GCRF-Measuring and Mapping the Prevalence and Patterning of Multiple Malnutrition in Young Children in West and Central Africa

Between 1990 and 2014, sub-Saharan Africa saw a 23% increase in the number of children experiencing stunting, with around 58 million children under 5 affected. Many of these children also experienced wasting, and the co-occurrence of these anthropometric deficits ("multiple malnutrition", MM) entail heightened morbidity risks. At household and community level, MM can refer to the co-existence of under- and over-nutrition, a pattern observed across many low and middle income countries (LMICs), and which the 2015 and 2016 Global Nutrition Reports have noted to be "the new normal". This project focuses on MM in young children in one of the world's poorest regions, the countries of West and Central Africa (WCA). Utilising data from existing household surveys from the 24 countries of WCA, the project will conduct quantitative analyses on anthropometric and demographic data and variables to explore the prevalence and patterning of MM. It will bring together individual and household level data from the surveys (DHS, MICS), and combine this information with macro-level indicators, of national governance, of public expenditure on health and nutrition, and of food prices, to examine the underlying, intermediate and basic causes of MM, as set out in UNICEF's conceptual framework on (mal)nutrition.
Malnutrition is associated with raised mortality risks, particularly in children; analysis of longitudinal survey data has shown that children experiencing multiple anthropometric deficits are 12.3 times more likely to die. Such children are likely to benefit most from nutrition and other child survival interventions (McDonald et al., 2013), as long as they can be indentified - which is not currently happening. Despite this, and the efforts and resources (national and international) which go to early child development programs in LMICs, a UNICEF/WHO/World Bank review of child malnutrition revealed that data on the prevalence and patterning of MM in young children are severely lacking, with no regional or global estimates of the number of children concurrently stunted and wasted. This knowledge gap is a real and ongoing problem for national governments and international agencies like UNICEF and the FAO. The analysis of existing household surveys, using advanced quantitative methods, will provide policy-relevant evidence on the determinants of MM for policy makers. We will also show how patterns of MM have changed over time, and identify key geographic and socio-demographic factors associated with MM.
The project focuses on children under 5 years of age, since this is a crucial period of physical development, and also because anthropometric data (heights, weights) on this age group are most reliable and routinely collected in national surveys. The WCA region has some of the world's poorest countries, many with high rates of child malnutrition. These countries also face on-going challenges of food security not least with respect to unstable food production in the context of increasing desertification, political and economic instability, and violent conflict (e.g. in northern Nigeria, Niger and Mali). WCA has excellent coverage in terms of the number of countries with existing survey data, all of which contain detailed, comparable data with which to investigate drivers of disparities in MM. Importatnly, the evidence generated by this project will aid assessment of progress towards the first three Sustainable Development Goals (SDG) - of ending poverty, hunger and reducing child mortality.

The Emergency Nutrition Network [www.ennonline.net/] has noted that despite millions of children experiencing wasting and stunting concurrently, "in the humanitarian and development architecture...wasting programmes (are) still largely funded and implemented under the 'humanitarian' remit, while stunting resides under 'development'". This is because wasting is considered an acute condition and stunting a chronic condition. What is required is for programmes and resources to be brought together, to tackle multiple malnutrition simultaneously since, as Bergeron and Castleman (2012) note, "divergences between programs focused on acute malnutrition and those focused on chronic malnutrition constitute important impediments to the effective delivery of comprehensive services". At an international UNICEF/ECOWAS/ILO/CROP workshop on child poverty in Abuja (June 2016), the PI showed how spatial analyses of MM could benefit governments; this generated considerable interest and offers of support and collaboration (see UNICEF letter of support). The research team will work with UNICEF from the outset of the project to identify data and analytical needs, as well as pathways to influence policy in each of the 24 WCA countries.
Who will benefit from this research? The ultimate beneficiaries of this project will be children and families living in poverty, whose lives are blighted by malnutrition. Other beneficiaries will include international organisations (UNICEF, FAO, WFP and the WHO), national ministries of health and child welfare, and UK departments like DFID. NGOs like Save the Children, Oxfam and Action Aid, all of whom have used the PIs work on child poverty in the past, will be able to use the evidence of MM in their campaigns against poverty and promoting child well-being.
How will they benefit from this research? UNICEF's 2016 State of the World's Children report makes clear that "problems that go unmeasured often go unsolved. Consistent, credible data about children's situations are critical to the improvement of their lives and indispensable to realising the rights of every child... Data do not, of themselves, change the world. They make change possible, by identifying needs, supporting advocacy and gauging progress". This research responds directly to this call for credible and reliable evidence about a critical issue affecting the lives of millions of children, as highlighted in the last two Global Nutrition Reports. Regional events and workshop(s) will be held in Dakar and/or in Abuja to disseminate results, provide training to local researchers and build capacity for local UNICEF/NGO staff working on nutrition programmes. Participants at the workshop will include local researchers, national media, policy makers, local NGOs, and others UNICEF consider relevant to invite. Project findings and materials (including maps) will identify areas and communities with a high prevalence of MM, which will help clarify where resources should be targeted. Outputs will include presentations at academic conferences, newspaper articles, and material for the website of regional actors including the African Child Policy Forum and UNICEF. Outputs will be published in English and French, making them accessible to users and audiences in both Franco- and Anglo-phone Africa. Links with high level users of the data (national statistical offices), national governments and policy makers are already well established (evidenced by the PI's earlier work on child poverty for UNICEF), and where possible these contacts will be used to promote the project, and to influence priorities, policy and practice. Cardiff University will work with the Welsh Assembly's Wales for Africa programme, to link researchers at universities in Wales with researchers in WCA and also to build networks with development actors and agencies , like UNICEF, the World Food Programme and the UN Food and Agriculture Organisation (FAO).