{"paper_id":"b3ea277a-d6f1-4686-b147-ea4fffe24405","body_text":"Perceived Determinants of Childhood Stunting in Rwanda: Insights from Parents and Frontline Workers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceived Determinants of Childhood Stunting in Rwanda: Insights from Parents and Frontline Workers Jean Dieu Habimana, Theogene Habumugisha, Noel Korukire, Maryse Umugwaneza, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7040307/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Childhood stunting remains a pervasive public health concern. Understanding the perceptions of parents and frontline workers regarding childhood stunting is essential in designing culturally appropriate intervention. The purpose of this study was to investigate the viewpoints of frontline workers and Rwandan parents regarding the determinants of childhood stunting. Methods We conducted a qualitative study using ten focus groups discussions and sixteen key informant interviews among 83 parents and frontline workers all from five districts scatted in Rwanda. We used NVivo 14, to conduct thematic analysis with open coding. Results There was inadequate knowledge about stunting: most respondents knew only visible signs of stunting. The key perceived determinants included poverty, poor children and maternal feeding practices, family conflict and behavioral resistance. Inconsistent adherence to recommended practices such as vegetable gardening and hygiene were attributed to limited program ownership hence poor feeding practices and increased rate of stunting. Participants also mentioned systemic barriers, poor management in the selection of beneficiaries and assistance distribution, as well as limited access to essential health and nutrition services. Conclusion Childhood stunting in Rwanda is influenced by a complex interplay of individual, household, and structural determinants. Addressing stunting requires community-driven and multisectoral interventions that aim to improve maternal and child nutrition, reduce socioeconomic vulnerabilities, and strengthen service delivery and program accountability. Stunting Childhood Perceived determinants Parents frontline workers Rwanda Figures Figure 1 Background Stunting, a manifestation of chronic malnutrition resulting in impaired linear growth, remains a persistent Public Health concern particularly in Low- and Middle-income countries (LMIC). As of 2023, an estimate of 148.1 million children i.e. around 22.3% of the children under five years of age globally were stunted [ 1 ]. According to UNICEF, WHO, and the World Bank Group in 2022, the Melanesian region has the highest prevalence of childhood stunting with 46.4 percent, followed by Southern Asia with 40.3 percent, Middle Africa with 37.4 percent, and Eastern Africa with 30.6 percent [ 1 ]. In Rwanda, 29.8% of children were stunted [ 2 ], showing a slow progress in the fight against chronic malnutrition. Stunting is not merely a matter of short stature, but also it reflects a failure to achieve optimal physical and cognitive growth, with lifelong consequences for health, education, and economic productivity. Stunting affects children's immune systems, rendering them susceptible to infections and diseases [ 3 – 5 ]. Stunting can also be associated with cognitive deficits which can result in decreased academic performance, limiting career opportunities in adulthood, and perpetuating poverty cycles [ 6 ]. Additionally, stunting limits individual economic viability, and in turn, poses a challenge to national development [ 7 ]. This is a problem that needs to be addressed as stunting not only causes individual harm but has wider implications for human capital and the economic development of the regions afflicted. Stunting results from a combination of inadequate nutrition, repeated infections, poor maternal health, and inadequate childcare and health practices, coupled with underlying poverty and inequities in access to essential services [ 8 ]. These elements combine in a pernicious feedback loop where scarce resources and inadequate living conditions lead to chronic malnutrition, and malnourished children are more vulnerable to diseases that affect their capacity to thrive [ 9 ]. Many other factors contribute to stunting, including poor maternal nutrition during pregnancy and lactation [ 10 ], and lack of access to clean water, adequate sanitation, and health services. The multisectoral problem of stunting demands a multisectoral solution that addresses the immediate, underlying and root causes of the condition. In Rwanda, despite significant strides in tackling malnutrition, a third of children under five years are still affected by stunting, denoting sustained disparity and the complex and multi-modality of the determinants of this phenomenon [ 2 ]. So, tackling stunting entails a multi-sectoral approach combining health, nutrition, sanitation, and education interventions. Despite years of programming to improve infant/young child feeding practices in Rwanda, including the promotion of exclusive breastfeeding with early initiation and continuous breastfeeding accompanied by maternal nutrition education, and community-based growth monitoring programs, the rate of stunting remains high, indicating gaps in knowledge and practice concerning essential nutritional behaviors [ 11 ]. Parents and frontline workers interact with children in providing the nutrition needed to grow. Preventive healthcare includes knowledge, beliefs, and practices ordination. It is important to understand the perceptions of causes, protective factors, and prevention of stunting among these key stakeholders for designing appropriate and sustainable context-based interventions [ 12 ]. Community perceptions offer important insights into local cultural practices, resource utilization, and barriers in scaling up stunting prevention measures. This study aims however, to explore the perspectives of Rwandan parents and frontline workers on factors affecting childhood stunting. Methods Study design and setting. A qualitative study using phenomenological approach was conducted across all provinces of Rwanda, including Kigali City. The study focused on five districts purposively selected based on their high prevalence of childhood stunting within their respective provinces including Kayonza (Eastern Province), Nyaruguru (Southern Province), Burera (Northern Province), Rutsiro (Western Province), and Gasabo (Kigali City) [ 13 ]. Study participants Eight-three individuals were selected purposively to take part in this study including thirty-eight parents, twenty-nine Community Volunteers and nineteen Key Informants. Parents were mothers and fathers all drawn from low-income households with stunted and non-stunted children aged 6–23 months. Frontline workers included both Community Volunteers and key informants with direct exposure in childcare, nutrition, and health service delivery. Community Volunteers included Community Health Workers, family friends, community farmer promoters, and villages social affairs. Key informants comprise people who hold important positions related to nutrition and child development, including district Early Childhood Development (ECD) promoters, nutrition officers, and health center managers. We conducted a total of ten focus group discussions (FGDs) to collect qualitative data, five with parents, and five with Community Volunteers, with eight participants in each group standing for an even distribution across participant types. All parents’ FGDs comprised four parents of stunted and four parents of non-stunted children. They were conducted across five districts, namely: Burera, Gasabo, Nyaruguru, Rutsiro and Kayonza. In addition, 16 KIIs from different Sectors consisted of representatives of social affairs (n = 3), Head of Health Centers (n = 4), nutritionists (n = 4), and ECD promoters (n = 5) with different views on child nutrition and development as detailed in Table 1 . Data Collection Procedures We performed a pilot test before the data collection. This allowed us to get familiar with the data collection tool, refine it, make sure it was clear and ensure that it answered questions we intended to ask. All FGDs and KIIs involved open-ended questions aimed at triggering participants' perceptions about the childhood stunting. Moreover, the principal investigator moderated all interviews assisted by trained research assistant by recording and taking detailed notes. All interviews were conducted in Kinyarwanda, and sessions lasted between 40 to 80 minutes. After data collection sessions, audio recordings and field notes were reviewed by the research team to resolve ambiguities and highlight key observations. Data was collected until no new themes or subthemes surfaced from further key informant interviews (KIIs) or focus group discussions (FGDs). Following the completion of the ninth FGD and the fourteenth KII, the research team observed that no new insights were being presented and that participant responses were restating previously identified concepts. After that, two more interviews were done to make sure saturation was reached. This iterative process ensured that the final dataset captured a comprehensive range of perspectives relevant to the study objectives. Conceptual framework guiding the analysis. This research is guided by the WHO conceptual framework on children stunting (WHO/NMH/NHD/17.7), which gives a thorough understanding of the multifaceted causes of stunting. The framework divides determinants into three categories: child-related consequences, immediate and underlying causes at the household level (e.g., insufficient dietary intake and poor caregiving practices), and broader contextual factors at the community level, such as socioeconomic, environmental, and policy conditions. Using this methodology, the study methodically investigates how numerous factors interact at different levels to influence childhood stunting, allowing for a more comprehensive analysis and interpretation of the data [ 14 ]. The paradigm emphasizes the negative effects of stunting at the child level. Their motor, cognitive, and language development also decelerate, which impacts their academic preparedness and social interaction [ 15 ]. Economically speaking, because stunted children require continuous care, their families frequently experience increased healthcare expenses and missed opportunities [ 16 ]. Additionally, the effects of stunting are extensive over time. Childhood stunting frequently results in smaller stature, increased risk of obesity and related non-communicable diseases, and possibly, a compromised reproductive health during adulthood [ 17 ]. Stunted children are also less likely to develop to their full potential, perform poorly in school, and have a decreased learning ability[ 18 ]. Reduced work capacity and productivity result from these effects, which feed the cycles of poverty and underperformance[ 19 ]. The approach pinpoints the immediate and underlying causal pathways that result in stunting at the household level. Preterm delivery, adolescent pregnancies, inappropriate birth spacing, intrauterine growth restriction (IUGR), maternal illnesses, and poor nutrition before and during pregnancy are all major maternal contributors [ 20 ]. Chronic disorders including hypertension and poor maternal mental health further exacerbate these biological risks[ 21 , 22 ]. Feeding habits for infants and young children also play a significant role. For instance, early nutrition is compromised by inadequate nursing, including delayed initiation, non-exclusive breastfeeding, and early cessation[ 23 ]. The dietary requirements of the developing infant are also not met by inadequate supplemental feeding techniques, such as infrequent feeding, offering thin or inadequately nourishing food, and poor feeding habits during illness[ 24 ]. With inadequate stimulation, poor response during feeding, and a dearth of secure and caring surroundings, childcare practices are frequently insufficient[ 25 ]. Frequent infections, especially respiratory infections, malaria, and enteric ailments like diarrhea, further impair appetite and nutrient absorption[ 26 , 26 , 27 ]. Consuming foods that are low in micronutrients, dietary diversity, and animal-based meals, as well as being exposed to contaminated food and water as a result of improper hygiene, unsafe storage, and preparation methods, are all major contributors to undernutrition [ 27 , 28 ]. Poor socioeconomic position, food insecurity, low caregiver education, low status of women, unequal food distribution within households, and limited access to clean water and sanitation are some of the household-level vulnerabilities that surround these immediate causes [ 16 ]. The framework outlines the wider contextual drivers of stunting at the local and national levels, which represent the structural setting in which families and kids reside. Through elements like poverty, income disparity, job prospects, food costs, trade regulations, social safety nets, and banking services, the political economy affects nutrition outcomes [ 7 ]. Through methods for food production, processing, and distribution, agricultural and food systems have an impact on the accessibility and cost of a variety of safe, nutrient-dense foods[ 29 ]. In addition to variables like urbanization, climate change, population density, and susceptibility to natural and man-made disasters, the water, sanitation, and environmental sector also plays a role in the provision and upkeep of clean water, sanitation infrastructure, and services[ 30 ]. Although health systems play a crucial role in preventing and treating childhood stunting, many communities struggle with issues such restricted access to care, a lack of qualified medical personnel, poor infrastructure, and a lack of supplies[ 31 ]. Education systems also have a cross-cutting effect since better health literacy, feeding habits, and cleanliness behaviors are linked to both children and caregivers having access to high-quality education. [ 32 ]Last but not least, societal and cultural norms influence attitudes and actions about women's position, childrearing, and caregiving responsibilities, all of which have a big impact on stunting[ 33 , 34 ]. Data Analysis Two researchers transcribed verbatims of all audio recordings of focus group discussions (FGDs) and key informant interviews (KIIs) in Kinyarwanda to preserve participants' exact responses. An outside consultant then translated those transcripts into English. To make sure the translated material was accurate, consistent, and culturally appropriate, a second expert performed back-translation. The principal investigator verified the transcripts by checking them against original recordings and field notes for accuracy. Data were imported into NVivo 14 for open coding and analysis. We undertook reading and rereading of the raw data to be familiar with the content and to extract a few emerging themes. First, the transcripts were decontextualized to extract discrete quotes and passages from the broader narratives. This was followed by a procedure of recontextualization, where these passages were analyzed in the context of the larger story to make sure they still made sense. Three data analysts independently categorized the data into themes, checking for saturating coverage. Discrepancies were discussed together among the researchers, which helped enhance validity and consistency. The ultimate step of the analysis was to converge and characterize the main themes, sub-themes, and categories supported and substantiated by quotes that underscore the main results. This systematic approach established credibility, validity, and a sound, iterative analysis process, and grounded the results firmly in the participants' perspectives. Results Sociodemographic characteristics of the study population Participant groups in the study included sixteen front-line employees who participated in Key Informant Interviews (KIIs) and sixty-seven participants in Focus Group Discussions (FGDs). The FGD participants were clearly dominated by women, with men making up a notably lower portion. The educational background of the participants varied; the largest educational category consisted of individuals who had finished primary school. A sizable fraction of them were also followed by those who had not attained that level. Fewer had not finished secondary school, whereas those with a secondary school education comprised a smaller but still substantial portion. With only a small minority, university graduates and those with vocational training were among the least represented. There were very few individuals who could not read or write. Regarding religion point of view, almost the half of FGD participants identified as Catholic, Adventists and Protestants shared the remaining portion with a small proportion of individuals said they had no religious connection. When it came to employment status, the vast majority were working casually, followed by a notable minority who were unemployed and a minimal representation of them were self-employed. Additionally, a dominant share of KII participants were men, while women making up only an exceedingly small portion of the total. While few of them held secondary-level education or an advanced diploma, the vast majority had a bachelor's degree. Concerning their appointments as frontline workers, many participants were nutritionists, followed by a significant subset of health center heads, a modest portion of social affairs officials, and early childhood development (ECD) promoters. Table 1 Description of study participants Types of interviews Number of participants Parents (38) 38 FGD1 (Burera District) 8 FGD2 (Gasabo District) 7 FGD3 (Nyaruguru District) 8 FGD4 (Rutsiro District) 7 FGD5 (Kayonza District) 8 Community volunteers (29) FGD1 (Burera District) 6 FGD2 (Gasabo District) 5 FGD3 (Nyaruguru District) 6 FGD4 (Rutsiro District) 6 FGD5 (Kayonza District) 6 KIIs (16) KIIs Social affairs 3 KIIs Head of Health Centers 4 KIIs Nutritionist 4 KIIs ECD Promoters 5 Total 83 Overview of core and subthemes The data analysis yielded three core themes being perceived manifestation of stunting, perceived determinants of stunting and perceived contextual constraints showing contextual determinants of childhood stunting causes and consequences as presented in Table 3 . These themes capture a multidimensional understanding of stunting, including its physical, nutritional, and developmental implications, as well as the underlying socioeconomic, cultural, and environmental factors. Each core theme is explored in depth with subthemes and categories to illuminate the various perceived causes and consequences. The first core theme, perceived manifestation of stunting, was presented with two subthemes including sub-optimal physical appearance, growth, and developmental impairments. Their categories reflect the local perception of stunting among study participants, which are mainly manifested in the presence of short stature, mismatch between age, weight, and height, inadequate height for age and reduced physical abilities. The second core theme, which is perceived determinants of stunting, covers a broad range of factors associated with stunting: low socioeconomic status and resource constraints. The first subtheme covers topics including poverty and economic constraints, misuse of distributed resources (e.g., selling food instead of eating it), and lack of livestock. The feeding barriers subtheme encompasses the categories of inadequate maternal and child nutrition, ignorance about balanced diets, early weaning and poor feeding practices, lack of animal-based proteins and balanced diets and inadequate or delayed weaning. The third subtheme, cultural and behavioral barriers, shelters the categories issues such as alcoholism and substance abuse, limited family planning practices, beliefs tied to witchcraft or religious restrictions, cultural beliefs and behavioral resistance, large family size, and poor understanding of health and nutrition recommendations. The fourth subtheme, parenting, and family dynamics barriers, includes family conflicts and poor caregiving practices, parental absence or neglect, children being left in the care of grandparents or housekeepers, lack of time for caregiving due to farming, workaholism among mothers, and early or unplanned pregnancies. Lastly, the subtheme poor hygiene barriers highlight poor handwashing practices, which contribute to disease and malnutrition in children. The third core theme, which is perceived contextual constraints, covered the sub them of economic support programs constraints which described the category of inaccuracy in finding aid-eligible households. The subtheme of service gaps covered the categories of lack of permanent staff in ECDs and poor access to family planning services and lastly, the subtheme of food insecurity covered the categories of hunger and food insecurity, poor reinforcement mechanism of the kitchen gardens. Table 3 Core themes, sub-themes, and categories Core theme Sub themes Categories Perceived manifestation of stunting Sub-optimal physical appearance Short stature Mismatch between age, weight, and height Inadequate height for age Delayed physical abilities Growth and developmental impairments Congenital abnormalities Delayed cognitive Perceived determinants of stunting Low socioeconomic status and resource constraints Poverty and economic constraints Misuse of distributed resources (e.g., food sold) Lack of livestock Feeding practices barriers Inadequate maternal and child nutrition Ignorance about balanced diets Early weaning and poor feeding practices Lack of animal-based proteins and balanced diets Inadequate or delayed weaning Cultural and behavioral barriers Alcoholism and substance abuse Limited family planning practice and larger family sizes. Beliefs (witchcraft, religious restrictions) Cultural beliefs, and behavioral barriers Resistance and poor understanding of health and nutrition recommendations Parenting and family dynamics barriers Family conflicts and poor caregiving practices Parental absence/neglect Children left with grandparents or housekeepers Lack of time for care due to farming Workaholism of mothers Early and unplanned pregnancies Poor hygiene barriers Poor handwashing practice Perceived contextual constraints Economic support programs constraints Inaccuracy in finding aid-eligible households Service gaps Lack of permanent staff in ECDs Poor access to family planning service Food insecurity Hunger and food insecurity. Poor reinforcement mechanism of the kitchen gardens Core theme 1: Perceived manifestation of stunting Sub-theme 1: Sub-optimal physical appearance , Stunting was commonly recognized through short stature, such as the disparity between a child’ s height and their age, along with signs of malnutrition. Respondents also linked stunting to cognitive and developmental delays. One respondent described stunting in terms of visible physical changes associated with stunting: “A stunted child has height that doesn’t correspond to the age, or they might lose weight and change of general aspect, which is how I understand it\" (Parent 1, Kayonza District). Stunting was also identified as a mismatch between age and physical growth: \"When you see the height of the child and you compare with his age, then you realize that they don’t correspond. You conclude that the child is malnourished. He is noticeably short and weak, lacking the energy and strength to grow properly\" (Parent 2, Gasabo District). Developmental delays were further linked to stunting, as explained by another parent: \"Sometimes you may find a 2-year-old child who doesn’t sit or walk. That is also a problem of malnutrition because their physical development has been delayed significantly.\" (Parent1, Kayonza District). Sometimes you can also see that the child is stunted based on what he does (Parent 2, Nyaruguru District). One Community Health Worker provided more perspectives, highlighting the use of measurement tools to identify stunting: \"Stunting is when a child’s height is measured, and they fall into the red zone. It shows that the child is already stunted, and their growth and brain development is far behind where it should be\" (CHW2, Rutsiro District). Sub-theme 2: Growth and developmental impairments The impacts of stunting extended beyond physical growth to include developmental delays and cognitive impairments. These delays often began early and persisted into later stages of childhood. Parents shared experiences of how stunting affected their children’s developmental milestones: \"Like mine is 10 months since the 30th, but he cannot sit, he cannot crawl. That is why he is among stunted children. His growth and development are slower compared to other children his age\" (Parent 4, Gasabo District). Community Health Workers emphasized the importance of monitoring developmental stages and identifying stunting early: \"Stunting signs can manifest from conception up to two years. We measure their height and compare it to the colors, green, yellow, red to determine if something is missing in their growth and nutrition\" (CHW6, Burera District). Core theme 2: Perceived determinants of stunting Socioeconomic factors. Poverty and economic constraints were the most often mentioned causes of stunting, underscoring a persistent lack of access to adequate food and resources. A parent described their dire financial struggles: \"For me, I eat, and I feed my children only after doing some job. Unfortunately, now I do not have any job for a whole month. I do not have anything; we are only surviving. It is extremely hard to see my children hungry while I cannot do anything to help them\" (Parent5, Gasabo District). The link between poverty and hunger was emphasized by another parent: \"Since many people who often have children with slow growing are poor, I think that stunting is mostly caused by hunger. Hunger is the root cause because if you do not have food, how can your child grow?\" (Parent 7, Gasabo District). An ECD promoter highlighted the misuse of resources in low-income households: \"Some parents used to sell the products given to children by the government, like Shishakibondo, saying children wouldn’t be drinking alone; they have to take a drink of alcohol. Instead of using the flour to prepare porridge, they sell it to buy beer\" (ECD Promoter, Kayonza District). This misuse was also connected to dietary practices: \"People go fishing for small fish but sell them to the market instead of preparing them for their children. The priority becomes earning money rather than feeding the children\" (ECD Promoter, Rutsiro District). Concerning livestock ownership, and the considerable number of populations, our participants suggested that owning livestock could help them to alleviate the burden both in farming and in animal food. \" Lack of livestock to provide manure for farming vegetables is a challenge in combating stunting\" Parent4, Kayonza District). Feeding practices barriers Improper feeding practices, including delayed weaning, poor dietary diversity, and busy schedules, were consistently cited as challenges. Poor feeding practices, ignorance about balanced diets, and early pregnancies worsen the issue. An ECD promoter detailed gaps in feeding practices: \"Parents, especially women, go to the field and carry food to eat at lunchtime. They all share the same food, which is not suitable for the small child. The child ends up eating what is available, not what they need\" (ECD promoter, Gasabo District). Another participant emphasized the seasonal dependency on food: \"On my side, I rely on the help of others. Sometimes people give me support so that my child might survive. But during the dry season, even the vegetables we depend on are gone, and there is nothing to give the children\" (Parent 4, Kayonza District). This highlights the need for consistent support and better planning to ensure children receive adequate nutrition year-round. To emphasize that, one parent elaborated on the struggles of breastfeeding: \"The reason why a mother can stop breastfeeding for six months is that she cannot get a balanced diet, making her lack breastmilk with enough nutrients, leading to child stunting\" (Parent 7, Rutsiro District). Additionally, the absence of balanced diets was a recurrent theme: \"When someone is poor and cannot afford to buy vegetables every day, if they don’t have the vegetable garden, the baby will be taking an unbalanced diet which lacks nutrients from vegetables, and stunting may develop\" (ECD Promoter, Burera District). Culture and behavior barriers Cultural norms, beliefs, and behaviors significantly influence stunting. Alcoholism, limited family planning practices, and traditional beliefs about child growth worsen the problem. A parent shared a personal encounter with cultural misconceptions: \"Initially, they told me that it is his heart that hinders him from growing. When I inquired about others, they told me that it was a witchcraft attack\" (Parent 4, Gasabo District). Limited access to family planning services further worsened stunting risks in areas with large family sizes. An ECD promoter emphasized the role of family planning: \"The secret behind stunting prevention is linked to having few children because they understood the benefits of family planning. When a family can manage their resources well, the children do not suffer\" (ECD promoter, Nyaruguru District). Religious restrictions also played a role: \"Adventists don’t eat meat or seafood, which have important nutrients for the baby. This cultural restriction can lead to deficiencies\" (Parent 8, Burera District). Resistance to education and poor awareness among families create significant barriers to addressing stunting. Many respondents noted that families often fail to implement advice or Health Education effectively. An ECD promoter described this challenge: \"You teach them, but they don’t put into practice what they learned. You tell them how important balanced diets and vegetables are, but you go back and find that they are still doing the same thing as before, and the child remains stunted\" (ECD Promoter, Nyaruguru). Parenting and family dynamics Parenting and family dynamics were identified as other contributors to childhood stunting. Poor caregiving practices, such as irregular feeding schedules and limited attention to children’s needs, were highlighted as major barriers to healthy development. Additionally, neglect, particularly when children are left in the care of housekeepers or grandparents due to parents’ commitments, further worsens the challenges. One recurring issue was the lack of time for consistent and responsive caregiving, which significantly influenced stunting outcomes. One parent shared their struggle with time constraints: \"Sometimes you get a job and go early in the morning to do it while you carry your child with you. You did not have time to prepare his porridge or pack food for the day, and he ends up eating nothing\" (Parent 3, Gasabo District). Further, family conflicts were repeatedly mentioned as an obstacle to proper childcare and feeding. One nutritionist explained how family conflicts disrupt caregiving: \"When there is no peace in the household between husband and wife, they start to argue. When the wife gets like one thousand and buys food, she is not able to get that balanced meal for the child. The consequences go to the child from their disagreements\" (IZU, Nyaruguru District). Another respondent emphasized the role of conflicts in creating neglect: \"When you have conflicts with your husband and you work alone for the children without anyone to help you, that also causes malnutrition. It is difficult to manage everything on your own\" (Parent 1, Gasabo District). Community Health Workers echoed this sentiment, highlighting neglect and substance abuse: \"Parents neglect their children by leaving them in the care of housemaids who might drink the child’s milk and give them diluted milk instead. This leads to malnutrition and stunting\" (CHW1, Gasabo District). Lastly, one nutritionist noted the impact of intimate partner violence: \"Intimate partner violence plays a great role, and I can say that it is the main cause of stunting because when a child is born, he/she must be raised by both parents who should collaborate. Without harmony, the child suffers\" (Nutritionist, Gasabo District). Poor hygiene barriers Poor handwashing was also mentioned as a barrier to childhood stunting. A parent explained the importance of practicing hygiene: \"Poor handwashing practices can also cause child stunting because if you wash your hands with water and soap and that you wash utensils and put them to dry, there is no problem. But when these practices are ignored, diseases spread, and the child suffers\" (Parent 5, Gasabo District). Core theme 3: Perceived contextual constraints Economic support programs constraints When it comes to socio-economic support programs constraints, participants from the present study recommended that they should be a well-structured and fair way of selecting eligible individuals for support. One participant mentioned it. “Some leaders select individuals eligible for aid based on their personal biases” (Parent 4, Burera District). Service gaps Lack of access to essential services, such as family planning and ECD programs, was a significant barrier. The absence of permanent staff in Health Centers also hindered sustained interventions. One respondent described the difficulty of supporting kitchen gardens: \"No, they are not available all the time because during the dry season, we don’t have vegetables. If you do not have a kitchen garden, you cannot cook a balanced meal. You can cook Irish potatoes, but you need vegetables to mix with them to make a nutritious meal\" (Parent 3, Rutsiro District). Hunger and food insecurity. Another participant emphasized the role of hunger and food insecurity to influence stunting: \"Since many people who often have children with slow growing are poor, I think that stunting is mostly caused by hunger. If you do not have enough food at home, what can you give to your child to grow?\" (Parent 7, Gasabo District). Vegetable gardening was rapidly mentioned as a factor that could promote dietary diversity hence improved nutrition status of children. However, some participants elucidated that some people do not adhere to the vegetable gardening program, and those who did manage they did it just to meet authorities’ expectations, not for their own benefit. “Kitchen gardens are few, poorly maintained, and mostly kept just to please authorities rather than for personal use” (Nutritionist, Kayonza District). Discussion This study explored the perspectives of Rwandan parents and frontline workers about determinants of childhood stunting. The three highlighted themes including manifestations of stunting, perceived factors, and contextual constraints, reflect the structure of the WHO conceptual framework. They illustrate how stunting is acknowledged at the individual level, molded by home practices and caregiver actions, and affected by overarching systemic obstacles. The first theme shows the perceived manifestation of stunting where two subthemes were explained as sub-optimal physical appearance and growth and developmental impairments, the findings indicate that although frontline workers and Rwandan parents could identify apparent indications of stunting, their comprehension of its fundamental origins and enduring effects was frequently constrained or influenced by misconceptions. One of the most often cited signs was short stature. Parents frequently referred to the observed obvious height discrepancies between their children and their age-group peers. According to several participant testimonials, children's diminutive bodies made them appear much shorter than their real age. Such poor physical manifestations are critical markers of a child's undernutrition, as supported by existing literature that highlights the importance of growth monitoring in early childhood [ 35 ]. Participants often characterized stunted children as not growing 'on time,' particularly highlighting discrepancies between height and age, thereby underscoring their recognition of observable physical symptoms. The articulated concern among parents on height-age discrepancies illustrates a pivotal moment in caregiver awareness about child development [ 36 ]. These discrepancies were occasionally taken as proof of inadequate diet or underlying medical issues [ 37 ]. Study participants identified the consequences of stunting as going beyond short stature. Stunting was also described by both parents and frontline health workers as a form of impairment, limiting a child's attainment of developmental milestones at expected ages. Scholars have described frequently associated stunting with missed milestones, such as sitting or crawling, as physical dimensions of impairment, while delays were also recognized as indicators and symptoms of brain dysfunction and growth impairment [ 18 ]. These testimonies reveal that caregivers see and acknowledge a developmental trajectory impeded by physical growth faltering. It also represents a high level parental awareness and stress, suggesting that stunting is not only a biological issue but also a psychological burden for parents and families [ 17 ]. CHWs articulated their concerns about stunting by stressing the need for early identification and continuous monitoring of child growth and development at the community level. They emphasized how continued anthropometric monitoring is designed as the first line of defense against stunting in children, but yet again reflects a community-based understanding of the appropriate \"first 1,000 days,\" where interventions are the most effective[ 38 ]. All this discussion underscores the complex nature of stunting, affecting not only children's height, but their quality of life and future developmental potential[ 39 ]. The information also reinforces the need to take an integrated approach with the community in mind which includes educating caregivers, monitoring early childhood development, and providing nutritional support, consistent with the life-course approach which accounts for the long-term impacts of stunting on education, economic productivity, and well-being. When it comes to the theme illustrating the perceived determinants of stunting, low socioeconomic status and resource constraints highlighted the profound influence on childhood stunting. Participants repeatedly pointed to the inability to afford nutritious foods as a key factor that compromises children’s growth. Food insecurity and hunger, often resulting from limited household income, prevent families from meeting their children's dietary needs, contributing to undernutrition [ 40 ]. Moreover, the mismanagement of resources intended to support nutritional interventions such as government food aid programs was cited as another barrier to addressing stunting. When these resources are not well distributed or not sufficient, they fail to reach the most vulnerable populations, exacerbating food insecurity and perpetuating the cycle of malnutrition[ 41 ]. Similarly, a study conducted in Nepal showed that child undernutrition was largely influenced by poor sociocultural and economic conditions [ 42 ]. The participants identified livestock ownership as a major pathway to reduce the burden of stunting, especially through both farming and nutrition. It was identified that livestock not only provides manure to improve soil fertility and increase vegetable production to promote food security in households, but that animal-source foods from livestock (milk, meat, and eggs) are also critical for children's growth and development [ 43 ]. This complements previous literature suggesting that livestock ownership is positively related to better nutritional outcomes for children because of nutrient-rich food access and agricultural productivity[ 44 ]. Respondents recognized that poor feeding practices during pregnancy could lead to adverse birth outcomes, such as low birth weight and signs of stunting from birth. This reflects an understanding that inadequate maternal nutrition disrupts fetal growth, laying the foundation for long-term growth deficits [ 45 ] and continues within all the period of 1000 days [ 46 ]. Additionally, inadequate dietary intake among mothers, and inadequate weight gain during pregnancy are more likely to impair fetal growth and increase the risk of low birth weight, which is a strong predictor of stunting in early childhood [ 47 ]. These insights emphasize the importance of targeting maternal nutrition as a key strategy for stunting prevention. Ensuring adequate nutrient intake during pregnancy not only reduces the risk of low birth weight but also supports healthy growth and development in early life [ 48 ]. One of the biggest obstacles to combating stunting is cultural and behavioral issues. Cultural opposition to community education and a lack of knowledge about the best ways to feed children impede behavior change in many contexts. Participants suggested behaviors like alcoholism, not using family planning, and traditional beliefs about the growth of children, which all negatively shaped child health outcomes. This was shown to be because of socio-cultural practices and constructs that impact prohibitive caregiving, nutrition practices, and healthcare seeking behaviors. These findings align with previous studies that show harmful cultural practices coupled with high maternal low autonomy have detrimental outcomes for feeding behavior, hygiene, access to health care exposing children to increased risk of stunting [ 49 ]. Reducing stunting would then not only be reliant on biomedical interventions but on culture-sensitive approaches that engage communities to change norms and embrace behaviors for a better future. Many families are hesitant to follow dietary advice, especially those that advocate for a varied and balanced diet, because of deeply ingrained cultural practices and beliefs, and no immediate, apparent benefits [ 44 , 45 ]. Cultural norms and traditions have an impact on health-related behaviors, which emphasizes the necessity of community-driven treatments that are customized for cultural and geographical settings. In addition, these cultural norms often prioritize traditional foods and meal patterns passed down through generations, which can conflict with modern nutritional recommendations[ 50 ]. Large family sizes and limited access to family planning services further amplify the risks of stunting, placing additional demands on already stretched resources. Promoting more advantageous use of resources helps to reduce stunting risk and access to family planning has been widely reported [ 51 ] to be a significant contributor to preventing short stature among women. Resistance to education and limited awareness within families were another social determinant identified to explain the ongoing childhood stunting. The health sector made health education and nutrition education available to families but in many instances many families seem to either ignore or inadequately act on the recommendations of frontline workers. The gap between knowledge and action may stem from limited literacy, skepticism of health messages or household priorities, as the family seeks to buy medicine and food for survival[ 52 ]. This resistance and lack of attention were cited as causes for not adhering to appropriate feeding and hygiene and seeking care for children as required in all aspects of preventing stunting[ 53 ]. On a positive note, our findings conform to many previous studies that highlight the role of caregiver knowledge and behaviors in influencing child nutrition outcomes[ 54 ]. Community education that is designed according to cultural practices and values may be more effective when implemented in the community and supported by appropriately trained field workers and appropriate community organization. Concerning Parenting and Family Dynamics, the findings of this study highlighted the profound impact on the prevalence of childhood stunting, saying that poor caregiving practices and increased familial stressors significantly affect child health development including linear growth. Family misunderstandings and conflicts, particularly intimate partner violence, appeared as substantial barriers to effective caregiving. The experiences shared by nutritionists explained how the stress and conflict arising within a family can disrupt parental focus on children's nutritional requirements to pay attention on conflicts, thus heightening risks of undernutrition [ 55 ]. This evidence shows that elevated tension in a household can negatively affect parental mental health and, in turn, compromises child nutrition. On contrary, investing more time and financial in childcare could contributes to the improvement of the nutrition outcomes [ 56 ]. Additionally, intimate partner violence claimed to have a detrimental effect on child development in general and hence affect nutrition status. Scholars have stated that children raised within conflictual households are mainly exposed to chronic psychosocial stress that affects their health and nutrition [ 57 ]. Frequent disputes, parental disagreement, or domestic violence are examples of household conflict that might interfere with feeding habits, emotional security, and caring practices [ 58 ]. Through pathways including stress-induced alterations in appetite regulation, food absorption, and metabolic function, these disturbances may also lead to inadequate nutritional status in addition to psychological suffering [ 59 ]. Children's healthy growth and development may be hampered by the cumulative effects of such an environment [ 60 ]. Studies have previously stated that poor responsive caregiving and inconsistent feeding schedules could be a critical determinant contributing to childhood stunting, particularly [ 24 , 61 ]. The testimonies from the participants illustrate how they understand poor attention to children's nutritional needs correlates with suboptimal growth outcomes. Moreover, the findings from the present study pointed out the key interaction between maternal health and child stunting in young children. Neglect was listed as a contributing factor to stunting, specifically when young children were placed under the supervision of a housekeeper or elderly grandparents because of parents working or busy with other responsibilities. Participants said that with such arrangements children are left at the mercy of what the caregiver thinks is good for the child. Overall, children in these situations get inconsistent and less responsive caregiving, especially when it comes to feeding, hygiene, and emotional engagement. This corresponds with the other literature out there reinforcing the importance of responsive caregiving during the early years, and that decreased/developing/dated socio-emotional interactions with caregivers can lead to poor nutritional outputs and poor growth[ 62 ]. Thus, being without their primary caregiver at important incremental developmental stages can affect both the children's immediate nutritional status and the potential for longer-term growth impairment. The statements from parents and the ECD promoter revealed a substantial gap in feeding practices that intensify the risk of stunting among children. Moreover, the insight provided by the ECD promoters about shared meals raised concerns about nutritional adequacy in family feeding practices. The phenomenon where children consume what is available rather than what is nutritionally appropriate can lead to inadequate dietary intake, ultimately affecting their growth and development adversely. Such practices reflect a broader issue of food security and access, where families, particularly those living in poverty, often prioritize survival over nutritional quality [ 63 ]. This has been articulated in the literature, which highlights how inadequate dietary diversity and poor feeding practices are significant contributors to the risk of stunting [ 64 ]. The findings from the present study highlighted the poor sanitation and hygiene to stunting. Scholars have shown how poor hygiene practices increase the likelihood of contracting diarrhea and environmental enteric dysfunction (EED), which impairs nutrient absorption and leads to chronic malnutrition [ 65 ]. For instance, an review published in Nutrition review showed how unsafe water and poor sanitation could leads to the diarrhea and EED [ 66 ]. Economic assistance initiatives are essential so that household food security and access to health services can be improved and childhood stunting avoided [ 67 ]. But respondents of this study expressed concerns about unfair processes for targeting aid, which in effect used along individuals' personal relationships with local leaders. Such biased sample selection compromises the fairness of programs and could exclude some of the targeted vulnerable families from the risk of child malnutrition. Such governance concerns undermine the trust of the community and effectiveness of supportive interventions. Frontline workers described difficulties in advocating for deserving families due to lack of clear and consistent criteria [ 68 ]. Restricted availability of essential services, including family planning and ECD programs, were a major barrier to progress on childhood stunting. Lack of consistent health personnel was reported as a barrier affecting their ability to provide continuous care and the delivery of nutrition-sensitive approaches [ 69 , 70 ]. Availability to kitchen gardens was also low mainly in the dry season, which also influenced the ability of the households to prepare meals that are balanced. Although vegetable gardening was often mentioned as a feasible way to enhance nutritional diversity and the nutrition of children, its practical application and use at the household level seemed to be restricted. Participants pointed out that despite national nutrition programs' promotion of kitchen gardens, adherence is still below ideal. According to several respondents, some households often grow vegetables only to satisfy administrative requirements rather than to satisfy their own nutritional needs. Similar fail also was observed in South Africa where, some households often cultivate vegetables just to satisfy administrative requirements rather than for nutritional purposes [ 71 ]. This reveals a gap between community ownership and program implementation, implying that the anticipated nutritional advantages of such interventions would not be completely achieved in the absence of true community engagement and perceived value [ 72 ]. One of the study's strengths was that it considered many FGDs and KIIs and conducted interviews until participants had no more ideas. In support of this notion, we were able to elicit a wide range of responses from the participants due to their diversity, which included participants from five different districts, both rural and urban, and composed of different kinds of people. However, some limitations may affect this study too. Firstly, social desirability bias may have affected interviews and focus group responses, especially on sensitive themes like caregiving and feeding. Secondly, transcripts were thoroughly transcribed and back translated, but some meanings may have been lost. Finally, this qualitative study in five purposively selected districts may not apply to all Rwandan areas or other situations. To conclude, the perception of parents and frontline workers recognized that childhood stunting in Rwanda is a multifaceted problem influenced by several factors, including socioeconomic hardships, poor maternal and child nutrition, poor parenting practices, and cultural and behavioral constraints. Low community ownership of important programs like kitchen gardens, governance problems in assistance delivery, and restricted access to basic health and nutrition services all exacerbate these problems. According to the findings, multisectoral, cultural awareness, and comprehensive solutions that address the structural and behavioral causes of stunting are necessary. Reducing childhood stunting in a sustainable manner and promoting healthy child development in Rwanda require increasing community involvement, enhancing program accountability, and guaranteeing fair access to nutrition-related services. Abbreviations LMIC Low- and Middle-Income Countries UNICEF United Nations International Children's Emergency Fund WHO World Health Organization ECD Early Childhood Development CHW Community Health Worker FGD Focus Group Discussion KII Key Informant Interview IRB Institutional Review Board EED Environmental Enteric Dysfunction Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki as revised in 2013. Ethical clearance was secured from the Institutional Review Board of the University of Rwanda's College of Medicine and Health Sciences, (N o 335/CMHS IRB 2021, later amended in 2022 under N o 178/CMHS IRB). A research visa was also obtained from the National Institute of Statistics of Rwanda and a research permit from and the Rwanda Ministry of Local Governance. Prior to conducting every interview, a full description of the study purpose was given to the participants prior to each interview, and the participants were fully informed of their involvement. All participants provided a written informed consent to confirm their willingness to take part in the study. To ensure confidentiality and compliance with good ethical practice, only authorized personnel had access to the data under clearly defined roles and responsibilities. Consent for publication Not applicable Data Availability Statement The datasets used during the current study are available from the corresponding author upon reasonable request. Competing Interests The authors declare no conflict of interest. Funding The Nestlé Foundation for the Problems of Nutrition in the World provided considerable financing for this project, which greatly helped in the data collection process. Additionally, “the Consortium for Advanced Research Training in Africa (CARTA) played a crucial role by providing financial backing that enhanced the study's impact. CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the U.K. Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training, and Science in Africa (DELTAS Africa) program” Acknowledgements Authors would like to convey their profound gratitude to the participants who voluntarily contributed their time and experiences to facilitate this study. 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Impact of permagarden intervention on improving fruit and vegetable intake among vulnerable groups in an urban setting of Ethiopia: A quasi-experimental study. PLoS ONE. 2019;14:1–14. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7040307\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":495959404,\"identity\":\"7a16d872-a283-464f-ae53-0ae808903278\",\"order_by\":0,\"name\":\"Jean Dieu Habimana\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIiWNgGAWjYBACxhkMbAwJIBZ7A1iAn4GZaC08B4BEAoNkAyEtDBJALRBGAlQLIR3Ms5ufPXiYY5fHP/Pxw8+VP+wkzNuZH35gqLhnh0sv45xj5gaJ25KLJW6nGUueSUiWkDnMZizBcKY4GaeWGQlmEonbmBMbbucAHZXAXCfBzMMgwdiWkIzLYYwz0r8BtdQnzr95hvlnQ0K9BFAL8w/8WnJAthxO3HCDhw1oy2GQFjaQLXZ4tJQD/XI8ceOZNDPLhrTjQC1sZhYJZxIScGkxnJG+7eHPbdWJ844ffnyzwaZaQoL/8OMbHyoS7HFqacAqDLQiEbsMA4M8LrMYcNoyCkbBKBgFIw4AABr9VgjdIqf3AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of Rwanda\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Jean\",\"middleName\":\"Dieu\",\"lastName\":\"Habimana\",\"suffix\":\"\"},{\"id\":495959405,\"identity\":\"9b6386e0-08f4-4336-a1a1-48d45f8c93ec\",\"order_by\":1,\"name\":\"Theogene Habumugisha\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Bergen\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Theogene\",\"middleName\":\"\",\"lastName\":\"Habumugisha\",\"suffix\":\"\"},{\"id\":495959406,\"identity\":\"389a31ad-4dd7-4d3d-ba56-e97d25c161f8\",\"order_by\":2,\"name\":\"Noel Korukire\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Rwanda\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Noel\",\"middleName\":\"\",\"lastName\":\"Korukire\",\"suffix\":\"\"},{\"id\":495959407,\"identity\":\"1e1109e2-24b2-45f2-8aca-4aae0b5e8cb8\",\"order_by\":3,\"name\":\"Maryse Umugwaneza\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Rwanda Food and Drug Administration\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Maryse\",\"middleName\":\"\",\"lastName\":\"Umugwaneza\",\"suffix\":\"\"},{\"id\":495959408,\"identity\":\"f2115c73-e0a1-49b2-b89f-79a42a4d123f\",\"order_by\":4,\"name\":\"Lawrence Rugema\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Rwanda\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Lawrence\",\"middleName\":\"\",\"lastName\":\"Rugema\",\"suffix\":\"\"},{\"id\":495959409,\"identity\":\"6f3a85f3-f8c1-4692-954e-989fc8b660e0\",\"order_by\":5,\"name\":\"Cyprien Munyanshongore\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Rwanda\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Cyprien\",\"middleName\":\"\",\"lastName\":\"Munyanshongore\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-07-03 16:53:17\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7040307/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7040307/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":88489181,\"identity\":\"aad4712d-c9ac-48f6-8a82-dab879510c96\",\"added_by\":\"auto\",\"created_at\":\"2025-08-07 04:03:21\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":66985,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eUnnumbered image in the Methods section.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"groupimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7040307/v1/72d93e8fa2c3d33aa994faf1.jpeg\"},{\"id\":105363161,\"identity\":\"5793d115-dee9-4813-8635-69717a60a530\",\"added_by\":\"auto\",\"created_at\":\"2026-03-25 08:13:43\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1050395,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7040307/v1/a3d819bb-89e4-4fad-b89c-f21694e7f3e7.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Perceived Determinants of Childhood Stunting in Rwanda: Insights from Parents and Frontline Workers\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eStunting, a manifestation of chronic malnutrition resulting in impaired linear growth, remains a persistent Public Health concern particularly in Low- and Middle-income countries (LMIC). As of 2023, an estimate of 148.1\\u0026nbsp;million children i.e. around 22.3% of the children under five years of age globally were stunted [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. According to UNICEF, WHO, and the World Bank Group in 2022, the Melanesian region has the highest prevalence of childhood stunting with 46.4 percent, followed by Southern Asia with 40.3 percent, Middle Africa with 37.4 percent, and Eastern Africa with 30.6\\u0026ensp;percent [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. In Rwanda, 29.8%\\u0026ensp;of children were stunted [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e], showing a slow progress in the fight against chronic malnutrition.\\u003c/p\\u003e\\u003cp\\u003eStunting is not merely a matter of short stature, but also it reflects a failure\\u0026ensp;to achieve optimal physical and cognitive growth, with lifelong consequences for health, education, and economic productivity. Stunting affects children's immune systems, rendering them susceptible to infections\\u0026ensp;and diseases [\\u003cspan additionalcitationids=\\\"CR4\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Stunting\\u0026ensp;can also be associated with cognitive deficits which can result in decreased academic performance, limiting career opportunities in adulthood, and perpetuating poverty cycles [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Additionally, stunting limits individual economic viability, and\\u0026ensp;in turn, poses a challenge to national development [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. This is a problem that needs to\\u0026ensp;be addressed as stunting not only causes individual harm but has wider implications for human capital and the economic development of the regions afflicted.\\u003c/p\\u003e\\u003cp\\u003eStunting results from a combination of inadequate\\u0026ensp;nutrition, repeated infections, poor maternal health, and inadequate childcare and health practices, coupled with underlying poverty and inequities in access to essential services [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. These elements combine in a pernicious feedback loop where scarce resources and inadequate living conditions lead to chronic malnutrition, and malnourished children are more vulnerable to\\u0026ensp;diseases that affect their capacity to thrive [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Many other factors contribute to stunting, including poor maternal nutrition during pregnancy and lactation [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e], and lack of access\\u0026ensp;to clean water, adequate sanitation, and health services. The multisectoral problem of stunting demands a multisectoral solution that addresses the immediate, underlying and root causes of the\\u0026ensp;condition.\\u003c/p\\u003e\\u003cp\\u003eIn Rwanda, despite significant strides in tackling malnutrition,\\u0026ensp;a third of children under five years are still affected by stunting, denoting sustained disparity and the complex and multi-modality of the determinants of this phenomenon [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. So, tackling stunting entails a multi-sectoral approach combining health, nutrition, sanitation, and education\\u0026ensp;interventions. Despite years of programming\\u0026ensp;to improve infant/young child feeding practices in Rwanda, including the promotion of exclusive breastfeeding with early initiation and continuous breastfeeding accompanied by maternal nutrition education, and community-based growth monitoring programs, the rate of stunting remains high, indicating gaps in knowledge and practice concerning essential nutritional behaviors [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eParents and frontline workers interact with children in\\u0026ensp;providing the nutrition needed to grow. Preventive healthcare includes knowledge, beliefs, and\\u0026ensp;practices ordination. It is important to understand the perceptions of causes,\\u0026ensp;protective factors, and prevention of stunting among these key stakeholders for designing appropriate and sustainable context-based interventions [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Community perceptions offer important insights into local cultural practices, resource utilization, and barriers in scaling up stunting prevention measures. This study aims however, to explore the perspectives of Rwandan parents and frontline workers on factors affecting childhood stunting.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cb\\u003eStudy design and setting.\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eA qualitative study using phenomenological approach was conducted across all provinces of Rwanda, including Kigali City. The study focused on five districts purposively selected based on their high prevalence of childhood stunting within their respective provinces including Kayonza (Eastern Province), Nyaruguru (Southern Province), Burera (Northern Province), Rutsiro (Western Province), and Gasabo (Kigali City) [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eStudy participants\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eEight-three individuals were selected purposively to take part in this study including thirty-eight parents, twenty-nine Community Volunteers and nineteen Key Informants. Parents were mothers and fathers all drawn from low-income households with stunted and non-stunted children aged 6\\u0026ndash;23 months. Frontline workers included both Community Volunteers and key informants with direct exposure in childcare, nutrition, and health service delivery. Community Volunteers included Community Health Workers, family friends, community farmer promoters, and villages social affairs. Key informants comprise people who hold important positions related to nutrition and child development, including district Early Childhood Development (ECD) promoters, nutrition officers, and health center managers.\\u003c/p\\u003e\\u003cp\\u003eWe conducted a total of ten focus group discussions (FGDs) to collect qualitative data, five with parents, and five with Community Volunteers, with eight participants in each group standing for an even distribution\\u0026ensp;across participant types. All parents\\u0026rsquo; FGDs comprised four parents\\u0026ensp;of stunted and four parents of non-stunted children. They were conducted across\\u0026ensp;five districts, namely: Burera, Gasabo, Nyaruguru, Rutsiro and Kayonza. In addition, 16 KIIs from different Sectors consisted of representatives of social\\u0026ensp;affairs (n\\u0026thinsp;=\\u0026thinsp;3), Head of Health Centers (n\\u0026thinsp;=\\u0026thinsp;4), nutritionists (n\\u0026thinsp;=\\u0026thinsp;4), and ECD promoters (n\\u0026thinsp;=\\u0026thinsp;5) with different views on child nutrition and development as detailed in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eData Collection Procedures\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eWe performed\\u0026ensp;a pilot test before the data collection. This allowed us to get familiar with\\u0026ensp;the data collection tool, refine it, make sure it was clear and ensure that it answered questions we intended to ask. All FGDs and KIIs involved open-ended questions aimed\\u0026ensp;at triggering participants' perceptions about the childhood stunting. Moreover, the principal investigator moderated all interviews assisted by trained research\\u0026ensp;assistant by recording and taking detailed notes. All interviews were conducted in Kinyarwanda, and sessions lasted between 40 to 80\\u0026ensp;minutes. After data collection sessions, audio recordings and field notes\\u0026ensp;were reviewed by the research team to resolve ambiguities and highlight key observations. Data was collected until no new themes or subthemes surfaced from further key informant interviews (KIIs) or focus group discussions (FGDs). Following the completion of the ninth FGD and the fourteenth KII, the research team observed that no new insights were being presented and that participant responses were restating previously identified concepts. After that, two more interviews were done to make sure saturation was reached. This iterative process ensured that the final dataset captured a comprehensive range of perspectives relevant to the study objectives.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConceptual framework guiding the analysis.\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis research is guided by the WHO conceptual framework on children stunting (WHO/NMH/NHD/17.7), which gives a thorough understanding of the multifaceted causes of stunting. The framework divides determinants into three categories: child-related consequences, immediate and underlying causes at the household level (e.g., insufficient dietary intake and poor caregiving practices), and broader contextual factors at the community level, such as socioeconomic, environmental, and policy conditions. Using this methodology, the study methodically investigates how numerous factors interact at different levels to influence childhood stunting, allowing for a more comprehensive analysis and interpretation of the data [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe paradigm emphasizes the negative effects of stunting at the child level. Their motor, cognitive, and language development also decelerate, which impacts their academic preparedness and social interaction [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Economically speaking, because stunted children require continuous care, their families frequently experience increased healthcare expenses and missed opportunities [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. Additionally, the effects of stunting are extensive over time. Childhood stunting frequently results in smaller stature, increased risk of obesity and related non-communicable diseases, and possibly, a compromised reproductive health during adulthood [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Stunted children are also less likely to develop to their full potential, perform poorly in school, and have a decreased learning ability[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Reduced work capacity and productivity result from these effects, which feed the cycles of poverty and underperformance[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe approach pinpoints the immediate and underlying causal pathways that result in stunting at the household level. Preterm delivery, adolescent pregnancies, inappropriate birth spacing, intrauterine growth restriction (IUGR), maternal illnesses, and poor nutrition before and during pregnancy are all major maternal contributors [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. Chronic disorders including hypertension and poor maternal mental health further exacerbate these biological risks[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Feeding habits for infants and young children also play a significant role. For instance, early nutrition is compromised by inadequate nursing, including delayed initiation, non-exclusive breastfeeding, and early cessation[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. The dietary requirements of the developing infant are also not met by inadequate supplemental feeding techniques, such as infrequent feeding, offering thin or inadequately nourishing food, and poor feeding habits during illness[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eWith inadequate stimulation, poor response during feeding, and a dearth of secure and caring surroundings, childcare practices are frequently insufficient[\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. Frequent infections, especially respiratory infections, malaria, and enteric ailments like diarrhea, further impair appetite and nutrient absorption[\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. Consuming foods that are low in micronutrients, dietary diversity, and animal-based meals, as well as being exposed to contaminated food and water as a result of improper hygiene, unsafe storage, and preparation methods, are all major contributors to undernutrition [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. Poor socioeconomic position, food insecurity, low caregiver education, low status of women, unequal food distribution within households, and limited access to clean water and sanitation are some of the household-level vulnerabilities that surround these immediate causes [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe framework outlines the wider contextual drivers of stunting at the local and national levels, which represent the structural setting in which families and kids reside. Through elements like poverty, income disparity, job prospects, food costs, trade regulations, social safety nets, and banking services, the political economy affects nutrition outcomes [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Through methods for food production, processing, and distribution, agricultural and food systems have an impact on the accessibility and cost of a variety of safe, nutrient-dense foods[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. In addition to variables like urbanization, climate change, population density, and susceptibility to natural and man-made disasters, the water, sanitation, and environmental sector also plays a role in the provision and upkeep of clean water, sanitation infrastructure, and services[\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eAlthough health systems play a crucial role in preventing and treating childhood stunting, many communities struggle with issues such restricted access to care, a lack of qualified medical personnel, poor infrastructure, and a lack of supplies[\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. Education systems also have a cross-cutting effect since better health literacy, feeding habits, and cleanliness behaviors are linked to both children and caregivers having access to high-quality education. [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]Last but not least, societal and cultural norms influence attitudes and actions about women's position, childrearing, and caregiving responsibilities, all of which have a big impact on stunting[\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cdiv id=\\\"Sec2\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eData Analysis\\u003c/h2\\u003e\\u003cp\\u003e Two researchers transcribed verbatims of all audio recordings of focus group discussions (FGDs) and key informant interviews (KIIs) in Kinyarwanda to preserve participants' exact responses. An outside consultant then translated those transcripts into English. To make sure the translated material was accurate, consistent, and culturally appropriate, a second expert performed back-translation. The principal\\u0026ensp;investigator verified the transcripts by checking them against original recordings and field notes for accuracy. Data were imported into NVivo 14 for open coding and analysis. We undertook reading and rereading of the raw data to be familiar with the content and to extract a few emerging themes.\\u003c/p\\u003e\\u003cp\\u003eFirst, the transcripts were decontextualized to extract discrete quotes and passages from the broader narratives. This was followed by a procedure of recontextualization, where these passages were analyzed in the context of the larger story to make sure they still made sense. Three data analysts independently categorized the data into themes, checking for\\u0026ensp;saturating coverage. Discrepancies were discussed together among the researchers, which helped enhance validity\\u0026ensp;and consistency. The ultimate step of the analysis was to converge and characterize\\u0026ensp;the main themes, sub-themes, and categories supported and substantiated by quotes that underscore the main results. This systematic approach established credibility, validity, and a sound, iterative analysis process, and grounded the results firmly in the participants'\\u0026ensp;perspectives.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003col\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eSociodemographic characteristics of the study population\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003c/p\\u003e\\u003cp\\u003eParticipant groups in the study included sixteen front-line employees who participated in Key Informant Interviews (KIIs) and sixty-seven participants in Focus Group Discussions (FGDs). The FGD participants were clearly dominated by women, with men making up a notably lower portion. The educational background of the participants varied; the largest educational category consisted of individuals who had finished primary school. A sizable fraction of them were also followed by those who had not attained that level. Fewer had not finished secondary school, whereas those with a secondary school education comprised a smaller but still substantial portion. With only a small minority, university graduates and those with vocational training were among the least represented. There were very few individuals who could not read or write.\\u003c/p\\u003e\\u003cp\\u003eRegarding religion point of view, almost the half of FGD participants identified as Catholic, Adventists and Protestants shared the remaining portion with a small proportion of individuals said they had no religious connection. When it came to employment status, the vast majority were working casually, followed by a notable minority who were unemployed and a minimal representation of them were self-employed. Additionally, a dominant share of KII participants were men, while women making up only an exceedingly small portion of the total. While few of them held secondary-level education or an advanced diploma, the vast majority had a bachelor's degree. Concerning their appointments as frontline workers, many participants were nutritionists, followed by a significant subset of health center heads, a modest portion of social affairs officials, and early childhood development (ECD) promoters.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eDescription of study participants\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"2\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTypes of interviews\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNumber of participants\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eParents (38)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e38\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD1 (Burera District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD2 (Gasabo District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD3 (Nyaruguru District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD4 (Rutsiro District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD5 (Kayonza District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eCommunity volunteers (29)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD1 (Burera District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD2 (Gasabo District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD3 (Nyaruguru District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD4 (Rutsiro District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFGD5 (Kayonza District)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eKIIs (16)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eKIIs Social affairs\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eKIIs Head of Health Centers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eKIIs Nutritionist\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eKIIs ECD Promoters\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e83\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003col start=\\\"2\\\"\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eOverview of core and subthemes\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe data analysis yielded three core themes being perceived manifestation of stunting, perceived determinants of stunting and perceived contextual constraints showing contextual determinants of childhood stunting causes and consequences as presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e. These themes capture a multidimensional understanding of stunting, including its physical, nutritional, and developmental implications, as well as the underlying socioeconomic, cultural, and environmental factors. Each core theme is explored in depth with subthemes and categories to illuminate the various perceived causes and consequences.\\u003c/p\\u003e\\u003cp\\u003eThe first core theme, perceived manifestation of stunting, was presented with two subthemes including sub-optimal physical appearance, growth, and developmental impairments. Their categories reflect the local perception of stunting among study participants, which are mainly manifested in the presence of short stature, mismatch between age, weight, and height, inadequate height for age and reduced physical abilities.\\u003c/p\\u003e\\u003cp\\u003eThe second core theme, which is perceived determinants of stunting, covers a broad range of factors associated with stunting: low socioeconomic status and resource constraints. The first subtheme covers topics including poverty and economic constraints, misuse of distributed resources (e.g., selling food instead of eating it), and lack of livestock. The feeding barriers subtheme encompasses the categories of inadequate maternal and child nutrition, ignorance about balanced diets, early weaning and poor feeding practices, lack of animal-based proteins and balanced diets and inadequate or delayed weaning.\\u003c/p\\u003e\\u003cp\\u003eThe third subtheme, cultural and behavioral barriers, shelters the categories issues such as alcoholism and substance abuse, limited family planning practices, beliefs tied to witchcraft or religious restrictions, cultural beliefs and behavioral resistance, large family size, and poor understanding of health and nutrition recommendations. The fourth subtheme, parenting, and family dynamics barriers, includes family conflicts and poor caregiving practices, parental absence or neglect, children being left in the care of grandparents or housekeepers, lack of time for caregiving due to farming, workaholism among mothers, and early or unplanned pregnancies. Lastly, the subtheme poor hygiene barriers highlight poor handwashing practices, which contribute to disease and malnutrition in children.\\u003c/p\\u003e\\u003cp\\u003eThe third core theme, which is perceived contextual constraints, covered the sub them of economic support programs constraints which described the category of inaccuracy in finding aid-eligible households. The subtheme of service gaps covered the categories of lack of permanent staff in ECDs and poor access to family planning services and lastly, the subtheme of food insecurity covered the categories of hunger and food insecurity, poor reinforcement mechanism of the kitchen gardens.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eCore themes, sub-themes, and categories\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCore theme\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSub themes\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eCategories\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"5\\\" rowspan=\\\"6\\\"\\u003e\\u003cp\\u003ePerceived manifestation of stunting\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e\\u003cp\\u003eSub-optimal physical appearance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eShort stature\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eMismatch between age, weight, and height\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eInadequate height for age\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eDelayed physical abilities\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eGrowth and developmental impairments\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eCongenital abnormalities\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eDelayed cognitive\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"19\\\" rowspan=\\\"20\\\"\\u003e\\u003cp\\u003ePerceived determinants of stunting\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003eLow socioeconomic status and resource constraints\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePoverty and economic constraints\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eMisuse of distributed resources (e.g., food sold)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLack of livestock\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e\\u003cp\\u003eFeeding practices barriers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eInadequate maternal and child nutrition\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eIgnorance about balanced diets\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEarly weaning and poor feeding practices\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLack of animal-based proteins and balanced diets\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eInadequate or delayed weaning\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e\\u003cp\\u003eCultural and behavioral barriers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eAlcoholism and substance abuse\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLimited family planning practice and larger family sizes.\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eBeliefs (witchcraft, religious restrictions)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eCultural beliefs, and behavioral barriers\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eResistance and poor understanding of health and nutrition recommendations\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"5\\\" rowspan=\\\"6\\\"\\u003e\\u003cp\\u003eParenting and family dynamics barriers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFamily conflicts and poor caregiving practices\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eParental absence/neglect\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eChildren left with grandparents or housekeepers\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLack of time for care due to farming\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eWorkaholism of mothers\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eEarly and unplanned pregnancies\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePoor hygiene barriers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePoor handwashing practice\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e\\u003cp\\u003ePerceived contextual constraints\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eEconomic support programs constraints\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eInaccuracy in finding aid-eligible households\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eService gaps\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eLack of permanent staff in ECDs\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePoor access to family planning service\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003eFood insecurity\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eHunger and food insecurity.\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePoor reinforcement mechanism of the kitchen gardens\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCore theme 1: Perceived manifestation of stunting\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSub-theme 1: Sub-optimal physical appearance\\u003c/b\\u003e,\\u003c/p\\u003e\\u003cp\\u003eStunting was commonly recognized through short stature, such as the disparity between a child\\u0026rsquo;\\u003cb\\u003es\\u003c/b\\u003e height and their age, along with signs of malnutrition. Respondents also linked stunting to cognitive and developmental delays. One respondent described stunting in terms of visible physical changes associated with stunting: \\u003cem\\u003e\\u0026ldquo;A stunted child has height that doesn\\u0026rsquo;t correspond to the age, or they might lose weight and change of general aspect, which is how I understand it\\\"\\u003c/em\\u003e (Parent 1, Kayonza District).\\u003c/p\\u003e\\u003cp\\u003eStunting was also identified as a mismatch between age and physical growth: \\u003cem\\u003e\\\"When you see the height of the child and you compare with his age, then you realize that they don\\u0026rsquo;t correspond. You conclude that the child is malnourished. He is noticeably short and weak, lacking the energy and strength to grow properly\\\"\\u003c/em\\u003e (Parent 2, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eDevelopmental delays were further linked to stunting, as explained by another parent: \\u003cem\\u003e\\\"Sometimes you may find a 2-year-old child who doesn\\u0026rsquo;t sit or walk. That is also a problem of malnutrition because their physical development has been delayed significantly.\\\"\\u003c/em\\u003e (Parent1, Kayonza District). \\u003cem\\u003eSometimes you can also see that the child is stunted based on what he does\\u003c/em\\u003e (Parent 2, Nyaruguru District). One Community Health Worker provided more perspectives, highlighting the use of measurement tools to identify stunting: \\u003cem\\u003e\\\"Stunting is when a child\\u0026rsquo;s height is measured, and they fall into the red zone. It shows that the child is already stunted, and their growth and brain development is far behind where it should be\\\"\\u003c/em\\u003e (CHW2, Rutsiro District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSub-theme 2: Growth and developmental impairments\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe impacts of stunting extended beyond physical growth to include developmental delays and cognitive impairments. These delays often began early and persisted into later stages of childhood. Parents shared experiences of how stunting affected their children\\u0026rsquo;s developmental milestones: \\u003cem\\u003e\\\"Like mine is 10 months since the 30th, but he cannot sit, he cannot crawl. That is why he is among stunted children. His growth and development are slower compared to other children his age\\\"\\u003c/em\\u003e (Parent 4, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eCommunity Health Workers emphasized the importance of monitoring developmental stages and identifying stunting early: \\u003cem\\u003e\\\"Stunting signs can manifest from conception up to two years. We measure their height and compare it to the colors, green, yellow, red to determine if something is missing in their growth and nutrition\\\"\\u003c/em\\u003e (CHW6, Burera District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCore theme 2: Perceived determinants of stunting\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSocioeconomic factors.\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003ePoverty and economic constraints were the most often mentioned causes of stunting, underscoring a persistent lack of access to adequate food and resources. A parent described their dire financial struggles: \\u003cem\\u003e\\\"For me, I eat, and I feed my children only after doing some job. Unfortunately, now I do not have any job for a whole month. I do not have anything; we are only surviving. It is extremely hard to see my children hungry while I cannot do anything to help them\\\"\\u003c/em\\u003e (Parent5, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eThe link between poverty and hunger was emphasized by another parent: \\u003cem\\u003e\\\"Since many people who often have children with slow growing are poor, I think that stunting is mostly caused by hunger. Hunger is the root cause because if you do not have food, how can your child grow?\\\"\\u003c/em\\u003e (Parent 7, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eAn ECD promoter highlighted the misuse of resources in low-income households: \\u003cem\\u003e\\\"Some parents used to sell the products given to children by the government, like Shishakibondo, saying children wouldn\\u0026rsquo;t be drinking alone; they have to take a drink of alcohol. Instead of using the flour to prepare porridge, they sell it to buy beer\\\"\\u003c/em\\u003e (ECD Promoter, Kayonza District). This misuse was also connected to dietary practices: \\u003cem\\u003e\\\"People go fishing for small fish but sell them to the market instead of preparing them for their children. The priority becomes earning money rather than feeding the children\\\"\\u003c/em\\u003e (ECD Promoter, Rutsiro District).\\u003c/p\\u003e\\u003cp\\u003eConcerning livestock ownership, and the considerable number of populations, our participants suggested that owning livestock could help them to alleviate the burden both in farming and in animal food. \\\"\\u003cem\\u003eLack of livestock to provide manure for farming vegetables is a challenge in combating stunting\\\"\\u003c/em\\u003e Parent4, Kayonza District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eFeeding practices barriers\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eImproper feeding practices, including delayed weaning, poor dietary diversity, and busy schedules, were consistently cited as challenges. Poor feeding practices, ignorance about balanced diets, and early pregnancies worsen the issue. An ECD promoter detailed gaps in feeding practices: \\u003cem\\u003e\\\"Parents, especially women, go to the field and carry food to eat at lunchtime. They all share the same food, which is not suitable for the small child. The child ends up eating what is available, not what they need\\\"\\u003c/em\\u003e (ECD promoter, Gasabo District). Another participant emphasized the seasonal dependency on food: \\u003cem\\u003e\\\"On my side, I rely on the help of others. Sometimes people give me support so that my child might survive. But during the dry season, even the vegetables we depend on are gone, and there is nothing to give the children\\\"\\u003c/em\\u003e (Parent 4, Kayonza District). This highlights the need for consistent support and better planning to ensure children receive adequate nutrition year-round.\\u003c/p\\u003e\\u003cp\\u003eTo emphasize that, one parent elaborated on the struggles of breastfeeding: \\u003cem\\u003e\\\"The reason why a mother can stop breastfeeding for six months is that she cannot get a balanced diet, making her lack breastmilk with enough nutrients, leading to child stunting\\\"\\u003c/em\\u003e (Parent 7, Rutsiro District).\\u003c/p\\u003e\\u003cp\\u003eAdditionally, the absence of balanced diets was a recurrent theme: \\u003cem\\u003e\\\"When someone is poor and cannot afford to buy vegetables every day, if they don\\u0026rsquo;t have the vegetable garden, the baby will be taking an unbalanced diet which lacks nutrients from vegetables, and stunting may develop\\\"\\u003c/em\\u003e (ECD Promoter, Burera District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCulture and behavior barriers\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eCultural norms, beliefs, and behaviors significantly influence stunting. Alcoholism, limited family planning practices, and traditional beliefs about child growth worsen the problem.\\u003c/p\\u003e\\u003cp\\u003eA parent shared a personal encounter with cultural misconceptions: \\u003cem\\u003e\\\"Initially, they told me that it is his heart that hinders him from growing. When I inquired about others, they told me that it was a witchcraft attack\\\"\\u003c/em\\u003e (Parent 4, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eLimited access to family planning services further worsened stunting risks in areas with large family sizes. An ECD promoter emphasized the role of family planning: \\u003cem\\u003e\\\"The secret behind stunting prevention is linked to having few children because they understood the benefits of family planning. When a family can manage their resources well, the children do not suffer\\\"\\u003c/em\\u003e (ECD promoter, Nyaruguru District). Religious restrictions also played a role: \\u003cem\\u003e\\\"Adventists don\\u0026rsquo;t eat meat or seafood, which have important nutrients for the baby. This cultural restriction can lead to deficiencies\\\"\\u003c/em\\u003e (Parent 8, Burera District).\\u003c/p\\u003e\\u003cp\\u003eResistance to education and poor awareness among families create significant barriers to addressing stunting. Many respondents noted that families often fail to implement advice or Health Education effectively. An ECD promoter described this challenge: \\u003cem\\u003e\\\"You teach them, but they don\\u0026rsquo;t put into practice what they learned. You tell them how important balanced diets and vegetables are, but you go back and find that they are still doing the same thing as before, and the child remains stunted\\\"\\u003c/em\\u003e (ECD Promoter, Nyaruguru).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eParenting and family dynamics\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eParenting and family dynamics were identified as other contributors to childhood stunting. Poor caregiving practices, such as irregular feeding schedules and limited attention to children\\u0026rsquo;s needs, were highlighted as major barriers to healthy development. Additionally, neglect, particularly when children are left in the care of housekeepers or grandparents due to parents\\u0026rsquo; commitments, further worsens the challenges. One recurring issue was the lack of time for consistent and responsive caregiving, which significantly influenced stunting outcomes. One parent shared their struggle with time constraints: \\u003cem\\u003e\\\"Sometimes you get a job and go early in the morning to do it while you carry your child with you. You did not have time to prepare his porridge or pack food for the day, and he ends up eating nothing\\\"\\u003c/em\\u003e (Parent 3, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eFurther, family conflicts were repeatedly mentioned as an obstacle to proper childcare and feeding. One nutritionist explained how family conflicts disrupt caregiving: \\u003cem\\u003e\\\"When there is no peace in the household between husband and wife, they start to argue. When the wife gets like one thousand and buys food, she is not able to get that balanced meal for the child. The consequences go to the child from their disagreements\\\"\\u003c/em\\u003e (IZU, Nyaruguru District). Another respondent emphasized the role of conflicts in creating neglect: \\u003cem\\u003e\\\"When you have conflicts with your husband and you work alone for the children without anyone to help you, that also causes malnutrition. It is difficult to manage everything on your own\\\"\\u003c/em\\u003e (Parent 1, Gasabo District). Community Health Workers echoed this sentiment, highlighting neglect and substance abuse: \\u003cem\\u003e\\\"Parents neglect their children by leaving them in the care of housemaids who might drink the child\\u0026rsquo;s milk and give them diluted milk instead. This leads to malnutrition and stunting\\\"\\u003c/em\\u003e (CHW1, Gasabo District). Lastly, one nutritionist noted the impact of intimate partner violence: \\u003cem\\u003e\\\"Intimate partner violence plays a great role, and I can say that it is the main cause of stunting because when a child is born, he/she must be raised by both parents who should collaborate. Without harmony, the child suffers\\\"\\u003c/em\\u003e (Nutritionist, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003ePoor hygiene barriers\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003ePoor handwashing was also mentioned as a barrier to childhood stunting. A parent explained the importance of practicing hygiene: \\u003cem\\u003e\\\"Poor handwashing practices can also cause child stunting because if you wash your hands with water and soap and that you wash utensils and put them to dry, there is no problem. But when these practices are ignored, diseases spread, and the child suffers\\\"\\u003c/em\\u003e (Parent 5, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCore theme 3: Perceived contextual constraints\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eEconomic support programs constraints\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eWhen it comes to socio-economic support programs constraints, participants from the present study recommended that they should be a well-structured and fair way of selecting eligible individuals for support. One participant mentioned it. \\u003cem\\u003e\\u0026ldquo;Some leaders select individuals eligible for aid based on their personal biases\\u0026rdquo;\\u003c/em\\u003e (Parent 4, Burera District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eService gaps\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eLack of access to essential services, such as family planning and ECD programs, was a significant barrier. The absence of permanent staff in Health Centers also hindered sustained interventions. One respondent described the difficulty of supporting kitchen gardens: \\u003cem\\u003e\\\"No, they are not available all the time because during the dry season, we don\\u0026rsquo;t have vegetables. If you do not have a kitchen garden, you cannot cook a balanced meal. You can cook Irish potatoes, but you need vegetables to mix with them to make a nutritious meal\\\"\\u003c/em\\u003e (Parent 3, Rutsiro District).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eHunger and food insecurity.\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eAnother participant emphasized the role of hunger and food insecurity to influence stunting: \\u003cem\\u003e\\\"Since many people who often have children with slow growing are poor, I think that stunting is mostly caused by hunger. If you do not have enough food at home, what can you give to your child to grow?\\\"\\u003c/em\\u003e (Parent 7, Gasabo District).\\u003c/p\\u003e\\u003cp\\u003eVegetable gardening was rapidly mentioned as a factor that could promote dietary diversity hence improved nutrition status of children. However, some participants elucidated that some people do not adhere to the vegetable gardening program, and those who did manage they did it just to meet authorities\\u0026rsquo; expectations, not for their own benefit. \\u003cem\\u003e\\u0026ldquo;Kitchen gardens are few, poorly maintained, and mostly kept just to please authorities rather than for personal use\\u0026rdquo;\\u003c/em\\u003e (Nutritionist, Kayonza District).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study explored the perspectives of Rwandan parents and frontline workers about determinants of childhood stunting. The three highlighted themes including manifestations of stunting, perceived factors, and contextual constraints, reflect the structure of the WHO conceptual framework. They illustrate how stunting is acknowledged at the individual level, molded by home practices and caregiver actions, and affected by overarching systemic obstacles.\\u003c/p\\u003e\\u003cp\\u003eThe first theme shows the perceived manifestation of stunting where two subthemes were explained as sub-optimal physical appearance and growth and developmental impairments, the findings indicate that although frontline workers and Rwandan parents could identify apparent indications of stunting, their comprehension of its fundamental origins and enduring effects was frequently constrained or influenced by misconceptions.\\u003c/p\\u003e\\u003cp\\u003eOne of the most often cited signs was short stature. Parents frequently referred to the observed obvious height discrepancies between their children and their age-group peers. According to several participant testimonials, children's diminutive bodies made them appear much shorter than their real age. Such poor physical manifestations are critical markers of a child's undernutrition, as supported by existing literature that highlights the importance of growth monitoring in early childhood [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eParticipants often characterized stunted children as not growing 'on time,' particularly highlighting discrepancies between height and age, thereby underscoring their recognition of observable physical symptoms. The articulated concern among parents on height-age discrepancies illustrates a pivotal moment in caregiver awareness about child development [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e]. These discrepancies were occasionally taken as proof of inadequate diet or underlying medical issues [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eStudy participants identified the consequences of stunting as going beyond short stature. Stunting was also described by both parents and frontline health workers as a form of impairment, limiting a child's attainment of developmental milestones at expected ages. Scholars have described frequently associated stunting with missed milestones, such as sitting or crawling, as physical dimensions of impairment, while delays were also recognized as indicators and symptoms of brain dysfunction and growth impairment [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. These testimonies reveal that caregivers see and acknowledge a developmental trajectory impeded by physical growth faltering. It also represents a high level parental awareness and stress, suggesting that stunting is not only a biological issue but also a psychological burden for parents and families [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eCHWs articulated their concerns about stunting by stressing the need for early identification and continuous monitoring of child growth and development at the community level. They emphasized how continued anthropometric monitoring is designed as the first line of defense against stunting in children, but yet again reflects a community-based understanding of the appropriate \\\"first 1,000 days,\\\" where interventions are the most effective[\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. All this discussion underscores the complex nature of stunting, affecting not only children's height, but their quality of life and future developmental potential[\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e]. The information also reinforces the need to take an integrated approach with the community in mind which includes educating caregivers, monitoring early childhood development, and providing nutritional support, consistent with the life-course approach which accounts for the long-term impacts of stunting on education, economic productivity, and well-being.\\u003c/p\\u003e\\u003cp\\u003eWhen it comes to the theme illustrating the perceived determinants of stunting, low socioeconomic status and resource constraints highlighted the profound influence on childhood stunting. Participants repeatedly pointed to the inability to afford nutritious foods as a key factor that compromises children\\u0026rsquo;s growth. Food insecurity and hunger, often resulting from limited household income, prevent families from meeting their children's dietary needs, contributing to undernutrition [\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e]. Moreover, the mismanagement of resources intended to support nutritional interventions such as government food aid programs was cited as another barrier to addressing stunting. When these resources are not well distributed or not sufficient, they fail to reach the most vulnerable populations, exacerbating food insecurity and perpetuating the cycle of malnutrition[\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e]. Similarly, a study conducted in Nepal showed that child undernutrition was largely influenced by poor sociocultural and economic conditions [\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e The participants identified livestock ownership as a major pathway to reduce the burden of stunting, especially through both farming and nutrition. It was identified that livestock not only provides manure to improve soil fertility and increase vegetable production to promote food security in households, but that animal-source foods from livestock (milk, meat, and eggs) are also critical for children's growth and development [\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e]. This complements previous literature suggesting that livestock ownership is positively related to better nutritional outcomes for children because of nutrient-rich food access and agricultural productivity[\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eRespondents recognized that poor feeding practices during pregnancy could lead to adverse birth outcomes, such as low birth weight and signs of stunting from birth. This reflects an understanding that inadequate maternal nutrition disrupts fetal growth, laying the foundation for long-term growth deficits [\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e] and continues within all the period of 1000 days [\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]. Additionally, inadequate dietary intake among mothers, and inadequate weight gain during pregnancy are more likely to impair fetal growth and increase the risk of low birth weight, which is a strong predictor of stunting in early childhood [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e]. These insights emphasize the importance of targeting maternal nutrition as a key strategy for stunting prevention. Ensuring adequate nutrient intake during pregnancy not only reduces the risk of low birth weight but also supports healthy growth and development in early life [\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eOne of the biggest obstacles to combating stunting is cultural and behavioral issues. Cultural opposition to community education and a lack of knowledge about the best ways to feed children impede behavior change in many contexts. Participants suggested behaviors like alcoholism, not using family planning, and traditional beliefs about the growth of children, which all negatively shaped child health outcomes. This was shown to be because of socio-cultural practices and constructs that impact prohibitive caregiving, nutrition practices, and healthcare seeking behaviors. These findings align with previous studies that show harmful cultural practices coupled with high maternal low autonomy have detrimental outcomes for feeding behavior, hygiene, access to health care exposing children to increased risk of stunting [\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e]. Reducing stunting would then not only be reliant on biomedical interventions but on culture-sensitive approaches that engage communities to change norms and embrace behaviors for a better future.\\u003c/p\\u003e\\u003cp\\u003eMany families are hesitant to follow dietary advice, especially those that advocate for a varied and balanced diet, because of deeply ingrained cultural practices and beliefs, and no immediate, apparent benefits [\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]. Cultural norms and traditions have an impact on health-related behaviors, which emphasizes the necessity of community-driven treatments that are customized for cultural and geographical settings. In addition, these cultural norms often prioritize traditional foods and meal patterns passed down through generations, which can conflict with modern nutritional recommendations[\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eLarge family sizes and limited access to family\\u0026ensp;planning services further amplify the risks of stunting, placing additional demands on already stretched resources. Promoting more advantageous use of resources helps to reduce stunting risk and access to\\u0026ensp;family planning has been widely reported [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e] to be a significant contributor to preventing short stature among women.\\u003c/p\\u003e\\u003cp\\u003eResistance to education and limited awareness within families were another social determinant identified to explain the ongoing childhood stunting. The health sector made health education and nutrition education available to families but in many instances many families seem to either ignore or inadequately act on the recommendations of frontline workers. The gap between knowledge and action may stem from limited literacy, skepticism of health messages or household priorities, as the family seeks to buy medicine and food for survival[\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. This resistance and lack of attention were cited as causes for not adhering to appropriate feeding and hygiene and seeking care for children as required in all aspects of preventing stunting[\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e]. On a positive note, our findings conform to many previous studies that highlight the role of caregiver knowledge and behaviors in influencing child nutrition outcomes[\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e]. Community education that is designed according to cultural practices and values may be more effective when implemented in the community and supported by appropriately trained field workers and appropriate community organization.\\u003c/p\\u003e\\u003cp\\u003eConcerning Parenting and Family Dynamics, the findings of this study highlighted the profound impact on the prevalence of childhood stunting, saying that poor caregiving practices and increased familial stressors significantly affect child health development including linear growth. Family misunderstandings and conflicts, particularly intimate partner violence, appeared as substantial barriers to effective caregiving. The experiences shared by nutritionists explained how the stress and conflict arising within a family can disrupt parental focus on children's nutritional requirements to pay attention on conflicts, thus heightening risks of undernutrition [\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e]. This evidence shows that elevated tension in a household can negatively affect parental mental health and, in turn, compromises child nutrition. On contrary, investing more time and financial in childcare could contributes to the improvement of the nutrition outcomes [\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eAdditionally, intimate partner violence claimed to have a detrimental effect on child development in general and hence affect nutrition status. Scholars have stated that children raised within conflictual households are mainly exposed to chronic psychosocial stress that\\u0026ensp;affects their health and nutrition [\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e]. Frequent disputes, parental disagreement, or domestic violence are examples of household conflict that might interfere with feeding habits, emotional security, and caring practices [\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e]. Through pathways including stress-induced alterations in appetite regulation, food absorption, and metabolic function, these disturbances may also lead to inadequate nutritional status in addition to psychological suffering [\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e]. Children's healthy growth and development may be hampered by the cumulative effects of such an environment [\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eStudies have previously stated that poor responsive caregiving and inconsistent feeding schedules could be a critical determinant contributing to childhood stunting, particularly [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e]. The testimonies from the participants illustrate how they understand poor attention to children's nutritional needs correlates with suboptimal growth outcomes. Moreover, the findings from the present study pointed out the key interaction between maternal health and child stunting in young children.\\u003c/p\\u003e\\u003cp\\u003e Neglect was listed as a contributing factor to stunting, specifically when young children were placed under the supervision of a housekeeper or elderly grandparents because of parents working or busy with other responsibilities. Participants said that with such arrangements children are left at the mercy of what the caregiver thinks is good for the child. Overall, children in these situations get inconsistent and less responsive caregiving, especially when it comes to feeding, hygiene, and emotional engagement. This corresponds with the other literature out there reinforcing the importance of responsive caregiving during the early years, and that decreased/developing/dated socio-emotional interactions with caregivers can lead to poor nutritional outputs and poor growth[\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e]. Thus, being without their primary caregiver at important incremental developmental stages can affect both the children's immediate nutritional status and the potential for longer-term growth impairment.\\u003c/p\\u003e\\u003cp\\u003eThe statements from parents and the ECD promoter revealed a substantial gap in feeding practices that intensify the risk of stunting among children. Moreover, the insight provided by the ECD promoters about shared meals raised concerns about nutritional adequacy in family feeding practices. The phenomenon where children consume what is available rather than what is nutritionally appropriate can lead to inadequate dietary intake, ultimately affecting their growth and development adversely. Such practices reflect a broader issue of food security and access, where families, particularly those living in poverty, often prioritize survival over nutritional quality [\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e]. This has been articulated in the literature, which highlights how inadequate dietary diversity and poor feeding practices are significant contributors to the risk of stunting [\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe findings from the present study highlighted the poor sanitation and hygiene to stunting. Scholars have shown how poor hygiene practices increase the likelihood of contracting diarrhea and environmental enteric dysfunction (EED), which impairs nutrient absorption and leads to chronic malnutrition [\\u003cspan citationid=\\\"CR65\\\" class=\\\"CitationRef\\\"\\u003e65\\u003c/span\\u003e]. For instance, an review published in Nutrition review showed how unsafe water and poor sanitation could leads to the diarrhea and EED [\\u003cspan citationid=\\\"CR66\\\" class=\\\"CitationRef\\\"\\u003e66\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eEconomic assistance initiatives are essential so that household food security and\\u0026ensp;access to health services can be improved and childhood stunting avoided [\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e]. But respondents of this study expressed concerns about unfair processes for targeting aid, which in effect used along individuals' personal relationships with\\u0026ensp;local leaders. Such biased sample selection compromises the fairness\\u0026ensp;of programs and could exclude some of the targeted vulnerable families from the risk of child malnutrition. Such governance concerns undermine the trust of\\u0026ensp;the community and effectiveness of supportive interventions. Frontline workers described difficulties in advocating\\u0026ensp;for deserving families due to lack of clear and consistent criteria [\\u003cspan citationid=\\\"CR68\\\" class=\\\"CitationRef\\\"\\u003e68\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eRestricted availability\\u0026ensp;of essential services, including family planning and ECD programs, were a major barrier to progress on childhood stunting. Lack of consistent health personnel was reported\\u0026ensp;as a barrier affecting their ability to provide continuous care and the delivery of nutrition-sensitive approaches [\\u003cspan citationid=\\\"CR69\\\" class=\\\"CitationRef\\\"\\u003e69\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR70\\\" class=\\\"CitationRef\\\"\\u003e70\\u003c/span\\u003e]. Availability to kitchen\\u0026ensp;gardens was also low mainly in the dry season, which also influenced the ability of the households to prepare meals that are balanced.\\u003c/p\\u003e\\u003cp\\u003eAlthough vegetable gardening was often mentioned as a feasible way to enhance nutritional diversity and the nutrition of children, its practical application and use at the household level seemed to be restricted. Participants pointed out that despite national nutrition programs' promotion of kitchen gardens, adherence is still below ideal. According to several respondents, some households often grow vegetables only to satisfy administrative requirements rather than to satisfy their own nutritional needs. Similar fail also was observed in South Africa where, some households often cultivate vegetables just to satisfy administrative requirements rather than for nutritional purposes [\\u003cspan citationid=\\\"CR71\\\" class=\\\"CitationRef\\\"\\u003e71\\u003c/span\\u003e]. This reveals a gap between community ownership and program implementation, implying that the anticipated nutritional advantages of such interventions would not be completely achieved in the absence of true community engagement and perceived value [\\u003cspan citationid=\\\"CR72\\\" class=\\\"CitationRef\\\"\\u003e72\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eOne of the study's strengths was that it considered many FGDs and KIIs and conducted interviews until participants had no more ideas. In support of this notion, we were able to elicit a wide range of responses from the participants due to their diversity, which included participants from five different districts, both rural and urban, and composed of different kinds of people. However, some limitations may affect this study too. Firstly, social desirability bias may have affected interviews and focus group responses, especially on sensitive themes like caregiving and feeding. Secondly, transcripts were thoroughly transcribed and back translated, but some meanings may have been lost. Finally, this qualitative study in five purposively selected districts may not apply to all Rwandan areas or other situations.\\u003c/p\\u003e\\u003cp\\u003eTo conclude, the perception of parents and frontline workers recognized that childhood stunting in Rwanda is a multifaceted problem influenced by several factors, including socioeconomic hardships, poor maternal and child nutrition, poor parenting practices, and cultural and behavioral constraints. Low community ownership of important programs like kitchen gardens, governance problems in assistance delivery, and restricted access to basic health and nutrition services all exacerbate these problems.\\u003c/p\\u003e\\u003cp\\u003eAccording to the findings, multisectoral, cultural awareness, and comprehensive solutions that address the structural and behavioral causes of stunting are necessary. Reducing childhood stunting in a sustainable manner and promoting healthy child development in Rwanda require increasing community involvement, enhancing program accountability, and guaranteeing fair access to nutrition-related services.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eLMIC\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eLow- and Middle-Income Countries\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eUNICEF\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eUnited Nations International Children's Emergency Fund\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eWHO\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eWorld Health Organization\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eECD\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEarly Childhood Development\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eCHW\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCommunity Health Worker\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eFGD\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eFocus Group Discussion\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eKII\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eKey Informant Interview\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eIRB\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eInstitutional Review Board\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eEED\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEnvironmental Enteric Dysfunction\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki as revised in 2013. Ethical clearance was secured from the Institutional Review Board of the University of Rwanda\\u0026apos;s College of Medicine and Health Sciences, (N\\u003cu\\u003e\\u003csup\\u003eo\\u003c/sup\\u003e\\u003c/u\\u003e 335/CMHS IRB 2021, later amended in 2022 under N\\u003cu\\u003e\\u003csup\\u003eo\\u003c/sup\\u003e\\u003c/u\\u003e 178/CMHS IRB). A research visa was also obtained from the National Institute of Statistics of Rwanda and a research permit from and the Rwanda Ministry of\\u0026ensp;Local Governance. Prior to conducting every interview, a full description of the study purpose was given to the participants prior to each interview, and the participants were fully informed\\u0026ensp;of their involvement. All participants provided a written informed\\u0026ensp;consent to confirm their willingness to take part in the study. To ensure confidentiality and compliance with good ethical practice, only authorized personnel had access to the\\u0026ensp;data under clearly defined roles and responsibilities.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used during the current study are available from the corresponding author upon reasonable request.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe Nestl\\u0026eacute; Foundation for the Problems of Nutrition in the World provided considerable financing for this project, which greatly helped in the data collection process. Additionally, \\u0026ldquo;the Consortium for Advanced Research Training in Africa (CARTA) played a crucial role by providing financial backing that enhanced the study\\u0026apos;s impact. CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the U.K. Foreign, Commonwealth \\u0026amp; Development Office, with support from the Developing Excellence in Leadership, Training, and Science in Africa (DELTAS Africa) program\\u0026rdquo;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors would like to convey their profound gratitude to the participants who voluntarily contributed their time and experiences to facilitate this study.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eJDD H: conceptualized the study, methodology, analysis, original draft preparation, manuscript review, and editing; TH and NK: methodology review, manuscript review, and editing; MU and LR: conceptualization, methodology, methodology, supervision, review, and editing, CM: overall supervision, conceptualization, methodology, manuscript review, and editing. All authors have read and agreed to this version of the manuscript\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWHO/World Bank Group Joint Child Malnutrition Estimates. Levels and trends in child malnutrition: UNICEF/. Key Findings of the 2023 Edition. Volume 24. UNICEF, World Health Organization and World Bank Group; 2023. p. 32.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eNISR. Rwanda Demographic and Health Survey 2019\\u0026ndash;2020. Kigali; 2021.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHoddinott J, Behrman JR, Maluccio JA, Melgar P, Quisumbing AR, Ramirez-zea M, et al. Adult consequences of growth failure in early childhood. Am J Clin Nutr. 2013;98:1170\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDewey KG, Begum K. Long-term consequences of stunting in early life. Matern Child Nutr. 2011;7:5\\u0026ndash;18.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eVictora CG, Christian P, Vidaletti LP, Gatica-Dom\\u0026iacute;nguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397:1388\\u0026ndash;99.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHimaz R. Stunting later in childhood and outcomes as a young adult: Evidence from India. World Dev. 2018;104:344\\u0026ndash;57.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSitorus NL. The Significance of Tackling Stunting for The Economic Prosperity of A Nation \\u0026ndash; A Narrative Review. J Indonesian Specialized Nutr. 2024;1:131\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. Childhood Stunting : Context, Causes, and Consequences. 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Lancet Child Adolesc Health. 2021;5:367\\u0026ndash;84.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMINAGRI NIS WFP UNICEF. Comprehensive Food Security \\u0026amp; Vulnerability Analysis- April 2018. Rwanda. 2018.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization [WHO]. Childhood Stunting : Context, Causes, and Consequences. World Health Organ. 2019;:4.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAkbar RR, Kartika W, Khairunnisa M. The Effect of Stunting on Child Growth and Development. Sci J. 2023;2:153\\u0026ndash;60.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eNzayirambaho M, Nsabimana A, Manirakiza V, Rutayisire PC, Njunwa K. Economic attributes and childhood stunting in Rwanda: case study of the City of Kigali. Pan Afr Med J. 2022;42.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMustakim MRD, Irwanto, Irawan R, Irmawati M, Setyoboedi B. Impact of Stunting on Development of Children between 1\\u0026ndash;3 Years of Age. Ethiop J health Sci. 2022;32:569\\u0026ndash;78.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSuryawan A, Jalaludin MY, Poh BK, Sanusi R, Tan VMH, Geurts JM, et al. Malnutrition in early life and its neurodevelopmental and cognitive consequences: a scoping review. Nutr Res Rev. 2022;35:136\\u0026ndash;49.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAkseer N, Tasic H, Nnachebe Onah M, Wigle J, Rajakumar R, Sanchez-Hernandez D, et al. Economic costs of childhood stunting to the private sector in low- and middle-income countries. eClinicalMedicine. 2022;45:101320.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWelch C, Wong CK, Lelijveld N, Kerac M, Wrottesley SV. Adolescent pregnancy is associated with child undernutrition: Systematic review and meta-analysis. Matern Child Nutr. 2024;20.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eIntan M, Pratiwi B, Ayu I, Qirani D, Anugrah PM. Linking minds and growth : maternal mental health and child stunting : a systematic review. :7013.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSawaya AL, Sesso R, Flor\\u0026ecirc;ncio TMDMT, Fernandes MTB, Martins PA. Association between chronic undernutrition and hypertension. Maternal Child Nutr. 2005;1:155\\u0026ndash;63.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSusianto SC, Suprobo NR. Maharani. Early Breastfeeding Initiation Effect in Stunting: A Systematic Review. Asian J Health Res. 2022;1:1\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMunawar K, Mukhtar F, Roy M, Majeed N, Jalaludin MY. A systematic review of parenting and feeding practices, children\\u0026rsquo;s feeding behavior and growth stunting in Asian countries. Psychol Health Med. 2024;29:1705\\u0026ndash;52.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003ePilditch K, Du Plessis L, Drimie S. Infant and young child feeding practices and behaviours of positive deviants among caregivers of children (6\\u0026ndash;18 months) at risk of stunting in informal settlements in Harrismith, Free State Province, South Africa. South Afr J Child Health. 2024;18:e795.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eArini D, Nursalam N, Mahmudah M, Faradilah I. The incidence of stunting, the frequency/duration of diarrhea and Acute Respiratory Infection in toddlers. J Public Health Res. 2020;9:117\\u0026ndash;20.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003ePalmer AC, Bedsaul-Fryer JR, Stephensen CB. Interactions of Nutrition and Infection: The Role of Micronutrient Deficiencies in the Immune Response to Pathogens and Implications for Child Health. Annu Rev Nutr. 2024;44:99\\u0026ndash;124.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKrasevec J, An X, Kumapley R, B\\u0026eacute;gin F, Frongillo EA. Diet quality and risk of stunting among infants and young children in low- and middle-income countries. Maternal Child Nutr. 2017;13:1\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eJones AD, Ejeta G. A global agenda for nutrition and health. Bull World Health Organ. 2015;94:228\\u0026ndash;9. September 2015.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003edel Carmen Casanovas M, Lutter CK, Mangasaryan N, Mwadime R, Hajeebhoy N, Aguilar AM, et al. Multi-sectoral interventions for healthy growth. Matern Child Nutr. 2013;9:46\\u0026ndash;57.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFosa ME. Assessing Programme Strategies in Managing Child Stunting at the Health Facility Level in Matelile Community Council. 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Healthc Low-resource Settings. 2024;7:23\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLeroy JL, Frongillo EA. Perspective: What Does Stunting Really Mean? A Critical Review of the Evidence. Adv Nutr. 2019;10:196\\u0026ndash;204.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003ePassarelli S, Sudfeld C, Davison KK, Fawzi W, Donato K, Tessema M, et al. Caregivers Systematically Overestimate Their Child\\u0026rsquo;s Height-for-Age Relative to Other Children in Rural Ethiopia. J Nutr. 2022;152:1327\\u0026ndash;35.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSharma K, Singh B, Naithani M, Chandra R, Verma PK. Short stature among girl child: a psychological burden or a social stigma-a review. Int J Community Med Public Health. 2021;8:2588.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLeroy JL, Ruel M, Habicht J, Frongillo E. a. 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Front Ecol Evol. 2022;10:1\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAlemu F, Mecha M, Medhin G. Impact of permagarden intervention on improving fruit and vegetable intake among vulnerable groups in an urban setting of Ethiopia: A quasi-experimental study. PLoS ONE. 2019;14:1\\u0026ndash;14.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Stunting, Childhood, Perceived determinants, Parents, frontline workers, Rwanda\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7040307/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7040307/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003eChildhood stunting remains a pervasive public health concern. Understanding the perceptions of parents and frontline workers regarding childhood stunting is essential in designing culturally appropriate intervention. The purpose of this study was to investigate the viewpoints of frontline workers and Rwandan parents regarding the determinants of childhood stunting.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eWe conducted a qualitative study using ten focus groups discussions and sixteen key informant interviews among 83 parents and frontline workers all from five districts scatted in Rwanda. We used NVivo 14, to conduct thematic analysis with open coding.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eThere was inadequate knowledge about stunting: most respondents knew only\\u0026ensp;visible signs of stunting. The key perceived determinants included poverty, poor children and maternal feeding practices, family conflict and behavioral resistance. Inconsistent adherence to recommended practices such as vegetable gardening and hygiene were attributed to limited program ownership hence poor feeding practices and increased rate of stunting. Participants also mentioned systemic barriers, poor management in the selection of beneficiaries and assistance distribution, as well as limited access to essential health and nutrition\\u0026ensp;services.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e\\u003cp\\u003eChildhood stunting in Rwanda is influenced by a complex interplay of individual, household, and structural determinants. Addressing stunting requires community-driven and multisectoral interventions that aim to improve maternal and child nutrition, reduce socioeconomic vulnerabilities, and strengthen service delivery and program accountability.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Perceived Determinants of Childhood Stunting in Rwanda: Insights from Parents and Frontline Workers\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-08-07 04:03:16\",\"doi\":\"10.21203/rs.3.rs-7040307/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"e7cfdc29-2a7d-457d-9f54-dc006381b8f5\",\"owner\":[],\"postedDate\":\"August 7th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-25T08:13:22+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-08-07 04:03:16\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7040307\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7040307\",\"identity\":\"rs-7040307\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}