The need for this study

Childhood malnutrition is a chronic problem and one of the major public health challenges in Ghana. Several attempts from the government of Ghana and non- governmental organizations (e.g. UNICEF, Food and Agriculture Organization, the World Food Programme, etc.) to address the problem have fallen below expectation. Some of the attempts from government and non-governmental organizations aimed at addressing child malnutrition include: 1) Early initiation and intensification of exclusive breastfeeding and complementary feeding of children aged below 5 years; 2)

management of child malnutrition (e.g. vitamin A supplementation); 3) management of the sick newborn; 4) growth monitoring and promotion using charts based on WHO Growth Standard; 5) prenatal nutrition including iron and foliate supplementation and 6) detection and treatment of problems complicating pregnancy. The Government of Ghana has supported the formulation and implementation of important legislation and policies with specific targets for nutrition: 1) Growth and Poverty Reduction Strategy I and II; 2) Ghana Shared Growth and Development Agenda I and II; 3) Breastfeeding Promotion and Regulation; 4) Infant and Young Child Feeding Strategy and 5) Vitamin A Policy (Government of Ghana, 2013).

According to the 2013 Ghana National Nutrition Policy for 2014-2017, the government of Ghana recognised the fact that “malnutrition is caused by a wide array of factors, which must be identified, prioritized, and addressed” (Government of Ghana, 2013). The Government of Ghana (GoG) also recognised the fact that desired outcomes in nutrition in Ghana have not been achieved for several reasons: 1) nutrition and

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nutrition-related interventions implemented by various sectors have not been adequately prioritized, coordinated, and integrated; 2) nutrition has not been prioritized as a key development issue and thus has not received adequate political and financial

investments; 3) the sheer scope of the problem is enormous-the entire population, especially women and children suffer from all the major micronutrient deficiencies (Government of Ghana, 2013). The GoG also recognised that the slow progress in addressing poor child feeding practices, infections, and food insecurity deterred progress in reducing malnutrition in the country (Government of Ghana, 2013).

This study therefore seeks to fill some of the knowledge gaps expressed by GoG. Below are specific knowledge gaps this study attempts to fill with the hope of helping the GoG and NGOs to facilitate actions aimed at minimizing child malnutrition in the country:

(1) Limited studies are available indicating determinants of malnutrition among children. As a result, less has been published about the social, economic and environmental factors facing the residents of Ghana that may explain the country’s relatively high rates of childhood malnutrition and, consequently, childhood and maternal mortality. This poses a key risk-factor knowledge gap for policymakers as this is necessary for planning effective policies,

interventions and programmes aimed at improving childhood nutrition. This thesis seeks to fill this gap by examining major risk factors for childhood

nutrition in Ghana and to further examine whether or not the nutritional outcome of children in Ghana differ substantially across households.

(2) Most of the limited studies (Antwi, 2008; Ghana Statistical Service et al., 2009) conducted in Ghana to examine child nutrition situations in the country did not use appropriate statistical methods in their analysis, especially those attempting to identify risk factors for child malnutrition. This could substantially impact

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negatively on the interpretation of the findings and, consequently, inefficient policies, interventions and programmes and this thesis seeks to fill this gap. (3) Childhood malnutrition could vary geographically across Ghana but an

appropriate study to examine the geographical variations in the risk of under- five children’s malnutrition continuously across the whole of Ghana to inform appropriate and efficient nutrition policies and interventions in the higher risk communities to be identified is presently unavailable in the country. This is key information gap facing policymakers responsible for the nutrition and health of children in Ghana because the public health resources available in the country are very limited and should be spent on the higher risk communities rather than universal intervention which is presently not feasible in the country. The aim of examining the geographical differences in the nutritional outcomes of children across Ghana in this thesis is to help policymakers in the targeting of scarce resources to the communities that needed it most and in the optimisation of public health policy intervention strategies in the country.

(4) Nutritional outcome of children could vary over place and time but none of the studies in Ghana investigates spatial and temporal variations in childhood chronic malnutrition. This is crucial because to better inform carefully targeted interventions to reduce childhood malnutrition prevalence to some appreciable level in Ghana, public health planners and policymakers need access to timely and relevant malnutrition prevalence data, trend analyses over time and place, and forecast estimates but these are largely unavailable presently. Also, since malnutrition prevalence persist in Ghana, continued examination of the trend in the risk of malnutrition over time and space and their confounders is warranted if an appreciable level of progress is to be made in reducing the prevalence

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closer to those expected in a healthy, well-fed under-five children population. This study seeks to fill this gap by investigating spatial and temporal trends in the risk of malnutrition and to identify communities at highest risk overtime in Ghana.

(5) The present childhood malnutrition interventions in Ghana are reactive: as child malnutrition prevalence persists in Ghana, mass interventions are conducted but this does not cover everyone affected due to limited public health resources in the country. Thus, this approach will not result in any real solution to the problem because the mass intervention might not reach those affected most or the communities at higher risk of malnutrition. This study seeks to feel this gap by identifying communities where the risk of malnutrition is highest to enable efficient and targeted nutrition policy and interventions in such communities to minimise the risk and to provide forecast estimates to inform pre-emptive malnutrition interventions, prioritisation, and effective and sustainable public health nutrition policies in Ghana.

(6) Also, addressing the problem of childhood malnutrition is an ongoing process and it is therefore pre-requisite in this process to conduct frequent nutritional studies to investigate the prevalence and its determinants.

The findings from this thesis are intended to help policymakers responsible for the health and nutrition of children to design efficient public health policies and targeted nutrition interventions and programmes amidst scarce public health resources available in Ghana to better understand, target and to minimise childhood malnutrition prevalence closer to the level expected in a healthy, well-fed population of children under-fives.

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