Malaria reduction drove childhood stunting decline in Uganda: A mixed-methods country case study

Abstract

Background: Uganda has achieved a considerable reduction in childhood stunting over the past two decades, though accelerated action will be needed to achieve 2030 targets.Objectives: This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda.Design: This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-in-difference multivariable hierarchical modeling; 3) national and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives. Results: Stunting prevalence declined by 14% points from 2000 to 2016, though geographical, wealth, urban/rural, and education-based inequalities persist. Child growth curves demonstrated substantial improvements in child height-for-age z-scores (HAZ) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women\u27s empowerment, cultural norms, water and sanitation, dietary intake/diversity, and childhood illness as important. The 2011 Uganda Nutrition Action Plan (UNAP) was an essential multi-sectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors. Conclusions: Uganda\u27s success in stunting reduction was multi-factorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated and rural populations along with high-burden northern and western districts