Supplement article - Research | Volume 7 (3): 8. 27 Jun 2024 | 10.11604/JIEPH.supp.2024.7.3.1532

Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

Emmerance Hirwa Igihozo, Francoise Mukanyangezi, Emile Abimana, Eric Matsiko

Corresponding author: Emmerance Igihozo Hirwa, Field Epidemiology Training Program, Kigali, Rwanda

Received: 19 Feb 2024 - Accepted: 16 May 2024 - Published: 27 Jun 2024

Domain: Hygiene and sanitation,Water resources,Work environment

Keywords: Factors, Stunting, Children, 6 to 59 months

This articles is published as part of the supplement Advancing Public Health through the Rwanda Field Epidemiology Training Program, commissioned by Rwanda Field Epidemiology Training Program (R-FETP).

©Emmerance Hirwa Igihozo et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Emmerance Hirwa Igihozo et al. Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023. Journal of Interventional Epidemiology and Public Health. 2024;7(3):8. [doi: 10.11604/JIEPH.supp.2024.7.3.1532]

Available online at: https://www.afenet-journal.net/content/series/7/3/8/full

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Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

Emmerance Hirwa Igihozo1,&, Francoise Mukanyangezi2, Emile Abimana3, Eric Matsiko4

 

1Field Epidemiology Training Program, Kigali, Rwanda, 2University of Rwanda, Clinical Pharmacy and Pharmacy Practice Department, School of Pharmacy and Medicine, Huye, Rwanda, 3Shyira District Hospital, Medical internist in Internal Medicine Department, Shyira District Hospital, Nyabihu, Rwanda, 4University of Rwanda, Human Nutrition and Dietetics Department, School of Public Health, Kigali, Rwanda, 5University of Rwanda, Human Nutrition and Dietetics Department, School of Public Health, Kigali, Rwanda

 

 

&Corresponding author
Emmerance Igihozo Hirwa, Field Epidemiology Training Program, Kigali, Rwanda.

 

 

Abstract

Introduction: Malnutrition is a leading cause of mortality among children around the world, with over 6 million deaths occurring each year and an estimated 144 million worldwide being stunted in 2020. Rwanda has one the highest rates of child stunting in the world at 33%. We identified factors associated with stunting among children in Nyabihu district, Rwanda.

 

Methods: A matched case-control study was conducted among children aged 6 to 59 months who attended health centres in Nyabihu district from March to April 2023. A total of 136 cases and 266 controls were included in the study. Cases were selected based on WHO anthropometric measurements and matched with children of the same age and residence. Primary data on socio-demographics, hygiene and sanitation, feeding practices and clinical characteristics were collected using a structured questionnaire. Multivariate logistic regression analysis was performed to identify independent associated factors.

 

Results: The following factors were significant to childs stunting: being in socio-economic category 1 (aOR 11.1; 95%CI: 4.328.4), non-parental caregivers (aOR 3.8; 95% CI: 2-7.4) and having more than one under-five children at household with odds increasing with increasing number of children: 2 under-five children (aOR 3; 95%CI 1.05-8.6), 3 under-five children (aOR; 5; 95%CI: 1.56.2), mostly of the agriculture produce was sold (aOR 4.3; 95%CI: 2.37.9), not treating drinking water (AOR 2.4; 95% CI 1.3- 4.5), washing hands before feeding a child (aOR 0.08; 95%CI: 0.04- 0.1), not attending ANC (aOR 8; 95%CI: 1.8 34.7), and attending mass campaign (aOR 0.34; 95%CI: 0.10.6).

 

Conclusion: The findings show that the first/lowest socio-economic category, washing hands before child feeding, treating drinking water, a greater number of under-five children in the household, attending ANC and vaccination campaigns were associated with stunting. Mitigating poverty, strengthening antenatal care attendance, child vaccination and improving hygiene and sanitation can help to reduce stunting.

 

 

Introduction    Down

Malnutrition is a leading cause of mortality among children around the world, with over 6 million deaths occurring each year and an estimated 144 million children worldwide being stunted in 2020 [1,2]. Malnutrition such as stunting can result in poor educational outcomes; which could spur a vicious cycle of poverty as well as impaired cognitive development [3].

 

The number of stunted children aged 6 to 59 months is projected to be 128 million globally in 2025, against a target of 100 million [4]. Child stunting rates exceeding 30% are observed in five sub-regions: western Africa (31.4%), middle Africa (32.5%), eastern Africa (37%), southern Asia (34.1%), and Oceania (38.3%, excluding Australia and New Zealand))[5].

 

A global review of stunting in low- and middle-income countries identified growth restriction, and lack of access to sanitation as the main drivers of stunting; but other contributing factors included ineffective child immunization, diarrhoea prevalence, low uptake of deworming medication and lack of maternal iron supplementation which often coincides with a reduction in stunting [6]. Stunting is one of the 6 global nutrition targets and it has been incorporated into the Sustainable Development Goals (SDG) framework under SDG 2 “End hunger, achieve food security and improved nutrition and promote sustainable agriculture and SDG target 2.2 which states “ end all forms of malnutrition for less than 5 years of age by 2030” [7].

 

In Africa, the prevalence of stunting decreased from 38.3% in 2012 to 30.3% in 2017, although the number of stunted children has increased due to population growth [8]. At present, approximately 34% of children under the age of five in sub-Saharan Africa experience stunting, with the highest prevalence observed in the Eastern African region at 37% [9]. Regionally, the current prevalence of stunting varies across different countries with 34.4 % in Tanzania, 36% in DRC, 26% in Kenya, 41.1 % in Uganda, 46.7% in Burundi, 14.4% in South Africa, 35.6% in Chad, 53.9% in Ethiopia, 25.6% in Cameroon, 24% in Benin and 18.7% in Senegal [10-12].

 

Rwanda has one of the highest rates of prevalence of child stunting in the world. The fact from National Institute of Statistics of Rwanda estimates that its prevalence of stunting in children 6 to 59 months of age was 37.4% in 2014, 38 % in 2015 and dropping to 33% in 2020 [10,13]. The prevalence of stunting changes with age with the lowest prevalence found among children less than 6 months of age and a peak of nearly 50% among children 18-23 months of age; Boys are more likely to be stunted than girls and stunting prevalence decreases as wealth increases [14]. By province, the proportion of stunted children is highest in the West and North at 40% and 41% respectively; Nyabihu district has the second highest stunting rate in the country at 46.7% , this is a very challenging issue as Nyabihu is one of the country´s top producers of Irish potatoes, vegetables as well as milk and milk products and there are no recent studies that have analyzed the determinants of malnutrition among under-five children in this area [13]. This study identified stunting determinants among children aged 6 to 59 months in the Nyabihu district.

 

 

Methods Up    Down

Study settings

 

A health center-based facility case control study design was used to assess the factors associated with stunting among children aged 6 to 59 months in Nyabihu district from March to April 2023. Nyabihu District is composed of 73 cells and 474 villages with a population of 294, 740 composed predominantly of females covering 53.2 %[15]. Nyabihu district has one district hospital, 12 sectors, 16 health centers and 33 health posts. It is among the Rwandan districts with high agricultural production of Irish potatoes, and vegetables [16,17] ,food items known for their richness in nutrients. However, during the last Demographic and Health Survey ( DHS )2019-2020, Nyabihu district had the second highest prevalence of stunting at 46.7% [13].

 

Study design and study period

 

A health facility-based 1:2 matched case-control study was used to assess the factors associated with stunting among children aged 6 to 59 months in Nyabihu district from March to April 2023.

 

Study participants

 

All mothers with children aged 6 to 59 months and their children who were willing to participate in the study, were residents of Nyabihu District and have attended any health center in the study area for any reason were eligible to participate in the study. Mothers with disabilities (specifically deaf and mute) were excluded from the study.

 

Sample size calculation

 

The sample size was computed based on James Schlesselmaflfl´s formula for case-control studies [18] with consideration of the Rwandan prevalence of delayed ANC visits (exposure) of 41%, this was chosen as prevalence of the exposure in the Rwandan population being studied previously[19]. The Assumptions: a 95% confidence level, and a margin of error of 0.05, the power of the study 80%, were considered to calculate the sample size, which ended up with a sample size of 136 children after adding a 2% non-response rate.

 

The ratio of cases to controls is 1:1.96. thus, the number of cases was 136 and the control 266 which gives a total of 402 children sampled.

 

Cases: Any child between 6-59 months old with height-for-age z-scores <-2SD.

 

Control: Any child aged between 6-59 months old with normal height-for-age z-scores. The control children had the same age in months and resided in the same cell as a case. This enhances the validity and reliability of the study's findings by minimizing the potential impact of these confounding variables.

 

Sampling and data collection procedures

 

Convenience nonprobability sampling was used where all children aged 6 to 59 months were screened for stunting by taking anthropometric measurements. A WHO child growth standard measurement was used to determine whether the child is stunted or not, after identifying the cases they were matched with their corresponding controls. The total sample size was 402 for 6 to 59 months children; this indicates 24 children (8 cases and 16 controls) per health center for the total of 16 health centers in Nyabihu district. However, there is an exception in 2 health centers chosen based on higher population serving where 11 cases and 22 controls were considered in order to reach our sample size. Mothers who provided consent and fulfilled the eligibility criteria were interviewed by using a questionnaire with closed-ended questions regarding determinants of stunting. The structured questionnaire was designed in English and translated into Kinyarwanda. Before being used in a study, it was shared with University of Rwanda supervisors for approval and pre-tested for inconsistency and modification. A two-day training on measuring the children's weight, height, and age; and a common understanding of the questionnaire and other communication skills were provided to nutritionists involved in data collection at health centers.

 

Study variables

 

Dependent variable

 

Stunting was a binary variable ie. Any child between 6-59 months old with height-for-age z-scores of less than minus two standard deviations <-2SD was considered stunted while any child aged between 6-59 months old with normal height-for-age z-scores was considered not to be stunted (control).

 

Based on the WHO stunting framework , the following independent variables were collected: Individual characteristics /social demographic factors (child´s age, child´s sex, child s weight, height, history of diarrhoea and or any other chronic diseases, children´s main caregivers, mothers age, marital status, Height, weight, education level, occupation, socio-economic categories, and residence); Household characteristics/factors (Distance to the water source, water supply, improved latrine, household family size, number of children aged 6 to 59 months in the household income, distance to the main road and market, facing natural disasters) feeding practices (Early initiation of breastfeeding, meal frequency, taking balanced diet in the last 2 weeks , mother´s body mass index (BMI), history of smoking ); and Clinical characteristics ( History of diarrhoea and other infections, received required vaccinations, Vit A, and deworming tablets ; Attending ANC, Number of ANC Visits attended).

 

The socio-economic categories are the classification system used by the Rwandan government to categorize households based on socioeconomic status by considering various factors related to household wealth, income, assets, and living conditions [20].

 

Anthropometrics measurements

 

Childs´ weight was measured with minimal clothing and recorded to the nearest 0.1kg using a scale. Child´s Height was measured to the nearest 0.1cm with the child in the upward upright position, legs stretched to a full extent and feet at right angles with legs by using fathom (Toise). To ensure data validity and consistency, two measurements were taken for each anthropometric measure and the average were recorded.

 

Data analysis procedures

 

Data from questionnaires were checked for completeness and inconsistencies, and then entered in a Microsoft Excel, and later exported to Stata version 14 for statistical analysis. Descriptive statistics with frequencies and summary statistics (mean, standard deviation, and percentage) were performed to explore the distribution of considered variables among study participants. Variables with P-value <0.05 in the bivariate analysis were transferred to the multivariate model. Multiple logistic regressions were done to identify an association between independent (predictors) and dependent variables. The decision to determine the statistically significant association was based on the adjusted odds ratios, 95% confidence interval and P-value.

 

Availability of data and materials

 

The datasets used and/ or analyzed during the current study are available from the corresponding author on reasonable request.

 

Ethical considerations

 

The Institutional Review Board (IRB) of the University of Rwanda, College of Medicine Health Science reviewed and approved the study and its implementation (Ref N0: CMHS/IRB/120/2023) and in accordance with the Declaration of Shyira district hospital/Nyabihu District through its ethical committee. A written informed consent form was obtained from each mother /caregiver before enrolling in the study. In addition, confidentiality was granted to each participant and the right to voluntary participation in the study with the freedom to withdraw at any time.

 

 

Results Up    Down

Socio-demographic characteristics of study participants

 

A total of 402 children participated in this study and the distribution of demographic characteristics was similar across both study groups with the exception of residence- all cases (136/136) resided in rural area while 97.8% (260/266) controls resided in rural area. The majority of children (62.7 %, 252/402) were aged between 6-23 months with a mean age of 22± 12.8 months; 56.5% (227/402) were males. Out of 402 mothers, 191 (47.6%) were between 30-39 years old, 34.5 % (139) didn´t attend any school, 78.9% (317) were farmers, and 73.4% (295) were in socio-economic category two (Table 1).

 

Respondent´s household characteristics Most of the participating households 43.8% (176/402) earn less than 7.8 USD per month and mostly from agriculture production, while 51.9% (208/402) of participants possess domestic animals and 68.4 % (275/402) had kitchen gardens (Table 2).

 

Environment, water, sanitation and hygiene (WASH) characteristics

 

The current study found that only 23.6 % (95/402) of the participants have easy access to water sources, 62.6% (252/402) use treated drink water and 53.2 % (214/402) wash their hands before feeding child. Also 65.2 % (262/402) of participating households use pit latrines and 23.7% (95/402) have an unimproved latrine (Table 3).

 

Caregivers feeding practices for children aged 6-59 months

 

The study findings show that out of 402 mothers 87.3% (351) had breastfed their children within one hour after birth; 72.2 % (290) started complementary feeding at 6 months, and 43.6% (175) children were breastfeed 3 times per day. In addition to that, most of the children ate different food groups such as grain root and tubers (75.1%, 302), beans, peas, lentils and nuts (77.3%, 311), milk products (32.4%, 130), eggs and meats 20.9% (84) and vegetables and fruits 84.8% (341) within the last 2 weeks before the study (Table 4).

 

Clinical features among children between 6 to 59 months

 

A total of 253 out of 402 mothers (63%) had their body mass index in the normal range, 96% (386) attended antenatal care visits and the majority of them (64.9%, 261) had at least four visits. The majority of participating children 79.6% (320/402) received required children's vaccinations, and 67% (269/402) received Vitamin A. However, only 53.6% (215/402) of the children received deworming tablets (Table 5).

 

Factors associated with stunting among children aged 0-59 months

 

Factors with p-value < 0.05 at bivariate analysis included socio-economic factors, number of under-five children in the family, washing hands, eating vegetables, child breastfeeding, treating drinking water, attending ANC visits, child caregiver, attending mass vaccination and nutrition campaigns and agriculture production use and were transferred to multiple logistic regression (Table 6).

 

After conducting multivariable logistic regression, the following factors were significantly associated with child´s stunting: Mothers who are in Socio-economic category 1 were 11.1 times more likely to have stunted children compared to those who were in category 2 (aOR 11.1; 95% CI: 4.3- 28.4), Children whose caregivers were not their parents were around 4 times more likely to be stunted compared to those whose cared for by their parents (aOR 3.8; 95% CI: 2-7.4) and families with more than 1 under-five child had higher odds of being stunted than those who had 1child only, odds ratio increased from 1 to 3 for those who had 2 children (aOR 3; 95% CI:1.05-8.6) to 5 for those with 3 children (aOR 5; 95% CI: 1.5-6.2). Those who mostly sold their agriculture products were 4.3 times more likely to have stunted children compared to those who used them for home consumption (aOR 4.3; 95% CI: 2.3-7.9). Mothers who didn´t treat drinking water were 2.4 times more likely to have stunted children than those who treat drinking water (aOR 2.4; 95% CI: 1.3- 4.5). Mothers who never attended ANC were 8 times more likely to have stunted children (aOR 8; 95% CI: 1.8- 34.7) than those who attended ANC visits. Children whose caregivers washed their hands before providing child care were 92% less likely to be stunted than children to those who did not wash their hands (aOR 0.08; 95% CI: 0.04- 0.1), children whose mothers attended mass vaccination campaigns were 66% less likely to be stunted than those who didn´t attended the campaigns (aOR 0.34; 95%CI: 0.1-0.6) (Table 6).

 

 

Discussion Up    Down

This case-control study involved 402 children aged between 6 to 59 months, among whom stunting remains be public health problem in Rwanda. Belonging to the lowest socio-economic category, having two or more under-five children in the family, caregivers´ not washing hands before feeding their children, not treating drinking water, not attending ANC visits, non-parental child caregivers, not attending mass vaccination and nutrition campaigns and mostly selling agriculture produce instead of reserving it for home consumption were associated with stunting. Households in the lowest socio-economic category were more likely to have stunted children than those in other wealth indexes. This category represents the most vulnerable households in terms of socioeconomic status with limited access to resources, basic services, and income-generating opportunities. This finding is consistent with results from a cross-sectional study that was conducted in 2015 in Rwanda[9]. This might be due to inadequate financial resources to provide an adequate balanced diet; poor households have reportedly been food insecure, which is a known risk factor for stunting. Previous studies revealed that children in food-insecure households were more likely to be stunted than children in food-secure households [21,22]. In support of those findings, our study, found that children in households that sold agriculture produce rather than using it for household consumption, had higher odds of being stunted. A possible explanation for this is, is that selling food reduces the availability and diversity of foods in the household [23].

 

The current study revealed that having more than one under-five child in a household was associated with child´s growth and the odds of stunting increased with the number of children. This finding is similar to the cross-sectional study done in Burundi where being in a household with more than two under five years´ children was associated with a higher risk of stunting than being in a household with one or two under five years´ children [11]. Our results corroborate with those of several studies conducted in developing countries [11,24].

 

In Rwanda, mass vaccination and nutrition campaigns are conducted twice per year; and this study revealed that those who attend those mass campaigns were protected from stunting. Our finding is also similar to a study conducted in Kenya where children without up-to-date vaccinations were more than twice as likely to be stunted than children who were with up-to-date vaccinations [25].

 

The mechanism through which vaccination may protect children from stunting might be related to reducing morbidity among vaccinated children especially due to vaccine-preventable infectious diseases[26].

 

Our study found out that children who were cared for by other people other than parents were more likely to be stunted compared to those under the care of their parents. This may be due to parents providing better care to their children compared to that offered by caregivers. Worse still, these caregivers are often young adults or teenagers who limited experience in childminding. This is supported by a study conducted in Ethiopia which found that teenage caregivers were more likely to have inadequate knowledge and experience in child feeding and care practices which was associated with a higher rate of stunting [11].

 

Washing hands before child feeding and using treated drinking water were protective against child stunting. These findings conform to literature which highlights that drinking untreated water, poor hand hygiene and sanitation, in general, exposes children to pathogens possibly due to human and animal faecal contamination leading to diarrhea/infections, which result in their bodies losing nutrients and fluids that are essential for growth and development, and loss of appetite which ultimately results in undernutrition and morbidity among children [12].

 

Mothers failure to attend ANC visits also contributes significantly to child stunting. In our study children whose mothers didn´t attend ANC visits were 8 times more likely to have stunted children than those who attended. This finding is similar an Indonesia study results [12]. The possible explanation is that attending ANC visits gives women the chance to get information on nutrition during pregnancy, breastfeeding and childhood. O

 

ur study findings may have a recall bias since some respondents may have experienced difficulty in accurately remembering past events. To minimize that, we limited our questions to only to two weeks back. Another limitation is that we were not able to collect information on community, societal and, political-economic factors which are known to significantly affect children´s growth.

 

 

Conclusion Up    Down

Child stunting remains a public health problem in Nyabihu District. The findings show that the lowest socio-economic category, household food security, washing hands before child feeding, treating drinking water, having more than one under-five child in a household, and attending ANC and vaccination campaigns were associated with stunting. Addressing poverty through women empowerment strategies, enhancing antenatal care attendance and child vaccination uptake as well as improvements in hygiene and sanitation at household level can help to reduce the stunting rate.

 

Recommendations

 

1. Reinforce school feeding for all children with balanced diet from Early Childhood Development (ECDs) to upper education levels

 

2. Raise awareness and implement hygiene and sanitation practices at the household level including personal hygiene, and treating drinking water.

 

3. Strengthen family planning among postpartum mothers and increasing family planning counselling at health facilities.

 

4. Increase mass vaccination and nutrition campaigns from twice per year to once a quarter, to reach children routinely in remote areas.

 

5. Increase mothers´ awareness of child nutrition through physical health education, mass campaigns, social media and preparation of balanced diet demonstrations in villages, and other public health places.

 

6. Reinforce government poverty reduction programs in order to increase the population wealth index

 

7. ANC Visits for pregnant women should be highly increased through mobilization and increasing mothers´ awareness of the advantages of attending ANC and risks of not attending or delayed attendance.

 

8. More efforts to strengthen the agricultural sector by increasing food production is key to reducing food insecurity at the household level

What is known about this topic

  • It is known that stunting refers to impaired growth and development in children, typically resulting from chronic malnutrition, inadequate nutrient intake, or repeated bouts of infection during the early years of life.
  • According to the 2019-2020 Rwandan DHS data, it was found that the stunting prevalence in Nyabihu District, Rwanda is 46,7 %,
  • Numerous Studies have shown that the factors associated to stunting varies across different countries and settings and it includes inadequate feeding practices, social economic status, poor hygiene and sanitation and food insecurity

What this study adds

  • The study provided data specific to Nyabihu District, offering insights into the Factors associated with high prevalence of stunting in that particular geographic area. This localized data helped to identify specific trends and patterns unique to the district as it is a district with higher stunting rate in country.
  • This study will provide the updated information regarding the determinants of Stunting; This included new variables such as washing hands before child feeding, treating drinking water, a greater number of under-five children in the household, and Attending vaccination campaigns. Understanding these specific factors in the context of Nyabihu District can help to plan targeted interventions and strategies to improve Maternal and new born health.
  • The findings of the study had practical implications for policy development and program implementation in Nyabihu District and countrywide as well. The data helped local healthcare authorities and organizations to identify gaps, prioritize interventions, and allocate resources.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors´ contributions Up    Down

All authors have contributed to this study. IHE Contributed to the beginning and design of the study, protocol preparation and search articles and data collection; conducted all analysis and data interpretation; drafted the manuscripts; and represented as corresponding author. FM and EM Contributed to the study design, reviewing and revising the manuscript, providing different comments, editing the manuscript and approving the manuscript. EA helped in the revision and provide inputs for given comments in a manuscript. All authors read and approved the final manuscript. All authors read and approved the final manuscript.

 

 

Acknowledgements Up    Down

We are grateful to the Government of Rwanda, AFENET, MOH /Rwanda Biomedical Center, the University of Rwanda, and the College of Medicine and Health Sciences. We would like to express our deepest thanks to FETP management which directed us to make such a study. We are also grateful to Nyabihu district for providing authorisation.

 

 

Tables Up    Down

Table 1: Social-demographic characteristic of participants recruited from Health centers of Nyabihu District, Rwanda from March to April 2023 (N=402)

Table 2: Household characteristics of participants recruited from Health centers of Nyabihu District, Rwanda from March to April 2023 (N=402)

Table 3: Water, Sanitation and Hygiene (WASH) characteristics of participants recruited from Health centers of Nyabihu District, Rwanda from March to April 2023 (N=402)

Table 4: Feeding practices applied by caregivers to the child aged 6-59 months of participants recruited from Health centers of Nyabihu District, Rwanda from March to April 2023 (N=402)

Table 5: Clinical characteristics of respondents recruited from health centers of Nyabihu District, Rwanda from March to April 2023 (N=402)

Table 6: Multivariable logistic regression analysis showing independent factors associated with stunting among 6 to 59 months´ children in Nyabihu District

 

 

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Research

Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

Research

Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

Research

Factors associated with stunting among children aged 6 to 59 months in Nyabihu District, Rwanda 2023

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Key words

Factors

Stunting

Children

6 to 59 months

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The Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). The contents of this journal is intended exclusively for public health professionals and allied disciplines.