The latest study has found that the use of Insecticide-treated Nets has facilitated the reduction of growth impairment among children below the age of five years in Uganda,
Titled; “Exemplars in Stunting Reduction: Uganda country Case Study”, the study was conducted by researchers from the Makerere University School of Public Health and the Centre for Global Child Health at the Hospital for Sick Children (SickKids), (Toronto, Canada), in collaboration with the Ministry of Health, Uganda, and advisory support from the Centre of Excellence for Maternal Newborn and Child Health.
It was conducted in two national subregions of Teso and Tooro. The districts focused on were; Serere in Teso has shown accelerated stunting progress (22.2%-point decrease) and Kasese in the Tooro that has lagged behind in stunting reduction (3%-point increase).
The investigators of this study were Dr. Zulfiqar A Bhutta and Dr. Emily Keats, from the Center for Global Health at The Hospital for Sick Children (Sick Kids) in Canada, and Dr. Richard Kajura and Dr. Peter Waiswa from Makerere University School of Public Health.
In this mixed-methods case study, Dr. Waiswa noted that malaria reduction interventions have had a great impact on stunting reduction before quickly adding that this is a new finding that needs to be further investigated. This was during the dissemination event on March 30, 2021, at Golf Course Hotel, in Kampala.
The researchers recommended that government should continue to prioritize malaria-reduction strategies, including bed-net distribution campaigns and prevention/treatment approaches for mothers and children since evidence had pointed it out as a key accelerator to stunting reduction.
“Among the interesting findings from the data we have so far and the greatest driver of reduction of stunting is the use of insecticide-treated nets. We have been fighting malaria not knowing that it was fighting stunting too despite their usage still being improper,” observed Dr. Waiswa.
A 2018 UNICEF Report on malaria prevention indicated that children under five years are most susceptible to malaria because they have very little acquired immunity to resist it. It further highlights that malaria during pregnancy may likely make a newly born underweight.
Dr. Esther Bagyitegere, a pediatrician specialist and head of Mulago nutrition unit Mwana Mugimu emphasized that uncontrolled malaria may weaken the immunity of a child and consequently make them stunt.
“Malaria is an infectious disease and repeated episodes mostly likely may render a child to suffer poor intake of food yet there is a lot of nutrient expenditure during the inflammatory process. All this affects the nutrition status, if malaria is not well controlled, they may consequently suffer stunting” said Dr. Bagyitegere
Ministry of Health National Malaria Control Program through the Malaria Reduction Strategic Plan (2014-2020), also points out that 27% of inpatient deaths among children under five years of age are due to malaria.
This has been reduced by the prevention interventions of Insecticide Treated Nets for pregnant women and under-fives, consequently advancing to an inclusive Long-lasting insecticidal net (LLINs), currently being promoted by WHO with a 27million distribution under the “Chase Malaria” campaign by 2018.
The findings also show that child stunting has sharply declined from 48% in 1988 to 29% in 2016. Dr. Richard Kajura, notes that besides coverage under Insecticide-treated Nets, there are other important drivers to stunting reduction including improved maternal nutrition, improved education, and improved maternal and newborn care.
Other stunting reduction drivers in Uganda as noted by the investigators are access to piped water, improved household wealth, reduced open defecation, women’s empowerment, improved inter-pregnancy interval, and declines in adolescent births.
Regarding women empowerment, Dr. Kajura noted that this driver contributes differently to the reduction rate due to differences in the level of empowerment in the two sampled subregions.
“In the Teso sub-region, women felt that being empowered financially would have influenced them to do independent decision making on what to feed their children irrespective of the men to decide what to eat. While for Tooro sub-region, both the mothers and stakeholders mentioned that they are not empowered to take these decisions, the burden of looking after the household is again on them and this is a complication” said Dr. Kajura.
Highlights of Further Findings
National stunting prevalence decreased by 16% points between 2000 and 2016. However, improvements were not consistent across Uganda’s regions with the Northern and Western regions experiencing the slowest gains.
Among children 0-59 months of age, malaria burden declined by 42.5% and 55.4% from 2009 to 2014 when testing by rapid diagnostic test (RDT) and microscopy, respectively. Similarly, the percentage of households with at least one insecticide-treated mosquito net or long-lasting insecticidal net increased by 93.1% and 97.3%, respectively, over the same period. Bed net coverage among children under-5 increased from 41.1% in 2009 to 77.5% in 2014.
Both the infant and under-5 mortality rates (per 1,000 live births) reduced substantially in Uganda between 2000 and 2016. Under-5 mortality has reduced from 147.8 in 2000 to 51.2 in 2016, a 65.4% decline. Maternal mortality (per 100,000 live births) has also decreased in the last two decades, from 578 in 2000 to 381 in 2016, a 34.1% decline. However, relative to other countries in the region, maternal mortality is still quite high, researchers say.
Over the past three decades from 48% in 1988 to 29% in 2016, Childhood stunting has decreased considerably despite a slight increase in the Gross Domestic Product of $957 from $377 over the same period.
Stunting reduction socio-demographic inequalities
Researchers also found that stunting and its reduction rates differed depending on the diverse socio-demographic factors in settlement status and regions. Teso sub-region had lower childhood stunting because of the dietary diversity compared to the Tooro sub-region which suffered a singular food preference.
Dr. Waiswa related that” Teso sub-region has a food diversification because the children feed on meat, milk, simsim, and millet compared to Tooro where children are limited to single foods.” Adding those other regions should learn from the Teso sub-region in both diet intake and the stunting reduction rates.
Also, disparities in stunting by urban and rural residents have declined over time with stunting consistently lower among urban children. But, Dr. Waiswa also notes that a barrier of poor sanitation in urban areas may influence the increase in urban stunting rates more than in rural areas.
The Barriers
One of the barriers to child growth discovered in the study was unfavorable cultural practices. Researchers observed that whereas some regions are food baskets, food is not necessarily given well in terms of food taboos for example the first breast milk is thrown away and not given to children for example central Uganda.
Given the dietary disparity in some regions, this poses as a barrier to stunting reduction due to the poor dietary intake which non-diversified according to the study. Other barriers mentioned in the study are; low fiscal allocation of resources to nutrition despite its importance, climate shocks, lack of arable land which is unfortunately increasing, food insecurity, and large household size.
The investigators to the study now want the government to strengthen strategies that deliberately target the poor, least educated, and rural populations, along with high-burden northern and western districts. This is in addition to investing in new technologies and nutrition-sensitive innovations in the agriculture sector to improve productivity.
They also say the government needs to develop and expand social protection schemes for vulnerable populations to manage the increasing impact of climate shocks and other humanitarian crises which can contribute to food security.
Additionally, the researchers want the government to ensure that adolescent-friendly health services are available and keep girls in school to further reduce adolescence.
Charles Asiimwe, a Consultant at Uganda Nutrition Action Plan said this analysed stunting data provides evidence that will help inform policy gaps. He
“We are supposed to do regional-based programming to support malnutrition. Such information helps us to see what are the contextual issues in each sub-region and how do we address them. For example, addressing these stunting issues in Toro as per the findings means we must implement a strong behavioral change communication,” Asiimwe observes.
Adding that; “Although the stunting levels and figures we have seen are low in Teso sub-region when you don’t act, it can still increase. We must continue advocacy in behavioral change focusing on nutrition as well as address issues of income and poverty reduction as shown in the figures presented.”
According to Asiimwe, fighting stunting is not one sector's business. “As you have seen, 80% of the actions that will address stunting are beyond the sector of health. However, the measurements are made on a human being which becomes a custodian of Ministry of Health for the indicator although if you are to address stunting, which now calls for multi-sectoral approach all other sectors must be brought on board.”
Written by Davidson Ndyabahika & Brenda Namata
