Understanding Undernutrition in Mozambique

Trying to Understand Undernutrition in Mozambique

By Elizabeth Rose

This article is a summary of an article previously published by the author in BMC Nutrition and the full article can be accessed here: https://www.ncbi.nlm.nih.gov/pubmed/27182448

Recent increases in globalization, urbanization, and the availability of processed foods high in sugars, sodium, and fat have contributed to a shift in focus from undernutrition to overnutrition in developing countries. Despite this shift, undernutrition continues to be a major problem, particularly in rural Africa. Among low- and middle-income countries (LMICs), the prevalence of chronic malnutrition, or stunting (height-for-age z-score less than -2), was 28% in 2011. When disaggregated by region, the prevalence of stunting in sub-Saharan African countries rose to 40% and in Mozambique, a country on the southeastern coast of Africa, the prevalence was even higher at 44%.

As the period for reaching the Millennium Development Goals (MDGs) drew to a close in 2015, assessing the reasons behind why goals were or were not reached will help guide future human development efforts in LMICs. Insufficient nutrition is a cross-cutting condition that both directly and indirectly impeded progress towards three MDGs: One (eradicating extreme poverty and hunger), Two (achieving universal education), and Four (reducing child mortality). In 2012, 25% of children under five years old (or 162 million children) suffered from stunting worldwide, with an additional 15% of children (112 million) classified as underweight (weight-for-age z-score less than -2).

Maternal prenatal nutrition and poor intake of micronutrients, such as vitamin A, by the infant in the “first 1000 days” (i.e. conception to age two years) can cause irreversible developmental damage and impediments in physical and cognitive growth that last into adulthood. Thus, proper nutrition in early childhood is important and poor nutrition at this age has been correlated with lower cognitive performance in school and decreased success in the labor market as an adult, which further perpetuates the cycle of poverty and undernutrition. Undernutrition, which includes stunting, underweight, and wasting (weight-for-height z-score less than -2), is the largest preventable cause of death among children under five years and is directly or indirectly attributed to 45% of child deaths (3.1 million). Ninety-eight percent of undernourished children live in developing countries, and while the prevalence of undernutrition has decreased across almost all world regions over the past two decades, rates have been increasing in Africa, mandating a better understanding of the determinants of undernutrition in this geographical setting.

Compounding the poor nutritional indices of Mozambique described above are the salient disparities in health care, outcomes, and budgeting allocations among the country’s provinces. The centrally-located Zambézia Province has the lowest per capita budget for health and education in Mozambique. It also has the lowest access to safe water (only 26% of people had access to safe water in 2009), the highest sanitation deprivation among children (73% of children did not have access to sanitation facilities in 2008), and the highest poverty headcount (71% of the population lived in poverty in 2008). Furthermore, this province also had some of the lowest performance indicators for health outcomes in the country, including the highest under 5 mortality rate (206 per 1000 live births, 10 year average 1998-2008) and among the highest child stunting rates (46%, 2008). Zambézia Province has been labeled as a development “priority province” and as such, numerous national and international programs have been undertaken, yet undernutrition rates have remained relatively stable. Aligning with the World Health Organization (WHO) recommendations that countries place the management of undernutrition as a public health priority, we sought to study the determinants of undernutrition among children under five years of age, over a four-year period, so as to inform future interventions and health practices that aim to reduce the prevalence of undernutrition in Zambézia Province.

In order to study the determinants of undernutrition in this population, we conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August–September 2010 (Baseline) and April–May 2014 (Endline) as part of the USAID-funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6–59 months at Baseline and 912 children at Endline and classified as: “stunted,” a height-for-age z-score less than -2; “wasted,” weight-for-height z-score less than -2; and “underweight,” weight-for-age z-score less than -2.

The results of this study included the following: Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child’s age was found to be associated with stunting and Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).

The prevalence of stunting in our study was “very high prevalence” as per WHO classification and also in comparison to worldwide rates of stunting in other LMICs that range from 5% to 65%. Recorded rates of wasting and underweight, as defined by the WHO, were categorized as “poor” and “medium prevalence,” respectively. Stunting prevalence is of particular concern since it reflects long-term structural factors of undernutrition and can serve as an indicator of a population’s well-being.

In conclusion, almost half of studied children aged 6-59 months in Zambézia Province were undernourished, revealing the need for sustained efforts to ameliorate this high prevalence rate. Of particular concern is the high rate of stunting that increased from 2010 to 2014. Intensified efforts to increase rates of vitamin A supplementation should be implemented, as well as other disease prevention measures such as interventions aimed at sustaining high rates of vaccine uptake. Interventions related to breastfeeding and hand washing practices as well as decreasing the extraordinary level of food insecurity that is prevalent throughout Zambézia Province should be implemented to help to reduce the prevalence of wasting and underweight. Future studies are needed to better explore local customs related to inter-household dietary diversity patterns, specifically focused on children under five years old. This study provided evidence that a combination of factors were associated with undernutrition. As such, use of multidimensional interventions should be considered to decrease undernutrition in children under five years old.

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Super Spending in the Super League

By Javan Latson

The People’s Republic of China is one of the world’s fastest growing economies. The rise of China has vaulted them onto the global stage and has made them a major player in global affairs. Although there is a heavy emphasis placed on manufacturing and being able to compete with other advanced nations in the economy, there is another area in which the PRC is trying to show its prowess – soccer. Having hosted the 2008 Summer Olympics and with the 2022 Winter Olympics on the way, the Chinese government has shown that they are capable of producing world class athletes. However, there is still a lot of room for improvement when it comes to their performance on the field.

President Xi Jinping is an avid fan of the sport and has laid out some pretty lofty goals for the nation’s soccer program. Unlike Brazil, Argentina or Germany, China doesn’t have any World Cup championships, or many high profile athletes competing in the top leagues. Whereas the women’s program has played in the World Cup six times, including a finals appearance in 1999, the men haven’t qualified since 2002.  In fact, the Chinese Men’s National Team is currently ranked a mediocre 86th behind countries like Belarus, Qatar, and Armenia. In an effort to improve China’s reputation, President Xi made a proclamation that he wanted to make his nation a major competitor by 2050. He aims to achieve this goal by investing heavily in infrastructure, developing domestic talent, and improving the quality of the nation’s professional league.

A similar initiative was proposed in the 1950s following the revolution that placed the communist government in power. Following the civil war, the plan was to use soccer to launch China onto the global scene. In order to achieve this goal, soccer became organized and financed by the government and what would eventually become the General Administration of Sport was founded. Under the oversight of the state, this government body helps regulate athletics, create standards of physical fitness, organize major international competitions, and encourage investment in the sports industry.

People in China are passionate fans and soccer is the most watched game in the entire country. More than 300 million people (about the population of the United States) tune in to watch English Premier League matches. In fact, demand is so high for these games that the league signed a three-year $700 million deal with the Chinese streaming site PPTV for broadcasting rights. To put things into perspective, NBC Universal paid $500 million to extend its contract with the league even though viewership in the US decreased by 17% last year. However, whereas there are many Chinese spectators, there are relatively few people that actually compete. According to the Chinese Football Association, there are only 7,000 players under 18 that are registered in the entire country.

To address the lack of soccer players President Xi plans to build at least 20,000 training centers and 70,000 soccer fields throughout the country by the end of the decade. Many people don’t play the game simply because they don’t have anywhere to compete, especially in rural areas. His goal is to increase the accessibility of citizens to high quality facilities and skills training. He wants every county to have two full sized fields and every residential area in larger cities to have at least one small sized court. In addition to building state of the art fields, billions of dollars will be spent on player development in the form of training programs or institutions. Children will be exposed to soccer as a part of their physical education curriculum, with the intention that students around the country will have the chance to become familiar with the game at an early age. This is important because when it comes to athletics, exposure at an early age plays a major role in future growth as a player.

By far the most spectacular example of China’s commitment to cultivating high quality prospects is the Evergrande Football School in Guangzhou. The building, which took ten months to build and cost $185 million, is the largest soccer school in the world. Although the primary focus is athletics, students also are taught the typical curriculum found at other schools (math, science, reading, etc.). The 2800 students at the school come from all around the country, including Tibet and the predominantly Muslim province of Xinjiang. They have access to more than 50 fields, special chefs, a library, swimming pools and a gym. The 160-acre campus is a testament to the enormous investment that the government is placing on the sport, which in the eyes of some plays a role in their nation’s prestige. Each week players are instructed in tactics and fundamentals by Chinese and Spanish coaches.

The European imports are the result of a strategic partnership with eleven time European champion Real Madrid. The aim of this partnership is to help develop quality Chinese players who, with the proper tutelage, will be able to compete for the top clubs of Spain, England, Germany and Italy. The opportunity to be taught by some of the world’s best is something that is highly desired by many players in the country, but it’s very hard to get into the school. It costs $9,200 a year for a child to attend Evergrande, which is more than the average yearly income for Chinese families. The more talented athletes are given scholarships to attend or are given financial assistance to help cover the cost of attendance. Thus, for the vast majority of children in China it’s highly unlikely that they’ll ever be able to attend this prestigious institution.

Exposure and access are two important things when trying to increase something’s popularity, but in the world of sports there must be opportunities for competition at the amateur and professional athletes. China’s goal isn’t simply to have more people playing, but to produce high-quality athletes that can go toe-to-toe with the world’s best. To solve this problem the government has begun a multimillion-dollar revamp of the Chinese Super League which is the country’s professional league. The CSL has 16 teams and is regulated by the Chinese Football Association. Chinese professional soccer has a rough history rife with mediocre teams, and corruption. In 2013, dozens of referees and former players were banned from soccer after an investigation into match fixing. The probe by the Chinese football association led to two high-ranking officials being arrested, the team Shanghai Shenhua vacating their 2003 championship.

In spite of these major setbacks, the CSL has seen tremendous growth in recent years to a growing amount of investment from Chinese corporations. Firms like multibillion-dollar Alibaba  have begun purchasing stakes in professional clubs. Much like his other strategies, President Xi is setting the bar high for the country’s professional clubs and expects a few to be dominating Asian competition within a few years. To accomplish this, clubs in China have spent large sums of money to acquire some of the world’s top talent.

In December of 2016, Oscar dos Santos Emboaboa Junior left Chelsea FC for Shanghai SIPG in a deal worth 52 million pounds (over 64 million dollars). The team was shocked that one of their marquee players left a team that placed first in the English Premier League.The Brazilian silver medalist had been a part of their 2012 championship team and had only cost Chelsea 19 million pounds to acquire, but was paid more than twice his initial value. That same month, Argentinian footballer Carlos Tevez made the decision to take his talents to the Chinese team Shanghai Shenhua in a 70 million pound (87 million dollar) transaction. Tevez, who spent the majority of his career in the Premier League, now makes more than 745,000 dollars per week.

Tevez and Oscar are two members of a growing class of high-level players that are leaving Europe for China. During the January-February transfer period of 2016, CSL clubs spent $365 million on player acquisition. In comparison the English Premier League spent $275 million during that same two-month window. In addition, many reputable managers are also making the trek east. Alberto Zaccheroni, who led the Japanese national team to an AFC Asian Cup championship in 2011 and a berth in the 2014 World Cup, 2010 Japanese league manager of the year Dragan Stojkovic, and former coach of the Brazilian national team Mano Menzenes are some high profile hires that have been made by CLS clubs.

Speculators predict that by next year the CSL will become the world’s third most watched league behind the Premier League and  the German Bundesliga. The broadcasting rights within the span of one year increased from a value of $8.6 million in 2015 to $1.11 billion in 2016. In fact five-time league champion Guangzhou Evergrande is now estimated to be the world’s most valuable soccer team.

The rapid ascension and growth of Chinese soccer has caught the attention of many. European clubs are anxious about CSL clubs due to their incredible spending power. It was reported that four-time FIFA player of the year Cristiano Ronaldo was offered a huge contract by one Chinese team, but declined in order to stay with Real Madrid. There are others however, that are skeptical of this desperate spending. Critics claim these high level transactions are simply not sustainable over the long term. Others are more worried that much of the money is being spent on foreign players rather than Chinese athletes. In order to address the rampant spending, the Chinese government has begun to call for the creation of salary caps that limit the amount clubs can spend on players. There are also now rules that limit the amount of foreign players that can be on the field at one given time.

President Xi’s desire to build up his nation as a soccer powerhouse is quite impressive. However, the increased focused on athletics could all be a cover for something else. It is possible XI is using soccer to distract the people from the slowing economy or the human right’s abuses of the Communist Party. On the other hand, it could be a ploy to gain favor with other nations. There has been a history of China practicing “stadium diplomacy” with resource rich nations of Africa and Latin America. For example when Angola hosted the African Cup of Nations, China paid the bill for the construction of four new facilities. Following this act of “generosity” Angola has now become China’s second largest source of oil. China has the capabilities to excel on the world stage. It may not be long from now that we turn on our TVs and see a Chinese player as the star on Real Madrid or Manchester United, or a World Cup trophy being hoisted up in Beijing.

Using Mobile Technology to Promote HIV Self-Testing

By Dr. Nickolas Zaller 

Dr. Nickolas Zaller is an Associate Professor in the Department of Health Behavior and Health Education and Director of the Office of Global Health at the University of Arkansas for Medical Sciences. On November 7th he was in Nashville and gave a talk at the Vanderbilt Institute for Global Health weekly Grand Rounds.

Dr. Zaller’s talk focused on mHealth to promote HIV self-testing among men who have sex with men (MSM) in Hefei, Anhui Province, China. Interestingly, HIV started in China primarily with unsafe practices surrounding rural blood donations for money. Currently, HIV risk is highest among MSM in China with rates growing compared to other high-risk populations such as sex workers. This is compounded by low rates of HIV testing among MSM.

It is in this context that Dr. Zaller and his team hope to develop a mobile platform to promote self-testing among MSM as a potentially scalable model applicable in other locations. He sees this as breaking the cycle in which the stigma of even going to a testing site combined with the fear of a positive result prevent men from getting tested. By offering self-testing at home, there is no stigma associated with going to a testing location and the barrier to entry is lower.

The natural tradeoff that comes with self-testing is the inability to counsel patients during a clinic visit. Dr. Zaller hopes to preempt this with a mobile education platform to improve HIV knowledge. Taking into account local context, this platform will be built through WeChat. While not very common in the United States, WeChat is the most common messaging platform in the world, and 25% of adult Internet users report using it. It is also by far the most common in the region.

The ultimate goal is to push educational information directly to users’ phones to both promote testing and improve HIV knowledge in this high-risk group. Dr. Zaller plans to complete a randomized controlled trial among men over 18 who self-identify as MSM with some receiving the messages and others not. Testing rates as well as other metrics—such as high-risk behavior—will be compared between the two groups. Once the content has been refined, it is potentially scalable to other cities and contexts.

The group has already performed qualitative interviews with potential participants to begin getting feedback on self-testing and the learning platform. People generally thought the test was easy and reported that it afforded improved privacy over going to a testing center. Participants were concerned about the accuracy of home testing and stated there was an inherent loss of privacy in physically purchasing the test. While they acknowledged the potential to buy tests online, they had less faith in these tests because of the potential for fakes. For the learning platform, they emphasized the need for a mix of both formal educational materials and fresh content to keep people interested. They also emphasized the need for privacy when content is pushed to a person’s phone to make sure others would not see it.

In summary, Dr. Zaller and his team aim to improve testing coverage among MSM in a scalable model using a mobile learning platform and self-testing.

Nigeria: An African Giant Divided

Southern regions along with Abuja (FCT) have long been the economic hub while the north is generally viewed as being backward. (Credit GeoCurrents / CGIDD)
Southern regions along with Abuja (FCT) have long been the economic hub of the country. (Credit GeoCurrents / CGIDD)

By Aalok Joshi

On January 17th the Nigerian air force moved forward with operations in the northeastern Nigerian state of Borno, bombing what they thought was a Boko Haram hideout. However, this supposed hideout turned out to be a refugee camp hosting families who have been displaced by the radical Islamist group, Boko Haram, ravaging their country. Additionally, the refugee camp was also the temporary base of operations for members of the Red Cross and Doctors Without Borders working in the area. Borno state officials have put the death toll from this horrible miscue by the Nigerian armed forces at 100. Meanwhile the Red Cross has reported that 6 of their personnel were killed in the bombing.

This most recent blunder by the Nigerian armed forces has come at a time in which Boko Haram continues to be a festering sore for the African giant. Nigeria is the wealthiest African nation by GDP and has been blessed by ample natural resources in the oil rich southern region of the Niger delta. This combined with the fact that Nigeria has an expanding middle class gives  Nigeria the potential to be one of the world’s leading economies. Additionally, Nigeria has the largest population of any African nation. This puts Nigeria in the unique position of being the largest market on the continent and thus being able to dictate African demand for a variety of products. However, because of its exploitive colonial legacy and the influx of large multinational oil conglomerates into the southern half of Nigeria, the northern section of the country is relatively underdeveloped. Most of the wealth in the nation is centered around the capital of Abuja, the commercial hub of Lagos, and the petrodollar region of the Niger delta. All of these regions, relatively speaking, are in the southern half of the nation. This leaves much of the north poor, underdeveloped, and cut off from the center. The north has less educational facilities and almost completely lacks any foreign investment. While much of the north relies on subsistence farming and other agricultural pursuits, the south has a long history of foreign trade and bustling economic activity.

Along with this economic divide, Nigeria faces a cultural and religious divide within the nation. The north is largely Muslim while the south is mostly Christian. However, the Christian and Muslim populations are relatively equal, and there are enclaves of both Christians and Muslims in the north and south. This means that though the regions are culturally different Muslims and Christians generally get along with each other. The northern states practice sharia law while the southern states do not. This north-south tension has also taken on political undertones. Many national elections, issues, and geopolitical stances in Nigeria pit north against south because the two regions have completely different priorities and interests. While the North wants more economic investment and integration with the booming South, the South insists that it must pay attention to its own expanding economic aspirations before focusing on the North. Additionally, the rise of radical Islamic terror groups, specifically Boko Haram, in the North, has made Southern businesses and firms even more hesitant to invest in the area.

Boko Haram was founded in 2010 in the city of Maiduguri in the state of Borno. Borno, in the northeastern corner of the country, is bordered by the Sambisa forest near the country of Chad. This thick forest cover provides a base from which Boko Haram conducts its attacks on the surrounding towns, cities, and states. In the past seven years of the insurgency, Boko Haram has conducted attacks not only throughout the northern periphery, around Yobe, Kano, and Borno, but also as far south as the Niger state and the federal capital territory of Abuja. In fact, the capital of Abuja has been terrorized by multiple bombings and shootings throughout the city. Boko Haram’s attacks have killed and wounded both Muslims and Christians, and though Boko Haram claims an Islamic affiliation they seem to have no mercy toward any religion. Some of Boko Haram’s most infamous attacks include the 2011 attack on the U.N. building in Abuja, the Bauchi Prison break, and the abduction of almost 300 schoolgirls from the northeastern town of Chibok.

The Nigerian government, however, has been severely criticized for not taking the Boko Haram threat seriously enough. Most infamously, Nigerian president Buhari claimed that Boko Haram was “technically defeated” in late 2015 when in fact Boko Haram still regularly carries out attacks. Because of increasing international pressure, especially following the kidnapping of the Chibok girls, former Nigerian president Goodluck Jonathan, a Christian from the south, and current Nigerian president Muhammadu Buhari, a Muslim from the north, have ordered an offensive deep into Boko Haram controlled territory. In the past two years the Nigerian military has stepped up their military operations and have managed to contain Boko Haram within its northeastern core. However, this means that cities like Maiduguri still face attacks on a weekly basis. Many of these attacks are concentrated on public squares and markets where people – including women and children, gather daily. Such attacks have meant that businesses don’t feel safe and accessing basic commodities has become hard for many residents of Boko Haram’s northeastern core. The World Food Programme feeds around 4.4 million people in and around Boko Haram’s home state of Borno, and WFP estimates suggest as many as 1.8 million people are at risk of starvation because of food aid being disrupted by Boko Haram attacks.

Looking at Nigeria from the outside it seems odd for an insurgency like Boko Haram to exist in this burgeoning African power. The McKinsey Global Institute (MGI) predicts that Nigeria is on pace to grow at a rate of 6% annually until 2030 and have a GDP of $1.6 trillion, putting it in the top twenty economies worldwide. Moreover, MGI estimates suggest that by 2030 Nigerian consumption could rise from $388 billion annually to $1.4 trillion. However, a cultural and socioeconomic divide between the increasingly unequal northern and southern regions of Nigeria has created a rift in this nation. The future of Nigeria will be decided by whether Abuja and the coastal economic hub will be able to address the lack of economic opportunity and upward mobility for the northern half of the country. Simultaneously, Nigeria will succeed if Muhammadu Buhari’s government can firmly stamp out Boko Haram and make northeast Nigeria suitable for business and development projects. It is very much within reach for Nigeria to have economic success relatively soon, however, if the festering sore that is Boko Haram is not handled soon it is unlikely that the economic wealth will be shared by all of Nigeria.