Jean Nepo Utumatwishima

Many low- and middle-income countries still encounter the persistent challenge of child stunting, despite the widespread implementation of public health interventions aimed at reducing it. Most studies and interventions have primarily focused on child-related factors, often overlooking the broader household conditions. A deeper understanding of the household environment, including the health and behaviors of mothers and the family dynamics surrounding child-rearing, is crucial for addressing the stunting problem more effectively. Aim: This thesis aims to investigate the association between household dynamics, such as gender roles, social support, women’s decision-making, intimate partner violence (IPV), mothers' behaviors related to child disciplining, and mothers’ mental health disorders, with stunting of children aged between one month and three years. Methods: The studies in this thesis are based on a cross-sectional, population-based study design. Data was collected through interviews with mothers using an investigator-administered questionnaire, which included standardized WHO questions for assessingIPV, the Mini International Neuropsychiatric Interview questionnaire for evaluating mental health, and UNICEF Multiple Indicator Cluster Surveys (MICS)-guided questions for assessing child abuse. The Multidimensional Poverty Index (MPI), created by Oxford University, was used to evaluate the household’s socioeconomic status. In total, 601 mothers along with their children, who were between one month and three years old, participated in the study. Using a geographic grid method in collaboration with Lund University, villages in Rwanda’s Northern Province were identified, and households were selected through a simple random sampling process. Child age, along with weight and height measurements, served to compute height-for-age z-scores for assessing stunting, per WHO anthropometric guidelines. Descriptive measures and logistic regression models, both bi-variable and multivariable, were employed in the data analysis, showing adjusted odds ratio (aOR) and 95% confidence intervals. Results: Among the 601 mother–child pairs, 27.1% of the children were stunted. Within the stunted group, 60.1% were boys and 39.9% were girls. Stunting increased with age, peaking at 39.9% in children aged 25–36 months. The mothers were predominantly from low-income backgrounds (88.4%), over 30 years old (56.4%), had low educational attainment (78.2%), and worked in unskilled jobs (97.3%). The average MPI was 0.265 across the sample. There was no statistical difference in the MPI scores between households with stunted children and those without stunted children. Nearly half (47.4%) of mothers endured IPV both prior to and during pregnancy. Mothers’ experience of physical IPV prior to pregnancy [aOR=1.29 (1.01 to 2.03)], along with sexual IPV encountered during pregnancy [aOR=1.25 (1.04 to 2.01)], were associated with child stunting. Depression was also a key risk factor, as children of mothers with current major depressive disorder had stunted growth [aOR = 1.67 (1.06–2.61)]. Both insufficient support while ill and lack of personal guidance of mothers were associated with child stunting, with [aOR=1.93 (1.13 to 3.28)] and [aOR=2.44 (1.41 to 4.26)], respectively. Harsh disciplining methods used by mothers, especially when both physical and non-physical approaches were employed, were linked to a higher odds ratio of child stunting [OR = 1.92 (1.08–3.41)]. Conclusions: Despite ongoing public health interventions in Rwanda, child stunting remains a significant problem. The findings highlight that child undernutrition is not only influenced by direct nutritional factors but is also deeply rooted in householddynamics, mothers’ well-being, and gendered social structures. Mental health disorders, exposure to IPV, lack of social support, and violent child-disciplining practices were all strongly associated with child stunting. Integrating mental health screening for pregnant women, educating expectant mothers on the importance of social support, and raising awareness about the dangers of violent child disciplining methods and encouraging non-violent alternatives are essential additions to the ANC content. These results underscore the need for a holistic, interdisciplinary, multisectoral approach that incorporates mental health services, IPV prevention, gender-sensitive interventions, enhanced ANC, and parental support programs into existing nutrition and child health initiatives. Tackling these broader determinants is essential for sustainable improvements in child growth and long-term public health gains and support in Rwanda. More details Click here