ISSN: 2572-5971

Research Article Advances in Nutrition & Food Science

Influence of Infant and Young Child Feeding Practices on Stunting in Children aged
6 – 23 months in Zambia
Andrew Banda1,2, Elizabeth T. Nyirenda2, Chabila C. Mapoma2, Bwalya B. Bwalya3, Nkuye Moyo4,1,*
1 Optentia research Unit, North-West University, South Africa *
Corresponding author
Nkuye Moyo, Peking University, Institute of Population Research, Beijing,
2 University of Zambia, Department of Population Studies,
China
Lusaka, Zambia
Submitted: 27 Dec 2021; Accepted: 14 Feb 2022; Published:20 Feb 2022
3 Mulungushi University, Department of Economics, Kabwe,
Zambia

4 Peking University, Institute of Population Research,

Beijing, China
Citation: Andrew Banda., Elizabeth T. Nyirenda., Chabila C., Mapoma, Bwalya B. Bwalya., Nkuye Moyo. (2022). Influence of Infant
and Young Child Feeding Practices on Stunting in Children aged 6 – 23 months in Zambia. Adv Nutr Food Sci, 7(1), 117-127.

Abstract
Background: Infant and child nutrition in Zambia remains a pressing public health problem. The Zambia Demographic and
Health Survey (ZDHS) indicates that 35% of children under-five and 36 % among those aged 6-23 months are stunted. This
study set out to assess the influence of Infant and Child Feeding (IYCF) practices on child stunting (6-23 months) in Zambia.

Methods: The 2008 ZDHS children’s data were analysed to measure stunting among infants aged 6-23 months. We fitted
a bivariate logistic regression to measure association between feeding practices and stunting in children. Pearson’s Chi-
square test of proportions and adjusted odd ratios (AOR) with confidence intervals at 95% are reported.

Results: Findings indicate that 36% of children 6-23 months old were stunted. IYCF practices indicators remain relatively
poor in Zambia with only 13% of children age 6-23 months having received minimum acceptable diet, 23% received
minimum dietary diversity and 42% received minimum meal frequency. Breastfeeding and receipt of a minimum dietary
diversity reduced the odds of stunting among children age 6-23 months by 38% and 33% respectively. A child’s perceived
low birth size, being male, maternal anaemia status and mother’s use of the internet were significant predictors of stunting.

Conclusion: The study shows that IYCF practices have an influence on stunting in Zambia and that socio-economic and
demographic factors are likewise associated with stunting although the main determinants are amendable to intervention.
Promoting the recommended WHO IYCF practices; breastfeeding, minimum meal frequency, receiving foods with diverse
dietary content and accelerated investment in nutrition programs is recommended.

Keywords: Stunting, Infant and Young Child Feeding, Nutritional Assessment.

Introduction Over the last two decades, childhood stunting has shown a posi-
Childhood stunting is one of the significant public health challeng- tive downward trend from 53% in 2001-02 to 35 % in 2018 [4].
es and impediments to child development in Zambia and the world Despite the considerable decline, the levels of stunting in Zambia
over, and reflects the country’s poor social and economic devel- remain among the highest in the region and is barely 5 percentage
opment[1]. Globally, 144 million children representing 21.3% are points below the World Health Assembly resolution 65.6 aimed at
stunted or they are too short for their age [2]. Thirty-nine per cent reducing to below 40% the number of children under-5 who are
of the worlds stunted children are in Africa[3]. According to the stunted [1].
Africa Development Bank President Ainwumi Adesina “Africa is
the only continent where the number of stunted children has in- Stunting is defined as a height that is less than two standard de-
creased over the last two decades: 58.5 million in 2018, up from viations below the World Health Organization (WHO) Child
50.3 million at the turn of the century” [3]. In Zambia, 35% of Growth Standards [5]. It is generally a manifestation of chronic
children under five are stunted with Northern and Luapula Prov- undernutrition which predisposes children to physical and cogni-
inces having the highest prevalence – 36% and 45% respectively. tive underdevelopment as well as exposes them to a greater risk of
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morbidity and mortality from common preventable infections as practice of breastfeeding and presence of childhood clinical and
well as worsening the severity and chance of recovery from such subclinical infections (diarrhoea and fever ) [12, 13].
infections. Whereas poor child health undermines societal devel-
opment, improved health is the first step toward enabling children Proper infant and young child feeding practices are central to
to break out of a cycle of ill health and poverty that may other- prevent irreversible consequences of nutritional problems among
wise continue for generations [6]. Literature suggests that mater- children [14]. At least 200 million children living in developing
nal, child-related factors and low socio-economic and households countries fail to meet their developmental potential[3]. Along with
characteristics of mothers [7] as well as the prevalence of anaemia undernutrition, related influences of infectious disease, environ-
among mothers are associated with childhood stunting. In Zambia, mental hazards, and societal and household violence, all contribute
it is unclear what drives the high prevalence of stunted children de- to this loss of potential. Unlike many other influences that are im-
spite considerable investment in Infant and Young Child Feeding mutable or tremendously difficult to change, nutrition is something
(IYCF) practices policies, programmes and nutrition interventions that can be controlled[15]. It is therefore important to prevent un-
[8]. dernutrition during the critical 1000 days of life from conception
up to two years of a child’s life by ensuring robust IYCF practices
Feeding practices remain an important part of reducing childhood based on the 8 core indicators of early initiation of breastfeeding;
stunting. Thus, what, when and how children are fed particularly exclusive breastfeeding for six months; continued breastfeeding at
in the first two years of life is critical to their health, development one year; introduction of solid, semi-solid or soft foods; minimum
and survival [9]. WHO recommends exclusive breastfeeding for dietary diversity; minimum meal frequency; minimum acceptable
the first 6 months of life because of its protective effect on the diet; and consumption of iron-rich or iron-fortified foods [16].
child from infections, malnutrition and obesity in later life [10, This study, therefore, sought to examine the association between
11]. In Zambia, breastfeeding is very common with the majority stunting (Nutritional status) and IYCF practices in Zambia. Con-
of children 98% breastfed and 70% of children under six months ceptual Framework
exclusively breastfed. In addition to breastfeeding, vitamin A and
iron supplementation are important to a child’s life. The 2018 To examine the effect of IYCF practices on stunting, the study
ZDHS shows that 79% of children 6-23 months ate foods rich in adapted an extract of the WHO conceptual framework of child-
vitamin A and about a three quarter (73%) of children 6-59 months hood stunting [12]. The key independent variables were based on
received vitamin A supplements six months before the survey the five IYCF indicators; currently breastfeeding, minimum dietary
[4]. The WHO framework for childhood stunting (see appendix diversity, minimum meal frequency, minimum acceptable diet, and
A) highlights four broad factors of stunting namely; household consumption of iron-rich foods controlled for other covariates such
characteristics, inadequate complementary feeding, inadequate child, maternal and household characteristics (figure 1).

Stunting Framework

Figure 1: Conceptual Framework of child stunting (6-23 months) and IYCF Practices by Child, Maternal and Household Characteristics
(Adapted from the WHO Childhood)
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Methods or four times for non-breastfed children age 6-23 months.
This study was based on a cross-sectional nationally representa- “Meals” include both standard meals and snacks (other than
tive Survey (ZDHS 2018) to provide reliable estimates on the core trivial amounts), and frequency was based on caregiver report.
health and demographic indicators at provincial and rural-urban 3. Minimum acceptable diet was measured based on the propor-
level. The ZDHS captured a total of 10,094 children under-5. A tion of children age 6–23 months who received a minimum
sample was drawn from 9,606 children under-5 with valid mea- acceptable diet. This indicator is a composite of children who
surement of height-for-age. To determine the effect of IYCF on met minimum dietary diversity and minimum meal frequency.
stunting, the study used data for 2730 children age 6-23 months 4. Consumption of iron-rich foods is defined as the proportion of
whose information on feeding practices was collected through in- children age 6-23 months who receive iron-rich food, which
terviews with their mothers in the ZDHS survey Variables. includes meat (and organ meat), fish, poultry, and eggs
5. Currently breastfed is defined as children age 6-23 months
Dependent Variable still being breastfed.
The dependent variable, stunting (height-for-age) was categorised 6. Covariates included were based on child’s characteristics such
as 1 if the child had -2 SD and 0 if otherwise based on the WHO as: age, sex, perceived size of the child at birth and whether a
Child Growth Standards reference population (WHO, 2006). child had received vitamin A recently as well as the presence
Stunting was computed from valid height-for-age Z-score. Chil- of common child illness two weeks prior to the survey (diar-
dren whose height-for-age Z-score was below minus two standard rhoea and fever). Other covariates were maternal that included
deviation (-2SD) from the median reference point were considered mother’s age, education level, employment status, number of
to be too short for their age (stunted) (WHO, 2009) and coded as antenatal visits, the birth interval between births and whether
1 (1=stunted) and if otherwise not stunted and coded 0 (0= Not a mother had anaemia (below 11g/dl) and Household charac-
Stunted). teristics included residence, wealth index and household wa-
ter and sanitation factors (source of drinking water, type of
Independent Variables toilet facilities and disposal of child’s stool).
The key independent variables were the five IYCF practices indi-
cators: currently being breastfed, minimum dietary diversity, min- Statistical analysis
imum meal frequency, minimum acceptable diet, and consumption The study analysis was performed in two steps. The first step in-
of iron-rich foods. These were defined into dummy binary vari- volved descriptive and bivariate analysis to generate the average
ables, were 1 if the child was currently breastfeeding, received percentages of children with stunting by IYCF practices and child,
minimum dietary diversity, was fed at minimum meal frequency, maternal and household characteristics. The second step involved
received a minimum acceptable diet and received iron-rich foods Survey-weighted logistic regression modelling was used to mea-
and 0 if otherwise (e.g. 1= Yes, currently breastfeeding and 0= Not sure the effect of independent variables on the dependent variable
currently breastfeeding). stunting among children 6-23 months, adjusted odds ratios (AOR)
and 95% confidence were used. Only significant variables from
1. Minimum dietary diversity refers to the proportion of chil- the bivariate analysis using the Pearson’s chi-square test (P<0.05)
dren age 6–23 months who received a minimum of 5 out of 8 (5%) were added in the model. Some variables at p<0.1 (10%) lev-
food groups during the previous day. These include; i. breast el were permitted into the model, this was done to retain as many
milk; ii. infant formula, milk other than breast milk, cheese or determinants as possible. All analyses were conducted using Stata
yoghurt or other milk products; iii. foods made from grains, version 14 and are based on weighted data.
roots, and tubers, including porridge and fortified baby food
from grains; iv. vitamin A-rich fruits and vegetables; v. other Results
fruits and vegetables; vi. eggs; g. meat, poultry, fish, and shell- Child Stunting and Infant and Young Child Feeding Practices
fish (and organ meats); vii. legumes and nuts. in Zambia
2. Minimum meal frequency denotes the proportion of children The 2018 Zambia Demographic and Health Survey shows that out
age 6-23 months who received solid, semi-solid, or soft food of the 9609 children under five (0-59 months) with valid measure-
(including milk feeds for non-breastfed children) the mini- ment for height and age, 35% were stunted. Of the 2730 children
mum number of times or more during the previous day. The ages 6-23 months, 2694 had valid measurement for height and age
minimum is defined as two times for breastfed infants age 6-8 and of those, 36% were stunted (Table 1).
months, three times for breastfed children age 9-23 months,

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Table 1: Summary of Child Nutritional Status (Stunting) among children 0-59 and 6-23 months, 2018 ZDHS
Stunting (Height-for-Age) Stunting (Height-for-Age)
(0-59 months) (6-23 months)
Total children age 6-23 months 2730
Number and % of children with valid 9,609 (95%) 2694 (27%)
measurements
Number children Stunted 3322 959
Per cent of children Stunted 34.6% 35.6%
Zambia’s childhood stunting levels have declined over the succes- Figure 4 demonstrates that about three in 10 children ages 6-23
sive demographic health surveys (between 2001/2 and 2018). The months were stunted across the three IYCF practices indicators,
highest stunting levels were reported in 2001/02 with one in every however, stunting was generally more prevalent among children
two children under five (53 %) being stunted (Figure 2). A similar who were not fed on iron-rich foods, did not receive diverse di-
depiction is observed for underweight and wasting levels over the etary meals, did not receive an acceptable diet and were not fed
same period. frequently. Similarly, more children were stunted among those
who were not currently breastfed (see table 2).

Figure 2: Trends in Nutritional Status of Children under five based

on 2006 WHO Child Growth Standards

Minimum dietary Diversity, Minimum meal Frequency and Min-

imum Acceptable diet and Stunting among children 6-23 months. Figure 4: Prevalence of IYCF Practices and Stunting among Chil-
Figure 3 shows the prevalence of IYCF practices among children dren age 6-23 months
6-23 months in Zambia over the successive demographic and
health surveys. The results show that 11% and 13% of children Child Stunting by Infant and Young Child Feeding (IYCF) Practic-
were fed on a minimum acceptable diet in the 24 hours preceding es and Child, Maternal, and Household Characteristics.
the interview in 2013/14 and 2018 respectively. Four in 10 chil-
dren in both surveys (2013/14 and 2018) were fed the minimum Table 2 shows bivariate analysis of stunting among children ages
meal frequency appropriate for their age. A similar pattern is ob- 6-23 months and other covariates; IYCF practices, child, maternal
served for children who received an adequate diverse diet, (22 % and household characteristics. The results confirm that child stunt-
in 2013/14 and 23% in 2018). Overall, the results appear to show ing was significantly associated with sex of the child, child’s age,
minimal improvement in absolute terms in the three IYCF practic- perceived size of child at birth, receipt of vitamin A supplement
es indicators between the two successive surveys. and child’s anaemia status. On the Maternal characteristics side,
maternal education, women’s access to the internet, the number of
antenatal visits attended and household wealth status are signifi-
cantly associated with child stunting (p<0.01).

Child and Maternal Characteristics on Stunting among

children age 6-23 months
The sex and age of the child are important attributes in child nu-
tritional assessment. Table 2 indicates that both the sex and age
of the child are significantly associated with stunting (p<0.01).
The prevalence of stunting appears to increase with increasing
age of the child with the highest prevalence among children age
18-23 months (46%) compared with 23% among children age 6-8
months.

Figure 3: Prevalence of infant and Young Child Feeding Practices Childs perceived size at birth is significantly associated with child
(IYCF) among children ages 6-23 months, ZDHS 2013/14 and 2018 stunting. Children with a perceived below average size at birth had
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a higher prevalence of stunting (47%) compared to those with a Zambia’s stunting prevalence among children ages 6-23 months
perceived above average size at birth. Similarly, maternal edu- appears to vary significantly by region and residence. The high-
cation, women’s access to the internet, the number of antenatal est prevalence is reported in Luapula (47%) and Northern (43%)
visits attended, household wealth status is significantly (p<0.01) provinces. Rural areas have a higher prevalence of child stunting
associated with child stunting. Stunting among children age 6-23 compared to urban areas (38% versus 33%; p<0.01). Children from
months appears to decrease with increasing mother’s level of ed- poorer households appear to have a higher prevalence of stunting
ucation. Household Characteristics on Stunting among Children at 45% compared with 25% among those from richer households
age 6-23 months. (p<0.01).

Table 2: Prevalence of stunting among children age 6-23 months by child, maternal, Household and IYCF characteristics(n=2730)

Characteristic % CI P-Value
Child’s Characteristics
Sex of the Child
Female 29.2 [26.5, 32.1]
Male 43.1 [39.9, 46.3] <0.001
Age of Child (Months)
6-8 Months 22.7 [18.6, 27.5]
9-11 Months 27.4 [22.2, 32.7] <0.001
12-17 Months 37.0 [33.2, 41.1]
18-23 Months 46.4 [42.8, 49.9]
Perceived Size of Child at Birth
Average and Above 34.5 [32.2, 36.8]
Below Average 46.8 [42.1, 52.7] <0.001
Birth Order
1st Child 36.2 [31.8, 40.9]
2nd Child 38.5 [33.5, 43.7]
3rd Child 32.6 [27.5, 38.1] 0.466
4th and Above 36.3 [33.2, 39.4]
Vitamin A in the last 6 months
Not Received/Not Known 30.2 [26.2, 34.6]
Received 37.9 [35.4, 40.4] 0.003
Child Anemia (<11g/dl)
No 30.4 [26.2, 34.8]
Yes 38.3 [35.7, 40.6] 0.003
Diarrhoea in the last 2 weeks
No 37.0 [34.5, 39.6]
Yes 33.9 [30.3, 37.6] 0.154
Maternal Characteristics
Age of Mother
Under 20 39.4 [33.7, 45.4]
20-29 35.9 [32.9, 39.2]
30-39 35.1 [30.9, 39.4] 0.702
40-49 36.0 [28.4, 44.4]
Mother’s Level of Education
No Education 41.2 [34.8, 47.9]

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 Primary 38.6 [36.0, 41.3] <0.001
Secondary 34.0 [30.4, 37.9]
Higher 10.9 [5.8, 19.7]
Mother’s Employment Status
Not Working 36.5 [33.6, 39.6]
Working 35.7 [32.7, 38.7] 0.685
Number of ANC Visits
None 35.6 [20.4. 54.3]
1-3 36.6 [32.8, 40.6] 0.003
4+ 34.9 [45.2, 65.6]
Maternal Anaemia (<11g/dl)
Yes 34.5 [31.9, 37.1]
No 41.2 [36.8, 53.1] 0.020
Birth Interval Group
>= 24 Months 39.4 [31.5, 47.9]
<24 Months 35.3 [32.2, 41.3] 0.581
Household Characteristics
Wealth Index
Poor 39.6 [36.9, 42.4]
Middle 36.5 [32.9, 40.2] <0.001
Rich 24.5 [19.3, 30.7]
Residence
Rural 37.9 [35.6, 40.3]
Urban 32.7 [28.6. 37.1] 0.039
Region
Central 41.5 [35.4, 47.9]
Copperbelt 34.2 [26.4, 43.0]
Eastern 35.4 [30.5, 40.8]
Luapula 47.2 [41.6, 52.9]
Lusaka 32.3 [26.1, 39.2] 0.003
Muchinga 25.9 [19.8, 33.3]
Northern 43.4 [37.3, 49.6]
North Western 32.9 [26.3, 40.3]
Southern 34.7 [29.3, 40.6]
Western 32.1 [26.2, 38.7]
Use of the Internet
Never Used or more than 12 months 37.6 [35.5, 39.8]
Yes, Last 12 Months 18.3 [12.3. 26.2] <0.001
Infant Young Children Feeding (IYCF) Practices
Minimum Meal Frequency
No 35.9 [32.7, 39.2]
Yes 31.1 [27.8, 34.6] <0.001

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 Minimum Acceptable Diet
No 36.9 [34.8, 39.1]
Yes 30.3 [24.2, 37.1] 0.058
Minimum Dietary Diversity
No 37.3 [34.9, 39.7]
Yes 33.1 [28.7, 37.8] 0.110
Consumption of Iron-Rich Foods
No 37.0 [34.1, 40.1]
Yes 35.3 [32.3, 38.5] 0.449

Infant and Young Child Feeding (IYCF) Practices on Stunting aternal characteristics such as the interval between the births,
among Children age 6-23 Months. mother’s employment status and maternal education were sig-
nificantly associated with stunting however, the odds of stunting
To measure the magnitude of association between IYCF and stunt- among children 6-23 months appear to reduce with increasing lev-
ing of children age 6-23 months, we ran an adjusted multiple re- el of education. Children born from mothers with anaemia (<11g/
gression logistic model. Table 3 shows the results of the adjusted dl) had 36% higher odds of being stunted than children born from
multiple regression model of stunting among children age 6-23 mothers with no anemia (AOR 1.36; 95% 0.061, 1.744).
months. The odds of stunting among currently breastfed children
age 6-23 months were 38% lower than for children who were not Among children from rich households, the odds of stunting were
breastfed (AOR 0.62; 95% CI 0.48, 0.79). Among children who 43% lower than children from poor households (AOR 0.57; 95%
received a minimum dietary diversity, the odds of stunting were CI 0.365, 0.889). The use of the internet by mothers at the house-
33% lower than children age 6-23 who did not receive a minimum hold level was significantly associated with child stunting. The
dietary diversity 24 hours prior the interview (AOR 0.67; 95% CI odds of stunting among children whose mothers reported the use
0.470, 0.951). of the internet within 12 months prior to the 2018 ZDHS were
54% lower than those who have never used or used more than 12
Child’s characteristics, sex and perceived weight of the child months ago (AOR 0.47; 95% CI 0.190, 1.135). Some coefficients
at birth by the mother are significantly associated with stunting on the IYCF practices variables (minimum acceptable diet and
among children age 6-23 months. Female children were 55% less consumption of iron-rich foods) failed to reach statistical signifi-
likely to be stunted than male children (AOR 0.45; 95% CI 0.359, cance at the 95% level and the variable minimum meal frequency
0.552). Among children with a perceived birth size of less than failed collinearity test with other IYCF practices variables hence,
average, the odds of stunting were 88% higher than those whose and thus was not included in the final model.
mothers said the birth size was more than average (AOR 1.88;
95% CI 1.381, 2.557).

Table 3: An Association between IYCF Practices and Stunting among children age 6-23 months adjusted for other variables
(Child, Maternal and Household characteristics)

Characteristic AOR 95% CI

IYCF Variables
Currently Breastfed
No 1
Yes 0.616*** [0.477, 0.796]
Minimum Acceptable Diet
No 1
Yes 1.373 [0.894, 2.107]
Minimum Dietary Diversity
No 1
Yes 0.669** [0.470, 0.951]
Consumption of Iron-Rich Foods
No 1
Yes 1.207 [0.945, 1.543]

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 Childs Characteristics
Sex of the Child
Male 1
Female 0.446*** [0.359, 0.552]
Perceived Size of Child at Birth (Average and above)
Average and Above 1
Below Average 1.879*** [1.381, 2.557]
Maternal Characteristics
Birth Interval Group
>=24 Months 1
< 24 Months 0.895 [0.605, 1.324]
Mother’s Level of Education
No Education 1
Primary 0.953 [0.665, 1.365]
Secondary 0.987 [0.656, 1.484]
Higher 0.587 [0.185, 1.862]
Mother’s Employment Status
Not Working 1
Working 1.003 [0.804, 1.252]
Maternal Anaemia (<11g/dl)
No Anaemia
Yes 1
Household Characteristics 1.361** [1.061, 1.744]
Wealth Index
Poor
Middle 1
Rich 0.942 0.190, 1.135]
Use of the Internet 0.569** [0.365, 0.889]
Never or more than 12 months
Yes, Last 12 Months 1
0.465* [0.190, 1.135]
***p<0.01, ** p<0.05, *p<0.1; AOR= Adjusted odds Ratio

Discussion tion in Stunting levels from 53% in 2001-02 to 35% in 2018, stunt-
This study investigated the influence of IYCF practices on stunting ing remains a public health challenge. More so, stunting among
in children age 6 – 23 months in Zambia using the 2018 ZDHS children age 6-23 months, a critical period for child growth and
data. Specifically, the study sought to determine the influence development, is even higher at 36%. The importance of age range
that breastfeeding, Minimum Acceptable Diet, Minimum Dietary 6-23 months for the growth and development of children as it af-
Diversity , Minimum Meal Frequency and consumption of Iron fects both the physical and mental growth of a child cannot be
rich-foods have on child stunting in Zambia and to determine the over-emphasized. Zambia’s Ministry of Health recognizes that ad-
child, maternal and household characteristics associated with equate nutrition is critical to children’s growth and development
child stunting in Zambia. The study, based on a sufficiently large and that the period from birth to age two is especially important
sample of nationally representative women in Zambia found that, for optimal physical and cognitive growth and development [17].
the level of under-five child stunting is at 35% and is the highest Stunting is the devastating result of poor nutrition in early child-
in Sub-Saharan Africa, it is only 4 percentage points short of the hood. Children suffering from stunting may never grow to their
developing world average (39%) and 5 percentage points short of full height and their cognitive ability may never develop to their
the sub-Saharan regional average of 40% [2]. Despite the reduc- full potential [9].

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While the findings show interesting associations, the fact that DHS showed that children 6-23 months from rich households had the
data are cross-sectional is an inherent limitation in this study, as lowest odds of being stunted. Other maternal characteristics sig-
causal relationships cannot be established. Besides, despite the nificantly associated with stunting are education, access to the in-
large sample size to enable the identification of the factors associ- ternet and the number of antenatal visits attended. Children whose
ated with stunting, sub-analysis to assess the relationship between mothers had more education, access to the internet, attended ANC,
the many co-variates was not possible due to the few cases of the belonged to the rich wealth index category were less likely to be
sample in each sub-group. For instance, we would have liked to in- stunted. These findings are consistent with the findings from oth-
vestigate the likelihood of stunting for children without minimum er studies in sub-Saharan Africa [20-22]. These associations come
acceptable diet and consumption of iron-rich foods but these co- as no surprise because women who are educated, mostly live in
efficients could not reach statistical significance at 95% level and urban areas where there is internet access and are more likely to
minimum meal frequency failed collinearity test with other IYCF know how to use the internet, have better health-seeking behaviour
practices variables. This however, does not negate the importance and access to health facilities to attend ANC and can afford to buy
of findings at sub-population level that give substantial insight in foods that are dietary diverse as well as know how to prepare them.
the possible determinants of nutrition deficiencies in young chil- A high maternal education translates into greater health care uti-
dren. lization, adoption of modern medical practices and greater female
autonomy, which in turn influences health-related decisions that
We identified IYFC practices that influence stunting in Zambia. improve child nutritional outcomes [22].
Our findings suggest that children who are breastfed and have min-
imum dietary diversity are less likely to be stunted compared to Children with a birth interval of fewer than 24 months have lower
children who were not. Children age 6-23 months who were still odds of being stunted. Due to the lower birth interval, one would
breastfeeding had lower odds (38%) (AOR 0.62; 99% CI 0.48, expect that breastfeeding duration is less than 24 months and care
0.79) of being stunted. The findings also show lower odds of stunt- may be inadequate and therefore stunting could be more prevalent
ing ((AOR 0.67; 95% CI 0.47, 0.95) among children who had min- but the results showed otherwise. We did not, however, explore
imum dietary diversity. This shows that breastfeeding plays a sig- the household or maternal characteristics of these children to de-
nificant role in averting stunting in children 6-23 months. These termine whether this unexpected finding is due to the latter factors.
findings suggest that breastfeeding up to the recommended dura- We can, however, speculate that these children may have received
tion of 24 months or beyond especially in low resource settings adequate care and were well-nourished despite having a less than
like Zambia can significantly reduce stunting. Dietary diversity as 24 months birth interval.
complementary feeding is introduced together with gradual wean-
ing can avert the stunting levels in Zambia [18] . Evidence from Stunting among children age 6-23 months differs by rural-urban
other studies suggest that interventions that promote and support and regional areas. Stunting was more prevalent in rural areas than
optimal breastfeeding practices and enable increased consumption in urban areas. Children in rural areas have higher odds of being
of nutritious local foods have potential to contribute to reducing stunted compared with counterparts in urban areas. Our findings
stunting [22]. Further, nutrition-specific interventions targeted at differ from a study conducted in Cambodia which showed lower
improving IYCF practices, dietary diversification and intake of odds for children in rural areas [23]. The difference in findings
nutrient-rich meals, should be adopted and scaled up to address could be explained by many socio-economic differences which
undernutrition23. this study did not seek to explore.

This study identified several children, maternal and household Conclusion and policy implications
characteristics associated with stunting among children 6-23 With 36% of children age 6-23 months stunted, this child nutrition
months in Zambia. The findings suggest that sex of the child, is still a public health challenge in Zambia. The study identified
child’s age, perceived size of child at birth, receipt of vitamin A sex of child, perceived size of child at birth, household wealth and
supplementation and child’s anaemia are significantly associated mother’s internet access as strong determinants of stunting. Male
with stunting, the results are consistent with other studies on stunt- children and children with perceived low birth size were more
ing among children age 6-23 months [19-21]. likely to be stunted whereas children from rich households have
the lowest odds of stunting. Children with mothers who have in-
Further, male children, older children (18-23 months), children ternet access also have lower odds of being stunted. Maternal ed-
with a perceived low birth size and children who did not receive ucation and antenatal attendance are significantly associated with
Vitamin A supplementation are more likely to be stunted. UNICEF stunting. Stunting levels reduce with increase in mother’s educa-
indicates that painful and debilitating cycles of illness, depressed tion and an increase in wealth status. Breast feeding and Minimum
appetite, insufficient food and inadequate care contribute to stunt- Dietary Diversity are two important IYCF practices that influence
ing. Many children do not survive such detriment while many of stunting. Children who are breastfed and have minimum dietary
those who do survive carry long-term defects in mental capacity diversity are less likely to be stunted. We, therefore, recommend
along with losses in stature [2]. Analysis of maternal characteristics that programmes on Infant and Young Child Feeding should em-

Adv Nutr Food Sci, 2022 www.opastonline.com Volume 7 | Issue 1 | 125

phasise breastfeeding especially in low-resource settings like 2020. doi: 10.18356/6ef1e09a-en.
Zambia and promote dietary diversity in order to reduce stunting. 3. B. Omilola and N. A. Sanogo, “Health, nutrition, and econom-
Further, IYCF practices such as breastfeeding and dietary diver- ic development in Africa,” Public Heal. Open J, vol. 5, no. 1,
sity should be emphasized during mothers ANC and PNC visits. pp. 14–16, 2020, doi: 10.17140/PHOJ-5-140.
ANC and PNC attendance should be encouraged for all mothers 4. ZDHS, “Zambia Demographic and Health Survey 2018; Zam-
to promote good nutrition during pregnancy; monitor growth of bia Statistical Agency, Ministry of Health & ICF,” 2018.
children and health of mothers; as well as provide information on 5. World Health Organization [WHO], “Global Nutri-
IYCF best practices and prevent illnesses that may lead to stunt- tion Targets 2025: Stunting Policy Brief,” 2014. doi:
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ucation on IYCF are essential to reduce child stunting in Zambia. 6. World Health Organization [WHO], “Indicators for assessing
Further, to yield a sustainable improvement in child nutrition in infant and young child feeding practices,” 2010. doi: ISBN
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the IYCF practices and socio-economic factors associated with 7. M. K. I. & U.-G. Gerdtham, “Moving towards universal cov-
stunting, thereby setting the country on the path to achieving the erage-about the series,” 2006. Accessed: Apr. 09, 2020. [On-
WHO global nutrition target by 2025 and achieving the SDG’s line]. Available: www.who.int/reproductive-health/mtuc.
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Acknowledgements 2013-2015,” no. December 2012, pp. 2011–2015, 2012, [On-
Not Applicable line]. Available: http://scalingupnutrition.org/wp-content/up-
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AB contributed to the conception and design of the study; AB and 10. UNICEF, “First 1000 Days; The Critical window to ensure
ETN did the literature search; AB performed the statistical anal- that Children survive and thrive,” 2017.
ysis; AB wrote the first draft of the manuscript. AB, ETN, CCM, 11. M. Katepa-Bwalya, V. Mukonka, C. Kankasa, F. Masaninga,
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proved the submitted version. ing practices and nutritional status in two districts of Zambia,”
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Funding 015-0033-x.
None. 12. United Nations Children’s Fund, “Programming guide infant
and young child feeding,” Nutr. Sect. UNICEF, no. May, p.
173, 2011, doi: http://www.unicef.org/nutrition/files/Final_
Availability of data and materials
IYCF_programming_guide_2011.pdf.
Data used in this article are available to bona fide researchers on
13. C. P. Stewart, L. Iannotti, K. G. Dewey, K. F. Michaelsen,
request from the DHS program
and A. W. Onyango, “Contextualising complementary feed-
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Ethics approval and consent to participate Child Nutr., vol. 9, no. S2, pp. 27–45, Sep. 2013, doi: 10.1111/
Not Applicable mcn.12088.
14. Kyaw Swa Mya, Aung Tin Kyaw, and Thandar Tun, “Feeding
Consent for publication Practice and Nutritional Status of Children Age 6-23 Months
Not applicable. in Myanmar: Further Analysis of the 2015-16 Demographic
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Competing interests 2018.
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ing in Children under Age 2 in the Cambodia and Kenya 2014
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Appendix
Appendices:
Appendix
Appendix
A: WHO Conceptual Framework for Childhood Stunting (adjusted*)
Childhood Stunting Framework Adapted from the WHO Framework for Childhood Stunting

Child Nutritional Concurrent Problems & Short Term Consequences Long-term Consequences

Child Economic Child Development Economic

Increased Health Health Outcomes and Growth Low work capacity
Health Outcomes Development and Adult NCDs Work productivity
Expenditure Low Learning outcomes
Increased Morbidity Growth Obesity and associated Labour force
The increased Learning capacity
Increased Mortality Low Cognitive comorbidities unachieved potential participation
opportunity cost for
Language Reproductive Health
mothers caring for sick
children

Consequences

Stunted, Wasting and Under-weight Growth

Causes
Hygiene and
Household Level Factors Feeding Practices Breastfeeding Infection Control

Maternal Factors HH Setting Food and Dietary Feeding Practices Breastfeeding

Preconception Poor Low child stimulate Diversity Infrequent feeding Food and Water Childhood Diseases
Practices
nutrition, pregnancy, activity Low micronutrient Inadequate feeding Safety Infection
lactation Delayed initiation
Poor care practices quality (during and after Water sources Diarrheal disease
Adolescent Non-exclusive feeding
Sanitation Low dietary diversity illness) Hygiene practices Fever and respiratory
pregnancy, preterm Food security Early cessation
and intake Insufficient Preparation Storage infections
birth, short birth Low caregiver quantities Complimentary Malaria
interval education, wealth feeding

Contextual Issues Community and Societal Factors

Political Economy Agriculture and Food Water, Sanitation and

Health and Healthcare Education
Policies, financial Society and Culture Security Environment
Access to healthcare Quality education
services, poverty, Health systems, Norms and beliefs Food production and Water and sanitation
Qualified teachers
income, wealth, infrastructure, policies Health educators, research, Social support network processing Infrastructure
employment, infrastructure, training Power relations Availability Population distribution and
livelihoods institutions Food safety and quality density, disasters

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Copyright: the
©2022the original
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et al. are
This isare credited.
ancredited.
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