A mixed-methods study of the drivers of stunting reduction among children under-5 in Ghana, 2003–2017

Background: Childhood stunting prevalence declined rapidly in Ghana in recent decades. Substantial economic growth over the same period will have contributed directly and indirectly to improved population health and nutrition in the country, but Ghana's progress in reducing stunting has outpaced that of multiple other countries with comparable or higher economic growth rates. Objectives: We aimed to better understand Ghana's exemplary progress in stunting reduction by examining the national-, community-, household-, and individual-level factors associated with the steep decline in stunting prevalence in recent decades. Methods: This mixed-methods study included literature review; secondary analysis of national household survey data, including Oaxaca–Blinder decomposition analysis; primary qualitative data collection and analysis; and a policy and program review. Results: Estimated from household surveys, under-5 stunting prevalence in Ghana declined from 35.1% in 2003 to 17.5% in 2017 and mean height-for-age z-score increased by 0.50, with the country's high-burden northernmost regions achieving the most rapid progress. Our modeling predicted 64% of the observed 0.43 height-for-age z-score increase among survey index children, with increases over time in mosquito net ownership, skilled birth attendance and antenatal care coverage, mean maternal age, urban residency, and household wealth accounting for most of the improvement in child growth over time. Qualitative findings highlighted similar and additional distal (e.g., income, maternal education, employment, women's empowerment, and political stability); intermediate (e.g., water and sanitation, infrastructure); and proximal (e.g., disease prevention and control programs, maternal care, and diet improvements) factors associated with stunting reduction. Of 134 nutrition-related policies and programs identified in our review, 23 national initiatives were assessed as having contributed importantly to reducing stunting in Ghana, reflecting the effectiveness of multisectoral action. Conclusions: Stunting reduction can be accelerated even further in Ghana through increased coverage of high-quality nutrition-specific interventions and greater health and nonhealth sector investments.