The current study was a large comparative study as compared to most of the studies in India among under five children of urban slum and rural area [1,2,3].This study is unique in providing information about undernutrition and it’s determinants at the community level. The data were collected by qualified and trained field supervisors and the quality checks for data collection was monitored by the site investigators from public health, community medicine and pediatrics specialty.
It was observed that overall prevalence of stunting among children under five was 45.9 %, wasting was 17.1% and 35.4% children were underweight. Similar statistics emerge from several studies in India[8,25,26]. High prevalence of stunting (89.6%) and underweight (73.2%) were reported in a study among under-five children in Uttar Pradesh, India [27].Whereas another study had revealed a low prevalence of both underweight (19.9%) and stunting (17.1%) and reversed the ranking [3].
Wasting may result from inadequate food intake or a recent episode of illness-causing weight loss. The highest prevalence of wasting is in South Asia, where approximately one in six children (16%) are moderately or severely wasted. The burden of wasting is highest in India, which has more than 25 million (20%) wasted children. This exceeds the combined burden of the next nine high-burden countries [28]. Overall, 17% of Indian children age 0–4 years were wasted [8], which is as per the present study finding.
Stunting reflects chronic undernutrition and hence UNICEF is also focusing on stunting among under five children[29].In the present study, we found that stunting was more prevalent in the urban slum(49.7%) as compared to rural area (42.1) whereas according to Comprehensive National nutrition survey report(2016-2018) higher prevalence of stunting in under-fives was found in rural areas (37%) as compared to urban areas (27%)[8]. We feel that the availability of food grains are more or less uniform throughout the year in an urban slum. In rural area seasonal availability of food grains increases. There is a tendency to purchase only locally produced and available seasonal grains, vegetables, and fruits which are comparatively cheaper in rural areas. Hence stunting is more prevalent in the urban area.
Many socio-demographic characteristics of the child and family are associated with the presence of undernutrition. They include the gender of the child, birth weight, birth order, number of siblings, exclusive breastfeeding, immunization status, mother’s education and occupation, family income, mother’s knowledge about the timing of weaning and diet, etc. Out of these factors’ majority and particularly most critical we assessed in the present study.
It was seen that exclusive breastfeeding up to 6 months gives protection against wasting to children both from a rural area (Adj OR=0.35, p<0.001) and urban slum (Adj OR=0.47, p<0.05). Exclusive breastfeeding up to 6 months acts as a protective factor against infection because it is rich in anti-infective factors that prevent respiratory infections and diarrheal diseases. It enhances the immunity of the child. However, it should be accompanied by timely weaning. Continuing exclusive breastfeeding beyond six months implies the child is getting inadequate nutrition and become malnourished.
Childhood infections like diarrhea and acute respiratory tract infection are important causes of malnutrition among under-five children in developing countries. As these are acute episodes, it results in immediate weight loss. In the present study prevalence of wasting was found higher in under-five children with acute diarrhea in the rural area (Adj OR=0.11, P=0.001), a similar finding was supported by other studies[30,31,32 ,33].
Birth order has always been an important determinant of undernutrition. As compared to children with birth order 2 or more than 2, children with birth order less than two were more likely to be stunted in the rural area (Adj OR=2.11, p<0.05). This finding was opposite to findings from other studies in India[11,25,26,34]. It may be because in Maharashtra teenage marriages are common[7].It triggers the link of early childbearing, low birthweight babies which results in developing long term undernutrition of the child. It was observed that the prevalence of stunting was more among boys as compared to girls (Adj OR=1.77, P<0.05) in the urban slum. This is in line with other studies [1,14,35,36]. Although the exact reason was not known, it may be due to the well-known fact that the male child is more affected by environmental stress than a female child. Contrary to this finding study from South West Rajasthan reported that stunting was 1.48 times more in females than in male children (OR=1.48; Cl=1.00-2.47) [37].
Family plays an important role in health and disease. It was seen that the joint family gives protection against stunting to under-five children of the urban slum (Adj OR=0.56, p<0.05). This emphasizes the importance of a joint family in society. The Indians understand the importance of a joint family system since time immemorial. Sharing resources and responsibilities amongst family members can help parents reduce the economical and physical stress. Children also get more attention in the joint family. Association between the type of family and undernutrition was not found significant by other studies [37,38].
As per the recommendation of global public health, for achieving optimum growth, development, and health a child should be breastfed exclusively during the first six months of life. To evolve as a healthy individual, the infant should be continued with adequate and appropriate safe complimentary food along with breast milk up to two years of age or beyond [5].In the present study also, similar finding was observed i.e. exclusive breastfeeding up to 6 months acts as a protective factor against underweight among under five children from a rural area (Adj OR=0.50, p<0.05). This finding was supported by other studies [39,9].
It is well known that socioeconomic status is one of the important determinants of the wellbeing of children and health [40]. Lower the socioeconomic status higher is the risk of undernutrition. A supportive study done in India and Africa reveals that families with low economic status have a significant association with undernutrition[6 ].With the improvement in socioeconomic status undernutrition proportionately declines[41]. It was observed that the low income of the family had resulted in underweight among children from an urban slum(Adj OR=2.16,p<0.05).A similar finding was also revealed by a study in urban slums of Delhi [42].
Another important factor affecting underweight was maternal education.It was observed that low maternal education was a risk factor for undernutrition among under five children of rural areas (Adj OR=0.44, p<0.05). Undernutrition decreases with an increase in the educational qualification of the mothers. This was in line with other studies[9,43,44]. Mother is a universally first caregiver for the child and hence mother’s education matters. Educated mothers are more aware of the health services available and the acceptance to utilize the same is better among them. Mother is also the first teacher of the child and hence mother and child are treated as one unit. Educated girls marry at slightly higher age comparative to less educated girls and accordingly late childbearing and have a fewer number of children.