Child Care Practices, Resources for Care, and Nutritional Outcomes in Ghana: Findings from Demographic and Health Surveys

Introduction: The overarching empirical question of this study is this: how are children growing in Ghana and how is childcare related to child growth? Child health is a fundamental public health issue, for children's sake AND because good child health sets one up for life long health and functioning, and well-being. In sub-Saharan Africa (SSA), child physical health is of particular concern due the high rates of illness and mortality in this region. The leading causes of child morbidity and mortality in SSA include but are not limited to measles, diarrheal infections, respiratory infections, malaria, HIV and nutritional deficiencies. In Ghana, the focus of this study, respiratory infections, diarrheal infections, malaria and nutritional deficiencies (malnutrition) remain the major diseases plaguing children less than 5 years of age. Malnutrition is the underlying cause of 40% of all deaths among children less than 5 years in Ghana and almost three out of every ten children in Ghana are stunted. There have been major interventions by the government of Ghana and her partners such as WHO and UNICEF to combat childhood diseases in the country. However, a lot needs to be done as yet, especially research on long term trends in child health within social segments in the country, that have yet to be elucidated well enough. This is important to help guide better national and local health promotion policy-making and practice. Further, while home care is understood to be of vital importance to child health, too little is yet known about childcare practices and how these influence child health in Ghana. The present study therefore set out to address the following questions: What are the trends over time in child malnutrition prevalence in socio-demographic subgroups within the 10 Ghana geographic regions (provinces)? What are the relationships of dietary diversity to childhood wasting in urban and in rural Ghana, when control variables related to maternal, child and household characteristics are accounted for? What influence do childcare practices have on children’s height-for-age z-scores, controlling for factors at child, maternal, household and community levels? Do some children in Ghana benefit more from care than others? Methodology: This dissertation uses data from the Ghana Demographic and Health Surveys (DHS), conducted in Ghana in 1993, 1998, 2003 and 2008. The main indicators of child growth were height-for-age, weight-for-age and weight-for-height Z-scores. Children with height-for-age, weight-for-age and weight-for-height Z-scores less than -2 standard deviations (SD) of the WHO reference population were defined as stunted (chronically malnourished), underweight, and/or wasted (acutely malnourished), respectively. In the present study, the indicators were used both as continuous and categorical variables. The study employs three main analytical methodologies: trend analysis—examines the time trends of child malnutrition over time, logistic regression analysis— examines the relationship between dietary diversity and child nutritional status, and multiple regression analysis—examines the association between childcare practices (CCP) score and height-forage z-scores (HAZ). Main results: The results of the time trends analysis at the national level showed statistically significant declining trends for stunting (F (1, 7204) = 7.89, p < .005) and underweight (F (1, 7441) = 44.87, p < .001). The declining trends for wasting were also statistically significant (F (1, 7130) = 6.19, p < .013). In the rural/urban place of residence data, there was a stable and statistically insignificant trend in stunting for urban males and females and rural females, while the declining trend for rural males was statistically significant. Analysis by maternal education show a significant increasing trend in stunting for males (F (1, 2004) = 3.92, p < .048) and for females (F (1, 2004) = 4.34, p < .037) whose mothers had higher than primary education, while the trends decreased significantly for male and females whose mothers had no education. The logistic regression results showed that high dietary diversity score (DDS) was associated with improved growth outcomes in rural settings. A unit increase in DDS was associated with an 11% reduced odds of being wasted (OR = 0.89, 95%, C.I 0.80-0.99). In the multiple regression analysis, CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ scores. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship, such that no subgroup benefited less from good care than other subgroups. Conclusions: Overall, national malnutrition trends have declined significantly, but this decline did not benefit all segments of society, as there were static to worsening trends in some socio-demographic subgroups. Also, dietary diversity has a modest but statistically significant association with acute malnutrition in rural but not in urban Ghana. Intervention research to combat acute malnutrition in rural settings should include efforts to promote the consumption of a variety of food groups