Drivers of stunting reduction in Nepal: a country case study

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

FIGURE 1

(A) Map of Nepal. (B) The prevalence of stunting in children aged under 5 y in Nepal and its neighboring countries in the South Asia Region, 1990–2018. Source: (1).

FIGURE 2

Conceptual framework showing distal, intermediate, and proximal determinants of stunting. Note: framework reflects only indicators that were measurable and available for quantitative analysis. Altitude, birthweight, and vitamin A were not available in the 2001 survey. DPT3, diptheria, pertussis, and tetanus vaccine.

FIGURE 3

(A) Kernel density plot for HAZ distribution in children aged <5 y, 1996–2016. (B) Victora curves using data from the 1996, 2001, 2006, 2011, and 2016 DHS surveys among children aged <5 y, including SEARO mean HAZ curve. SEARO, which stands for the Regional Office for South East Asia, is 1 of the WHO's 6 regions of focus. SEARO includes Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. (C) Victora curves using data from the 1996, 2001, 2005, 2011, and 2016 DHS surveys among children <5 y with piecewise linear splines. *Note: DHS 1996 included <36 mo population only and thus values were adjusted to reflect the entire 24-59 mo population as described in the methods. DHS, Demographic and Health Survey; HAZ, height-for-age z-score.

FIGURE 4

(A) Subnational stunting estimates for children aged under 5 y in Nepal in 2016. (B) CAGR by state, 2001–2016. Prior to 2015, Nepal was subnationally divided into 5 regions rather than the current 7 states. Where possible, back-calculation of subnational stunting estimates by state was done through an amalgamation of data at the district level. This was not possible for 1996 as the DHS district identifiers were not available for this year. As such, CAGR calculations are presented for the period 2001–2016. CAGR, compound annual growth rate; DHS, Demographic and Health Survey.

FIGURE 5

(A) Stunting prevalence in Nepal by wealth quintile, 1996–2016. (B) Stunting prevalence in Nepal by maternal education, 1996–2016. (C) Stunting prevalence in Nepal by residential area, 1996–2016.

FIGURE 6

Decomposing predicted changes in HAZ (i.e., percent contribution of determinant domains) from 2001 to 2016. 1. Maternal and newborn health care (SBA and ANC 4+), maternal nutrition (maternal BMI and maternal height), fertility (number of children and pregnancy interval), reduction in diarrhea incidence, economic improvement (wealth index), other (child age, gender, and region), breastfeeding practices (duration of breastfeeding), child diet improvement (use of grains, roots, tubers, fruits, and vegetables), number of health facilities (total number of health posts or lower level health facilities per 10,000 population), parental education (maternal and paternal education), reduced open defecation. 2. Parental education breakdown: children 6–23 mo: maternal: 14.6%, paternal: 14.3%; children 24–59 mo: maternal: 13.6%, paternal: 7.1%; and children aged under 5 y: maternal: 12.2%, paternal: 12.5%. Other category includes child age, gender, and region. Note the under 6 mo age category results are not presented due to the small sample size. The 1996 DHS collected data on children aged under 3 y only and thus was not used as the starting point for analysis. ANC, antenatal care; DHS, Demographic and Health Survey; HAZ, height-for-age z-score; SBA, skilled birth attendant.

FIGURE 7

Overview of laws, policies, programs, and enablers between 1990 and 2018 in Nepal. CAGR, compound annual growth rate. IYCF, Infant and Young Child Feeding; SUAAHARA, 'Good Nutrition,' a USAID/Nepal project; SUN, Scaling Up Nutrition.