Drivers of stunting reduction in the Kyrgyz Republic: A country case study

Abstract

Background: Chronic malnutrition among infants and children continues to represent a global public health concern. The Kyrgyz Republic has achieved rapid declines in stunting over the last 20 y, despite modest increases in gross domestic product per capita.

Objective: This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic.

Methods: This mixed methods study employed 4 inquiry methods, including: 1) a systematic scoping literature review; 2) retrospective quantitative data analyses, including linear regression multivariable hierarchical modeling, difference-in-difference analysis, and Oaxaca-Blinder decomposition; 3) qualitative data collection and analysis; and 4) analysis of key nutrition-specific and -sensitive policies and programs.

Results: Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Child growth Victora curves show improvements in height-for-age z-scores (HAZ) for children in the Kyrgyz Republic between 1997 and 2014, indicating increased intrauterine growth and population health improvements. The decomposition analysis explained 88.9% (0.637 SD increase) of the predicted change in HAZ for children under 3 y (1997-2012). Key factors included poverty (61%), maternal nutrition (14%), paternal education (6%), fertility (6%), maternal age (3%), and wealth accumulation (2%). Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as key drivers of stunting decline. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms.

Conclusions: Improvements in stunting were achieved amidst political and economic changes. Multilevel enablers, including poverty reduction, improved food security, and introduction of land and health reforms have contributed to improvements in health, nutrition, and stunting among children in the Kyrgyz Republic.

Keywords: Central Asia; Kyrgyz Republic; children; exemplar; linear growth; mixed methods; nutrition; stunting.

FIGURE 1

A) Map of the Kyrgyz Republic. B) The prevalence of children aged under 5 y stunting in Central Asian countries, 1990–2017. Source: (1)

FIGURE 2

Conceptual framework showing distal, intermediate, and proximal determinants of stunting in the Kyrgyz Republic. Note: framework reflects only indicators that were measurable and available for quantitative analysis. DPT3, diphtheria-tetanus-pertussis.

FIGURE 3

A) Kernel density plot for height-for-age z-score distribution in children aged <5 y, 1997–2014. B) Victora curve using data from the 1997, 2005–06, 2012, and 2014 surveys among children aged <5 y, including WHO Regional Office for Europe (EURO) mean. C) Victora curve using data from the 1997, 2005–2006, 2012, and 2014 surveys among children <5 y with linear splines. lpoly smooth, Kernel-weighted local polynomial smoothing; *child anthropometry data was collected for children <3 years only in DHS 1997. DHS, Demographic and Health Survey; EURO, European Union Region; HAZ, height-for-age z-score; MICS, Multiple Indicator Cluster Survey.

FIGURE 4

A) Subnational stunting estimates for children aged under 5 y in the Kyrgyz Republic in 2014. B) Compound annual growth rate by oblast, 1997–2014. Child anthropometry data was collected for children <3 years only in the DHS 1997; the following formula was used to estimate % stunting: % stunted under 5 years = -0.0114274 + (1.104429 ^∗ % stunted under three years) (64).

FIGURE 5

A) Stunting prevalence by wealth quintile, 1997–2014. B) Stunting prevalence by maternal education, 1997–2014. C) Stunting prevalence by residential area, 1997–2014.

FIGURE 6

Decomposing predicted changes in height-for-age z-score (i.e., percent contribution of determinant domains) from 1997 to 2012. Note: the under 6-mo age category results are not presented due to small sample sizes and the under 5-y age category due to the 1997 MICS survey not including height-for-age z-score data on children over the age of 35 mo. Indicators included: maternal nutrition (BMI and height), paternal education, higher calorie (daily intake of calories), economic improvement (wealth index and percent of families below national poverty line), maternal age, and fertility (interpregnancy interval and parity). Other category includes child age, gender, and region. CAGR, compound annual growth rate.

FIGURE 7

Overview of laws, policies, and programs in the Kyrgyz Republic from 1990–2016. ¹Policy ended in 2010 but was implemented until Den Sooluk.