title: Factors behind the success story of under-five stunting in Peru: a district ecological multilevel analysis.
abstract: BACKGROUND
  Stunting prevalence in children less than 5 years has remained stagnated in Peru from 1992 to 2007, with a rapid reduction thereafter. We aimed to assess the role of different predictors on stunting reduction over time and across departments, from 2000 to 2012.
  
  
  METHODS
  We used various secondary data sources to describe time trends of stunting and of possible predictors that included distal to proximal determinants. We determined a ranking of departments by annual change of stunting and of different predictors. To account for variation over time and across departments, we used an ecological hierarchical approach based on a multilevel mixed-effects regression model, considering stunting as the outcome. Our unit of analysis was one department-year.
  
  
  RESULTS
  Stunting followed a decreasing trend in all departments, with differing slopes. The reduction pace was higher from 2007-2008 onwards. The departments with the highest annual stunting reduction were Cusco (-2.31%), Amazonas (-1.57%), Puno (-1.54%), Huanuco (-1.52%), and Ancash (-1.44). Those with the lowest reduction were Ica (-0.67%), Ucayali (-0.64%), Tumbes (-0.45%), Lima (-0.37%), and Tacna (-0.31%). Amazon and Andean departments, with the highest baseline poverty rates and concentrating the highest rural populations, showed the highest stunting reduction. In the multilevel analysis, when accounting for confounding, social determinants seemed to be the most important factors influencing annual stunting reduction, with significant variation between departments.
  
  
  CONCLUSIONS
  Stunting reduction may be explained by the adoption of anti-poverty policies and sustained implementation of equitable crosscutting interventions, with focus on poorest areas. Inclusion of quality indicators for reproductive, maternal, neonatal and child health interventions may enable further analyses to show the influence of these factors. After a long stagnation period, Peru reduced dramatically its national and departmental stunting prevalence, thanks to a combination of social determinants and crosscutting factors. This experience offers useful lessons to other countries trying to improve their children's nutrition.
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, LI33, Lima, Peru. lhuicho@gmail.com.|School of Medicine, Universidad Peruana Cayetano Heredia and Universidad Nacional Mayor de San Marcos, Lima, Peru. lhuicho@gmail.com.|Instituto Nacional de Salud del Niño, Lima, Peru. lhuicho@gmail.com.
authors.forename: Luis
authors.identifier: http://orcid.org/0000-0002-5272-5885
authors.initials: L
authors.lastname: Huicho
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, LI33, Lima, Peru.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Huayanay-Espinoza
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, LI33, Lima, Peru.|Instituto Nacional de Salud del Niño, Lima, Peru.
authors.forename: Eder
authors.initials: E
authors.lastname: Herrera-Perez
authors.affiliation: School of Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
authors.forename: Eddy R
authors.initials: ER
authors.lastname: Segura
authors.affiliation: Ministerio de Economía y Finanzas, Lima, Peru.
authors.forename: Jessica
authors.initials: J
authors.lastname: Niño de Guzman
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, LI33, Lima, Peru.|Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: María
authors.initials: M
authors.lastname: Rivera-Ch
authors.affiliation: International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
authors.forename: Aluisio J D
authors.initials: AJ
authors.lastname: Barros
mesh_terms: D002675:Child, Preschool; D057217:Economic Development; D005260:Female; D006130:Growth Disorders / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D006291:Health Policy; D054624:Health Status Disparities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015233:Models, Statistical; D010568:Peru / Q000453:epidemiology; D011203:Poverty / Q000517:prevention & control*; D015995:Prevalence; D065840:Protective Factors; D012423:Rural Health; D064890:Social Determinants of Health
keywords: Childhood interventions; Children; Ecologic study; Economic growth; Multilevel mixed-effects analysis; Poverty; Social determinants; Stunting