A Research Report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfillment of the requirements for the degree of Degree of Master of Public Health Johannesburg, June 2017 / Background The disparities in health outcomes between the poor and the rich are increasingly widened, with conditions like stunting still dominating the public health agenda. Policy-makers and researchers need to investigate and inform policies that are aimed at reducing inequities and implement interventions based on available evidence. Objectives The study aimed to investigate the relationship between household socio-economic status and stunting in children younger than five years in Zimbabwe using the 2010 Demographic and Health Survey (DHS). The specific objectives were (i) to describe the different levels of stunting in children under-five years of age; (ii) to determine the association between socio-economic status and stunting in the under-five year age group; and (iii) to determine other factors associated with stunting in children under-five years of age in Zimbabwe. Methods Data from the 2010 Zimbabwe DHS was used for a cross sectional analysis. A modified Poisson regression was used to compute the crude and adjusted prevalence ratios (PR) and the 95% confidence interval (CI) of the association between socio-economic status and stunting. For multivariate models, variables that were identified a priori, those that had a p-value <0.20 in bivariate analyses and inclusion of variables that resulted in a change of 10% or more in the estimate of outcome, were included in the multiple regression models as potential confounders. Results A total of 1,080 children (25.3%; 95% CI: 23.8-26.8 %) of the 4,761 included in the sample were stunted. In univariate analysis, children in the richest households were shown to have a 43% significantly reduced prevalence of stunting as compared to the poorest households [crude PR=0.57, 95% CI (0.45 – 0.72)]. In multivariate analysis, the richer households had less stunted children than the poorest households (adj PR 0.63; 95% CI: 0.47 - 0.84), richer (adj PR 0.79 95% CI: 0.63 - 0.97 ;), middle (adj PR 1.01; 95% CI: 0.87 – 1.17 ;), and poorer (adj PR 0.85; 95% CI: 0.74 – 0.97). Other factors associated with stunting were the child’s anaemia status, age, sex, weight, living with mother or other, the mother’s height and the mother’s body mass index (BMI). Conclusion This study showed that household socio-economic status is associated with stunting in children under the age of five years in Zimbabwe. Stunting is still an immense challenge for most economically unindustrialized nations, Zimbabwe included, and threatens the possibility of many of these countries meeting the Sustainable Development Goals. Therefore there is need for multi-sectoral interventions that include poverty alleviation, social welfare, educational and health policies that will enhance the socio-economic status of the household in order to improve children’s nutritional status in Zimbabwe. / MT2017

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Background: This research aims to explore the recommendations of the 2013 Lancet Series on maternal and child nutrition in the case study of Yemen (2013-2014), by answering the question “What mix of public interventions works best in a given context to reduce child stunting prevalence?” Yemen was selected due to its Government commitment to use a multi-sectoral approach in its planning and financing cycle for nutrition. Method: The research applied a mixed method, starting with a literature review and a cross-country secondary-data analysis to produce evidence for composing a research framework for Yemen. Subsequently, a descriptive analysis, two types of regressions (Probit and Poisson) and an adapted ‘Delphi method’ for discussion with decision-makers from various sectors were carried out. Results: Based on the descriptive analysis, Yemen progressed in: maternal and child health care, drinking water supply and sanitation, girls’ education, delayed marriage and pregnancy. However, infant and young child feeding practices remained inadequate. Significant determinants of child stunting identified by the regressions included characteristics of: child (age, gender and diet diversity), mother (undernutrition, birth-spacing and head of family) and household (access to water and sanitation). Children of households that engaged in agriculture, livestock and fishing were the most likely to access diet diversity and animal-protein sources. Other significant determinants of child diet included maternal education, per capita expenditure, income-related shocks and ownership of a cooking stove and fridge. Results: from the adapted ‘Delphi-method’ discussion showed that decision-makers were ready to use multi-sectoral approaches to converge their existing interventions in the most vulnerable geographical areas. However, they were less keen to retarget beneficiaries based on age, gender or livelihoods. Conclusions The research demonstrates how the applied mixed method can provide a comprehensive way to examine child stunting as a multi-sectoral issue, rather than just considering it as a health problem.

Populations of non-native signal crayfish, Pacifastacus leniusculus, are damaging to UK native species and habitats though their populations are expanding with no coherent framework in place for their control. This is partly the result of a literature gap on the effect of trapping on non-native crayfish population structure which this thesis will explore in order to add to the European literature. Population size structure analysis has been facilitated via the creation of novel samplers and an in-depth analysis of the effect of aperture on the size/life stage of crayfish sampled. Smaller trap apertures, the addition of refuge material and novel samplers increased the catch of juvenile crayfish. Sex was indeterminable for up to 50% of juvenile crayfish, with juvenile sex ratios potentially biased towards females. Conditions on the River Lark did not limit populations, though temperature varied significantly between sites whilst substrata, pH and biological oxygen demand did not. Three years of trapping and juvenile sampling enabled population analysis at a site level. The population at Lark Head (professionally trapped), had a consistent size structure from 2010 to 2012, whilst individuals at Barton Mills (community trapped) and the Plough (untrapped), showed size decreases over time. The proportions of adult to juvenile individuals, and males to females, were similar at all three sites in 2011 & 2012. Catch per unit effort, decreased at all three sites with the greatest reductions at trapped sites. There is no evidence that catch sizes, or the proportion of juveniles, increased with trapping in spite of one site being trapped by the community since 2001 and another trapped by professionals since 2005. This refutes inferences that trapping causes an increase in biomass due to a reduction in the number of cannibalistic and dominant large males, with size and sex bias in traps also not corroborated.

Undernutrition is a major public health problem, contributing to 33% of deaths in infants and young children globally. In Kygryzstan, Central Asia, Mercy Corps provided 6 metric tons of rice, flour and oil as well as nutritional education to kindergartens in 40 rural regions, serving 41,000 children, for one year. Anthropometric measurements were collected at the beginning and end of the program. Children, who were stunted, wasted and underweight at baseline, recovered by follow-up, with rates of recovery of 50%, 65% and 50%, respectively. The prevalence of stunting, wasting and underweight in the population decreased from 13.8%, 3.4% and 3.2%, respectively, to 8.6%, 2.1% and 2.3%, respectively. This study shows that preschool feeding programs have the potential to improve nutritional outcome. These results are particularly significant as the dearth of research on preschool feeding’s impact on growth and nutrition has led to this particular intervention being deemed ineffective for improvement of nutritional outcome.

Body composition profiles including stunting, wasting and underweight, overweight and obesity, can all affect the health, motor development and academic achievements of children. South Africa (SA), a developing, middle-income country, with large socio-economic inequalities, is one of the most complex nations with regard to race and ethnicity. It therefor results in different body composition profiles of children and adolescents, where undernutrition and obesity can occur among children and adolescents in the same socio-geographic population in disadvantaged communities, as well as in the same household. The aim of this study was firstly, to determine the incidence of overweight and obesity among Grade 1-learners in the North West Province of SA and to determine whether this incidence is related to gender, race and the socio-economic circumstances in which these learners live. Secondly, the study aimed to determine the incidence of stunting, wasting and underweight among this group of Grade 1-learners and to determine whether these incidences are related to gender, race and the socio-economic circumstances in which these learners live. The anthropometric measurements that were used in the study were height (cm), body mass (kg), 3 skinfolds [(sub-scapular, triceps and medial calf)] (mm) and waist circumference (cm). These measurements were taken by trained researchers according to the guidelines International Society for the Advancement of Kinanthropometry (ISAK). Body mass index (BMI) [(body mass (kg)/height (m)2)] was calculated and international age-specific cut-off points for BMI was used to determine whether a learner was overweight or obese. Z-scores of less than -2 standard deviation (SD) for height-for-age and weight-for-age were calculated to determine the prevalence of stunting and underweight, while the Z-scores for wasting was determined using BMI-for-age, under the 5th percentile from an international reference population. The Statistica-computer programme (Statsoft, 2011) and AntroPlus software (version 1.0.2) in SAS (Statistical Analysis System) were used to analyse the data. Data were descriptively analysed by using percentages, means (), minimum and maximum values and standard deviations (SD). Two-way frequency tables were used to analyse the incidence for overweight, obesity, stunting, wasting and underweight. Pearson Chi Square analysis p≤0,05 was used to determine statistical significance of differences in stunting, wasting and underweight between school types, race and genders. Practical significance of differences was determined using effect sizes (d≥0,1 which indicates a small effect, d≥0,3 indicating a medium effect and d≥0,5 indicating a large effect). Tukey’s Post Hoc tests were used to determine the significance of differences between the groups and genders. The results revealed an incidence of 11,6% of overweight and obesity in the group (N=816) of Grade 1-learners. Overweight in the group was 7,8% and overweight was more prevalent in 7 year old learners with 10,5%, compared to 6 year old learners with 6,3%. Obesity (3,8%) showed a lower incidence compared to overweight, were 2,5% learners at 6 years and 0,7% learners at 7 years were obese. The boys showed the highest prevalence for severe obesity at 6 and 7 years (2,4%). White learners showed the highest prevalence for overweight, obesity and severe obesity at 6 and 7 years. The group of Grade 1-learners furthermore showed lower percentages of stunting (4,3%), wasting (7,4%) and underweight (4,3%) compared to overweight and obesity incidences. A higher prevalence of wasting and underweight were found among the boys (8,4%; 6,0%) compared to the girls (6,3%; 2,5%), although the difference was only significant for underweight (p=0,02), while stunting was similar among girls (4,5%) and boys (4,1%; p>0,05). Black learners showed the highest incidence for underweight (5,5%; p<0,01), while small percentages of underweight were found in the white learners. Only the black learners showed stunting (p<0,01), while wasting occurred in black (n=39) and white (n=15) learners. Quintile 1-3 schools had the highest prevalence of underweight (5,1% – 8,2%) and stunting (3,9% – 10,7%), which was significantly higher than in Quintile 4 and 5 schools (p<0,01), and agreed with higher prevalences found in rural areas in other South African studies. Knowledge about the body composition profiles of young school beginners is important since extremes such as obesity, stunting and wasting play an important role in the further development and health of children. The results of this study make a valuable contribution to knowledge that can be used in this regard for preventative purposes. / Thesis (MSc (Kinderkinetics))--North-West University, Potchefstroom Campus, 2013.

Body composition profiles including stunting, wasting and underweight, overweight and obesity, can all affect the health, motor development and academic achievements of children. South Africa (SA), a developing, middle-income country, with large socio-economic inequalities, is one of the most complex nations with regard to race and ethnicity. It therefor results in different body composition profiles of children and adolescents, where undernutrition and obesity can occur among children and adolescents in the same socio-geographic population in disadvantaged communities, as well as in the same household. The aim of this study was firstly, to determine the incidence of overweight and obesity among Grade 1-learners in the North West Province of SA and to determine whether this incidence is related to gender, race and the socio-economic circumstances in which these learners live. Secondly, the study aimed to determine the incidence of stunting, wasting and underweight among this group of Grade 1-learners and to determine whether these incidences are related to gender, race and the socio-economic circumstances in which these learners live. The anthropometric measurements that were used in the study were height (cm), body mass (kg), 3 skinfolds [(sub-scapular, triceps and medial calf)] (mm) and waist circumference (cm). These measurements were taken by trained researchers according to the guidelines International Society for the Advancement of Kinanthropometry (ISAK). Body mass index (BMI) [(body mass (kg)/height (m)2)] was calculated and international age-specific cut-off points for BMI was used to determine whether a learner was overweight or obese. Z-scores of less than -2 standard deviation (SD) for height-for-age and weight-for-age were calculated to determine the prevalence of stunting and underweight, while the Z-scores for wasting was determined using BMI-for-age, under the 5th percentile from an international reference population. The Statistica-computer programme (Statsoft, 2011) and AntroPlus software (version 1.0.2) in SAS (Statistical Analysis System) were used to analyse the data. Data were descriptively analysed by using percentages, means (), minimum and maximum values and standard deviations (SD). Two-way frequency tables were used to analyse the incidence for overweight, obesity, stunting, wasting and underweight. Pearson Chi Square analysis p≤0,05 was used to determine statistical significance of differences in stunting, wasting and underweight between school types, race and genders. Practical significance of differences was determined using effect sizes (d≥0,1 which indicates a small effect, d≥0,3 indicating a medium effect and d≥0,5 indicating a large effect). Tukey’s Post Hoc tests were used to determine the significance of differences between the groups and genders. The results revealed an incidence of 11,6% of overweight and obesity in the group (N=816) of Grade 1-learners. Overweight in the group was 7,8% and overweight was more prevalent in 7 year old learners with 10,5%, compared to 6 year old learners with 6,3%. Obesity (3,8%) showed a lower incidence compared to overweight, were 2,5% learners at 6 years and 0,7% learners at 7 years were obese. The boys showed the highest prevalence for severe obesity at 6 and 7 years (2,4%). White learners showed the highest prevalence for overweight, obesity and severe obesity at 6 and 7 years. The group of Grade 1-learners furthermore showed lower percentages of stunting (4,3%), wasting (7,4%) and underweight (4,3%) compared to overweight and obesity incidences. A higher prevalence of wasting and underweight were found among the boys (8,4%; 6,0%) compared to the girls (6,3%; 2,5%), although the difference was only significant for underweight (p=0,02), while stunting was similar among girls (4,5%) and boys (4,1%; p>0,05). Black learners showed the highest incidence for underweight (5,5%; p<0,01), while small percentages of underweight were found in the white learners. Only the black learners showed stunting (p<0,01), while wasting occurred in black (n=39) and white (n=15) learners. Quintile 1-3 schools had the highest prevalence of underweight (5,1% – 8,2%) and stunting (3,9% – 10,7%), which was significantly higher than in Quintile 4 and 5 schools (p<0,01), and agreed with higher prevalences found in rural areas in other South African studies. Knowledge about the body composition profiles of young school beginners is important since extremes such as obesity, stunting and wasting play an important role in the further development and health of children. The results of this study make a valuable contribution to knowledge that can be used in this regard for preventative purposes. / Thesis (MSc (Kinderkinetics))--North-West University, Potchefstroom Campus, 2013.

The relationships between water, sanitation, and hygiene (WASH) interventions and malnutrition markers such as stunting, wasting, and underweight have been poorly characterized until recently. There is a need to identify interventions that may play a role in these relationships to improve nutritional status of children under 5 years old. In 2013, Zambia was not on track to meet MDG 7c, to halve the proportion of the population without sustainable access to safe drinking water and basic sanitation. To address this goal, the Zambian government implemented the Zambia Sanitation and Hygiene Program (ZSHP). The goal of the program was to reduce WASH-related diseases in rural areas by promoting community wide sanitation using community-led total sanitation (CLTS), legal enforcement, and hygiene promotion. An important component of the ZSHP is CLTS, which has been implemented in a majority of districts. The overall study aims to explore the effectiveness of a CLTS intervention on coverage and quality of household sanitation facilities, defecation behavior, and child health in a rural setting in Zambia. A secondary outcome that was measured in the analysis of the overall study was the effect of CLTS on stunting, wasting, and underweight in children under the age of 5. These three outcomes are the focus of this thesis. It was hypothesized that these three outcomes would decrease in prevalence with an increase in sanitation coverage resulting from the CLTS program. Cross-sectional anthropometric and household data for Zambian children under 5 and their households from baseline and end line surveys were analyzed to determine any association between multiple WASH indicators and nutritional status. The baseline survey was conducted in 2013 and the end line in 2016. Only households with at least one child under the age of 5 were surveyed at both baseline and end line. Primary caretakers were interviewed during home visits to assess sanitation resources, child-feeding practices, and the health status of their children under the age of 5. In addition, anthropometric data of children under the age of 5 was taken to assess their nutritional status of their children. The prevalence of underweight, stunting, and wasting at end line was 12.9%, 40.9%, and 7.4% respectively, all of which showed statistically significant decreases from baseline measurements (p=≤0.001, 0.03, and ≤0.001 respectively). Predictors of undernutrition were analyzed using logistic regression controlling for age and sex. Nutritional status of children under 5 years of age was found to be associated with several WASH indicators. Children who were taken to a clinic during an episode of diarrhea and children who lived in households with an improved water source had 46% and 26%, respectively, decreased odds of being stunted. Children who lived in households that were close (<4 min walk) to a water source had a 73% decrease in odds of being wasted. Finally, children who had diarrhea in the two weeks before the survey had 63% and 42% increased odds of being underweight or wasted respectively. Focus areas of the program have increased coverage of key indicators of sanitation and hygiene but a relatively high prevalence of sanitation- and hygiene-related diseases remain. These rural areas have high rates of reported diarrhea, acute respiratory illness, and stunting among young children even though most have had exposure to the ZSHP activities. With increased focus, not only on better human sanitation, but also on household environment sanitation, the prevalence of disease and malnutrition will start to decrease and we will begin to see healthier communities in Zambia.

Yes / Objectives: Recent developments in incremental dentine analysis allowing increased temporal resolution for tissues formed during the first 1000 days of life have cast doubt on the veracity of weaning studies using bone collagen carbon (δ13C) and nitrogen (δ15N) isotope ratio data from infants. Here we compare published bone data from the well-preserved Anglo-Saxon site of Raunds Furnells, England, with co-forming dentine from the same individuals, and investigate the relationship of these with juvenile stature. The high resolution isotope data recorded in dentine allow us to investigate the relationship of diet with juvenile stature during this critical period of life. Materials and methods: We compare incremental dentine collagen δ13C and δ15N data to published bone collagen data for 18 juveniles and 5 female adults from Anglo Saxon Raunds Furnells alongside new data for juvenile skeletal and dental age. An improvement in the method by sampling the first 0.5mm of the sub-cuspal or sub-incisal dentine allows the isotopic measurement of dentine formed in utero. Results and Discussion: δ13C profiles for both dentine and bone are similar and more robust than δ15N for estimating the age at which weaning foods are introduced. Our results suggest δ15N values from dentine can be used to evaluate the maternal/in utero diet and physiology during pregnancy, and that infant dentine profiles may reflect diet PLUS an element of physiological stress. In particular, bone collagen fails to record the same range of δ15N as coforming dentine, especially where growth is stunted, suggesting that infant bone collagen is unreliable for weaning studies. / Funded in part by the NERC standard grant NE/F018096/2; University of Bradford.

Magister Public Health - MPH / Childhood stunting is an issue of global public health concern, and its irreversible effects can have far-reaching consequences, well into adulthood. Despite various interventions and efforts, stunting in Zimbabwe remains high. Few studies have looked at the factors associated with stunting, by province, in Zimbabwe. The aim of the study was to contribute to the scientific evidence on this topic. This was done by describing stunting and its associations with maternal and child health, nutrition and sociodemographic determinants at provincial level. The second level was to map, visualise and describe stunting in relation to physical geography by province in Zimbabwe.