Risk Factors for Stunted Growth among Children Aged 6–59 Months in Rural Uganda

Despite the agreed global and national stunting reduction targets, Uganda has made very little progress. Understanding context-specific risk factors for stunted growth is therefore pertinent to designing programs to address the problem. A cross-sectional study was conducted in 32 randomly selected villages in Buhweju district, Southwest Uganda. Data entry, cleaning and analysis were carried out using Statistical Package for Social Sciences (SPSS) version 21. A regression analysis was conducted to examine the associations between potential risk factors and stunted growth. The survey covered 256 households and anthropometric measurements were taken for 221 children aged 6–59 months. The majority of the households (66%) in the district were food insecure and had a low socioeconomic status (84%). The prevalence of stunting in Buhweju district was 51%, which is significantly higher than the regional and national averages. Only 28% of the children were exclusively breastfed in the first 6 months of life, and only 10% of them received the minimum acceptable diet (MAD). The findings of this study demonstrate that reductions in stunted growth at national or regional levels has not necessarily translated into similar trends in rural areas of Uganda. The notable contributors to stunting in these areas include morbidity, sub-optimal infant and young child feeding (IYCF) practices, low consumption of animalsource foods, food insecurity, lack of access to high-quality drinking water, sanitation and hygiene (WASH) facilities and poverty. Increased investment in both nutrition specific and sensitive interventions is therefore crucial to address these risk factors. DOI : 10.14302/issn.2379-7835.ijn-16-1408 Corresponding author: John Bukusuba, School of Food Technology, Nutrition and Bio-engineering, Makerere University, Kampala, Uganda, Tel: +256772683177, Email: jbuk2001ug@yahoo.com


Background
Stunting has recently gained international attention because it has severe short-and long-term health consequences and affects 178 million children in low-and middle-income countries (1,2). Globally, the prevalence of stunting is highest in Eastern Africa, where 50% of children under 5 years old are stunted (1), and Uganda has one of the highest burdens of stunted growth (2,3). Therefore, in 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target of a 40% reduction in the number of stunted children under 5 years old by 2025 (2).
Despite the agreed global and national stunting reduction targets, Uganda has made very little progress, and it is currently not on course to meet the Second National Development Plan (NDP II) and World Health Assembly (WHA) targets, as shown in Figure 1 and 2 (2,4,5,6,7,8). The risk factors for stunted growth in rural Uganda are still poorly understood, particularly the risk factors in the southwest region where, despite 95% of the households reportedly being food secure, two out of every five (42%) children are stunted (8,9,10).
Stunting is a well-established risk marker for poor child development and an enormous drain on economic productivity and growth. Adults who were stunted as children earn 20% less compared with nonstunted individuals (11), stunted children are four times more likely to die before their fifth birthday (1) and the World Bank estimates that stunting can reduce a country's gross domestic product (GDP) by up to 3% (12). However, the economic losses in Uganda are likely even to be much higher. It is estimated that 5.6% of Uganda's GDP ($899 million) is lost every year as a result of undernutrition (13,14). Understanding the context-specific risk factors for stunted growth is therefore pertinent to designing programs to address the problem. This study adapted the conceptual framework developed by Stewart et al.(15) to assess the potential predictors of stunted growth in the study district.

Study Site and Design
A cross-sectional study was conducted in Buhweju district in Southwest Uganda. Structured questionnaires were developed and pre-tested prior to starting data collection. The fieldworkers underwent a 2 -day training course, which included a 1-day class and a standardization test on the second day. Sixteen focus group discussions and 16 interviews with key informants were also conducted (in addition to the

Socio-Demographic Characteristics
The survey covered 256 households and anthropometric measurements were taken for 221 children aged 6-59 months. Among the households surveyed, 11% were female-headed households and the average household size was 5 people. The ratio of boys to girls was 1 to 1.
The majority of heads of households (86%) were Banyankore by tribe and had education levels of up to primary school (59%), and their main occupation was farming (73%). The SES of most households (84%) was low, and female-headed households were significantly (p < 0.05) more likely to be of low SES.

Nutrition Status
The prevalence of stunted growth found in this study (i.e., a 2016 survey) in Buhweju district was lower than that in 2004 (51% vs. 56%), but the difference was not significant. However, the prevalence of stunted growth in Buhweju district was significantly (p < 0.05) higher than both the southwest average (51% vs. 42%) and the national average (51% vs. 33%). The prevalence of stunted growth was also higher among boys compared with girls (54% vs. 48%), although the difference was not significant. Only 44% of the children were born in a health facility (Table 1), and these children were significantly (p < 0.05) less likely to be stunted. Most mothers (61%) of stunted children said that they did not know that their children were stunted.
Even among mothers of severely stunted children, most of them (58%) did not know that their children were stunted.
The prevalence of wasting was 5% while the prevalence of being underweight was 21% ( Table 2).
The prevalence rates of wasting and underweight were higher than the southwest regional averages, (5.2% vs. 4.9%) and (21% vs. 15%) respectively, but the differences were not significant.
Stunting was significantly higher among young children under 2 years (p < 0.05) compared with older children above 2 years of age. Stunted growth was shown to increase in among children between 6 months (when complementary foods are introduced) and 12-17 months, and peak in the 18-23-month age group.
Although it was shown to decrease among older age groups, the prevalence of stunting in Buhweju district is still above acceptable limits in all age groups ( Figure 2). This is evidence of diets that are of low quantity and and girls in the surveyed population, which could be leading to differences in the growth patterns ( Figure 3).
Children from households with a low SES were also more likely to be stunted compared with those from households with a high SES.   were therefore assumed to be of adequate quality.
However, the majority of households (65%) reported that the distance to the water source was >30 minutes.
The average time taken to collect water from the main drinking-water source was approximately 42 minutes.
Access to improved water sources is important because 23% of the respondents reported that they do not treat water to make it safe for drinking. Those who reported treating water to make it safe for drinking mainly boil it (87%). The majority of households (72%) also reported that they were not satisfied with their water supply.
Only 23% of the households reportedly used an improved toilet facility although the majority of households with children under 3 years of age safely disposed of the children's excreta (96%). Most of the toilets (83%) observed did not have a facility for hand washing. Therefore, it is unsurprising that only 54% of respondents washed their hands after using the toilet ( Figure 6). Only 2% of the households had access to improved WASH facilities (i.e., drinking-water sources, toilets and hand washing facilities). Children from households with access to safe water for drinking or other improved WASH facilities were less likely to be stunted, although the differences were not statistically   years and above 65 years).

Discussion
Linear growth is the best overall indicator of children's wellbeing and provides an accurate marker of inequalities in human development (21). Stunting is also currently the most prevalent form of child undernutrition and its inclusion among the six global nutrition priorities underscores the urgency to address it (2). Although the Uganda Demographic and Health Surveys (UDHS), which are conducted every 5 years, report on trends in stunting, the focus is mainly at the national and regional levels. Therefore, in the absence of district-level prevalence data, tracking stunting trends and planning for interventions to address stunting mainly relies on regional data. This results in an underestimation of the Lack of access to improved WASH facilities is a known contributor to stunted growth, as this study also found. For example, studies of determinants of stunting among children under 5 years old in Tanzania found that unsafe drinking-water sources were one of the major predictors of stunted growth (22,26). Providing people with access to improved WASH facilities (i.e., safe drinking water, adequate sanitation and facilities to wash their hands with soap) would reduce incidences of diarrhea among children under five and, therefore, they would reduce mortality. Diarrhea is the second most common cause of child death worldwide, and it contributes to child morbidity and mortality by directly affecting children's nutritional status (27). Hand washing with soap at critical times (including before eating or preparing food and after using the toilet) can reduce diarrhea rates by more than 40% (28). This makes it one of the most cost-effective interventions to prevent diarrhea-related disease and deaths. However, this study found that the practice of hand washing after using the toilet was very low.

Conclusion
The findings of this study demonstrate that reductions in stunted growth at the national and regional levels have not necessarily translated into similar trends in rural areas of Uganda. The notable contributors to the persistently high levels of stunting in these areas include morbidity, sub-optimal IYCF practices, low consumption of animal-source foods, food insecurity, lack of access to improved WASH facilities and poverty. Increased investment in both nutrition specific and sensitive interventions is therefore crucial to address these risk factors.