Early Undernutrition and Unmet Learning Needs: Exploring Relationships between Stunting, Cognition, and Teacher Perceptions of Early Grade Learning in Ghana

Abstract

While the past several decades witnessed considerable improvements in poverty reduction and educational access across the globe, millions of children remain at risk of not reaching their developmental potential (R. Black, Victora, et al., 2013). Although children in low- and middle-income countries (LMICs) are more likely to reach their fifth birthday than ever before, early poverty-related exposures such as food insecurity, infectious diseases, and pollution carry significant health risks which shape their development. Simultaneously, sustained efforts to improve educational access for all children, including those exposed to early adversity, have increased both enrolment and diversity in primary classrooms across LMICs. The extent to which this diversity indicates divergent learner needs and differentiated classroom instruction is not well understood (Bundy et al., 2017). Focusing on unmet learning needs following early childhood adversity, this thesis explores whether there is anything specific about the cognitive impairment associated with stunted growth in early childhood that might inform targeted educational interventions to improve learning outcomes once children enter primary school. Highlighting developmental health risks linked to undernutrition, it set out to delineate the differences between early primary students categorised as stunted and their classmates in patterns of cognitive performance and teacher-observed measures of classroom learning in rural and peri-urban government schools in the Northern region of Ghana. This study explores the specifics of how students categorised as stunted struggle with classroom learning. Because of the risk of stigmatising learners with stunted growth, it is critical to first understand the extent to which this population’s needs are distinct from their classmates before considering targeted interventions. The study aimed to establish whether, in under-resourced classrooms in a highly marginalised context, children categorised as stunted perform differently from their classmates on measures of attention, processing speed, and memory; and whether stunting correlates with teacher perceptions of student performance on predictors of successful classroom learning. To do so, 228 Dagbani-speaking students in the first year of primary school (P1) were recruited from 11 rural and peri-urban schools at the outskirts of the Tamale Metropolitan District in the Northern region of Ghana. A three-task cognitive battery assessed attention, processing speed, and memory as the areas of cognition most affected by stunting. A five-item teacher perception matrix captured teacher impressions of student performance on predictors of classroom learning related to aptitude and school readiness. Anthropometric measurement and birth record data were collected to calculate height-for-age z-scores, and household surveys collected data from caretakers to understand the extent to which additional equity dimensions including gender, rural location, and relative poverty affect cognition and classroom learning. Multivariate regressions found that differences between the stunted and non-stunted groups were not statistically significant for any of the key variables, and there was considerable heterogeneity in scores within both groups. After correcting for changes in standard error associated with multiple hypothesis testing, no statistically significant differences were found between stunted and non-stunted groups for the cognitive domains of visuospatial reasoning, visual selective attention, processing speed, short term memory, working memory, and declarative memory; and teacher perceptions of verbal comprehension, letter sound recognition, letter writing, attention, and overall academic ability. Given the high levels of growth-limiting exposures found across the study sample, these findings do not indicate specific learning needs which were distinct to participants with stunted growth. When compared to their classmates, some learners categorised as stunted performed well on the cognitive battery and teacher observations; others struggled. Teachers observed that many of their students (not just those categorised as stunted) struggled academically and characterised the majority of students in both groups as slow learners. Worldwide, stunting researchers find that community-level efforts to prevent and mitigate the developmental risks associated with stunting dramatically outperform household- and individual-level interventions, while bypassing the deficit framing which often accompanies interventions targeting children and their families. This highlights the potential of free government primary education as the most widely scaled community-level child cognitive development intervention already in place. This study’s purposive pro-poor sampling strategy resulted in a study sample that collectively faced many disadvantages when compared to regional and national averages: underinvestment from colonial and postcolonial governments, centuries of out-migration, episodic conflict, increased climatic variability, and food insecurity among others. These factors increased the likelihood of exposure to early adversity for most if not all study participants, not just those whose height fell below the technical threshold for stunting. The distribution curve of student heights contained within my study sample skewed noticeably left when compared to the World Health Organization’s global height distribution curve. Therefore, while many students in my sample were categorised as stunted, a much larger portion of the sample were likely to have been affected by stunting. In conclusion, this thesis finds that in rural and peri-urban government schools at the outskirts of the Tamale Metropolitan District, some students categorised as stunted struggled with learning, but so did many of their classmates. In a population where few students are likely to meet their physical growth potential, differences in patterns of individual student performance could not be predicted by whether that student’s growth was categorised as stunted. Rather than risk stigmatising this particular set of learners, findings indicate improved provision of academic support to all struggling students – at least in the research context – regardless of height-for-age z-score.