Abstract
BackgroundStunting is determined by using the World Health Organization (WHO) child growth standard which was developed using precise measurements. However, it is unlikely that large scale surveys maintain the same level of rigour and precision when measuring the height of children. The population measure of stunting in children is sensitive to over-dispersion, and the high prevalence of stunting observed in surveys in low and middle-income countries (LMIC) could partly be due to lower measurement precison.ObjectivesTo quantify the incongruence in the dispersion of height-for-age in national surveys of < 5 y children, in relation to the standard WHO Multicenter Growth Reference Study (MGRS), and propose a measure of uncertainty in population measures of stunting.MethodsAn uncertainty factor was proposed and measured from the observed incongruence in dispersion of the height-for-age of < 5 y children in the MGRS against carefully matched populations from the Demographic Health Survey of 17 countries (‘test datasets’, based on the availability of data). This also allowed for the determination of uncertainty-corrected prevalence of stunting (height-for-age Z score < − 2) in < 5 y children.ResultsThe uncertainty factor was estimated for 17 LMICs. This ranged from 0.9 to 2.1 for Peru and Egypt respectively (reference value 1). As an explicit country example, the dispersion of height-for-age in the Indian National Family Health Survey-4 test dataset was 39% higher than the MGRS study, with an uncertainty factor of 1.39. From this, the uncertainty-adjusted Indian national stunting prevalence estimate reduced to 18.7% from the unadjusted estimate of 36.2%.ConclusionsThis study proposes a robust statistical method to estimate uncertainty in stunting prevalence estimates due to incongruent dispersions of height measured in national surveys for children < 5 years in relation to the WHO height-for-age standard. The uncertainty is partly due to population heterogeneity, but also due to measurement precision, and calls for better quality in these measurements.
Highlights
Stunting is determined by using the World Health Organization (WHO) child growth standard which was developed using precise measurements
This study proposes a robust statistical method to estimate uncertainty in stunting prevalence estimates due to incongruent dispersions of height measured in national surveys for children < 5 years in relation to the WHO height-for-age standard
Stunting is defined as a deficit in height relative to a child’s age, that is, 2 standard deviations (SD) below the median height-for-age derived from the WHO (World Health Organization) child growth standards [8]
Summary
Stunting is determined by using the World Health Organization (WHO) child growth standard which was developed using precise measurements. India reported a national average of 36% in < 5 y children in National Family Health Survey (NFHS-4) [5] and 35% in 0–4 y children in the recent Comprehensive National Nutrition Survey (CNNS) [6] This measure of chronic underunitrition is related to poor outcomes in health, cognitive development, educational and economic attainment later in life [7]. Stunting is defined as a deficit in height relative to a child’s age, that is, 2 standard deviations (SD) below the median height-for-age derived from the WHO (World Health Organization) child growth standards (hereon referred to as the WHO standard) [8] This growth standard is based on the WHO Multicentre Growth Reference Study (MGRS) [8], of the anthropometric indices of children living in what were considered to be the ‘best case’ for socioeconomic circumstances and nutritional access [8]. In the MGRS, the very low (~ 3%) between-country variation of age-specific mean height, and a strong similarity in the mean and SD of linear growth from birth to 5 y in different country samples provided sufficient justification for pooling data across countries to obtain a global standard [8]
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