INVESTIGATING THE CAUSES OF CHILD UNDERNUTRITION AND POOR DEVELOPMENT IN VAKINANKARATRA, MADAGASCAR: A MIXED- METHODS STUDY By HASINA RAKOTOMANANA Bachelor of Science in Agronomy Option Agricultural and Food Science and Technology University of Antananarivo Antananarivo, Madagascar 2012 Master of Science in Nutritional Sciences Oklahoma State University Stillwater, OK 2016 Submitted to the Faculty of the Graduate College of the Oklahoma State University in partial fulfillment of the requirements for the Degree of DOCTOR OF PHILOSOPHY July, 2020 INVESTIGATING THE CAUSES OF CHILD UNDERNUTRITION AND POOR DEVELOPMENT IN VAKINANKARATRA, MADAGASCAR: A MIXED- METHODS STUDY Dissertation Approved: Dr. Barbara J. Stoecker Dissertation Adviser Dr. Deana Hildebrand Dr. Gail Gates Dr. Fanjaniaina Fawbush-Razafimbelo Dr. David Thomas ACKNOWLEDGEMENTS “Mahay ny zavatra rehetra aho ao amin’Ilay mampahery ahy.” Filipiana 4:13 (I can do all things through Him who strengthens me) I am grateful for God Almighty’s love and abundant blessing that guided me throughout this journey. I would like to gratefully acknowledge my Advisor and Mentor Dr. Barbara J. Stoecker, for her insightful guidance, her unfailing support, and her exemplary dedication to help her students. I am also grateful to my other committee members Dr. Gail Gates, Dr. Deana Hildebrand, Dr. David Thomas, and Dr. Fanjaniaina Fawbush-Razafimbelo for their continuing support, shared expertise, and encouragements. I am thankful for the Regional Nutrition Office of Vakinankaratra for their support. I would like to acknowledge particularly the community nutrition agents and the field monitors in each of the fokontany we visited for their help during data collection. I am also thankful for my data collection team and my research assistants. I am grateful to all the parents and their young children for their patience and their cooperation and for agreeing to be part of this study. I am also very grateful for my family back in Madagascar (Neny, Heritiana sy Njiva, Harivola, Tsanta sy Hary) for their full support throughout my studies. Even thousand miles away from them, I have always felt their unwavering support and encouragements. I also appreciate all of the Nutritional Sciences Department faculty and staff for creating a welcoming environment for learning and growth to all of the students. I also would like to thank my friends back in Madagascar as well as my friends here in the US for their support. I also thank all the colleagues in Dr. Stoecker’s lab for their help and their encouragements. God bless you all! iii Acknowledgements reflect the views of the author and are not endorsed by committee members or Oklahoma State University. Name: HASINA RAKOTOMANANA Date of Degree: JULY, 2020 Title of Study: INVESTIGATING THE CAUSES OF CHILD UNDERNUTRITION AND POOR DEVELOPMENT IN VAKINANKARATRA, MADAGASCAR: A MIXED-METHODS STUDY Major Field: NUTRITIONAL SCIENCES Abstract: The Vakinankaratra region of Madagascar has the highest burden of child undernutrition in the country. The purpose of this study was to investigate the factors associated with child undernutrition and to assess child development among children aged 6 to 23 months using a mixed-methods approach. Individual interviews (n = 8) and focus group discussions among fathers and mothers (10 with 63 total participants) were conducted. A sample of 391 mother-child dyads were included in the surveys and anthropometric measurements. Stunting rates were very high (69.4%) and 23.4% were underweight. Proportions of children achieving minimum dietary diversity (MDD) (35.8%) and consuming iron-rich foods (14.1%) were very low. Maternal knowledge of child feeding was associated with better feeding practices [Adjusted odds ratio: 1.2 (1.1 – 1.4)] for MDD. Consumption of iron-rich foods was significantly associated with lower odds of underweight [AOR: 0.3 (0.1 – 0.7)]. Barriers to optimal feeding practices included beliefs regarding certain foods considered as heavy, food insecurity, and heavy workload. Enablers include perceived benefits of appropriate complementary foods and positive relationships between the mothers and the community nutrition agents. Strong traditional gender roles around child care were a salient theme throughout the qualitative data as mothers were considered the primary child care providers. Fathers actively involved in child care activities would be ridiculed by the community and their wives would be considered lazy or unable to take care of their children. Besides providing for their families, fathers were also involved in home stimulation activities and support their wives with household chores when they were unavailable. Work conditions, separation and distance and reluctance prevented fathers from being more involved. Both fathers and mothers expressed interest in engaging fathers more in child care. Higher birthweight predicted increased length (ß = 0.11), weight (ß = 0.18), and weight-for-length (ß = 0.13). Higher maternal height predicted increased both length (ß = 0.17) and weight (ß = 0.16), while larger household size was associated with lower length (ß = -0.10) and weight (ß = -0.16). Using the Bayley’s scale, children aged 11 – 13 months had low cognitive, motor, language, and socioemotional development scores. iv TABLE OF CONTENTS Chapter Page I. INTRODUCTION ................................................................................................. 1 Significance of the study ...................................................................................... 3 Limitations .......................................................................................................... 4 II. REVIEW OF LITERATURE ................................................................................ 6 1. Child undernutrition ....................................................................................... 6 2. Nutrition before and during the first two years ............................................... 8 3. Complementary feeding practices ................................................................ 12 4. Hygiene and sanitation ................................................................................. 18 5. Other sociodemographic determinants of undernutrition .............................. 20 6. Child development ....................................................................................... 22 7. Nutrition interventions ................................................................................. 27 8. Fathers’ involvement in child care ............................................................... 33 9. The case of Madagascar ............................................................................... 36 Summary ........................................................................................................... 39 III. METHODS ....................................................................................................... 40 1. Study population and research setting .......................................................... 40 2. Qualitative methods ..................................................................................... 41 3. Quantitative methods ................................................................................... 46 4. Statistical analyses ....................................................................................... 52 5. Ethical considerations .................................................................................. 54 v Chapter Page IV. CHILD UNDERNUTRITION AND MATERNAL KNOWLEDGE, ATTITUDES, AND PRACTICES OF COMPLEMENTARY FEEDING IN THE VAKINANKARATRA REGION OF MADAGASCAR ........................... 55 Abstract ............................................................................................................. 55 1. Introduction ................................................................................................. 57 2. Methods ....................................................................................................... 58 3. Results ......................................................................................................... 61 4. Discussion ................................................................................................... 70 5. Conclusion ................................................................................................... 76 References ......................................................................................................... 77 V. CHARACTERIZING FATHERS’ INVOLVEMENT IN CHILD CARE ACTIVITIES: PERCEPTIONS FROM CAREGIVERS AND THE COMMUNITY IN THE HIGHLANDS OF MADAGASCAR ........................... 91 Abstract ............................................................................................................. 91 1. Introduction ................................................................................................. 93 2. Methods ....................................................................................................... 94 3. Results ......................................................................................................... 97 4. Discussion ................................................................................................. 105 5. Conclusion ................................................................................................. 108 References ....................................................................................................... 109 VI. SOCIODEMOGRAPHIC