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Background: Stunting is a major public health problem in Africa and is associated with poor child survival and development. We investigate factors associated to child stunting in three Tanzanian regions.Methods: A cross-sectional two-stage cluster sampling survey was conducted among children aged 6-59 months. The sample included 1360 children aged 6-23 months and 1904 children aged 24-59 months. Descriptive statistics and binary and multivariate logistic regression analyses were used.Results: Our main results are: in the younger group, stunting was associated with male sex (adjusted odds ratio [AOR]: 2.17; confidence interval [CI]: 1.52-3.09), maternal absence (AOR: 1.93; CI: 1.21-3.07) and household diet diversity (AOR: 0.61; CI: 0.41-0.92). Among older children, stunting was associated with male sex (AOR: 1.28; CI: 1.00-1.64), age of 4 and 5 (AOR: 0.71; CI: 0.54-0.95; AOR: 0.60; CI: 0.44-0.83), access to improved water source (AOR: 0.70; CI: 0.52-0.93) and to a functioning water station (AOR: 0.63; CI: 0.40-0.98) and mother breastfeeding (AOR: 1.97; CI: 1.18-3.29).Conclusions: Interventions that increase household wealth and improve water and sanitation conditions should be implemented to reduce stunting. Family planning activities and programmes supporting mothers during pregnancy and lactation can positively affect both newborns and older siblings.
The study was conducted in the regions of Iringa, Njombe and Mbeya, where 4.4 million people live, 72% of whom live in rural areas [22]. Although these regions receive the highest rainfall and are Tanzania’s bread baskets, stunting prevalence was 51.3%, 51.5% and 36.0%, respectively, in 2014 [20]. These are the second and the third highest values in Tanzania, well above the national prevalence (34.7%). The study population includes children under 5 in rural and urban households in the three regions. One cross-sectional survey was conducted in each region in November 2013, using a two-stage cluster sampling design. Sixty-three clusters were selected in each region by probability proportional to the size using ENA delta software [23]. Twenty households were chosen in each cluster by random sampling, using a random number table. A complete list of households with children under 5 in each cluster was prepared before the survey date. Households were visited for verification if necessary. Sample size was calculated to detect a 10 percentage point reduction in stunting among children 24–47 months by the end of the project in each region. Power was set at 80%, level of confidence at 95% (one-tailed test), design effect at 1.5 and non-response at 10%. A sample of 501 children in the age group 24–47 months per region was required. A total of 1253 households with children under 5 were targeted in each region to achieve the required sample size. Data were collected using a standardized questionnaire on a digital data gathering (DDG) device, via face-to-face interview with the main caregiver of the child. The following data were collected for anthropometric measurements of all children under 5: sex, age, weight, height and presence of bilateral pitting oedema. Length was taken for children under 24 months in horizontal position; height was taken standing for older children; both to the nearest 0.1 cm with a standard 130-cm height/length board. Weight was measured with an electronic scale to the nearest 0.1 kg. Stunting was defined as height-for-age z-score (HAZ) below −2 SD from the median height of the WHO reference population. Additional data were collected to reflect selected immediate, underlying and basic causes of undernutrition as illustrated in the UNICEF Conceptual Framework [24]. These were regrouped in child characteristics: IYCF practices, occurrence of diseases, supplementation and treatments received; maternal characteristic: nutritional status, pregnancy and breastfeeding status, workload, habits and supplementation during pregnancy and nutritional information received; and household characteristics: water source, sanitation facilities, use of iodized salt, household dietary diversity and farm diversity. When more than one child aged 6–23 months was present in a sampled household, only data from the youngest child were collected. Definition and measurements of variables used in the analysis are presented in Table 1. Definitions and measurement of variables used in the analysis The SMART methodology was used to ensure standardized procedures and tools [28]. After a 6-day training, data collectors had to pass a standardization test to assess accuracy and precision of their anthropometric measurements. The questionnaire was piloted and finalized. Team leaders ensured data quality during data collection. Checks, skip functions and acceptable ranges were pre-established in the DDG devices to reduce mistakes. Implausible anthropometric measurements were defined as ±6 SD, as per WHO criteria [29]. The analysis of factors associated with stunting was divided by age groups: 6–23 and 24–59 months, and conducted for the entire sample and broken down by region. Baseline sociodemographic and clinical characteristics of the sample were described with simple frequency distribution. Crude associations between stunting and sociodemographic and clinical variables were investigated using Pearson’s chi-square test. A multivariate logistic regression model was constructed to identify factors associated with stunting. Odds ratios (OR), 95% confidence intervals (CI) and p-values were obtained. P-values <0.05 were considered significant. Sampling weights were applied to ensure the representativeness of the sample at the regional level. The analysis was conducted in STATA IC/12.1 for Windows and SPSS 20.0. Anthropometric indicators were calculated with ENA software. Concern Worldwide routinely conducts nutrition surveys within its programmes, which are not subject to research ethical scrutiny. The organization subscribes to the ethical principles outlined in the Humanitarian Charter [30]. Furthermore, the project protocol and questionnaire were reviewed and approved by the Government of Tanzania and UNICEF. Oral informed consent was obtained by the interviewees. Consent to conduct anthropometric measurement was obtained from a parent or guardian in the local language.
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