the Amazon region. More studies on the prevalence of parasitic infections and anemia and on the feeding practices and dietary habits of indigenous communities are needed in order to better understand their nutritional intake. A program for monitoring the diet of indigenous peoples is necessary and should be established.     

Malnutrition among children in an urban Indian slum and its associations

In a cross-sectional study in Bhopal, India, mothers and other family members were surveyed by questionnaire, then 1000 randomly selected slum children were clinically examined, to detect nutritional deficiency diseases. Anthropometric measurements were also taken. Malnutrition classification followed the Harvard classification (weight in relation to the age of the child) modified by the Indian Academy of Pediatrics. The weight of the children was recorded using the Avery personal weighing machine. Of the 1000 children, 520 were males and 480 were females almost matched in age and birth order. The prevalence of various nutritional deficiency diseases comprised: protein calorie malnutrition (63.4%), vitamin A deficiency (23.4%), vitamin B deficiency (16.2%), vitamin C deficiency (2.6%), vitamin D deficiency (9.4%), fluorine deficiency (2.9%), and anemia (7.2%). The prevalence of malnutrition was 65.0% among females compared to 61.9% in males (p 0.05). However, higher grades of malnutrition (III+IV) were 13.12% among females in comparison to 7.87% among males (p 0.05); whereas lower grades of malnutrition (I+II) were 54.04% among males and 51.87% among females (p0.05). The birth order of the children was positively associated with their grades of malnutrition (p 0.05). On the other hand, an inverse relationship was observed between birth interval and grades of malnutrition (p 0.05). The prevalence of malnutrition was significantly higher among those children whose fathers were illiterate (p 0.05). In general, as the literacy status of father increased, the prevalence of malnutrition among children decreased. The prevalence of malnutrition had a positive association (p 0.05) with children's family size: 3 members (47.0%), 4-6 members (63.9%), and 7 members and above (70.6%). On the other hand, an inverse correlation was observed between socioeconomic status and the prevalence of malnutrition (p 0.05). The prevalence of malnutrition was significantly (p 0.05) higher among the children with a history of infection (81.8%) and worm infestation (77.0%) in comparison to those without history of infection (13.1%) and worm infestation (61.9%), respectively. Similarly, nonimmunized children experienced more malnutrition (66.4%) in comparison to immunized children (57.0%).     

Infant and Young Child Feeding Practices among Adolescent Mothers and Associated Factors in India

Adequate infant and young child feeding (IYCF) improve child survival and growth. Globally, about 18 million babies are born to mothers aged 18 years or less and have a higher likelihood of adverse birth outcomes in India due to insufficient knowledge of child growth. This paper examined factors associated with IYCF practices among adolescent Indian mothers. This cross-sectional study extracted data on 5148 children aged 0–23 months from the 2015–2016 India National Family Health Survey. Survey logistic regression was used to assess factors associated with IYCF among adolescent mothers. Prevalence of exclusive breastfeeding, early initiation of breastfeeding, timely introduction of complementary feeding, minimum dietary diversity, minimum meal frequency, and minimum acceptable diet rates were: 58.7%, 43.8%, 43.3%, 16.6%, 27.4% and 6.8%, respectively. Maternal education, mode of delivery, frequency of antenatal care (ANC) clinic visits, geographical region, child’s age, and household wealth were the main factors associated with breastfeeding practices while maternal education, maternal marital status, child’s age, frequency of ANC clinic visits, geographical region, and household wealth were factors associated with complementary feeding practices. IYCF practices among adolescent mothers are suboptimal except for breastfeeding. Health and nutritional support interventions should address the factors for these indicators among adolescent mothers in India.     

Use of mid-upper arm circumference for evaluation of nutritional status of children and for identification of high-risk groups for malnutrition in rural Bangladesh

Measurements of mid-upper arm circumference (MUAC) of 8,881 children were considered cross-sectionally to determine the effects of diarrhoea, breast-feeding, and birth-spacing on the nutritional status of children in rural Matlab, Bangladesh. It was observed that age was one of the most significant determinants of child nutrition. The younger children (< 2 years) had significantly higher levels of severe malnutrition than the children aged 2 years or older. Children who had diarrhoea during the last 12 months prior to the study had significantly (p < 0.001) higher severe malnutrition than the children who did not suffer from diarrhoea. Children born with a longer interval after birth of an elder sibling (24+ months) and who were breastfed for a longer duration (2-3 years) were less likely to be severely malnourished than those who were born with a shorter birth interval or who terminated breast-feeding prior to 2 years of age. Education of mothers, housing space, family size, religion, and sex of children had significant effects on the nutritional status of children. Results of the study suggest that MUAC is a potential anthropometric indicator of child nutrition.     

Does maternal autonomy influence feeding practices and infant growth in rural India?

The high prevalence of child under-nutrition remains a profound challenge in the developing world. Maternal autonomy was examined as a determinant of breast feeding and infant growth in children 3-5 months of age. Cross-sectional baseline data on 600 mother-infant pairs were collected in 60 villages in rural Andhra Pradesh, India. The mothers were enrolled in a longitudinal randomized behavioral intervention trial. In addition to anthropometric and demographic measures, an autonomy questionnaire was administered to measure different dimensions of autonomy (e.g. decision-making, freedom of movement, financial autonomy, and acceptance of domestic violence). We conducted confirmatory factor analysis on maternal autonomy items and regression analyses on infant breast feeding and growth after adjusting for socioeconomic and demographic variables, and accounting for infant birth weight, infant morbidity, and maternal nutritional status. Results indicated that mothers with higher financial autonomy were more likely to breastfeed 3-5 month old infants. Mothers with higher participation in decision-making in households had infants that were less underweight and less wasted. These results suggest that improving maternal financial and decision-making autonomy could have a positive impact on infant feeding and growth outcomes.     

Strategies for nutritional improvement

India has achieved self-sufficiency in the production of food grains, yet the production of milk, legumes, vegetables, oils and fats, eggs, and meat is far short of the needs of the population. The Indian diet predominantly comprises cereals, and the diets of expectant and nursing mothers as well as children are grossly deficient in protective foods. Serious nutritional inadequacies have resulted in low birth weight, retarded growth, and nutritional deficiencies (protein energy malnutrition in preschool children, vitamin A deficiency, iron deficiency in women of reproductive age, and iodine deficiency disorders among neonates and schoolchildren). General malnutrition is prevalent in 25% of the rural and 20% of the urban population. Deficiency symptoms of vitamin B complex and vitamin C are also not uncommon. 37% of the population of India lives below the poverty limit, the literacy rate is only 52.1% (39.4% for women), safe drinking water is scarce, nutritional ignorance is rampant, there is a lack of personal hygiene, and poor sanitation all account for malnutrition. A number of government and nongovernmental organizations' programs have attempted to raise the level of nutrition and the standard of living of the people. Some of them include the integrated child development services, special nutritional program, national vitamin A deficiency prophylaxis program, national anemia prophylaxis program, national goiter control program, midday meal program, special class feeding programs, universal immunization program, nutritional and health education through the mass media as well as the observance of world food day and world health day. The national health policy gives high priority to the promotion of family planning, the provision of primary health care, and the acceleration of welfare programs for women and children. As a result of policies and programs of health and nutrition, the infant, child, and maternal mortality rates have declined and life expectancy at birth has risen.     

Social factors,nutrition and child mortality in a rural subsistance economy

Data from the Zambia National Nutrition Status Survey was used to identify socioeconomic, health, and nutritional factors associated with child mortality among rural residents. In each sample village, all children, who were both under the age of 5 and the youngest child in the family, were given physical examinations and their mothers were interviewed about the socioeconomic characteristics of the family. Mothers were also asked to provide information on the number of live births they had and on the number of children they had who died. Physical disorders, revealed in the physical examinations, were analyzed in regard to their relationship to sibling death rates, and the socioeconomic characteristics of the family were analyzed in regard to their relationship to the child deaths reported by the mothers. Findings were 1) high sibling death rates were positively associated with the presence of malaria and with the presence of malnutrition in the youngest child in the family; 2) the role of malaria in sibling deaths was greater than the role of malnutrition; 3) social factors associated with high child deaths were parental residence in tribal areas, high maternal parity, and low parental educational attainment; 4) subsistence farm families lost 26.0% of their children compared to other occupational groups which lost an average of 20.9% of their children; 5) polygamously married women lost 28.7% of their children compared to monogamously married women. These findings will be used to help formulate policies aimed at reducing the high child mortality rates in rural Zambia. Only after this rate is reduced will rural residents be receptive to family planning.     

Maternal mental health and child nutritional status in four developing countries

OBJECTIVE: To test the hypothesis that maternal common mental disorders (CMD) are associated with poorer child nutritional status in four developing countries (Ethiopia, India, Vietnam, and Peru). DESIGN: Community based cross sectional survey in 20 sites in each of the four countries. Maternal CMD measured by the self reporting questionnaire 20 items (SRQ20). Potential confounding factors include: household poverty, household composition, maternal characteristics such as age and education, child characteristics such as birth weight, age, and sex. Possible mediating factors included the child's physical health and breast feeding status. SETTING: Urban and rural, poor and middle income areas in each country. PARTICIPANTS: 2000 mothers and their children aged 6-18 months in each country. MAIN OUTCOME MEASURES: Child stunting and underweight measured using standard anthropometric techniques. RESULTS: Levels of maternal CMD and child malnutrition are high in each study setting. After adjusting for confounding factors, the odds ratios (OR) for the association of maternal CMD with child stunting are: India 1.4 (95%CI 1.2 to 1.6), Peru 1.1 (0.9 to 1.4), Vietnam 1.3 (0.9 to 1.7), and Ethiopia 0.9 (0.7 to 1.2). For child underweight, the confounder adjusted ORs are: India 1.1 (0.9 to 1.4), Peru 0.9 (0.6 to 1.2), Vietnam 1.4 (1.1 to 1.8), and Ethiopia 1.1 (0.9 to 1.4). No clear evidence for effect modification by the child's age or sex was found. Possible mediating factors for the effect of maternal CMD on child malnutrition did not provide strong suggestions for potential mechanisms. CONCLUSIONS: There was a relation between high maternal CMD and poor child nutritional status in India and Vietnam. However, the findings from Peru and Ethiopia do not provide clear evidence for a similar association being present in non-Asian countries. Regardless of the direction of the relation, child nutrition programmes in Asia should consider incorporating promotion of maternal mental health.     

Socioeconomic determinants of nutritional status of children in Lao PDR: effects of household and community factors

The prevalence of undernutrition among Lao children is among the highest in the region. However, the determinants of childhood undernutrition in Laos have not been fully analyzed. This paper, using the dataset of the Lao Multiple Indicator Cluster Survey 3, which is a nationally-representative sample in Laos, investigated the effects of socioeconomic factors at both household and community levels on the nutritional status of children. In the estimation, a multilevel linear model with random-intercepts was used for estimating the determinants of child anthropometric indices. The empirical results revealed that children from households in southern Laos and from ethnic minority groups were less-nourished. Level of education of parents, attitudes of mothers towards domestic violence, assets of household, local health services, and the condition of sanitation and water were considered to be important determinants of nutritional status of children. The pattern of growth-faltering in children by age was identified. Children aged 12-59 months were less-nourished than those aged 0-11 months. The empirical results were consistent with the collective household model which incorporates a decision-making process within the household. Since there is scarce evidence about the predictors of childhood undernutrition in Laos, the findings of this study will serve as a benchmark for future research.     

烟台5市区0~6岁儿童营养状况调查

目的:了解及掌握烟台5市区儿童营养状况及健康水平,有效地干预目前儿童健康中存在的问题。方法:采用问卷形式,由调查人员询问并填写,对烟台5市区740名0~6岁儿童的身高、体重进行测量,采用WHO推荐的美国国家卫生统计中心的不同体重身高为标准参考值,评价营养状况。结果:调查的儿童营养正常率为84.0%,总营养不良率为7.8%,总营养过剩率为8.2%。儿童营养状况受性别、地区、年龄的影响,男女儿童营养状况无显著差别;农村儿童营养不良率为10.5%,城市为6.0%,两者差异有显著性意义(χ2=10.32,P<0.05);0~岁年龄段的儿童营养过剩率最高,3~岁年龄段的儿童营养过剩率最低,不同年龄段儿童营养过剩率有显著性意义(χ2=8.94,P<0.05)。结论:应加强母亲的健康育儿知识教育,普及母乳喂养,积极提倡科学饮食,同时通过适量的有氧运动,减少儿童肥胖率的发生。