Socio-economic inequalities in child stunting reduction in sub-Saharan Africa

  • Nutrients, Volume 12, No. 1, Year 2020

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Study Justification:
– Stunting in children under five years of age is a significant issue in Sub-Saharan Africa.
– The study aimed to evaluate changes in stunting prevalence based on socio-economic status and rural/urban residence.
– It also assessed inequalities in children’s diet quality and access to maternal and child health care.
– The study used nationally representative data to provide insights into the current situation and identify areas for improvement.
Highlights:
– Stunting prevalence has decreased over the past decade, with faster reductions observed in the most disadvantaged groups (rural and poorest wealth quintile).
– However, progress in reducing stunting has not been accompanied by improved equity.
– Inequalities in diet quality and access to health care persist based on wealth quintile and rural-urban residence.
– Aligning food and health systems interventions is necessary to accelerate stunting reduction more equitably.
Recommendations:
– Implement interventions that address both food and health systems to effectively reduce stunting.
– Focus on improving access to health care and nutrition-specific interventions for the most disadvantaged groups.
– Strengthen efforts to improve diet quality, especially among children from poorer households.
– Monitor progress and evaluate the impact of interventions to ensure effectiveness and equity.
Key Role Players:
– Government agencies responsible for health and nutrition policies and programs.
– Non-governmental organizations (NGOs) working in the field of child health and nutrition.
– Health care providers and community health workers involved in delivering maternal and child health services.
– Education sector to promote nutrition education and awareness.
– Research institutions and universities to provide evidence-based recommendations and support monitoring and evaluation efforts.
Cost Items for Planning Recommendations:
– Funding for health care infrastructure and services, including maternal and child health clinics.
– Resources for training and capacity building of health care providers and community health workers.
– Budget for nutrition-specific interventions, such as supplementation programs and counseling services.
– Investment in nutrition education and awareness campaigns.
– Monitoring and evaluation costs to assess the impact of interventions and track progress towards reducing stunting.
Please note that the cost items provided are general categories and not actual cost estimates. The actual costs will vary depending on the specific context and implementation strategies.

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Stunting in children less than five years of age is widespread in Sub-Saharan Africa. We aimed to: (i) evaluate how the prevalence of stunting has changed by socio-economic status and rural/urban residence, and (ii) assess inequalities in children’s diet quality and access to maternal and child health care. We used data from nationally representative demographic and health- and multiple indicator cluster-surveys (DHS and MICS) to disaggregate the stunting prevalence by wealth quintile and rural/urban residence. The composite coverage index (CCI) reflecting weighed coverage of eight preventive and curative Reproductive, Maternal, Neonatal, and Child Health (RMNCH) interventions was used as a proxy for access to health care, and Minimum Dietary Diversity Score (MDDS) was used as a proxy for child diet quality. Stunting significantly decreased over the past decade, and reductions were faster for the most disadvantaged groups (rural and poorest wealth quintile), but in only 50% of the countries studied. Progress in reducing stunting has not been accompanied by improved equity as inequalities in MDDS (p < 0.01) and CCI (p < 0.001) persist by wealth quintile and rural-urban residence. Aligning food- and health-systems’ interventions is needed to accelerate stunting reduction more equitably.

The most recent available data were obtained from nationally representative cross-sectional Demographic and Health Surveys (DHS) from Sub-Saharan African countries. The DHS gather data on indicators that can help assess access to health care, child nutrition, and infant and young child feeding practices. For example dietary diversity, meal frequency, and the proportion of children meeting the minimum adequate diet are captured using standardized questionnaires. The DHS uses a multistage stratified sampling design, with households drawn randomly at the last stage. Stunting was defined as height/length-for-age z-scores <−2 SD relative to the WHO child growth standards [11]. The prevalence of stunting was estimated for children younger than five years of age. The time trends in stunting by urban-rural residence and wealth quintile was presented for countries with at least two surveys spaced between 1998–2008 and 2009–2018. The annual absolute excess change was presented by deducting the percentage point changes in the urban to the rural, and the prevalence in the wealthiest to the poorest. Negative values indicated faster changes in the most disadvantaged group (poorest wealth quintile/rural). The Composite Coverage Index (CCI) is a weighted score reflecting the coverage of the following eight preventive and curative Reproductive, Maternal, Neonatal and Child interventions (RMNCH) along the continuum of care—(1) demand for family planning satisfied (modern methods); (2) antenatal care coverage (at least four visits); (3) births attended to by skilled health personnel; (4) BCG immunization coverage among one-year-olds; (5) measles immunization coverage among one-year-olds; (6) DTP3 immunization coverage among one year-olds; (7) children aged less than five years with diarrhea receiving oral rehydration therapy and continued feeding; and (8) children aged less than five years with pneumonia symptoms taken to a health facility [12,13]. The interventions, although not directly linked to nutritional outcomes, are good proxies of access to health care, which is the entry point for most nutrition-specific interventions. For example, vaccination coverage can be a proxy for Vitamin A supplementation, 4+ antenatal care for nutrition counseling, and oral rehydration therapy, and continued feeding during diarrhea can be related to counseling on child feeding during and after sickness. The CCI has been successfully used to track the changes in universal health coverage, but also to monitor the within country socio-economic inequalities [13,14]. Data used to calculate the CCI are derived from the re-analysis of the Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and Reproductive Health Surveys (RHS) data, which are publicly available. The proportion of infants and young children that are meeting the minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) were calculated using the revised UNICEF/WHO indicators [15]. As part of the DHS survey design, these indicators are collected from the youngest child under two years of age born to mothers aged 15–49 years and from children living with the mother at the time of the survey. The revised UNICEF/WHO indicator counts breastfeeding as one group, thus allowing better comparability between breastfed and non-breastfed children. Wealth quintiles and place of residence were used as stratification variables in our analyses. DHS uses a wealth index derived using principal component analyses applied to a list of household assets/characteristics, which are country-specific. The first quintile (Q1) represents the 20% poorest families, and the last quintile (Q5) represents the 20% wealthiest families. Quintiles correspond to the relative position of households within each national sample. Urban and rural residence was classified according to boundaries provided by local authorities. All the analyses were based on publicly available data from national DHS surveys. Ethical clearance was the responsibility of the institutions that administered the surveys. The data was obtained after registering in the DHS website, and the datasets did not contain any personal identifiers. Analyses were done using SPSS version 20. Descriptive statistics were presented as a mean or median for continuous variables, and as a percentage for counts. Inequalities in stunting prevalence and complementary diet quality measures were presented by wealth quintile and rural/urban residence using equiplots (http://www.equidade.org/equiplot.php) generated using STATA version 12. Each horizontal line shows the results by quintile or rural/urban for a given country. Normal distributions of the variables were checked using Kolmogorov-Smirnov test. Independent-t-test was used to compare CCI and DDS between rural-urban and poorest-richest wealth quintiles. p-values ≤ 0.05 were considered statistically significant.

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women and new mothers with information and reminders about prenatal care, nutrition, and child health. This can help improve access to important health information, especially in remote or underserved areas.

2. Telemedicine: Implement telemedicine programs to connect pregnant women and new mothers with healthcare providers through video consultations. This can help overcome geographical barriers and improve access to specialized care, especially for those in rural areas.

3. Community Health Workers: Train and deploy community health workers to provide maternal health education, prenatal care, and postnatal support in underserved communities. These workers can bridge the gap between healthcare facilities and the community, improving access to essential services.

4. Maternal Health Vouchers: Introduce voucher programs that provide pregnant women with financial assistance to access quality maternal health services. These vouchers can cover costs related to prenatal care, delivery, and postnatal care, ensuring that women have access to necessary healthcare without financial barriers.

5. Public-Private Partnerships: Foster collaborations between the public and private sectors to improve access to maternal health services. This can involve leveraging private healthcare providers and facilities to expand service coverage and reduce wait times.

6. Transportation Solutions: Develop innovative transportation solutions, such as mobile clinics or ambulances, to ensure that pregnant women can reach healthcare facilities in a timely manner, particularly in remote or hard-to-reach areas.

7. Maternal Health Information Systems: Implement robust information systems to track and monitor maternal health indicators, allowing for better resource allocation and targeted interventions. This can help identify areas with low access to maternal health services and guide efforts to improve access.

It is important to note that the specific context and needs of each community should be considered when implementing these innovations. Additionally, ongoing evaluation and monitoring should be conducted to assess their effectiveness and make necessary adjustments.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthen Integrated Health Systems: Develop and implement integrated health systems that combine both nutrition-specific and nutrition-sensitive interventions. This can be achieved by aligning food and health systems interventions to accelerate stunting reduction more equitably.

2. Improve Access to Reproductive, Maternal, Neonatal, and Child Health (RMNCH) Interventions: Enhance access to RMNCH interventions by focusing on the most disadvantaged groups, such as those living in rural areas and the poorest wealth quintile. This can be done by increasing the coverage of interventions such as antenatal care, skilled birth attendance, immunization, and oral rehydration therapy.

3. Enhance Nutrition Counseling: Strengthen nutrition counseling during antenatal care visits to improve maternal and child diet quality. This can be achieved by providing comprehensive information on the importance of a diverse and balanced diet, including breastfeeding and complementary feeding practices.

4. Address Socio-economic Inequalities: Implement targeted interventions to address socio-economic inequalities in access to maternal health. This can be done by providing financial support or incentives for the most disadvantaged groups to access maternal health services, ensuring that cost is not a barrier.

5. Strengthen Data Collection and Monitoring: Improve the collection and analysis of data on maternal health indicators, including stunting prevalence, dietary diversity, and access to RMNCH interventions. This will enable better monitoring of progress and identification of areas that require further attention.

6. Collaborate with Stakeholders: Foster collaboration between governments, non-governmental organizations, and other stakeholders to implement and scale up innovative approaches to improve access to maternal health. This can include partnerships to provide training, resources, and support for healthcare providers and community health workers.

By implementing these recommendations, it is possible to develop innovative solutions that can improve access to maternal health and reduce stunting in Sub-Saharan Africa.
AI Innovations Methodology
To improve access to maternal health in Sub-Saharan Africa, here are some potential recommendations:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and trained healthcare professionals in rural areas can improve access to maternal health services.

2. Expanding mobile health (mHealth) initiatives: Utilizing mobile phones and technology to provide maternal health information, appointment reminders, and telemedicine consultations can help overcome geographical barriers and improve access to care.

3. Community-based interventions: Implementing community health worker programs can bring essential maternal health services closer to remote communities, providing education, antenatal care, and postnatal support.

4. Improving transportation: Enhancing transportation networks and providing affordable transportation options can help pregnant women reach healthcare facilities more easily, especially in rural areas.

5. Addressing socio-economic barriers: Addressing poverty, gender inequality, and cultural norms that hinder access to maternal health services can help improve access for marginalized populations.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current state of maternal health access, including indicators such as distance to healthcare facilities, availability of healthcare professionals, utilization rates, and socio-economic factors.

2. Modeling the interventions: Develop a simulation model that incorporates the potential impact of each recommendation on access to maternal health. This could involve estimating the increase in healthcare facilities, the number of mobile health interventions implemented, the number of community health workers deployed, transportation improvements, and the reduction of socio-economic barriers.

3. Data analysis: Use the simulation model to analyze the potential impact of the recommendations on access to maternal health. This could include estimating changes in utilization rates, reduction in travel time to healthcare facilities, and improvements in socio-economic indicators.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the results and understand the potential variations in outcomes based on different assumptions or scenarios.

5. Policy recommendations: Based on the simulation results, provide policymakers with evidence-based recommendations on which interventions are most effective in improving access to maternal health and prioritize their implementation.

It is important to note that the methodology described above is a general framework and can be tailored to the specific context and available data in Sub-Saharan Africa.


Statistics:
Citations: 16
Identifiers:
DOI: 10.3390/nu12010253
Research Areas:
Community Interventions, Disparities, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
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