District-level ecological analysis of the association between stunting and infectious diseases among children under 2 years in Rwanda, 2020–2024

Background – Stunting among children under 2 years remains a major public health problem in Rwanda despite substantial investments in nutrition, water, sanitation, and hygiene (WASH), and maternal-child health. Infectious diseases, particularly diarrheal diseases, malaria, respiratory infections, and schistosomiasis, significantly contribute to growth faltering; however, their association and interconnectivity with stunting in Rwanda have not been comprehensively examined. Methods – This district-level ecological study analyzed data from 2020 and 2022-–2024 by combining aggregated stunting prevalence from the national nutrition surveillance system with facility-reported infectious disease data from the District Health Information System-2. Stunting and infectious disease records were analyzed. Descriptive statistics, spatial analyses, Pearson's correlation, and multivariable linear regression were performed to assess district-level associations between stunting and selected infectious diseases, while adjusting for population density and maternal education. Results – National stunting prevalence declined from 33.1% in 2020 to 21.7% in 2024. At the district level, Rubavu had the highest stunting prevalence (35.0%), whereas Nyarugenge recorded the lowest (6.0%). No significant correlations were observed between stunting and infectious diseases during 2020–2023; however, in 2024, diarrheal diseases showed a significant positive correlation with stunting (r = 0.477, p < 0.05). The correlations varied widely by district. Malaria showed a significant positive correlation with stunting in Rutsiro, Musanze, Nyamagabe, Nyaruguru, Rubavu, and Kamonyi, with Pearson's r values of 0.96, 0.93, 0.91, 0.90, 0.85, and 0.82, respectively (p < 0.05). Diarrheal diseases were associated with stunting in Gisagara District, with a Pearson's r of 0.98 (p < 0.05). Respiratory diseases were positively associated with stunting in Nyamasheke (Pearson's r = 0.94, p < 0.05) but negatively associated in Nyarugenge, Kamonyi, and Muhanga (Pearson's r = −0.98, −0.96, and −0.96, respectively). In multivariable analysis, none of the infectious disease indicators were significantly associated with district-level stunting prevalence, while population density showed a strong inverse association (β = −0.0052, p < 0.001). Conclusion – District-level patterns of stunting in Rwanda were not consistently associated with facility-reported infectious diseases. Since the data on stunting and infections were aggregated and not linked to the same individual child, these findings should be interpreted as ecological associations rather than evidence of causality. The results support the need for ongoing multisectoral interventions in nutrition, WASH, maternal and child health, and district-tailored infection control, particularly in persistently high-burden areas.