Malnutrition in children’s is becoming a key worldwide health challenge given the widespread nature of the population it affects. Children can also encounter various types of malnutrition: 3.62% of children under the age of five are both stunted and wasted, while 1.87% of children under the age of five are both stunted and overweight worldwide (6). It is related to the under nourishment or over nourishment of nutrients in an individual. The under nourishment section involves stunting, wasting, micro-nutrient deficiency while the over nourishment involves obesity, higher chances of developing non communicable diseases 1. Malnutrition affects almost every part of the world impacting the health outcomes of individuals reducing their productivity. There are number of factors that is associated with the under nourishment in children which may include poverty, high food prices, lower prevalence of breastfeeding. About 45% of mortality among children under the age of 5 are linked to malnutrition. These mostly occur in countries with low and middle incomes. At the same time, rates of childhood obesity and obesity are increasing in those same countries (5)
Child malnutrition in Bangladesh
Despite the years of progress made after the independence, under nourishment of children’s is still creating difficulties in making children’s realize their potential. Under nourishment has poor impact on child’s health, education, and economic outcomes. Over half of the population is suffering from malnutrition. 450,000 children are affected by severe acute malnutrition; while close to 2 million children have moderate acute malnutrition. 52 percent of children under five years of age are affected by anemia (4). Over thousands of child deaths a year in Bangladesh are caused by chronic malnutrition (stunting) and acute malnutrition (wasting) Children in rural Bangladesh are more at risk of stunting than in urban areas. Child under-nutrition in Bangladesh remains one of the key causes for childhood disease and mortality. Though Bangladesh has made substantial progress in reducing the mortality rate of infants and adolescents, the country has not achieved the same level of success in tackling child nutrition 2. Bangladesh's malnutrition levels are among the highest in the world. Over 54% of pre-school children, or more than 9.5 million children, are stunted, 56% are underweight, and more than 17% are wasted (3).
Major factors
Role of poverty
Bangladesh is an under developed country with majority of its population living below the poverty line as a result they have less resources for disposal. As a result majority of population is unable to meet the nutritional need which is required by the children’s during there early years of development which results into mass wasting and stunting among the children’s. Lack of economic resources has a direct relation to the health outcomes of a country. In the wealthiest families, the prevalence of stunting, wasting and underweight was less than in the poorest households. The wealth index's exposure to child hunger has risen over time and the wealth index has explained the biggest contribution to pro-poor inequality (Islam, 2020). Given the prevalent poverty and the scarcity of resources, people will invest less in healthcare of the children. The standard of living is poor and also poor access to healthy food is there. They are not able to afford things which will keep them healthy. Children from the poorest families have suffered more from the burden of malnutrition than those from the richest households. The level of inequality among rural children has also increased, though it has remained stagnant among urban children (Pulok and Enemark, 2016). All these have resulted into the increased child mortality in Bangladesh.
Food insecurity
A quarter of Bangladesh population suffers from food shortage making them food insecure. Food protection, which is related to health and nutrition, is a complex development problem. Hunger and hunger are closely correlated with food insecurity and are viewed as a major public health issue with long-term detrimental effects on the health of children. Food insufficiency in urban slums of Bangladesh is associated with stunting and underweight, but not with waste. The essence of food insecurity in households tends to be the product of a number of risk factors, as well as the inability to handle those risks due to constraints on income and resources. Moreover, one of the common scenarios in the study area is a reduction in food intake during the Monga era. Marginal effects and elasticity after probit regression reveal that household income; the per capita share of medical expenditure, the involvement of safety net and the area of residence appear to be the main factors significantly affecting seasonal food insecurity during the Monga period (Ahamad, 2013)
Limited access to sanitation facilities
Diarrheal diseases among children often results into malnourishment among the children’s.
Significant risk factors for diarrhea are inadequate supply of clean water and proper sanitation practices. In comparison with others, the practice of washing hands and the use of heated drinkable water was poor among lower socio-economic families. A higher risk was correlated with lack of hand hygiene before feeding their kids, and hand cleaning without soap. Water transport methods and inadequate water treatment at the household scale, the concentration of polluted water in the street, storage, processing, and disposal of wastewater, quality of domestic water reservoirs, and the development of vectors predispose children under five to diarrhea. All of these together increase child malnutrition rates among children due to diarrhea
Health care access and quality
The access to primary health care services and also the quality of healthcare which is provided plays a pivotal role in aggravating the cases of child malnutrition in Bangladesh. People living in rural areas have poor access to primary and secondary health care services. Lack of hospitals, medical staff, and the poor quality of health services that are tendered has resulted in increased mortality among children due to malnutrition. The major section of the population still lacks health insurance which makes them vulnerable as they cannot afford the basic medication. Lack of properly trained health care professionals and poor counseling also adds to the problem.
Low rate of breastfeeding
Breastfeeding provides the essential nutrients in proper proportion which is required for the overall development of the children. One of the major reasons attributable to the rising children's mortality due to child malnutrition is the low maternal literacy backed by low breastfeeding. Infants who have been breastfed for less than two years are also found to be at a higher risk of malnutrition relative to those who have been breastfed for some more than two years. A structural and institutional analysis found that failure to breastfeed culminated in increased mortality risk from malnutrition relative to exclusive breastfeeding among infants aged five months. The analysis showed that there were an increasing proportion of teenage mothers. Much of the mothers belonged to lower socioeconomic backgrounds of nuclear families. Children corresponding to low socioeconomic status had a higher incidence of stunting and wasting than the better socioeconomic community. The mother's education level showed a strong association with the health result of children.
Health education
Despite having adequate availability of fish and vegetables basic health knowledge is lacking among the common people of Bangladesh. Most of them fail to understand the importance of diversity of food which is required to obtain the nutrition. There are many traditional beliefs which are prevalent which considers vegetables as not a good food option for children’s (7). In Bangladesh, there is poor access to quality education in rural and semi-urban areas which is being reflected in the health outcomes of a country. People with a poor educational background will lack the basic understanding of the importance of healthcare in children, the nutritional needs of children, importance of exclusive breastfeeding, their basic medical needs, and precautions to be taken. All these have resulted in making malnutrition a serious threat in Bangladesh. The level of education has a direct correlation with health outcomes. Higher education will lead to increased expenditure on children's health. As educated parents will take the health of the children more seriously and will look after its growth. In comparison with those of mothers with higher education, the prevalence of malnutrition, while decreasing, was consistently high among children of mothers with lower education. Children of mothers with secondary or higher education were at lower risk of childhood stunting, wasting, in adapted models integrating time effects, compared to children of mothers with no education (Hasan, 2016)
Role of gender
Girls were more impacted by wasting and stunting than boys among the respondents in the study. Girl children had a significantly higher incidence of acute malnourishment than boys. In this area, this may point to a potential cultural impact by which the health of female children is overlooked, limiting their access to quality health care. Patriarchy is highly prevalent in society which can also be seen in the wide range of disparity between the health outcomes of both genders. The health care of girl children is often neglected to make them more vulnerable to malnutrition given the lack of access to proper healthy food and hygiene.
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Sustainable development goals success
With minimal resources, Bangladesh has seen one of the highest declines in poverty anywhere in the world in the last 15 years. Three years ahead of schedule, the country has met the target of reducing the proportion of population below the national poverty line. It has met the targets of reducing the rate of infant mortality from 92 per 1,000 live births in 1990 to 46 now; and reducing the prevalence of underweight children less than five years of age from 66 percent in 1990 to 32.6 percent now. The country has reached almost 100 percent enrollments in primary schools in terms of education, and has achieved gender parity with more girls than boys in primary and secondary schools. The goals for reducing malarial deaths and increasing the share of people using an enhanced source of drinking water have also been reached. In terms of achieving the Sustainable Development Goals, as one of the best performing nations (social watch, 2020)
Challenges
Disorganized urbanization has faced many massive issues due to the lack of planned growth, particularly large and fast-growing slum areas that lack essential services (particularly people without access to adequate sanitation, safe water and energy independence) and solid waste is being produced at a quicker speed, posing a serious threat to administration and the ecosystem. The solid waste management is a daunting challenge as the population grows and the form of waste varies. Waste disposal activities need to be concerned not only with the growth of their generation, but also with their ineffective practice. Socio-economic factors, demography, weather conditions, lack of knowledge and poor management practice influence waste generation. In addition, more than half of the population may not have access to electricity, and those connected to the grid frequently encounter extremely intermittent service. For cooking, inhabitants of rural communities use unsustainable and unsafe indoor stoves (13). Due to the proximity with the coastline Bangladesh is prone to extreme climate events in the forms of cyclone which negatively impacts the economy of Bangladesh and makes it difficult to manage its economic resources. It also negatively affects the food security of Bangladesh as sea water enters the field which affects the productivity.
Suggestions
For basic infrastructure such as highways, rail and ports, power stations, water and sanitation, as well as for sectors such as agriculture and rural development, climate change mitigation and adaptation, health and education, a nation such as Bangladesh would require enormous investment. Bangladesh government can actively work with the private sector players in order to diversify its finances which will be required in meeting the sustainable development goals. It can also work with multilateral institutions in order to get finances.
Way forwards
Providing food security
Providing food security to the people of Bangladesh should remain the top priority of the government. Increased food security will result into improving the health outcomes of the people of Bangladesh who are suffering from mass wasting and stunting. Government should focus on importing food grains from the neighboring countries in order to give food security to its people. Further, more focus should be given on the technological portion to increase the productivity. More land should be brought under the agricultural ambit so that the production level increases. Government can run subsidized food for children in schools in order to raise their nutritional status.
Taking help of Ngo’s and civil society
Help of Ngo’s and civil societies can also be taken to reach out to children who are undernourished. They will help the government in collecting the proper data regarding the prevalence of wasting and stunting among children. They can also be used for the proper implementation of programs and policies of the government regarding the child nourishment as they have deep rooted connections and people feel comfortable in dealing with them. Specific programs can be made solely for reducing wasting and stunting among children by taking the help of Ngo’s who works in the area of child development
Reducing poverty
Steps needs to be taken for reduce the level of poverty prevalent in the society by generating economic opportunities. More focus needs to be there to generate employment in the economy. If the per capita income of the people increases than it will have positive result in health outcomes. The people will start to invest more on the health and nutrition of child ultimately leading to reducing the child mortality among children. The government should focus on creating special economic zones which will radiate economic prosperity. Attention also needs to be taken to increase the export of the country. These steps will add to the per capita income of Bangladesh making it enhance its fight against child under nourishment.
Improving health care services
There is need to enhance primary and secondary healthcare services so that the child mortality relating to the under nourishment of the child can be reduced. Food fortification can also be done in order to provide essential nutrients to the malnourished children. Availability of doctors in the rural areas can be improved where there is more number of under nourished children and also monthly checkups can also be arranged. Door to door campaign can be launched where trained health professionals can be given the task to distribute iron and zinc tablets among the beneficiaries. The healthcare budget of the country needs to be expanded and more allocation of funds needs to be given to the areas which lag behind in the health and nutritional parameters of children. Healthcare infrastructure should be expanded in remote and rural areas which shares the major burden in child wasting and stunting.
Improving the sanitation and hygiene level
The implementation of systematic programs led by government to increase the supply of clean drinking water to the majority of the population specially those who live below poverty line. It is also important to increase the number of access to clean drinking water at a suitable distance from houses to decrease the number of individuals that share one washroom. Improved sanitation and hygiene has a positive correlation with the health outcomes and will ultimately lead towards reducing the mortality and morbidity that is associated with children's due to malnourishment caused by diarrhea.
Government interventions
Higher maternal education, improved socio-economic conditions in households and extended birth intervals alone are not sufficient to bring about a major reduction in the prevalence of child malnutrition in Bangladesh. In addition to enhancing maternal education and other socio-demographic factors, tailored strategies should be planned to minimize the prevalence of low birth weight (Rahman, 2016). Steps also need to be taken to provide primary and secondary health care services to the rural population. Proper counseling sessions need to be carried out to enhance the people's knowledge about the preventive steps that are available to deal with under nourishment in children where they should be educated about the importance of breastfeeding, the role of sanitation and hygiene, importance of diversity of food, child’s nutritional needs. At last proper programs and policies should be carried out which will be oriented towards the elimination of wasting and stunting in children as they are the future of the country.
Conclusion
Sharing the huge burden of children suffering from mass under nourishment due to the mass poverty, lack of food security, poor health facilities, and steps needs to be taken to address this growing challenge which is hindering the growth and development of children in Bangladesh. Further decline is possible through multi-pronged regional-specific approaches that can resolve area-specific covariates to break the cycle of undernutrition, such as strengthening economic and educational status, highlighting the role of fathers in enhancing their expertise in various aspects such as family planning, fertility reduction and improving the health of mothers. All these steps are necessarily needed in order to achieve the sustainable development goal by 2030.
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