Drivers of stunting reduction in Nepal: a country case study

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ABSTRACT

Background

Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting – a physical manifestation of chronic malnutrition – despite only modest economic growth and significant political instability.

Objective

This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country.

Methods

Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses.

Results

Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction.

Conclusions

Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal’s stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.

Keywords:

stunting
linear growth
HAZ
children
under-5
nutrition
Nepal
South Asia
mixed methods

Abbreviations used:

ANC
antenatal care
CAGR
compound annual growth rate
CB-IMNCI
Community-based Integrated Management of Neonatal and Childhood Illness
CIX
concentration index
DHS
Demographic and Health Survey
DID
difference-in-difference
FCHV
female community health volunteer
GDP
gross domestic product
HAZ
height-for-age z-scores
NHSP
Nepal Health Sector Program
SII
slope index of inequality
WASH
water, sanitation, and hygiene.

Cited by (0)

Presented at the conference, World Health Assembly held in Geneva, Switzerland, 17–21 May, 2020.

This study was funded by a grant to the Centre for Global Child Health from Gates Ventures.

Data described in the manuscript, code book, and analytic code will be made available upon request pending application and approval.

Published in a supplement to the American Journal of Clinical Nutrition. The Guest Editor for this supplement was Mark Manary and reports no conflicts of interest. The publication costs for this supplement were defrayed in part by the payment of page charges by Gates Ventures. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, Editor, or Editorial Board of the American Journal of Clinical Nutrition.

The supplement coordinator for the supplement publication was NA, Gates Ventures/Hospital for Sick Children, Toronto, Canada. The supplement coordinator reports no conflicts of interest. The Stunting Exemplars research principal investigator was ZAB, Hospital for Sick Children, Toronto, Canada. The principal investigator reports no conflicts of interest.

Supplemental Tables 1–12, Supplemental Figures 1–10, and Supplemental Appendices 1–7 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/ajcn/.

SB and JW, authors listed alphabetically.