stunting and wasting in children under 2 in a semi-nomadic pastoralist population in kenya...
TRANSCRIPT
©2013 International Medical Corps
STUNTING AND WASTING IN CHILDREN UNDER 2 IN A SEMI-NOMADIC PASTORALIST
POPULATION IN KENYA
Amelia Reese-Masterson Nutrition, Food Security & Livelihoods – International Medical Corps
Masumi Maehara
Graduate Intern – London School of Hygiene and Tropical Medicine
Correlations, Risk Factors, and Implications
©2013 International Medical Corps
Outline
• Background
• Objectives
• Literature Review
• Methodology
• Findings & Interpretation
• Limitations
• Recommendations
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Background
The HiNi program – Efficacy-proven nutrition interventions
– HiNi in Kenya - 11 interventions across 5 counties
– We began supporting HiNi in Samburu in 2011
Samburu – The Rift Valley region of Kenya
– Arid/semi-arid land
– Semi-nomadic pastoral community
– Ianottie & Lesorogol 2014
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Samburu County
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Objectives Overall Aim: To identify socio-economic and health-related risk factors associated with stunting and wasting in children 6-23 months in the Samburu population
Specific Objectives
– To investigate factors (and effect size) associated with stunting, wasting, and both
– To investigate the relationship between stunting and wasting
– To provide evidence-based recommendations to inform nutrition programs in this population/region
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Literature Review (1)
STUNTING
Maternal height Wasting Zinc inadequacy Environmental enteric dysfunction Previous stunting Birth outcomes (preterm, SGA)
WASTING Intrauterine growth restriction (IUGR) Seasonality (less strong for stunting) Infectious disease Poor IYCF (non-exclusive BF, poor complementary feeding) Diarrhea Dietary inadequacy Poor WASH practices Underlying factors: socioeconomic status, maternal education, child age, occupation
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Literature Review (2)
STUNTING
WASTING
Delayed/poor neurological development Poor educational attainment hampered economic growth Increased risk of cardiovascular disease, overweight/obesity later in life Poor Reproductive Health outcomes
Mortality (wasting has double the risk as stunting, stunting + wasting is highest risk) Susceptibility to infections (pneumonia, measles, other) Diarrhea
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Methodology (1)
• Merged SMART survey data from Samburu, 2013
– Anthropometric dataset
– Household dataset
– IYCF dataset
• Adjusted for cluster sampling methodology
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Methodology (2) Stunting = LAZ <-2
• Chi-squared test • Univariate logistic regression (p<0.10) • Multivariate logistic regression (adjusted Wald
test due to sampling, p<0.05)
Wasting = WLZ <-2
• Chi-squared test (p<0.10)
Correlation between LAZ & WLZ
• Pearson’s correlation coefficient – strength of linear correlation
• Compared predictors of LAZ and WLZ to identify any common predictors
Both LAZ & WLZ • Chi-squared test – association between stunted + wasted children and explanatory variables
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Findings & Interpretation
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Descriptive Statistics: Household
43%
57%
Household size
2-5 people >5 people
69%
31%
Household head occupation
Livestock herding Others
n=277 in merged dataset
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Descriptive Statistics: WASH
0
20
40
60
80
100
Before eating Before cooking After defecation After cleaningchild
% Hand washing at critical moments
Yes
No
Only 13.22% of caretakers washed hands at all 4 critical moments
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Descriptive Statistics: WASH
0
10
20
30
40
50
60
70
80
Total treated Total not treated Safe Unsafe
%
Water source and treatment
Treated Not treated
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Descriptive Statistics: WASH
Yes 39%
No 61%
Access to toilet
Open pot 68%
Closed pot 32%
Water storage
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Descriptive Statistics: Child Health
02468
10121416
% Morbidity
0 50 100
Vitamin A supp
Deworming
Measles
OPV
BCG
Vaccination, vitamin A supplementation,
deworming
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Descriptive Statistics: Child Health
0
10
20
30
40
50
60
70
No Yes
%
Health seeking behavior
76%
11% 9% 4%
Care sought if child sick (n=71)
Public clinic
Herbal remedies
Traditional healers
Others
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Descriptive Statistics: Household Food Security
55% 40%
5%
Household dietary diversity
≤3 food groups 4-5 food groups
6+ food groups
01020304050607080%
Main food source
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Descriptive Statistics: IYCF
90.31
9.69
73.57
26.43
INITIATION OF BF FEEDING 3 DAYS AFTER DELIVERY
Breastfeeding
<1 hr >1 hr BM only Non-BM items
61%
34%
5%
Dietary diversity (6-23m)
1 or less 2 food groups 3 or more
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Univariate Findings: Wasting
• Prevalence of wasting (WLZ <-2): 8.81% (only 2 cases severe)
• Lack of access to toilet facilities significantly associated wasting (p=0.09)
• Wasting increases with increasing age, with 18-23 month old children at 10% (not significant)
• No other variables were significant
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Univariate Findings: Stunting
Child age (months)
n Median LAZ1 (IQR) Moderate stunting (%)
Severe stunting (%)
6-11 59 -0.87 (-1.53, -0.38) 10 (16.95) 0 (0.00)
12-17 69 -1.19 (-2.06, -0.48) 12 (17.39) 6 (8.70)
18-23 99 -1.59 (-2.31, -1.09) 30 (30.30) 6 (6.06)
Stunting median z-scores (IQR) and prevalence, by age groups (n=227)
1Based on the WHO Child Growth Standard
Overall stunting prevalence was 28.19% in this population
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Association Between Risk Factors and Stunting: Unadjusted and Adjusted
Variables OR (95% CI) P-value aOR (95% CI) P-value (Wald)
Hand washing at critical moments
No Yes
0.47 (0.21-1.07)
0.07*
0.51 (0.23-1.17)
0.11
Fever/Malaria No Yes
0.26 (0.08-0.89)
0.03*
0.26 (0.07-1.00)
0.05**
Livestock herding Yes No
1.22 (0.73-2.02)
0.43
1.16 (0.72-1.88)
0.52
Child sex Male Female
0.69 (0.36-1.34)
0.27
0.68 (0.33-1.99)
0.28
Child age (months) 6-11 12-17 18-23
1.73 (0.71-4.19) 2.8 (1.16-6.77)
0.22 0.02*
1.62 (0.65-4.02) 2.51 (1.00-6.35)
0.15
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Univariate findings: stunting & wasting in same child
No livestock Own livestock Total
Not stunted + wasted 40 (93.02) 180 (97.83) 220 (96.92)
Stunted + wasted 3 (6.98) 4 (2.17) 7 (3.08)
Total 43 (100.00) 184 (100.00) 227 (100.00)
P-value=0.03
Chi-squared test of livestock by stunting + wasting (n=227)
Double burden of stunting + wasting significantly more common in those who do not own livestock
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Limitations
• Cross-sectional
• Low statistical power
• Info on micronutrient deficiencies, maternal nutritional status, maternal education, pregnancy outcomes, socio-economic status not available
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Recommendations
Program Specific
• Address poor WASH practices among Samburu
• Address access to health care for pastoralist communities
• Improve dietary diversity among children under two
• Increase integration in RH, WASH, health, and nutrition programs to address multifactorial risk factors
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Data/Measurement-Related
• Consider powering SMART to look at stunting as well
• Adjust reporting functions in ENA to include stunting
• Ensure data quality (unique IDs to linking datasets)
• Improve M&E integration: RH, WASH, nutrition, infectious disease
• Trials needed to determine best measurement of wasting (MUAC vs. WHZ) in pastoralist before meaningful work on stunting + wasting
Recommendations
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Thank you!