Malnutrition in Children Under Five Years in a Squatter Settlement of Karachi; a Case-control Study

doi:10.21203/rs.3.rs-3572721/v1

Download PDF

Research Article

Malnutrition in Children Under Five Years in a Squatter Settlement of Karachi; a Case-control Study

https://doi.org/10.21203/rs.3.rs-3572721/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 19 Mar, 2024

Read the published version in BMC Public Health →

You are reading this latest preprint version

Background: Multidimensional factors such as socioeconomic or environmental factors influence malnutrition. Several studies have linked malnutrition strongly to poverty. Some international studies point to worse nutritional status of urban slum children compared to rural children. Not much data is available regarding the nutritional status of slums’ children in Karachi. This study aims to find characteristics of malnourished children in an urban squatter settlement of Karachi, Pakistan.

Methods: A Case- Control study was done in the primary healthcare centre of a squatter settlement of Karachi, Pakistan. All children under five years visiting the primary healthcare centre were recruited consecutively. Cases were defined as children with z scores < -2 SD of WHO reference measurements of WFA, HFA, WFH and OFC. Controls were similar age group and but had z scores between -2SD and +2SD. Face to face interviews were carried out with the mothers included information about socio-demographic, economic and environmental and child related characteristics. Univariate and multivariate logistic regression were conducted. Crude and adjusted odds ratio were calculated with 95% confidence interval.

Results: A total of 280 participants including 140 cases and 140 controls participated in the study. A larger proportion originated from low household income. After adjusting for all confounders, childhood malnutrition was significantly associated with low education of father (aOR 4.86, 95% CI 2.23-10.60), monthly income less than 25,000 PKR a month (aOR 7.13, 95% CI 1.67-30.54), pour pit latrine type of toilet (aOR 4.41, 95% CI 2.67-7.3), less than six months exclusive breast feeding (aOR 3.578, CI (1.58-8.08), inappropriate weaning age (aOR3.71, 95% CI 1.53-9)

Conclusion: Malnutrition in under five children of the community is associated with low family income, low paternal education, and poor toilet facilities as well as inappropriate breast feeding and weaning practices. Implementation of poverty reduction programmes and sanitation provision at affordable rates is needed. A community-based breast feeding and weaning education intervention is urgently needed to efficiently improve child nutritional status.

Children

malnutrition

risk factors

Case Control

squatter settlement

Karachi

Malnutrition signifies the deficiencies or immoderations in a person’s intake of energy and/or nutrients. Children are the most terribly affected and young children are significantly more vulnerable. The World Health Organization has identified malnutrition as the single most perilous threat to global public health. [1]The maximum burden of malnourished children is in Asia with almost 70% of malnourished children dwelling here. [2]In comparison to other developing countries, Pakistan has one of the highest prevalence of child malnutrition.[3] As reported by the National nutritional survey 2018, 40.2% children below the age of five years are stunted, 29%children underweight and 17.7% suffer from wasting in Pakistan.[4] Baluchistan and Sindh are two of Pakistan’s provinces having highest prevalence of malnutrition as well as poverty. [5]In the province of Sind, 42% of children under 5 years are underweight and approximately half are stunted (48%). [6]

Multidimensional factors such as socioeconomic or environmental factors influence malnutrition. Several studies have linked malnutrition strongly to poverty.[7] Poverty is connected with insufficient food, and poor sanitation along with maternal depression, stress and low maternal education as well as scarce stimulation at home.[8] All these factors detrimentally affect child development. According to world bank, poverty ratio in Pakistan in 2020-21 is 39.3% based on lower- middle- income poverty rate at 3.2$ per day.[9] past studies have explored various risks for childhood malnutrition such as the education of women/ parents, occupation of the head of the family, family income and size, residence location and land availability, all have been documented to influence nutritional status of children.[10]

In Pakistan, malnutrition studies mostly target rural populations. No recent studies have specifically targeted the under-five children of urban slums of Karachi. Studies that targeted slums population are either very old, related to older children or specific micronutrient deficiency. One malnutrition survey was conducted in Karachi’s Mahmoudabad slum area in 1989.[11] Latest national estimates are available from the National Nutrition survey (NNS) 2018. The NNS segregates population on the basis of province, city, district and urban/ rural residence, but it does not specify smaller urban squatter settlement.[12] In the city of Karachi, the disparity within districts can be very high with high level housing areas attached to a squatter settlement with in same districts.[13] Some international studies point to worse nutritional status of urban slum children compared to national, urban as well as rural children. Gosh S et al stated that the children residing in urban slum have the worst nutritional status among all urban groups and is even below the rural usual. [14]Risk factors of malnutrition may seem understood, but which risk factors should be prioritized targets for future nutritional intervention in urban squatter community needs to be documented. The objective of this study is to measure the risk factors of malnutrition in children under 5 years of age in a squatter settlement of Karachi, Pakistan. This study would further help in prioritizing selective factors for intervention.

Study design and setting

This Case- Control study was conducted from December 2021 to December 2022 in, Gulshan- e- Sikenderabad area, an urban squatter settlement in Keamari area of Karachi, Pakistan. The area is divided into five blocks and the estimated population is 35000 approx. in year 2010. [15]The current (undocumented) population estimates by community health workers estimate around 75,000 to 100,000. Most of the people belong to lower socioeconomic status. There is no government healthcare facility running in the area. There are few dispensaries running in the area by quacks. Some non- governmental organizations are operational in the vicinity. Some private and non- governmental organizations are operational in the vicinity. Most of the population consists of Pashtoon in-migrants from KPK or immigrants from Afghanistan with a small proportion of in-migrants from other parts of Pakistan like south Punjab (Saraiki). The population consists of low income, large poorly spaced families with the birth rate higher than the city average.[15]

Study population and sampling:

All children under five years visiting the primary healthcare centre in Sikenderabad and residents of the settlement were consecutively enrolled after taking informant written consent from parents and screening for malnutrition was done using anthropometric measurements.

Malnourished children were identified and selected as cases. Cases were defined as children with z scores less than − 2 SD from median of WHO reference for anthropometric measurements of weight for age, height for age, weight for height and head circumference. All children regardless of the type of malnutrition, can be either underweight, stunting, wasting or combination of all. Controls were children visiting the same healthcare centre and belonged to the same age group and but had z scores between − 2SD and + 2SD measurements of weight for age, height for age, weight for height and head circumference.

The Children who were diagnosed cases of special needs, had an ongoing serious or chronic illness, children with physical challenges, children with diagnosed mental illness or mental retardation as well as Pre- term babies (less than 37 weeks gestation) were excluded from the study. Children with severe acute illnesses or severe dehydration, hypothermia, hypoglygemia, hyperpyrexia were also excluded.

Sample size determination:

Sample size was calculated from openepi.com, Version 3, open source calculator—SSCC for Case Control study. Since the local prevalence of other risk factors was lacking, poverty being the major risk factor was taken as exposure. In Pakistan, the probability of exposure to poverty (< 3.2$) among controls is 0.393.[9] The odds ratio for poor household with malnourished children as compared to non-poor house hold is 2.15. [16]Sample size was calculated at α = 0.05 with 80% power of study and 1:1 ratio of cases to controls. Hypothetical proportion of controls with exposure was 39.3% and hypothetical proportion of cases with exposure at OR 2.15 was 58.19. Sample size with continuity correction was thus calculated to be 120 cases and 120 controls making a total of 240. Data was collected from a total of 280 participants (140 cases and 140 controls)considering a non- response rate of ≥ 16%, total of 280 respondents were finalized for the study. Estimated 140 cases and 140 controls were included in the study.

Data collection and measurement of variables:

Research investigator collected data by face off interviews with mothers of children. The information included socio-demographic, economic and environmental characteristics, feeding practices and morbidity. The nutritional status was examined by taking anthropometric measurements. Length, height and weight for each child were recorded as per WHO recommended protocols. Mothers of the respondents were interviewed in Urdu based on self-structured questionnaire. The risk factors were assessed through questionnaire. One child corresponded to only one household. Only mothers of children were interviewed for minimizing recall bias. In case the mothers were not living with the participants or deceased, primary guardian was interviewed.

The anthropometric measurements were taken by the principal investigator and community health worker following WHO protocol for measurement of height, weight, and head circumference for the Indicators of Malnutrition: Under weight (low weight for age), Stunting (low height for age), Wasting (low weight for height), and low Occipitofrontal circumference. Outcome variable was malnutrition and key risk factors were low income, history of Migration, Mother’s lack of education, Father’s lack of education, nuclear family system, Uncemented House, two or less rooms, inaccess to proper toilet facilities, large number of family members, High Number of children, more than one child under 5 years of age. Home delivery, Low birth weight, delivery by a relative or unskilled attendant.In-exclusive breast feeding of infants under 6 months, Lack of two years breast feeding, early or late weaning, frequency of recurrent illnesses, history of Worm infestation, Incomplete EPI immunization.

Data processing and Analysis:

All duly filled forms were verified manually and errors were identified and rectified. Incomplete forms were completed and verified data were entered in SPSS version 24 for further processing. A backup depository was developed to prevent data loss. Descriptive statistics such as mean and standard deviation were used for quantitative variables like age, weight, height, head circumference, birth weight, house hold size, number of siblings, number of siblings under two years and house hold income. Percentage and frequency were utilized for qualitative variables like gender, ethnicity, housing, water source, immunization status, parents’ educational status, parents working status, father’s job type, and father’s profession. Forecasters of childhood malnutrition were investigated using logistic regression analysis. A variety of household, maternal and child related factors were included First a univariate analysis was conducted to determine independent effect of each predictor on outcome. Then all predictors were included in multivariate analysis to investigate net effect after adjusting for all other factors in the model. Adjusted OR were calculated to study the predictive power of independent variables in relation to malnutrition. The statistical significance set at p value < 0.05.

Ethical approval:

The approval for research was taken from Institutional Review Board of Dow university of Health Sciences, Karachi, Pakistan. Reference: IRB-2345/DUHS/Approval/2021/692. A formal permission was taken from Ziauddin University’s Department of Family Medicine for Primary Healthcare Center’s assistance in data collection.

Total sample size was n=280 having 140 cases and 140 controls. The mean age of the sample was 31.2 +/- 18months. Mean quantitative variables of cases and controls are given in Table 1.

Table 1: Description of study participants:

Factors	Cases (n=140) Mean + std. deviation	Controls (n=140) Mean + std. deviation
Age in months	32.6 + 16.25	29.6 + 19.6
Weight in Kg	11.3 + 4.2	11.9 + 3.9
Height in cm	80 + 11.6	84.7 + 17
OFC in cm	48 + 5.7	47.6 + 4.5
Mean Birth weight in Kg	2.58 + 1.7	2.59 + 0.3
Exclusive breast feeding (months)	4.01 + 2.87	4.7 +1.7
Weaning age in months	8.2 +3.7	6.65 + 1.67
Monthly income in PKR:	12,042 + 6276	16,754 + 15326
Number of immediate family members	6.5 + 1.8	6.1 + 1.7
Number of total household members	9.2 + 5	8.8 + 4
Number of siblings	3.7 + 1.8	3.2 + 1.6
Number of siblings <2 yrs.	0.5571	0.471
Period of residence in Karachi (years)	12.49 +10.8	15.78 + 12.49

The sociodemographic factors and the association of various social, economic and environmental factors with malnutrition status are given in Table 2 and 3 respectively.

Table 2: The sociodemographic characteristics of the study population.

Sociodemographic characteristics	Cases n=140 (%)	Controls n=140 (%)
Gender
Male n= 145	79 (56.4)	66(47.1)
Female n=135	61 (43.57)	74 (52.85)
Ethnicity
Pushtun (from Pakistan)	58 (41.4)	70(50)
Saraiki	30 (21.4)	22(15.71)
Pashtun (from Afghanistan)	24 ((17.1)	20(14.2)
Punjabi	22(15.71)	18(12.8)
Sindhi	5(3.5)	7(5)
Urdu Speaking	1(0.07)	1(0.07)
Other	0	2(1.4)
Migration
Settled in Karachi since<15years	93(66.4)	80(57.1)
Settled in Karachi since > 15 years	47((33.6)	60(42.8)
Father’s Educational level
No education	48(34.3)	40(28.57)
Primary or less	67(47.8)	50(35.7)
Secondary	25(17.8)	48(34.2)
Graduate/ Post graduate	0	2(1.4)
Mother’s Educational level
No education	91(65)	70(50)
Primary or less	43(30.7)	58(41.4)
Secondary	6(4.2)	12(8.5)
Graduate/ Post graduate	0	0
Mother's working status
Housewife	120	123
Working	20	17
Father's working status
Jobless	4	5
Employed	136	135
Father's job type
Daily wage	78(55.7)	57(40)
Temporary	52 (37.1)	67(47.8)
Permanent	10(7.1)	17(12.1)
House hold type
Joint / Extended family	53(38)	52(37.1)
Nuclear family	87(62)	88(62.8)
Monthly Household Income In PKR ($)
<25000 (<$84)	131(93.6)	115(82.1)
> 25000 (>$84)	9(6.4)	25(17.8)

Breast feeding practices:

Mean age of exclusive breast feeding was 4+/- 2.4 months. Mean age of inexclusive breast feeding was 19 +/- 9 months. Only n= 108 (38.5%) participants (Cases+Controls) did exclusive breast feeding for six months. A total of 145 (52%) participants had exclusive breast feeding for less than six months and n=20 (7%) had exclusive breast feeding for more than six months. Various other types of products were used during first six months by majority of the participants. 18% had used formula, 29% had Buffalo or Cow milk, 2% had goad milk while 6% infants were given a tea whitener during the first six months of life.

Among the 172 (61.5%) participants using other types of products, feeding bottle was the most frequent method of giving other than breast milk n= 148(86%). Only n=9 mothers used cup and spoon (5%).

Weaning:

Mean age of weaning among participants was 7.4+/- 3 months.

Table 3: Socioeconomic and environmental risk factors for malnutrition

	Case	Control	Odds Ratio OR	95% Confidence Interval CI	P-value
Gender			1.45	0.907-2.325	0.060
Male	79	66
Female	61	74
Monthly household income			3.164	1.41-7.06	0.002
<25,000 PKR (<$84)	131	115
>25,000 PKR (>$84)	9	25
Migration
Settled in Karachi since <15years	93	80	1.484	0.9-2.41	0.055
Settled in Karachi>15years	47	60	1.484	0.9-2.41	0.055
Mother’s Educational level			1.84	1.1-2.97	0.0066
Illiterate	91	70
Primary and above	49	70
Father’s Educational level	Case	Control	2.56	1.47-4.4	0.0004
Illiterate /Primary	115	90
Secondary and above	25	50
Mother’s Working status	Case	Control	1.2	0.6-2.4	0.298
Working	20	17
Housewife	120	123
Father’s Employment status	Case	Control	0.79	0.2-3.0	0.368
Jobless	4	5
Employed	136	135
Father’s job type			1.78	0.1-2.86	0.0086
Daily Wage	78	58
Temporary stable/ Permanent	62	82
House hold Type			1.03	0.6-1.6	0.45
Nuclear family	48	47
Joint family	92	93
Number of siblings			1.68	0.99-2.8	0.025
3 or more	106	91
2 or less	34	49
No. of rooms			2.1	1.13-4.1	0.02
2 or less	123	108
3 or more	17	32
Type of toilet			4.46	2.7-7.34	0.0001
Pour/Pit latrine/ open sewer	96	46
Flush/ VIP latrine	44	94

There was no significant association between malnutrition and having siblings under the age of 2 years (OR=1.22, p value= 0.4). There was no association between living in a rented house and malnutrition (OR=0.73, p- value 0.2). No association between uncemented house and malnutrition was observed. (OR=1.3, p value=0.4)

Most of the participants were weaned after 6.5 months n=154(55%). Only n=88 (31.4%) mothers weaned their children at 6 months. Inappropriate weaning was observed in n=192 (68.5%) majority of whom were cases as shown in Table 4.

Table 4: Child related risk factors for malnutrition

Risk factor	Case	Control	Odds ratio OR	95% confidence interval	P-value
Delivery place			1.87	1.14-3.08	0.007
Home/ private clinic	100	80
Hospital	40	60
Total	140	140
Delivery conducted by			1.91	1.18-3.08	0.004
Dai/Relative/LHW	91	69
Doctor/ trained Midwife	49	71
Birth weight			1.17	0.6-2.22	0.625
LBW	24	21
Normal weight	116	119
Total	140	140
Immunization			1.56	0.889- 2.73	0.060
Incomplete for age/ no record	38	27
Complete for age	102	113
Breast feeding			3.778	2.22-6.4	0.0001
No Exclusive for 6 months	112	72
Exclusive breastfeeding for 6 months	28	68
Weaning age			2.593	1.53-4.39	0.0002
Early or late (<6m or >6.5 months)	110	82
Appropriate (6-6.5m)	30	58
Frequency of common illnesses			1.02	0.6-1.6	0.453
Once in 2 months or more frequently	70	69
Once in 3 months or occasionally	70	71
History of worm infestation			1.35	0.7-2.5	0.171
Yes	27	21
No	113	119
Soil/mud eating habit			0.56	0.2-1.4	0.120
Yes	7	12
No	133	128

The significant results of the multivariate analyses are presented in Table 5.

Table 5: SIGNIFICANT RESULTS OF MULTINOMIAL LOGISTIC REGRESSION

RISK FACTOR	ADJUSTED ODDS RATIO	95% CONFIDENCE INTERVAL	P-VALUE
Father’s education primary or less	4.86	2.23- 10.60	0.0001
Monthly income less than 25 thousand PKR a month	7.134	1.67-30.54	0.008
Pour/ pit latrine type of toilet	4.41	2.67-7.3	0.0001
Inappropriate duration of exclusive breast feeding (<6 months)	3.578	1.58-8.08	0.002
Inappropriate weaning age (Early or Delayed)	3.71	1.53-9.0	0.004

Malnutrition is a multifactorial illness and children can be affected by a wide variety of modifiable and non-modifiable determinants. This study found various associated factors that were consistent with the findings of previous studies and some factors showed higher risk than others. The association of economic status with malnutrition is well documented. [17] This study showed similar findings. Although the community under study is overall a poor community, the malnutrition risk of households with low family income earning below or equal to national minimum wage for unskilled work in Pakistan i.e., PKR 25,000/= was high (OR=3.18).

The educational status of parents is associated with the nutritional status of child. Most previous studies have highlighted mothers’ education to be an important factor.[18-20] In this study Father’s education (primary or below) was found to have higher association compared to low maternal education. A possible explanation could be that Fathers play a leading role in patriarchal tribal communities even if they migrate and reside in urban squatters.

Daily wagers are vulnerable in many ways and it was reflected as an influencer in the current study showing a daily wager father is 1.8 times more likely among cases.

Although most of the participants were born in Karachi, their parents had moved to the city from other parts of Pakistan or from Afghanistan less than fifteen years back (61.8%). The risk of malnutrition was 1.48 times increased in children whose parents migrated less than fifteen years back. However, the result was not significant (p-value 0.055). The reporting bias is very likely as many participants are suspected to have hidden their migration from Afghanistan due to current sociopolitical issues including risk of deportation. And since most Afghans are ethnically Pashtoon, it is impossible for a non-Pashtun to differentiate between a Pakistani Pashtun and an Afghan Pashtun.

Environmental factors are strong predictor of malnutrition in previous literature. [21,22] This study showed significantly strong association of pour/pit/ open sewer with malnutrition which was consistent after adjustment for confounders. Some past studies points to crowding as a predictor of malnutrition. [23] In the current study, the number of two or less rooms in the house were independently associated with undernutrition (OR=2.1).

Six months exclusive breast feeding of infants is recommended for achieving optimal growth and physical and mental development. [24] Breast feeding should be continued for up to two years along with ignition of weaning at six months. In this study only 35% children were exclusively breast fed for 6 months. [22] Pakistan is a country with lowest exclusive breast feeding rates in South Asia. [25] It has been observed that bottle feeding is widespread in poor households and high dilution is used by parents due to affordability issues. Low concentration of formula further deteriorates nutrition along with other bottle associated factors. The present study found that not just formula but buffalo and goat milk as well as tea whitener was being given to total 6% of infants. This is a serious issue that needs to be addressed. Parents must be educated about the serious impact of such use. In the current study, the inappropriate duration of breastfeeding was associated with 3. 57 times risk of malnutrition. Breast feeding promotion is thus an urgent and efficient to intervention to fight malnutrition in the children under 5 years.

Weaning should be timely, adequate, safe and proper. [26] Majority of the participants (68.5%) showed inappropriate weaning age, mostly delayed. Only 31% participants were weaned at the WHO recommended age of six months. The association with malnutrition was strong and inappropriate weaning age was associated with 3 times malnutrition chance in this study.

Several studies have shown independent association between incidence of common illnesses such as diarrhea, cough and cold with the development of malnutrition. Acute infections can lead to weight loss and underweight can suppress immunity and make child vulnerable to infections. Thus, a vicious cycle goes on. [16,22] But the current study failed to establish association between frequent common illnesses and malnutrition.

The current study did not find any strong association with low birth weight (OR=1.17). It is in contrast to past studies. ^16,22,27 But the possible explanation is that most of the participants were born in homes or private clinics run by non- trained staff and there was no documented evidence of birth weight. The recall of weight by mothers could thus not be trusted. However, this study found an association between delivery at home and malnutrition (OR=1.87). An association between birth attendant being a relative or traditional attendant (Dai) and malnutrition was also established in the present study (OR=1.91). But adjusted rates did not verify this association.

This study found environmental factor as an important predictor. Children with access to VIP or flush toilet showed a lower risk of malnutrition. Unhygienic conditions such as open defecation and pour or pit latrine are associated with malnutrition according to many past studies conducted in rural settings. [28] The findings are consistent in the current study showing four times higher risk of malnutrition in children using pour pit toilet.

Children with complete Immunization status did not show lower risk of malnutrition unlike some previous studies on the subject. [29,30] The children showed overall better immunization coverage (n=215) as compared to national coverage probably due to setting of a primary healthcare center providing immunization facility.

A very disturbing experience while conducting the current study was that it was easier and quicker to enroll cases while it became very difficult to find controls who met the inclusion criteria of WFA, WFH, HFA and OFC of z score above -2sd.

The nutritional status of urban squatter settlement children is very poor and needs special consideration. Avery high prevalence of malnutrition is suspected in the community and a prevalence study in the same community is needed. Access to proper flush toilet is significantly needed for health improvement. The economic condition of Pakistan is deteriorating and improvement of quality of life of urban slum residents may seem long term and ambitious but simple practical measures such as exclusive breast feeding for six months, and appropriate timely weaning, are cost effective methods that can improve the nutritional status without financial burden on parents. The parents need to be educated on this subject. Measures for promotion of breast feeding are urgently needed and should be given priority by the stake holders.

WFA( weight for age)

HFA (Height for age)

WFH (weight for height)

OFC (occipitofrontal circumference)

Ethical approval and consent The approval for research was taken from Institutional Review Board of Dow university of Health Sciences, Karachi, Pakistan. Reference: IRB-2345/DUHS/Approval/2021/692. A formal permission was taken from Ziauddin University’s Department of Family Medicine for Primary Healthcare Center’s assistance in data collection. Informed written consent was taken from parents of all participants. Data was psedoanonymised and kept confidential.

Consent for publication Not applicable

Data availability: Data belongs to vulnerable and conservative tribal community residing in urban squatters. Keeping in mind the vulnerability of the population, anonymized data will be shared after approval of the IRB committee of Dow university of Health Sciences if data requestors provide a methodically sound proposal. Data requestors may contact the corresponding author for details.

Competing interest: Authors declare no competing interests.

Funding None

Authors’ contributions GA conceptualized the study, collected data, performed data analysis and interpretation. All authors drafted the manuscript and approved the final manuscript.

Acknowledgements: We are grateful to Dr. Fatima Jehangir, head of the department of Family Medicine, and Ms. Shehla Khan, Community health worker, Ziauddin University for their support during data collection.

Principal Author’s information: Dr. Gati Ara is an MBBS doctor who acquired her FCPS in Community Medicine. She is currently working as Assistant Professor in the department of Community Medicine in Dow Medical College, Dow University of Health Sciences. Her interest is Maternal, neonatal and child health (MNCH) as well as Medical Education and family practice.

Fact sheets - Malnutrition [Internet]. [cited 2023 Sep 10]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition
2018 Global Nutrition Report reveals malnutrition is unacceptably high and affects every country in the world, but there is also an unprecedented opportunity to end it [Internet]. [cited 2023 Sep 10]. Available from: https://www.unicef.org/rosa/press-releases/2018-global-nutrition-report-reveals-malnutrition-unacceptably-high-and-affects
Asim M, Nawaz Y. Child Malnutrition in Pakistan: Evidence from Literature. Children [Internet]. 2018 May 1 [cited 2023 Sep 10];5(5). Available from: /pmc/articles/PMC5977042/
National Nutrition Survey 2018 | UNICEF Pakistan [Internet]. [cited 2023 Sep 11]. Available from: https://www.unicef.org/pakistan/national-nutrition-survey-2018
Pakistan: Food Security Snapshot Balochistan & Sindh | March - September 2021 - Pakistan | ReliefWeb [Internet]. [cited 2023 Sep 11]. Available from: https://reliefweb.int/report/pakistan/pakistan-food-security-snapshot-balochistan-sindh-march-september-2021
The Multiple Indicator Cluster Survey Sindh Report Launched [Internet]. [cited 2023 Sep 19]. Available from: https://www.unicef.org/pakistan/press-releases/multiple-indicator-cluster-survey-sindh-report-launched
Shahid M, Cao Y, Shahzad M, Saheed R, Rauf U, Qureshi MG, et al. Socio-Economic and Environmental Determinants of Malnutrition in under Three Children: Evidence from PDHS-2018. Children 2022, Vol 9, Page 361 [Internet]. 2022 Mar 4 [cited 2023 Sep 20];9(3):361. Available from: https://www.mdpi.com/2227-9067/9/3/361/htm
Azlina Chee Din M, Islami Mohd Fahmi Teng N, Abdul Manaf Z, Alam P, Darul Ehsan S. Is Maternal Depression a Risk Factor for Malnutrition Among Malay Children? A Case-Control Study in Selangor, Malaysia. Malaysian Journal of Medicine and Health Sciences. 2021;17(SUPP3):2636–9346.
Poverty in Pakistan up from 4.4pc to 5.4pc: WB [Internet]. [cited 2023 Sep 21]. Available from: https://www.thenews.com.pk/print/852321-poverty-in-pakistan-up-from-4-4pc-to-5-4pc-wb
Ghosh S. Factors responsible for childhood malnutrition: A review of the literature. Current Research in Nutrition and Food Science. 2020 Aug 1;8(2):360–70.
Qureshi AF, Shaikh TQ. MALNUTRITION OF CHILDREN UNDER 5-FINDINGS FROM MAHMOODABAD SURVEY.
National Nutrition Survey 2018 | UNICEF Pakistan [Internet]. [cited 2023 Sep 21]. Available from: https://www.unicef.org/pakistan/national-nutrition-survey-2018
Urban sprawl: Rethinking the management of Karachi’s slums [Internet]. [cited 2023 Sep 22]. Available from: https://tribune.com.pk/story/636541/urban-sprawl-rethinking-the-management-of-karachis-slums
Nutritional problems in urban slum children - PubMed [Internet]. [cited 2023 Sep 22]. Available from: https://pubmed.ncbi.nlm.nih.gov/15297683/
JPMA - Journal Of Pakistan Medical Association [Internet]. [cited 2023 Sep 22]. Available from: https://www.jpma.org.pk/article-details/2171
Wong HJ, Moy FM, Nair S. Risk factors of malnutrition among preschool children in Terengganu, Malaysia: A case control study. BMC Public Health [Internet]. 2014 Aug 3 [cited 2023 Sep 22];14(1):1–10. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-785
Siddiqui F, Salam RA, Lassi ZS, Das JK. The Intertwined Relationship Between Malnutrition and Poverty. Front Public Health [Internet]. 2020 Aug 28 [cited 2023 Sep 20];8:453. Available from: /pmc/articles/PMC7485412/
Razi S, Zaidi H, Iqbal J, Mahmud T, Raheel N, Fatima A. Maternal literacy and malnutrition in children: A comparative study. Pakistan Postgraduate Medical Journal [Internet]. 2020 Mar 17 [cited 2023 Sep 24];31(01):29–31. Available from: http://ppmj.org.pk/index.php/ppmj/article/view/128
Gupta MC, Mehrotra M, Arora S, Saran M. Relation of childhood malnutrition to parental education and mothers’ nutrition related KAP. Indian J Pediatr [Internet]. 1991 Mar [cited 2023 Sep 24];58(2):269–74. Available from: https://pubmed.ncbi.nlm.nih.gov/1879910/
Khattak UK, Iqbal SP, Ghazanfar H. The Role of Parents’ Literacy in Malnutrition of Children Under the Age of Five Years in a Semi-Urban Community of Pakistan: A Case-Control Study. 2017;
van Cooten MH, Bilal SM, Gebremedhin S, Spigt M. The association between acute malnutrition and water, sanitation, and hygiene among children aged 6–59 months in rural Ethiopia. Matern Child Nutr [Internet]. 2019 Jan 1 [cited 2023 Sep 25];15(1). Available from: /pmc/articles/PMC7232102/
Ansuya, Nayak BS, Unnikrishnan B, George A, Shashidhara NY, Mundkur SC, et al. Risk factors for malnutrition among preschool children in rural Karnataka: a case-control study. BMC Public Health [Internet]. 2018 Feb 26 [cited 2023 Sep 25];18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29482540/
Ambadekar NN, Zodpey SP. Risk factors for severe acute malnutrition in under-five children: a case-control study in a rural part of India. Public Health. 2017 Jan 1;142:136–43.
Infant and young child feeding [Internet]. [cited 2023 Sep 26]. Available from: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding
Torlesse H, Raju D. Feeding of Infants and Young Children in South Asia. 2018 [cited 2023 Sep 25]; Available from: www.worldbank.org/research.
Complementary feeding [Internet]. [cited 2023 Sep 26]. Available from: https://www.who.int/health-topics/complementary-feeding#tab=tab_1
Rahman MS, Howlader T, Masud MS, Rahman ML. Association of Low-Birth Weight with Malnutrition in Children under Five Years in Bangladesh: Do Mother’s Education, Socio-Economic Status, and Birth Interval Matter? PLoS One [Internet]. 2016 Jun 1 [cited 2023 Sep 26];11(6). Available from: https://pubmed.ncbi.nlm.nih.gov/27355682/
Rahman MHU, Malik MA, Chauhan S, Patel R, Singh A, Mittal A. Examining the linkage between open defecation and child malnutrition in India. Child Youth Serv Rev. 2020 Oct 1;117:105345.
Shinsugi C, Mizumoto A. Associations of Nutritional Status with Full Immunization Coverage and Safe Hygiene Practices among Thai Children Aged 12–59 Months. Nutrients [Internet]. 2022 Jan 1 [cited 2023 Sep 27];14(1). Available from: /pmc/articles/PMC8746758/
Prendergast AJ. Cite this article: Prendergast AJ. 2015 Malnutrition and vaccination in developing countries. Phil Trans R Soc B [Internet]. [cited 2023 Sep 26];370:20140141. Available from: http://dx.

No competing interests reported.

Download PDF

Journal Publication

published 19 Mar, 2024

Read the published version in BMC Public Health →

Editorial decision: Revision requested
30 Dec, 2023
Reviews received at journal
27 Dec, 2023
Reviewers agreed at journal
20 Dec, 2023
Reviews received at journal
12 Dec, 2023
Reviewers agreed at journal
10 Dec, 2023
Reviewers agreed at journal
19 Nov, 2023
Reviewers agreed at journal
16 Nov, 2023
Reviewers invited by journal
15 Nov, 2023
Editor assigned by journal
15 Nov, 2023
Editor invited by journal
15 Nov, 2023
Submission checks completed at journal
15 Nov, 2023
First submitted to journal
07 Nov, 2023

You are reading this latest preprint version

Malnutrition in Children Under Five Years in a Squatter Settlement of Karachi; a Case-control Study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Study design and setting

Study population and sampling:

Sample size determination:

Data collection and measurement of variables:

Data processing and Analysis:

Ethical approval:

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1