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Child Stunting in Madagascar and Zambia: An Examination of Maternal and Child Characteristics, Household Water/Sanitation, and Armed Conflict Exposures


Child stunting, or linear growth faltering, affects 1 in 5 children under the age of five years. These 151 million stunted children predominantly live in low- and middle-income countries. For decades, clinicians and researchers considered stunting a form of chronic malnutrition but modest gains were made in eliminating stunting through nutritional interventions. This dissertation explored emerging areas in child stunting. Chapters 1 and 2 introduced stunting and provided backgrounds, respectively. The research was guided by the Social Ecological Model and Life Course Perspective in approaching stunting as embedded in macro structures at multiple levels over the life course of women and children. Chapter 3 described theoretical frameworks and an integrated model. The analyses focused on Madagascar and Zambia, which were ranked among countries with the highest proportions of child stunting. We used health data from the Demographic and Health Surveys (DHS) and armed conflict data from the Armed Conflict Location and Event Data Project (ACLED) database in Madagascar and Zambia. Chapter 4 detailed the methodology, including multivariate logistic and linear regression models assessing child stunting and height-for-age z-score (HAZ) outcomes. Chapter 5 examined maternal anthropometry and child gender factors. Results indicated that short stature or underweight in mothers were associated with increased stunting odds while higher maternal height and BMI scores were associated with higher child HAZ. Chapter 6 investigated household water and sanitation measures. We found that households without piped water and finished flooring were associated with increased stunting odds. Stunting was associated with lack of an advanced flush toilet in Zambia but not in Madagascar. Chapter 7 explored proximity of armed conflict events during critical developmental periods with child stunting and height. Conflict exposure during pregnancy was associated with increased stunting odds and lower HAZ in Madagascar but decreased odds and higher HAZ in Zambia. This dissertation framed stunting as occurring over the life course and embedded in multiple external structures. These studies were among the first to examine population-level environmental enteric dysfunction risk factors and apply disaggregated conflict data to stunting. We also contributed stunting context in Madagascar and Zambia, which have been understudied.

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