| BackgroundGlobally,childhood undernutrition is an important public health issue,as it impacts on children’s short-and-long-term health,well-being,and functioning.According to WHO standards,child undernutrition is measured by three indicators:stunting,underweight,and wasting.In Nepal,child undernutrition remains a particular concern due to the high prevalence of the all three forms of undernutrition which is above the cut-off value for public health significance.The problem of undernutrition is alarming,and it is the underlying causes of all forms of deaths in children aged under five years in Nepal.In 2016,almost 36.0% children in Nepal are stunted,27.0% are underweight,and 10.0% are wasted.Therefore,different stakeholders such as the Nepalese government,non-governmental organizations,and donor organizations have coordinated and implemented different programs and interventions as a commitment to achieve the international and national child nutrition targets to end all forms of undernutrition by 2030.In this case,Nepal has set its target to lessen stunting to 24.0% and decrease wasting to 5.0% by 2025 for attaining global targets of World Health Assembly’s.Further,Nepal has target of decreasing stunting to 15%,wasting to less than 4%,and underweight to 10% by 2030.However,previous studies in Nepal have not considered the three indicators of undernutrition to comprehensively assess the trend of decline of undernutrition,and there is no research to predict whether Nepal can achieve the global and national nutritional targets.Similarly,previous studies in Nepal have reported determinants of stunting in children,but few studies have focused on the determinants of wasting and underweight.Additionally,previous studies which explored the determinants of childhood undernutrition only used a single-level analysis method,ignoring the hierarchical structure of the data,which may underestimate or overestimate the actual affects.In addition,although previous studies have identified the main factors of childhood undernutrition and formulated continuous intervention plans,the prevalence is still high in Nepal,which indicates that there could be other factors that contribute to the occurrence of childhood undernutrition.Past studies have shown that in other parts of the world,disasters(such as earthquakes)can have longterm effects on child undernutrition however,this issue still remains unidentified in the case of Nepal though it is one of the most vulnerable countries to disaster in the world.ObjectivesFirst,the study explores the trends in prevalence of stunting,wasting,and underweight among children under five years of age at national level,regional level,and different socio-demographic groups from 2001 to 2016.Then,the study predicts the prevalence of childhood undernutrition till 2030 based on the trends from 2001 to2016 to inform the progress in achieving the nutritional targets set at national level and global level.Second,the study explores the determinants of stunting,wasting,and underweight in children under five years of age applying multilevel model analysis.Third,the study explores the impact of Gorkha earthquake-2015 on the childhood nutritional status by comparing the children from earthquake affected areas and earthquake non-affected areas.MethodologyData for this dissertation comes from two sources for addressing the research objectives.The data to achieve the first two research objectives come from the nationwide survey namely Nepal Demographic and Health Surveys(NDHS),which are conducted every five years by the Ministry of Health of Nepal,conducted in 2001,2006,2011,and 2016.The two-stage stratified random sampling methods was applied in NDHS for selecting households.Firstly,the clusters/communities were chosen as the primary sampling units(PSUs)with probability proportion to size.Then,households were chosen using the equal probability systematic selection procedure from sampled PSUs in the second stage.A total of 8,602 households were interviewed in 2001;8,707 in 2006;10,826 in 2011;and 11,040 in 2016.The data of the third research objective was collected through field survey in 2019 from 866 children under five years of age,which is 4.5 years after the Gorkha earthquake(2015).(1)In order to achieve the first research objective,the NDHS data collected in2001,2006,2011 and 2016 were merged and polled together for the trend analysis.Then,the analysis was conducted in two stages.First,the descriptive analysis was conducted considering the primary sampling units(clusters),strata,and weight variable through a complex sample analysis procedure to standardize the prevalence of undernutrition in different years.Second,logistic regression analysis was applied to test the trends of prevalence of undernutrition over time using stunting,wasting,and underweight as dependent variables,and using the year represented by four data collection as the independent variable.All trend analysis is stratified by gender to compare and reveal the difference in the prevalence of undernutrition among boys and girls,and to test whether the declining trend of undernutrition in each subgroup is statistically different based on gender.In addition,forecast analysis was conducted using the autoregressive integrated moving average(ARIMA)model with the data on prevalence of child undernutrition from 2001 to 2016.The model fit was assessed and determined using the values of root mean square error(RMSE),mean absolute error(MAE),and mean absolute percentage error(MAPE).(2)In order to achieve the second research objective,multilevel model analysis is used to examine the determinants of childhood undernutrition in individual,household,and community level.NDHS data was collected by using a multistage sampling method to extract some individuals from the sampled communities.It has a "community-individual" hierarchical structure,where the lower level of hierarchy(children under five years)is nested within the communities.Socio-ecological framework was used for a multilevel model to analyze the individual,household,and community-level factors of childhood undernutrition.The main explanatory variables at individual level included the child’s age and gender,birth weight,birth order,child morbidities of fever,diarrhea,in the last two weeks(fever,diarrhea),duration of breastfeeding.The interpersonal factors included mother’s age,education level,occupation,body mass index,mother’s health seeking behavior in pregnancy(number of antenatal visits,intake of iron/folic acid tablets).The household level factors included family size,caste/ethnicity,and wealth quintiles.Similarly,community level factors included the economic situation of the community,the educational level of women in the community,place of residence(rural or urban),and ecological regions.(3)In order to achieve the third research objective,field survey and data collection were conducted from 866 children under five years of age in November to December 2019.In the earthquake-affected and non-affected areas,households with children under the age of five were selected,and data were collected through face-toface interviews at homes using a structured questionnaire.The questionnaire mainly includes the basic characteristics of the caregiver,the exposure status in the earthquake,the basic characteristics of the children,and the nutritional assessment of the children through anthropometric measurements.Single factor analysis found that there are differences in some characteristic factors of children and their caregivers in the areas affected by the earthquake and those not affected by the earthquake.Therefore,before the multivariate analysis,propensity score matching(PSM)was used for one-to-one matching of the samples from two areas(earthquake affected and earthquake nonaffected)for reducing the problem of systematic differences in the basic characteristics between two groups and for reducing the self-selection bias.After matching,the factors were balanced.Then,multivariate logistic regression analysis was conducted using stunting,wasting,and underweight as dependent variables,and earthquake exposure as the main explanatory variable,including other covariates to explore the association between earthquake and childhood undernutrition.Main resultsThe trend analysis results of the NDHS data of the national survey show that the trends of stunting,wasting and underweight have a significant declining trend.Between 2001 and 2016,the stunting prevalence dropped from 57.2% to 35.8%(P<0.001),the wasting prevalence dropped from 11.2% to 9.7%(P<0.05),and the underweight prevalence dropped from 42.7% to 27.0%(P<0.001).Although significant progress has been made at the national level,the results show that the region,place of residence,economic status,and mother’s education level are different from the national trend.According to the analysis of the child’s gender,male and female children have a significant declining trend in stunting and underweight(P<0.001),while the decline in wasting of female children is not statistically significant.The analysis by place of residence shows that the prevalence of undernutrition in all three indicators is higher among children in rural areas.The decreasing trend of stunting in urban male and female children was statistically significant(P<0.001),while the decreasing trend of wasting in urban male and female children was not statistically significant.Similarly,the declining trend of underweight was only statistically significant among male and female children in rural areas(P<0.001).The prevalence of undernutrition in different groups such as children in mountain region,children in rural areas,children with uneducated mothers,and children from poorest wealth quintile were very high compared to the other groups and national prevalence even though the declining trend was significant.Nepal’s childhood stunting needs to be reduced by 11.8 percentage points and wasting needs to be reduced by 4.7 percentage points to achieve the global target of child undernutrition by 2025,and needs 12 percentage points reduction in underweight to achieve the national targets by 2025.The forecast analysis results show that by 2025,the stunting prevalence will be 21.6%,the wasting prevalence will be 9.0%,and the underweight prevalence will be 15.5%,which is reduction of 14.2 percentage points,0.7 percentage points,and 11.5 percentage points from 2016,respectively.Similarly,by 2030,the stunting prevalence is expected to be 14.3%,the wasting is expected to be 8.4%,and the underweight is expected to b 9.8%,which is reduction of 21.5percentage points,1.3 percentage points,and 18.2 percentage points respectively from2016.Based on these predictions,Nepal is expected to achieve the targets of reducing stunting prevalence for 2025 and 2030 and the national target of reducing underweight prevalence in 2030.However,Nepal may not be able to achieve the global and national targets for reducing wasting prevalence by 2025 and 2030.The multilevel model analysis of the determinants of childhood undernutrition shows that it is associated with various factors at the individual,household,and community levels.In all survey years,different factors such as child birth weight and wealth quintile are associated to stunting,underweight,and wasting.In addition to the above factors,the survey also found that the mother’s higher age(OR = 0.6,95%CI0.4-0.9),the higher level of mother’s education(OR = 0.6,95%CI 0.4-0.9),higher number of antenatal visits(≥4 visits)during pregnancy(OR = 0.7,95%CI 0.5-0.9),children from Janjati caste/ethnicity(OR = 0.6,95%CI 0.5-0.8),children from richest wealth quintile(OR = 0.6,95%CI 0.5-0.8),and Terai areas(OR = 0.7,95%CI 0.6 –0.9)are protective factors for stunting whereas rural place of residence(OR = 1.4,95%CI 1.1-1.8)and low birthweight than average(OR = 2.0,95%CI 1.6-2.3)are risk factors for stunting.Similarly,female children(OR = 0.8,95%CI 0.6-0.9),mothers of age 20-24 years old(OR = 0.5,95%CI 0.2-0.9),children from Janjati caste/ethnicity(OR = 0.5,95%CI 0.3-0.7),the richest wealth quintile(OR = 0.5,95%CI 0.3-0.8)are protective factors for wasting whereas low birth weight(OR =1.7,95%CI 1.3-2.1),fever in the last two weeks(OR = 1.5,95%CI 1.2-2.0),living in rural areas(OR = 1.5,95%CI 1.1-2.1)and Terai areas(OR = 2.2,95%CI 1.4-3.6)are the risk factors of wasting.In addition,children from Janjati caste/ethnicity(OR = 0.4,95%CI 0.3-0.6)and the higher education level of the mother(OR = 0.6,95%CI 0.4-0.9),higher number of antenatal visits in pregnancy(OR = 0.8,95%CI 0.6-0.9),intake of ≥180 tablets of iron/folic acid tablets in pregnancy(OR = 0.4,95%CI 0.2-0.9)were protective factors for underweight;maternal high body mass index(OR = 1.6,95%CI 1.4-1.9),fever(OR = 1.2,95%CI 1.1-1.4)and/or diarrhea(OR = 1.4,95%CI1.1-1.7)two weeks preceding the survey,the larger family size(OR = 1.5,95%CI1.1-2.1)and Terai areas(OR = 1.5,95%CI 1.1-2.0)are risk factors for underweight.Field survey results showed that the prevalence of stunting in the earthquakeaffected group was 28.0%(95%CI 23.9-32.4)and 17.3%(95%CI 13.8-21.2)in earthquake non-affected group,the difference is statistically significant(P<0.01).The prevalence of underweight was 8.0%(95%CI 5.6-11.1)in earthquake non-affected group,while it was 14.2%(95%CI 11.1-17.8)in earthquake affected group,and the difference was statistically significant(P<0.01).The prevalence of wasting in the earthquake-affected group was 15.1%(95%CI 11.9-18.8)while it was 11.6%(95%CI8.7-15.0)in the non-earthquake-affected group,and the difference was not statistically significant(P > 0.05).The results of multivariate analysis showed that those children who were in the mother’s womb and under 6 months of age at the time of earthquake were 2.4 times more likely to stunting than children who were not affected by the earthquake((OR = 2.4,95%CI 1.5-3.7).Similarly,the risk of underweight was 2.6 times higher(OR = 2.6,95%CI 1.4-4.7)in those children who were in the mother’s womb and under 6 months of age at the time of earthquake compared to children who were not affected by the earthquake.ConclusionsOverall,childhood undernutrition has declined significantly in the last two decades at the national level in Nepal,however,still a lot has to be done in the field of childhood undernutrition in Nepal.A substantial inequality exists across different socio-economic and regional groups.Moreover,Nepal is likely to achieve the global nutritional targets for stunting but will not meet the targets for wasting.Nepal is likely to achieve the national targets for underweight by 2030.Factors such as normal birth weight,mother’s higher education level,urban place of residence,improved household wealth quintiles,improved community education,and reduced community poverty level are the protective factors for childhood undernutrition in Nepal.In addition,the association between the earthquake and childhood stunting and underweight after the4.5 years of earthquake among affected children implies that the disaster can have a long-term impact on children urging the need of the long-term nutritional programs after disasters in addition to the programs on immediate food supplementation,and emergency health and nutritional responses.Therefore,inter-sectoral coordination,targeted nutritional interventions,and multi-sectoral programs are recommended for high-risk groups in order to reduce the undernutrition gap between different subpopulations in Nepal. |
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