The importance of public health, poverty reduction programs and women’s empowerment in the reduction of child stunting in rural areas of Moramanga and Morondava, Madagascar

BackgroundMalnutrition accounts for 45% of mortality in children under five years old, despite a global mobilization against chronic malnutrition. In Madagascar, the most recent data show that the prevalence of stunting in children under five years old is still around 47.4%. This study aimed to identify the determinants of stunting in children in rural areas of Moramanga and Morondava districts to target the main areas for intervention.MethodsA case-control study was conducted in children aged from 6 to 59.9 months, in 2014–2015. We measured the height and weight of mothers and children and collected data on child, mother and household characteristics. One stool specimen was collected from each child for intestinal parasite identification. We used a multivariate logistic regression model to identify the determinants of stunting using backwards stepwise methods.ResultsWe included 894 and 932 children in Moramanga and in Morondava respectively. Stunting was highly prevalent in both areas, being 52.8% and 40.0% for Moramanga and Morondava, respectively. Stunting was most associated with a specific age period (12mo to 35mo) in the two study sites. Infection with Trichuris trichiura (aOR: 2.4, 95% CI: 1.1–5.3) and those belonging to poorer households (aOR: 2.3, 95% CI: 1.6–3.4) were the major risk factors in Moramanga. In Morondava, children whose mother had activities outside the household (aOR: 1.7, 95% CI: 1.2–2.5) and those perceived to be small at birth (aOR: 1.6, 95% CI: 1.1–2.1) were more likely to be stunted, whereas adequate birth spacing (≥24months) appeared protective (aOR: 0.4, 95% CI: 0.3–0.7).ConclusionInterventions that could improve children’s growth in these two areas include poverty reduction, women’s empowerment, public health programmes focusing on WASH and increasing acceptability, and increased coverage and quality of child/maternal health services.

背景：尽管全球已发起慢性营养不良防控行动，但营养不良仍造成5岁以下儿童45%的死亡。在马达加斯加，最新数据显示5岁以下儿童生长迟缓（stunting）的患病率仍约为47.4%。本研究旨在明确莫拉曼加（Moramanga）与莫隆达瓦（Morondava）两地区农村儿童生长迟缓的影响因素，以确定主要干预靶点。
方法：本研究为病例对照研究（case-control study），于2014-2015年开展，研究对象为6至59.9月龄的儿童。研究人员测量了母亲与儿童的身高、体重，收集了儿童、母亲及家庭特征相关数据；同时采集每名儿童的粪便标本用于肠道寄生虫鉴定。本研究采用多因素logistic回归（multivariate logistic regression）模型，通过逐步后退法（backwards stepwise methods）筛选生长迟缓的影响因素。
结果：莫拉曼加与莫隆达瓦地区分别纳入894名和932名儿童。两地的生长迟缓患病率均处于较高水平：莫拉曼加为52.8%，莫隆达瓦为40.0%。两个研究区域中，12至35月龄的儿童均为生长迟缓的最高发群体。在莫拉曼加地区，鞭虫（Trichuris trichiura）感染（调整后比值比aOR=2.4，95%置信区间CI：1.1~5.3）与家庭经济贫困（aOR=2.3，95%CI：1.6~3.4）是生长迟缓的主要危险因素。在莫隆达瓦地区，母亲外出务工的儿童（aOR=1.7，95%CI：1.2~2.5）、出生时被评估为低体重的儿童（aOR=1.6，95%CI：1.1~2.1）发生生长迟缓的风险更高；而充足的出生间隔（≥24个月）则具有保护作用（aOR=0.4，95%CI：0.3~0.7）。
结论：可改善上述两地区儿童生长发育的干预措施包括：降低贫困程度、赋能女性群体、实施以水、环境卫生与个人卫生（WASH）为核心的公共卫生项目，以及提升儿童与孕产妇健康服务的覆盖率与服务质量。