Matern Child Health J (2017) 21:2256–2266

DOI 10.1007/s10995-017-2348-2

Prevalence and Risk of Moderate Stunting Among a Sample

of Children Aged 0–24 Months in Brunei
Sinead Boylan1   · Seema Mihrshahi1 · Jimmy Chun Yu Louie2 · Anna Rangan2 ·
Hj Norsal Salleh3 · Hj Ilham Md Ali3 · Hjh Roseyati Dato Paduka3 · Timothy Gill4 

Published online: 4 August 2017

© Springer Science+Business Media, LLC 2017

Abstract  Objectives Globally, one-fifth of the world’s
children are stunted, however this statistic may be an under-
estimate as many countries lack comprehensive monitor-
ing of height-for-age. Until a recent national health survey,
Negara Brunei Darussalam has lacked the data to offer a
comprehensive assessment of height-for-age among chil-
dren. The aim of this study is to determine the prevalence
of and factors associated with stunting among children
aged 0–24 months in Negara Brunei Darussalam (Brunei).
Methods A cross-sectional analyses of 396 children aged
<24 months. Demographic, dietary and anthropometric
measurements were recorded. Multivariate logistic regres-
sion was used to analyse factors associated with moder-
ate stunting. Results Almost one-quarter of infants (24%)
were stunted. Male children and children who were preterm
(<37 weeks gestation) were more than twice as likely to be
stunted as their counterparts, respectively (OR 2.48; 95%
CI 1.49–4.12; OR 2.14; 95% CI 1.06–4.33, respectively).
Those who were born low birth weight (<2.5 kg) were three
times more likely to be stunted than those born normal
birth weight (OR 2.99; 95% CI 1.44–6.17). Conclusions for
* Sinead Boylan
sinead.boylan@sydney.edu.au
1
Prevention Research Collaboration, School of Public Health,
Charles Perkins Centre, The University of Sydney, Sydney,
NSW 2050, Australia
2
School of Molecular Bioscience, Charles Perkins Centre, The
University of Sydney, Sydney, NSW 2050, Australia
3
Community Nutrition Division and Community Nursing
Division, Department of Health Services, Brunei Ministry
of Health, Jalan Pelumpong, Muara, Brunei
4 infants and frequent monitoring of low birth weight infants
School of Public Health, Charles Perkins Centre, Boden
Institute of Obesity, Nutrition, Exercise and Eating Disorders,
The University of Sydney, Sydney, NSW 2050, Australia
Practice This study presents data on prevalence of stunt-
ing in Brunei based upon the World Health Organization’s
growth charts. In addition it is also the first time that the
factors associated with stunting among infants aged <24
months have been examined in Brunei. The stunting prev-
alence in Brunei is of concern due to the reported short
and long-term negative impact on health later in life. The
authors recommend close monitoring of pregnant women
who are at risk of delivering low birth weight infants and
frequent monitoring of low birth weight infants in line with
World Health Organization nutrition goals. Existing height-
for-age data should be integrated into global databases.
Keywords  Stunting · Growth · Determinants · Brunei
Significance
Globally, 25% of all children under 5 years of age are cur-
rently classified as stunted. These children will experience
short and long-term consequences, including an increased
risk of nutrition-related diseases and a reduced neurodevel-
opmental capacity. The World Health Organisation aims to
reduce the number of stunted children under 5 years of age
by 40% by 2025.
Many countries have insufficient data on stunting, mak-
ing it difficult to track its progress. This is the first time
that the factors associated with stunting among infants
have been examined in Brunei. The stunting prevalence in
Brunei is of concern, with birth weight being the strong-
est predictor of stunting. Close monitoring of pregnant
women who are at risk of delivering low birth weight
is recommended.

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Matern Child Health J (2017) 21:2256–2266 2257
Objectives
In 2012, the World Health Organisation adopted a reso-
lution on maternal, infant and young child nutrition that
included six global targets to reduce the high burden of
disease associated with malnutrition, particularly during
the critical period from conception to 24 months of age
(World Health Organisation 2012). The first target aims
to reduce the number of stunted children under 5 years of
age by 40% by 2025. According to the WHO child growth
standard, stunting is measured by a Z-score of standardized
height-for-age (HFA)—stunted or severely stunted children
are those children with a Z-score below −2 or −3, respec-
tively (WHO Multicentre Growth Reference Study Group
2006). The WHO has several reasons for setting this target:
globally, between 161 million or 25% of all children under
5 years of age are currently classified as stunted (Interna-
tional Food Policy Research Institute 2015); the short and
long-term health consequences for these children are evi-
dent throughout the life-course, including poor cognition
and educational performance, low adult wages, lost pro-
ductivity, increased risk of nutrition-related chronic dis-
eases (Victora et al. 2008), reduced physical and neurode-
velopmental capacity (Prendergast and Humphrey 2014).
Stunting is inevitably a problem requiring a multi-sectoral
response (del Carmen Casanovas et  al. 2013; Ruel and
Alderman 2013).
Studies indicate that multiple determinants of stunting
exist (Fenske et  al. 2013). Fenske et  al. (2013) undertook
a comprehensive analysis of these factors and developed
a conceptual model depicting 16 main groups of determi-
nants under three categories (underlying, intermediate and
immediate determinants) (Fenske et  al. 2013) Stunting
under 5 years of age appears to be more related to environ-
mental factors than to genetics (Vella et al. 1994)—perhaps
not surprising therefore, that the highest prevalence esti-
mates are among developing regions (de Onis et al. 2013).
While the statistics are concerning, some regions are show-
ing signs of improvement. For example, stunting among
children aged under 5 years in Brazil dropped from 37.1%
in 1974 to 7.1% in 2007 (World Health Organisation 2015),
and between 1990 and 2010, Asia nearly halved the number
of stunted children—from 190  million to 100  million (de
Onis et al. 2013).
However, the picture is incomplete, as a recent report
indicates that more than one-third (35%) of the United
Nations member countries have insufficient data on stunt-
ing, making it difficult to track its progress (International
Food Policy Research Institute 2015). One of these coun-
tries, Negara Brunei Darussalam (Brunei), previously col-
lected data on stunting in their first national survey in 1997
(Ministry of Health 1997). The results from this survey
showed that 12.9% of children under 5 years of age were
stunted. This statistic may be surprising to some given that
Brunei is a developed country and currently ranks fourth in
the world by gross domestic product per capita at purchas-
ing power parity. Saying that, these data were limited by
a small sample size and the use of old growth charts, and
are now approximately 20 years old (Ministry of Health
1997). Between March and August 2009, Brunei under-
took their second National Health and Nutritional Status
Survey (NHANSS)—a much more comprehensive analy-
sis of the health and nutritional status of the population,
including collection of data on HFA. These data provide a
unique opportunity to assess the recent extent of stunting in
Brunei.
The aim of this study was to determine the prevalence of
and risk of stunting among children aged 0–24 months in
Brunei by conducting a secondary analysis of the NHANSS
2009 data. The results will help in monitoring progress and
in establishing whether any optimal points of intervention
exist.
Methods
Data Collection
This study presents the findings from the 2009 NHANSS,
carried out by the Ministry of Health in Brunei. Data
were collected on children from birth to under-5 years old
throughout the four districts (Brunei Muara, Tutong, Belait
and Temburong) from March 30th until August 10th 2009
(Phase 1). Data were also collected from children and
adults aged 5–75 years old throughout the four districts
from June 2010 till March 2011 (Phase 2), however this
current study analyses data from Phase 1 only. The study
was conducted according to the guidelines laid down in the
Declaration of Helsinki and all procedures involving human
subjects were approved by the Ministry of Health, Brunei
Darussalam. Formal letters by the Ministry of Health were
sent to potential participants to invite them to take part in
the study. Signed proof of receiving the letter was obtained
upon delivery. At the same time, appointments were
arranged with parents/caregivers to attend the survey at a
specified survey centre. Each participant was identified by
a unique identifier and questionnaires were stored in locked
cabinets at the Community Nutrition Division Ministry of
Health office in Brunei Darussalam. All members of the
survey team comprising of dietitians, nutritionists, inter-
viewers, research assistants, community health nurses and
data-entry personnel attended a 5-day training workshop
from 2nd to 7th of March, 2009 at the Health Promotion
Centre, Ministry of Health.
District participation in the current survey is reflec-
tive of the population distribution of the four districts
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2258
of Brunei—Brunei Muara (72%), Belait (15%), Tutong
(11%) and Temburong (2%) (Brunei Department of Eco-
nomic Planning and Development 2017). A self-weighted
sample of at least 1300 healthy 0–5 year old children who
were citizens or permanent residents of Brunei Darussalam
residing in the country was required to achieve a nationally
representative sample. An Equal Probability of Selection
Method was employed to ensure that every individual in
the population of interest had an equal probability of selec-
tion. The required sample size was estimated conserva-
tively assuming a 50% prevalence of any nutritional indi-
cator, a 3% margin of error, and a 95% confidence level.
For 49,000 children aged 0–5 years, the estimated required
sample size was 1044. To allow for an estimated 10% non-
response, the required sample was increased to 1149 which
was further rounded to 1300. Children were excluded
from survey selection if they were mentally or physically-
disabled or aged beyond 5 years on the day of interview.
Face-to-face interviews with parents and/or caregivers were
conducted by trained dietitians/nutritionists and research
assistants following standard data collection protocols at
the main Maternal and Child Health Clinics (MCH) nation-
wide. At the time of the survey, a total of 32 MCH Clin-
ics nationwide were serving an estimated 35,000 children
with uptakes of MCH services for children under 5 years
in Brunei known to be above 90%. This rate allowed us to
reliably draw samples of 0–5  year old children from reg-
istration records of MCH clinics nationwide (Ministry of
Health 2009).
A questionnaire based on previous national surveys
and consultation with international experts, was devel-
oped and collected information on demographics, birth
details (birth weight, gestational age, type of birth),
parental details, housing and socio-economic status
(parental employment, education and income), parental
and household smoking indicators, length of maternity
leave and usage of vitamin and mineral supplements. Diet
was assessed for 0–1  year olds using 24-h recall ques-
tions similar to those questions used by the Demographic
Health Surveys (United States Agency for International
Development [USAID] 2013), however this dietary data
was not analysed in this current study as the data was
not available for 1–2  year olds. In addition, infant and
young child feeding indicators (World Health Organi-
sation 2008) and breastfeeding indicators (Webb et  al.
2001) were collected for 0–2  year olds. Anthropomet-
ric measurements were collected using standard tech-
niques (Cogill 2003; Hammond 2002). Body weight was
measured for all children and other measurements taken
depended on the age of the child i.e. standing height
(cm) for children above 2 years old, supine length (cm)
for infants and children <2 years old, head circumference
for child <2 years old, mid upper arm circumference for
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Matern Child Health J (2017) 21:2256–2266
child between 1 and 5 years of age. All survey proce-
dures were pilot-tested on 41 children who attended rou-
tine check-up at five MCH Clinics in Brunei Muara and
Tutong districts.
Statistical Analysis
Analysis for this current study began in October 2015,
following government reporting of Phase 1 and 2 sur-
vey results. In this current analysis, we examined infants
aged 0–24 months, as stunting prevalence progressively
increases until it reaches a plateau at around 24 months
and it also becomes very difficult to reverse stunting after
this critical time window (Fenske et al. 2013). A detailed
macro was developed using World Health Organization
(WHO) growth standards to calculate standardized HFA
z-scores (WHO Multicentre Growth Reference Study
Group 2006). Previous growth standards suffer from a
number of technical and biological drawbacks that make
it inadequate to monitor the rapid and changing rate of
early childhood growth (National Centre for Health Sta-
tistics [NCHS] 1977). Stunted children were those chil-
dren with a HFA Z-score ≤−2 SD. Logistic analyses
were deemed appropriate in investigating the factors
associated with stunting by Fenske et  al. (2013), there-
fore univariate and multivariate binary logistic regression
were conducted in this current analyses. Stunting was the
outcome of interest and was treated as a categorical vari-
able (z-score ≤−2 SD). Factors included in the multivari-
ate regression models were also categorical and included
those factors that indicated significance in the univariate
regression model. We also used an evidence-based frame-
work to guide our inclusion of variables (Fenske et  al.
2013). SPSS version 22.0 (IBM 2013) was used for all
statistical analysis and a p value <0.05 signified statisti-
cal significance.
The complex interplay of factors which have been asso-
ciated with stunting has been mapped by Fenske et  al.
(2013). These factors were considered in this current analy-
sis if available and included critical non-modifiable factors
such as age and sex; immediate factors such as diet; inter-
mediate factors such as household food competition (num-
ber of people living in the household, number of siblings),
water and sanitation (use of a piped water supply), environ-
mental tobacco smoke, breastfeeding and complementary
feeding practices, illnesses, household and regional charac-
teristics (income, education, occupation, home ownership).
It has also been suggested that gestational age may be a
predictor of stunting (Christian et al. 2013). As birth weight
is a composite of gestational age and foetal growth (Oken
et al. 2003), the effect of any interaction between included
in the models were also investigated.
Matern Child Health J (2017) 21:2256–2266 2259
Results
Subject Characteristics
From a sample size of 1300 children under 5 years that
were initially recruited, a total of 1132 children completed
the survey (87% response rate) and 729 children were aged
2–5 years. From this sample, HFA data were available on
396 infants aged <24 months (7 infants had missing HFA
data). The data showed that 47.5% (n = 188) of the infants
were aged 12–24 months, 50.3% (n = 199) were female,
12.9% (n = 51) were born preterm (<37 weeks gestation)
and 12.6% (n = 50) were born low birth weight (<2.5  kg;
Table  1). Table  1 shows that 17.4% (n = 69) of women
had a university education and 42.3% (n = 167) of women
were unemployed. Few women reported being current
smokers (1.3%; n = 5) or that they were previous smokers
(9.1%; n = 36). Only 1% of women reported smoking dur-
ing pregnancy. Most women reported that they had ever
breastfed (98.7%; n = 383), and 57.1% (n = 218) of the
women reported breastfeeding for at least 6 months. Only
23.8% (n = 92) reported exclusive breastfeeding for at least
6 months. The median age for introduction of solids was
at just over 6 months (26 weeks), with commercial baby
food (50.9%; n = 172) or home-made rice porridge (53%;
n = 179) being the most common introductory foods. Sup-
plements were used regularly among 61.8% (n = 84) of
infants (mostly combined multivitamin and mineral sup-
plements). A small proportion of men had a university
education (10.5%; n = 41) and 65.1% (n = 256) worked for
the Government. Current smoking habits were reported
by 50.9% (n = 199) of men. Regarding household charac-
teristics, 49.2% (n = 194) of the households had a monthly
income of over $2000 (Brunei Dollars, approximately
$1470 US dollars) and 36.6% (n = 145) of households con-
sisted of 10 or more people, 76% (n = 301) reported that the
parent was the main carer for the infant. A large majority
of the participants (75%; n = 297) lived in the main region,
Brunei-Muara.
Child Stunting
Twenty-four percent (n = 96) had a height-for-age Z-score
≤−2SD and 6.1% (n = 24) were severely stunted (Table 1).
The mean (SD) HFA z-score was −1.25 (1.2). Table 2 com-
pares the characteristics of stunted and not stunted infants
using prevalence data and the crude odds ratio (OR). A
significantly lower risk of stunting was found among those
children born to parents who had a university education
compared to those parents with none or primary educa-
tion (women OR 0.32; 95% CI 0.12–0.85; men OR 0.28;
95% CI 0.08–0.95). A significantly lower risk of stunt-
ing was found among those children born to women who
had an institute/post-secondary education compared to
those parents with none or primary education (women OR
0.34; 95% CI 0.12–0.93). Male children (OR 2.36; 95% CI
1.5–3.8), children who were born preterm (OR 3.69; 95%
CI 2.01–6.79) and children born low birth weight (OR
3.51; 95% CI 1.90–6.48) had a significantly higher risk of
moderate stunting. Infants who had taken vitamin supple-
ments were more likely to be stunted (OR 1.63; 95% CI
1.02–2.62).
Table  3 shows the results of the multivariate logis-
tic regression. Male children and children who were pre-
term were over twice more likely to be stunted than their
counterparts (OR 2.48; 95% CI 1.49–4.12; OR 2.14; 95%
CI 1.06–4.33, respectively). Children who were born low
birth weight were three times more likely to be moder-
ately stunted than children born full-term (OR 2.99; 95%
CI 1.44–6.17). The interaction between gestational age and
birth weight was not a significant predictor of stunting (OR
0.29; 95% CI 0.71–1.26). Also, no significant gender dif-
ferences were found among any of the variables included
in the model. The inclusion of women’s or men’s education
in the final multivariate logistic model weakened the final
model and therefore these variables were not included.
Discussion
This study presents the most comprehensive data to date on
the prevalence of stunting in Brunei based upon the most
recent WHO growth charts (World Health Organisation
2006). The results show that 24.2% were stunted and 6.1%
were severely stunted. Birth weight was the most signifi-
cant predictor of stunting in this sample. Other significant
predictors were non-modifiable factors (age, gender and
gestational length).
The rates of stunting found in this current sample are of
concern. According to the WHO, countries with a stunt-
ing prevalence of >5% and remaining stationary or getting
worse, are off course in meeting the WHA target (Interna-
tional Food Policy Research Institute 2015). Unfortunately,
as the previous data on stunting in Brunei was collected
over 20 years ago, we cannot calculate the annual rate of
reduction but the prevalence of stunting in Brunei presented
in this paper indicates a medium severity of malnutrition
(World Health Organisation). The rates for stunting in this
current sample are higher than those rates reported in the
1997 National Health and Nutritional Status Survey in Bru-
nei Darussalam (1997: 12.9% 0–5  year olds; 2009: 19.3%
0–5 year olds) (Ministry of Health 1997). However, direct
comparison between the 1997 and 2009 surveys are not
recommended as the latter survey was more comprehensive
and had a larger sample size. In addition, the two surveys
used different growth charts to assess the level of stunting
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Table 1  Distribution of non- Variable Description Number %a

modifiable and modifiable
characteristics (n = 396) Stunting
 Height-for-age z-score Mean (SD) −1.25 (1.2) –
 Moderately stunted (z-score ≤−2) Yes 96 24.2
No 300 75.8
 Severely stunted (z-score ≤−3) Yes 24 6.1
No 372 93.9
Non-modifiable factors
 Child age (months) 0–6 62 15.7
6–12 146 36.9
12–24 188 47.5
 Gender Male 197 49.7
Female 199 50.3
 Gestational length Preterm (<37 weeks) 51 12.9
Full-term (≥37 weeks) 344 87.1
 Birth weight Low (<2.5 kg) 50 12.6
Normal (2.5–4.5 kg) 346 87.4
 Birth order 1 116 29.3
2 79 19.9
3 98 24.7
4 58 14.6
5 45 11.4
Breastfeeding and weaning practices
 Breastfeeding duration <6 months 164 42.9
≥6 months 218 57.1
 Exclusive breastfeeding duration <6 months 294 76.2
≥6 months 92 23.8
 Ever breastfed Yes 383 98.7
No 5 1.3
 Formula, cow’s milk, other milk Median weeks (SD) 17.3 (15.1) –
 Water, sweet-drinks, tea Median weeks (SD) 19.5 (11.4) –
 Solids Median weeks (SD) 26.0 (4.7) –
 Any of the above Median weeks (SD) 8.7 (9.3)
 Vitamin supplements taken regularly by child Yes 84 61.8
No 52 38.2
 Vitamin supplements taken ever by child Yes 135 34.1
No 261 65.9
 Ever given solid/semi-solid/soft foods regularly Yes 339 85.6
No 57 14.4
 Commercial baby food introduction Yes 172 50.9
No 166 49.1
 Home-made rice porridge introduction Yes 179 53.0
No 159 47.0
Maternal characteristics
 Women’s race Malay 337 85.1
Other 59 14.9
 Maternity leave (weeks) <8 weeks 15 7.6
8–9 weeks 166 83.8
≥9 weeks 17 8.6

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Table 1  (continued) Variable Description Number %a

 Education University 69 17.4

Institute/post-secondary 60 15.2
Secondary 241 60.9
Primary/no education 26 6.6
 Occupation Employed 228 57.7
Unemployed 167 42.3
 Current smoker Yes 5 1.3
No 391 98.7
 Previous smoker Yes 36 9.1
No 360 90.9
Paternal characteristics
 Education University 41 10.5
Institute/post-secondary 69 17.7
Secondary 259 66.4
Primary/no education 21 5.4
 Occupation Government 256 65.1
Private sector 94 23.9
Self-employed 29 7.4
Unemployed 12 3.1
 Current smoker Yes 199 50.9
No 192 49.1
 Previous smoker Yes 62 33.5
No 123 66.5
Household characteristics
 Parental monthly income (BND) <$2000 200 50.8
≥$2000 194 49.2
 Household size Small 1–6 137 34.6
Medium 7–9 114 28.8
Large ≥10 145 36.6
 Number of siblings 1–2 189 47.8
3–5 206 52.2
 Main carer(s) of the child Mother 301 76.0
Other 95 24.0
 Housing status Parents own 73 18.4
Rented 109 27.5
Grandparents/other 214 54.0
 District Brunei-Muara 297 75
Other 99 25
a
 Valid percentages

with the 1997 survey using the older National Center for
Health Statistics (NCHS) reference and the 2009 sur-
vey employing the new WHO growth standards (National
Centre for Health Statistics (NCHS) 1977; World Health
Organisation 2006). It has been suggested that the more
recent WHO growth charts overestimate stunting preva-
lence (de Onis et al. 2006). We undertook further analyses
(not presented here) using the NCHS standards to calcu-
late stunting rates in the 2009 survey and found that the
observed increase in stunting rates may be partly explained
by the different growth charts used in both surveys. Com-
pared to using the WHO growth standards, rates of mod-
erate stunting were 6% lower among males and females
using the NCHS charts. We also examined the quality of
the 2009 data by assessing the SD as a quality indicator for
anthropometric data (Mei and Grummer-Strawn 2007) and
examining whether or not age heaping was evident. These
assessments did not reveal any concerns.
The higher prevalence of stunting found among male
children is a phenomenon which tends to be restricted to

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Table 2  A comparison of characteristics between moderately stunted and not moderately stunted children using prevalence data and logistic
regression [crude odds ratio (OR) and 95% confidence interval (CI)]
Variable Description Moderately stunted Not moderately stunted Crude OR 95% CI
HFA Z-score ≤−2 SD HFA Z-score >−2 SD
n-size (%) n-size (%)

Non-modifiable characteristics
 Child age (months) 0–6 17 (17.7) 45 (15.0) Ref –
6–12 43 (44.8) 103 (34.3) 1.10 (0.57–2.14)
12–24 36 (37.5) 152 (50.7) 0.63 (0.32–1.22)
 Gender Male 63 (65.6) 134 (44.7) 2.36b (1.5–3.8)
Female 33 (34.4) 166 (55.3) Ref –
 Gestational length Preterm (<37 weeks) 25 (26.0) 26 (8.7) 3.69b (2.01–6.79)
Full-term (≥37 weeks) 71 (74.0) 273 (91.3) Ref
 Birth weight Low (<2.5 kg) 24 (25.0) 26 (8.7) 3.51b (1.90–6.48)
Normal (2.5–4.5 kg) 72 (75.5) 274 (91.3) Ref –
 Birth order 1 30 (31.3) 86 (28.7) Ref –
2 15 (15.6) 64 (21.3) 0.67 (0.33–1.35)
3 21 (21.9) 77 (25.7) 0.78 (0.41–1.48)
4 16 (16.7) 42 (14.0) 1.09 (0.54–2.22)
5 14 (14.6) 31 (10.3) 1.29 (0.61–2.76)
Breastfeeding and weaning practices
 Breastfeeding duration <6 months 35 (37.2) 129 (44.8) Ref –
≥6 months 59 (62.8) 159 (55.2) 1.37 (0.85–2.21)
 Exclusive breastfeeding duration <6 months 66 (70.2) 228 (78.1) Ref –
≥6 months 28 (29.8) 64 (21.9) 1.51 (0.89–2.55)
 Breastfeeding duration <6 months 35 (37.2) 129 (44.8) Ref –
≥6 months 59 (62.8) 159 (55.2) 1.37 (0.85–2.21)
 Exclusive breastfeeding duration <6 months 66 (70.2) 228 (78.1) Ref –
≥6 months 28 (29.8) 64 (21.9) 1.51 (0.89–2.55)
Weaning practices
 Formula, cow’s milk, other milk Median weeks (SD) – – 0.99 (0.97–1.01)
 Water, sweet-drinks, tea Median weeks (SD) – – 0.96 (0.99–1.03)
 Solids Median weeks (SD) – – 1.01 (0.96–1.07)
 Any of the above Median weeks (SD) 1.01 (0.97–1.04)
 Vitamin supplements taken regu- Yes 23 (54.8) 61 (64.9) 0.65 (0.31–1.37)
larly by child No 19 (45.2) 33 (35.1) Ref –
Maternal characteristics
 Education University 13 (13.5) 56 (18.7) 0.32a (0.12–0.85)
Institute/post-secondary 12 (12.5) 48 (16.0) 0.34a (0.12–0.93)
Secondary 60 (62.5) 181 (60.3) 0.45 (0.19–1.04)
Primary/no education 11 (11.5) 15 (5.0) Ref –
 Occupation Employed 51 (53.1) 177 (59.2) Ref –
Unemployed 45 (46.9) 122 (40.8) 0.78 (0.49–1.24)
Paternal characteristics
 Education University 6 (6.3) 35 (11.9) 0.28a 0.08–0.95
Institute/post-secondary 16 (16.8) 53 (18.0) 0.49 0.17–1.39
Secondary 65 (68.4) 194 (65.8) 0.54 0.22–1.37
Primary/no education 8 (8.4) 13 (4.4) Ref –
 Current smoker Yes 52 (54.7) 147 (49.7) 1.23 (0.78–1.95)
No 43 (45.3) 149 (50.3) Ref –
 Previous smoker Yes 13 (31.7) 49 (34.0) 0.90 (0.43–1.89)
No 28 (68.3) 95 (66.0) Ref –

13
Matern Child Health J (2017) 21:2256–2266 2263

Table 2  (continued)
Variable Description Moderately stunted Not moderately stunted Crude OR 95% CI
HFA Z-score ≤−2 SD HFA Z-score >−2 SD
n-size (%) n-size (%)

Household characteristics
 Parental monthly income (BND) <$2000 52 (54.7) 148 (49.5) Ref –
≥$2000 43 (45.3) 151 (50.5) 0.81 (0.51–1.29)
 Household size Small 1–6 31 (32.3) 106 (35.3) Ref –
Medium 7–9 23 (24.0) 91 (30.3) 0.86 (0.47–1.59)
Large ≥10 42 (43.8) 103 (34.3) 1.39 (0.81–2.39)
 Number of siblings 1–2 45 (46.9) 144 (48.2) Ref –
3–5 51 (53.1) 155 (51.8) 1.05 (0.66–1.67)
 Main carer(s) of the child Mother 71 (74.0) 230 (76.7) Ref –
Other 25 (26.0) 70 (23.3) 0.864 0.51–1.47
 Housing status Parents own 17 (17.7) 56 (18.7) 0.95 (0.51–1.77)
Rented 27 (28.1) 82 (27.3) 1.03 (0.60–1.75)
Grandparents/other 52 (54.2) 162 (54.0) Ref –
 District Brunei-Muara 73 (76.0) 224 (74.7) Ref –
Other 23 (24.0) 76 (25.3) 0.93 (0.54–1.59)
a
 p < 0.05
b
 p < 0.001

Table 3  Adjusted odds ratios Variable Moderately Not moderately Adjusted OR 95% CI

(ORs) and 95% confidence stunted stunted
intervals (CIs) for the covariates HFA Z-score ≤−2 HFA Z-score >−2
in the final logistic regression SD SD
model n-size (%) n-size (%)

Age (months)
 0–6 17 (17.7) 45 (15.0) Ref –
 6–12 43 (44.8) 103 (34.3) 1.12 0.55–2.25
 12–24 36 (37.5) 152 (50.7) 0.63 0.31–1.28
Gender
 Male 63 (65.6) 134 (44.7) 2.48c 1.49–4.12
 Female 33 (34.4) 166 (55.3) Ref –
Gestational length
 Preterm (<37 weeks) 25 (26.0) 26 (8.7) 2.14a 1.06–4.33
 Full-term (≥37 weeks) 71 (74.0) 273 (91.3) Ref –
Birth weight
 Low (<2.5 kg) 24 (25.0) 26 (8.7) 2.99b 1.44–6.17
 Normal (2.5–4.5 kg) 72 (75.5) 274 (91.3) Ref –
a
 p < 0.05
b
 p < 0.01
c
 p < 0.001

low-income countries and those children from poorer
households (Wamani et  al. 2007, 2004). The data from
Asia is more equivocal with many studies showing a higher
prevalence of stunting among female children (Khatun et al.
2004), but a recent study showed that male children from
mid-western rural China were more likely to be stunted
than females (Jiang et al. 2015). Several hypotheses regard-
ing the sex differences in stunting have been discussed
(Wamani et al. 2007). Epidemiological studies in neonates
and pre-term infants and children suggest that male gender
is associated with increased neonatal mortality and morbid-
ity and hence are more vulnerable than females (Wamani

13

2264
et  al. 2007). Indeed, a higher infant mortality rate is evi-
dent among males in Brunei compared to females (United
Nations Inter-agency Group for Child Mortality Estimation
2015). Still, the underlying mechanisms of these sex-differ-
ences are poorly understood (Wamani et al. 2007).
The prevalence of stunting, particularly among children
<2 years of age, can also reflect the prevalence of low birth
weight in a population, with one study indicating that as
much as 40% of the prevalence of growth stunting in the
first 2 years of life can be attributed to low birth weight
(Lewit and Kerrebrock 1997). Indeed, low birth infants
were three times as likely to be stunted compared to those
children born normal birth weight in this current analysis.
Low birth weight may be a proxy for inadequate nutri-
tion and therefore an increased risk of chronic or recurrent
infection during infancy. This increased vulnerability to
infection may contribute to stunting (Lewit and Kerrebrock
1997). Birth weight, which a is composite of fetal growth
and gestational age (Oken et  al. 2003), significantly pre-
dicted the risk of stunting in this current analysis. While
few studies have examined the effects of gestational age
on HFA (Christian et al. 2013), results from a recent meta-
analysis indicate that foetal growth restriction independent
of low birth weight, can predict risk of stunting (Christian
et al. 2013).
Evidence suggests that growth faltering, especially in
the first 2 years of life, seems to be more related to environ-
mental factors than to genetics in under-resourced settings
(Christian et  al. 2013). While we do not have the genetic
data available from the NHANSS, the significant predictors
of stunting in this sample were primarily non-modifiable
characteristics (apart from birth weight). The economic
environment in Brunei is one of Southeast Asia’s strong-
est. Brunei has the sixth-highest Human Development
index among the Asian nations, is classified as a ‘devel-
oped country’ (United Nations Development Program
2014) and is ranked fourth in the world by gross domestic
product per capita at purchasing power parity (The World
Bank Group 2014). Still, the rates of stunting found in this
Brunei population sit between, not below, its less develop-
ing and developed neighbours, Malaysia (17%) and Indone-
sia (36%), and well above its developed neighbours, China
(9%) and Japan (7%) (International Food Policy Research
Institute 2015). However, environmental factors associated
with stunting can be proximal or distal. For example, the
household environment has been identified as an interme-
diate determinant of stunting due to several reasons (e.g.
larger families stretching resources and crowding) (Fenske
et  al. 2013). However, the household environment factors
assessed by the NHANSS were not associated with stunting
in this sample.
Other potential environmental cofounders were not
considered in this study, e.g. the in-utero and political
13
Matern Child Health J (2017) 21:2256–2266
environments. Other factors which are important deter-
minants of stunting but not assessed as part of this sur-
vey include maternal age, stature, nutritional status and
psychosocial health, healthcare seeking, micronutrient
deficiencies and intrauterine growth restriction (Fenske
et  al. 2013). Intake and uptake of calories and nutrients
are seen as immediate determinants of stunting (Victora
et  al. 2010), however, we had limited data on children’s
diet. While breastfeeding and complementary feeding
practices have been found to have significant effects on
stunting (Dewey and Adu-Afarwuah 2008; Moursi et  al.
2008; Ruel and Menon 2002; Sguassero et  al. 2012),
breastfeeding and introduction of solids were not signif-
icantly associated with stunting in this sample. In addi-
tion, the intergenerational effects on linear growth are
widely recognised with possible mechanisms including
shared genetic characteristics, epigenetic effects, pro-
gramming of metabolic changes, a reduced space for the
foetus to grow and socio-cultural factors such as poverty
(Martorell and Zongrone 2012).
Another limitation of this study was the insufficient
number of responses for some potentially important
confounding variables, e.g. women’s race. Including
such variables in the multivariate models, would reduce
the sample size used in the multivariate analyses, hence
weakening the models and making it difficult to make any
valid inferences. Stunting prevalence also varies consid-
erably between (Kyu et  al. 2009) and within countries
(Gwatkin et  al. 2007) as the capacity to produce food
(Jones et al. 2012) and distribute food, population growth,
land degradation and climate are variable and may impact
food production and increase the burden of child under-
nutrition (Mc Michael 2001). However, three-quarters
of this current sample were from Brunei Muara district
hence making any regional comparisons in this current
analysis difficult. The other regions, Belait, Tutong and
the Temburong District make up 16.5, 11.2 and 2.3% of
the total population, respectively. Other potential deter-
minants, e.g. limited water supply and childhood infec-
tions were assessed but very few subjects reported these
issues. While the survey used a rigorous sampling tech-
nique, this analysis was undertaken on a subsample
of 396 children aged <24 months in this current study.
Therefore, the results may not be representative of this
age group in Brunei. In addition, we do not have data on
the non-responders (13% of 0–5 year olds sampled). Nev-
ertheless, it is the most comprehensive insight into stunt-
ing among this age group in Brunei. The collection of
high quality data was ensured through rigorous training
and development of data collection and data entry proto-
cols and thorough data entry.
Matern Child Health J (2017) 21:2256–2266 2265
Conclusion
This study is the first to examine the factors associated
with stunting among infants aged <24 months in Brunei.
The stunting prevalence in Brunei is of concern due to the
reported short and long-term negative effects on health later
in life. Birth weight was the strongest predictor of stunting in
this sample. Close monitoring of pregnant women who are at
risk of delivering low birth weight infants and frequent moni-
toring of low birth weight infants in line with World Health
Organization nutrition goals is recommended. As per recent
WHO recommendations, governments should also work
with WHO and UNICEF to get more existing HFA data into
global databases.
Acknowledgements  The authors would like to acknowledge all of
the project staff from the Community Nutrition Division and Commu-
nity Nursing Division, Department of Health Services at the Brunei
Ministry of Health. The survey, conducted as a national project would
also not have materialized without the contributions from the follow-
ing sectors of the Ministry of Health: Directorate and Administra-
tion of Department of Health Services; Directorate of Department of
Environmental Health Services, Disease Control Division; Division
of Estate Management and Development; Department of Health Care
and Technology; Department of Administration and Finance; Depart-
ment of Policy and Planning, Public Relation Division; the Health
Promotion Centre; members of staff of Health Centres and District
Health Offices throughout the country and the Dietetic Unit, Depart-
ment of Medical Services. The authors would also like to extend their
acknowledgment to others at The University of Sydney who provided
advice on survey design -Professor Ian Caterson, Professor Stephen
Colagiuri, Professor Adrian Bauman, Dr. Vicki Flood, and Dr. Debra
Hector.
Funding  The NHANSS was funded by The Brunei Ministry of
Health in collaboration with The Department of Economic Plan-
ning and Development of The Prime Minister’s Office under the 9th
National Development Plan.
Author Contributions  SB, JL, AR, TG acted as consultants for the
design and monitoring of the NHANSS 2011–2012 data collection.
SB conducted the statistical analyses and drafted the manuscript. SM,
JL, AR and TG provided advice regarding the statistical analyses. NS,
IA and RY were involved with data collection. All authors read the
final manuscript and provided comments.
Compliance with Ethical Standards  (2015). Prevalence and risk factors for stunting and severe stunt-
Conflict of interest  None declared.
Ethical Approval  This study was conducted according to the guide-
lines laid down in the Declaration of Helsinki and all procedures
involving human subjects were approved by the Ministry of Health,
Brunei Darussalam.
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