Based on the literature, we have a good understanding of the reasons and severe consequences of the childhood malnutrition [11, 12]. However, these characteristics are not uniformly distributed across any population and may partially explain the varied etiology of that characterizes children in PNG. Therefore, evaluating the impacts of interventions may be difficult because communities may vary in their responses to an intervention and it may not be possible to make the best analytical adjustments for features associated with this variability. Effective strategies to prevent childhood malnutrition are likely to be those that address as many of the local factors as possible.
The objective of this paper was to describe the state of geographical variations of severe malnutrition such as stunting and wasting among a cohort of children who participated the study from Eastern Highlands and Madang Provinces in PNG. Our data clearly indicates one of the highest rates of stunting among children under the age of 5 in world. According to our knowledge, Eastern Highland Province had one of the highest rates of stunting reported in last 20years with 59%. This prevalence was even higher than the one observed among children (aged <5years) in Guatemala in 1995 (56%) [13]. Beside this unacceptably high childhood malnutrition figures, malaria, tuberculosis, typhoid, and pneumonia remain the largest causes of death amongst adults in PNG. This country is also responsible for the majority of new HIV infections across the entire South Pacific region [14–16].
By identifying high-risk areas of malnutrition, the current study made it possible to stratify district-specific risk spatially. Although, the entire country has been known to have one of the world’s highest rates of child death rates because of the various reasons such as malaria, measles, meningitis and malnutrition, identification of the hot-spots demonstrates the high geographical variability of stunting and wasting over the targeted region. The use of geographical information of the children’s residents made it possible to analyse these variations precisely, at the level of small-districts, improving our knowledge of the malnutrition in two provinces of PNG.
Because of the strong geographical variation, comparing the health outcomes at provincial levels do mask important district features and may even lead to misleading conclusions. This can be easily observed comparing the results between Table 1 and the statistical image plots presented in Figures 2a-2f. It is evident that spatial effects of districts within the same province can vary a lot. Therefore, the interpretations for regions drawn from Table 1 will be biased for some of the districts within a region.
The result of the nonlinear effect of child’s age on stunting suggests that children aged 20–40months old are the most vulnerable group—particularly compared to those younger than 20months. Although this result contradicts some of the literature which links the malnutrition of young children to insufficient breast milk in early years, this could influence child’s health differently in the PNG setting where poverty is a part of life [17].
Our study also showed increasing trends in stunting and wasting when child was cared by young and old caregivers. Studies found strong link between the caregiver’s socioeconomic characteristics and the child’s malnutrition status. This is also consistent with the literature, children become more vulnerable when they are cared for by very young (such as older siblings) or very aged (relatives) [18, 19].
It is clear that preventing or treating growth retardation in countries with poor economic conditions may play a key role in social and economic development. Therefore, there is an urgent need for monitoring of the nutritional status in developing countries such as PNG. Children require routine care to ensure that they are not being subjected to excessive periods of under-nutrition which can play a major role in promoting future productivity and overall social and economic development.
Previous studies linked many variables to stunting and wasting without accounting for geographical effects [1, 3]. Describing geographical variations of malnutrition among children is important for scaling-up interventions. Although these data can provide snapshots of the malnutrition status and its determinants at local community level, further analyses and population-based data sources are needed to obtain a more complete picture of malnutrition in this region.
Our study has several limitations. First, we were not able to determine wealth and employment of the household. Studies reported that the poor socioeconomic status of a household had an association to stunting in children in developing countries [20, 21]. Second, the original birth weight of all the children was not known which could be a crucial factor in determining from the start the growth pattern of the child, but also more importantly the deficits in the child’s growth [22]. Third, other anthropometric measurements that are now included in the WHO Growth Standard namely: head circumference-for-age (0–60months), arm circumference-for-age, triceps skin-for-age, subscapular skinfold-for-age (3–60months) were not available in our study. The use of these other anthropometric measurements in determining the nutritional status of children is a crucial aspect in the monitoring of child development [23]. The physical development of the children’s children physical is also being is also correlated to their interaction with their environment, how they move about to gain food for instance. Therefore, it is also important to assess a child’s overall development according to a child’s motor development. Fourth, current study only collected information (such as age and education level) from the caregivers rather than parents (particularly mothers). However, in PNG, mothers are usually the immediate and first care giver of the child, is an important attribute of improving and maintaining the nutrition of the child [24, 25]. Therefore, our results regarding the characteristics of the caregivers can be broadly related to the mother’s characteristics of the child. In addition, mother’s malnutrition status was not collected. Maternal health studies have showed that if the mother was malnourished she would most likely give birth to low birth weight babies [26]. Consequently, babies would not fully develop physically and psychologically. Finally, the data used for this analysis were from 2003–4. However, more recent literature [27] suggest that child-mortality and stunting rates remain unacceptably high.
Despite its limitations, investigating small-scale geographical disparities using appropriate statistical approaches such as the one used in this study are useful to describe the features of the sparsely populated large geographical areas in detail.
These results may not be surprising since all the previous nutritional studies in PNG have reported low dietary intakes of protein and, in most cases of energy [28, 29]. Papua New Guinea has also been classified by the World Health Organisation as an area where clinical vitamin A deficiency (VAD) exists [30]. For example, according to the National Health Survey/National Nutritional Survey (NHS/NNS) which was conducted in 1982/83, approximately 90% of the population was estimated to have had poor nutritional status [31]. In a study conducted among a cohort of children who lived in the East Sepik Province (north of Madang), protein and zinc deficiency were evident and significantly associated with stunting [32]. Low energy and protein levels were also reported among children who lived in Lufa (Eastern Highlands Province) and Kaul (Madang Province) [33]. Data on the status about iodine nutrition in children in Papua New Guinea (PNG) are scarce. However, at least one published literature indicated moderate iodine deficiency among a cohort of 350 school children (6–12years old) in the Southern Highlands Province [34].