Meagan Erhart
PH 221
19 February 2015
Public Health Program Purpose and Literature Review:
Child malnutrition is responsible for nearly half of all child deaths globally1. Malnutrition in young children typically manifests itself in one of two ways: stunting or wasting. Stunting is characterized by abnormally short stature, defined by the WHO as a state of being more than two standard deviations below the reference height for a given age and is indicative of chronic malnourishment beginning very early in life, frequently in utero. Wasting is characterized by extreme underweight, being more than two standard deviations below the reference weight for a given height, and is typically a manifestation of a period of acute malnourishment. The WHO estimates that a total of 165 million children suffer from stunting worldwide, and 52 million suffer from wasting1. Yet unlike in cases of wasting, stunting frequently goes undetected in regions of high prevalence because short stature is perceived as normal.2 Due to both the highly preventable nature and the high mortality associated with stunting, the World Health Assembly has identified a reduction in stunting among children under five by 40% by 2025 as one of it’s global targets towards improving maternal, infant, and child nutrition.3
The effects of child stunting are profound and far-reaching. Studies have demonstrated that early stunting is associated with lower educational attainment4 and decreased cognitive functioning in later childhood, even when adjusted for differences in socioeconomic status.5 Stunted children are more susceptible to childhood illness and infection, and take longer to recover.1 Later in life, early childhood stunting is associated with decreased productivity and lower wages.2 Women who experienced stunting during childhood are more likely to give birth to underweight babies as adults, and short stature increases the risk of complications during childbirth.4 Additionally, when paired with excessive weight gain later in life, stunted individuals are at greater risk for heart disease and diabetes.6,2 This is particularly relevant today, as developing countries are rapidly shifting from traditional to more Westernized diets. Prevalence of stunting within a country reinforces patterns of poverty and inequity, restricts economic development, and hinders progress towards the achievement of the WHO’s millennium development goals. Studies have indicated, however, that stunting can be reversed at an early age, and school aged children who recovered from stunting during the first few years of life displayed cognitive and quantitative skills comparable to those who had not experienced stunting.7 This indicates that the first few years of life is an opportune time for nutrition interventions because the long term detrimental effects of stunting may still be preventable.
The burden of stunting is not evenly distributed; although stunting afflicts one-fourth of all children globally,3 within lower- and middle-income countries the figure is one in three, and 90% of cases occur in 36 countries.4 The focus of this stunting research and intervention will be Panama. Within Panama, the prevalence of stunting is 19%, higher than the regional average of 12%.3 A total of 66,000 children under five are estimated to be stunted.3 Within the country, significant disparities exist between rural and urban populations, and between native and non-native people. One study found that the rate of stunting in rural, indigenous populations was twice that of urban populations,8 and another found that over half of all indigenous children were stunted.9 Similarly, poor children were twice as likely to be stunted as children from more affluent households.3
Because stunting is the result of numerous socioeconomic, behavioral, and biological factors, there is no single intervention that can reduce stunting. Previous interventions have worked both at the community and policy level to target breastfeeding, female empowerment, nutrient fortification, and poverty reduction3. This project responds to the need for analysis of the specific factors contributing to high rates of child stunting in a rural, indigenous community in Panama so that future interventions may be effectively targeted towards this specific population.
Program Overview:
In an effort to inform future interventions aimed at reducing malnutrition and child stunting in rural Panama, this project aims to collect data and conduct an analysis of the factors that contribute to early childhood stunting in the rural community of El Cacao in El Capira, Panama. The target population of the intervention will be families with children under five who are currently experiencing stunting and malnourishment.
Inputs:
The inputs in the project include staff and volunteer time, university resources and funding that will be used towards travel, tools and technology for conducting anthropomorphic measurements and statistical analysis, office space, and participation of families within the community and community partners including university students, university faculty members, and community health workers. Key stakeholders include researchers, who will be able to develop effective interventions based on the information gathered in the analysis, participating families, and stunted children themselves.
Program Activities:
After identifying and consulting with key partners and stakeholders, the main activities will revolve around data collection and analysis. Data will be gathered through a combination of qualitative and quantitative measures. Methods of assessment will include questionnaires around food consumption patterns and availability, focus groups in which participants discuss factors contributing to food choices, and anthropomorphic measurements to determine the severity of stunting presence including mid-upper arm circumference and height-(or length-)to-weight measurements. Families will also be assessed on their knowledge of child stunting, and educated on how to identify the problem in cases where stunting is undetected. Once data is collected, it will be compiled and common themes will be identified among families experiencing stunting. Common themes will be used to inform future interventions targeting child stunting in the community of El Cacao.
Short-term outcomes are a better understanding of the factors that contribute to stunting in the community, including the challenges faced by individual families towards a consuming a nutritious diet and perceiving themselves as food secure. A community needs assessment will be conducted utilizing the data gathered in the first phase of the project. Medium term interventions include the development of a work plan based on this assessment. Individual and community strategies may focus on interventions targeting nutritional education, sanitation programs, or improved agricultural practices, among other things. Program development and implementation also fall under the category of medium-term program outcomes.
Information gathering and program development are mechanisms through which the final outcome can be reached. The ultimate outcome of the project is to reduce the incidence of child stunting in rural Panama. This will improve educational outcomes for the country, reduce mortality and morbidity in children, and lead to increased vitality and productivity overall.
Potential Obstacles:
The major downfall to this model is that it makes assumptions about participation and funding that cannot be guaranteed. This program operates on the assumption that partnerships and resources that are currently in place will remain so for several years. Additionally, it assumes that the community will be receptive and willing to participate in research and interventions. It is inherently assumed, therefore, that staff and volunteers will not only be available, but be able to successfully develop a culturally competent method of surveying and intervention. Finally, it assumes that a reduction of stunting within the community is feasible and can be influenced, which is difficult to determine without adequate data. There are many external factors that contribute to stunting which could also hinder the progression of the project. These may include cultural norms, environmental changes (e.g. inability to grow traditional foods,) and financial constraints that prohibit full participation. Keeping these assumptions and external factors in mind while planning for this project will improve the likelihood that an intervention in this community will be successful.
References
1. Becker, P. J., Carney, L. N., Corkins, M. R., Monczka, J., Smith, E., Smith, S. E., ... & White, J. V. (2014). Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition). Journal of the Academy of Nutrition and Dietetics, 114(12), 1988-2000.
2. De Onis, M., Blössner, M., & Borghi, E. (2012). Prevalence and trends of stunting among pre-school children, 1990–2020. Public Health Nutrition, 15(01), 142-148.
3. Improving child nutrition: the achievable imperative for global progress. United Nations Children's Fund, 2013.
4. Dewey, K. G., & Begum, K. (2011). Long‐term consequences of stunting in early life. Maternal & Child Nutrition, 7(s3), 5-18.
5. Berkman, D. S., Lescano, A. G., Gilman, R. H., Lopez, S. L., & Black, M. M. (2002). Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. The Lancet, 359(9306), 564-571.
6. Uauy, R., Kain, J., & Corvalan, C. (2011). How can the Developmental Origins of Health and Disease (DOHaD) hypothesis contribute to improving health in developing countries?. The American journal of clinical nutrition, 94(6 Suppl), 1759S-1764S.
7. Crookston, B. T., Penny, M. E., Alder, S. C., Dickerson, T. T., Merrill, R. M., Stanford, J. B., ... & Dearden, K. A. (2010). Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition. The Journal of nutrition, 140(11), 1996-2001.
8. Pino, M., Brignardello, J., & Goldfield, M. Report from Latin America. 13 Sight and Life, 69.
9. Halpenny, C. M., Koski, K. G., Valdés, V. E., & Scott, M. E. (2012). Prediction of child health by household density and asset-based indices in impoverished indigenous villages in rural Panamá. The American journal of tropical medicine and hygiene, 86(2), 280-291.