nutrients
Article
Determinants of Stunting among Children under Five in Pakistan
Sajid Bashir Soofi 1,2 , Ahmad Khan 1 , Sumra Kureishy 1 , Imtiaz Hussain 1 , Muhammad Atif Habib 1 ,
Muhammad Umer 1 , Shabina Ariff 2 , Muhammad Sajid 1 , Arjumand Rizvi 1 , Imran Ahmed 1 , Junaid Iqbal 2 ,
Khawaja Masuood Ahmed 3 , Abdul Baseer Khan Achakzai 3 and Zulfiqar A. Bhutta 1,4,5, *
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2
3
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5
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Citation: Soofi, S.B.; Khan, A.;
Kureishy, S.; Hussain, I.; Habib, M.A.;
Umer, M.; Ariff, S.; Sajid, M.; Rizvi,
A.; Ahmed, I.; et al. Determinants of
Stunting among Children under Five
in Pakistan. Nutrients 2023, 15, 3480.
https://doi.org/10.3390/nu15153480
Academic Editor: Bruce W. Hollis
Received: 14 July 2023
Revised: 31 July 2023
Accepted: 2 August 2023
Published: 7 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
Center of Excellence in Women & Child Health, The Aga Khan University, Karachi 74800, Pakistan;
sajid.soofi@aku.edu (S.B.S.); ahmad.sherali@aku.edu (A.K.); sumrakureishy@gmail.com (S.K.);
imtiaz.hussain@aku.edu (I.H.); habibatif@yahoo.com (M.A.H.); muhammad.umer@aku.edu (M.U.);
sajid.muhammad@aku.edu (M.S.); arjumand.rizvi@aku.edu (A.R.); imran.ahmed@aku.edu (I.A.)
Department of Pediatrics & Child Health, The Aga Khan University, Karachi 74800, Pakistan;
shabina.ariff@aku.edu (S.A.); junaid.iqbal@aku.edu (J.I.)
Ministry of Health Services Regulation & Coordination, Islamabad 44020, Pakistan;
nfapakistan@gmail.com (K.M.A.); achakzaibk@gmail.com (A.B.K.A.)
Lawson Centre for Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada
Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
Correspondence: zulfiqar.bhutta@aku.edu
Abstract: Introduction: Child stunting remains a public health concern. It is characterized as poor
cognitive and physical development in children due to inadequate nutrition during the first 1000 days
of life. Across south Asia, Pakistan has the second-highest prevalence of stunting. This study assessed
the most recent nationally representative data, the National Nutrition Survey (NNS) 2018, to identify
the stunting prevalence and determinants among Pakistani children under five. Methods: The NNS
2018, a cross-sectional household-level survey, was used to conduct a secondary analysis. Data on
malnutrition, dietary practices, and food insecurity were used to identify the prevalence of stunting
among children under five years in terms of demographic, socioeconomic, and geographic characteristics. The prevalence of stunting was calculated using the World Health Organization (WHO) height
for age z-score references. Univariate and multivariable logistic regressions were conducted to identify the factors associated with child stunting. Results: The analysis showed that out of 52,602 children
under five, 40.0% were found to be stunted. Male children living in rural areas were more susceptible
to stunting. Furthermore, stunting was more prevalent among children whose mothers had no
education, were between 20 and 34, and were employed. In the multivariable logistic regression, male
children (AOR = 1.08, 95% CI [1.04–1.14], p < 0.001) from rural areas (AOR = 1.07, 95% CI [1.01–1.14],
p = 0.014), with the presence of diarrhea in the last two weeks (AOR = 1.15, 95% CI [1.06–1.25],
p < 0.001) and mothers who had no education (AOR = 1.57, 95% CI [1.42–1.73], p < 0.001) or lower
levels of education (primary: AOR = 1.35, 95% CI [1.21–1.51], p < 0.001; middle: AOR = 1.29, 95% CI
[1.15–1.45], p < 0.001), had higher odds of stunting. Younger children aged < 6 months (AOR = 0.53,
95% CI [0.48–0.58], p < 0.001) and 6–23 months (AOR = 0.89, 95% CI [0.84–0.94], p < 0.001), with
mothers aged 35–49 years (AOR = 0.78, 95% CI [0.66–0.92], p = 0.003), had lower odds of stunting. At
the household level, the odds of child stunting were higher in lower-income households (AOR = 1.64,
95% CI [1.46–1.83], p < 0.001) with ≥ 7 members (AOR = 1.09, 95% CI [1.04–1.15], p < 0.001), with no
access to improved sanitation facilities (AOR = 1.14, 95% CI [1.06–1.22], p < 0.001) and experiencing
severe food insecurity (AOR = 1.07, 95% CI [1.01–1.14], p = 0.02). Conclusion: Child stunting in Pakistan is strongly associated with various factors, including gender, age, diarrhea, residence, maternal
age and education, household size, food and wealth status, and access to sanitation. To address this,
interventions must be introduced to make locally available food and nutritious supplements more
affordable, improve access to safe water and sanitation, and promote female education for long-term
reductions in stunting rates.
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Nutrients 2023, 15, 3480. https://doi.org/10.3390/nu15153480
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Nutrients 2023, 15, 3480
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Keywords: undernutrition; childhood stunting; risk factors; children under five; national nutrition
survey; Pakistan
1. Introduction
Child stunting remains a global public health concern [1,2]. It is characterized as poor
cognitive and physical development in children due to inadequate nutrition during the
first 1000 days of life—from conception to two years of age [2]. These children cannot attain
their full potential and face disadvantages and difficulties in their schooling, careers, and
ability to contribute and engage within their communities. In 2020, almost 150 million
children under five experienced stunting worldwide [3]. Over the past three decades,
the number of children experiencing stunting has decreased by 109 million, with one of
the highest reductions observed in south Asia (44 million fewer stunted children from
1990 to 2020) [1]. However, these numbers are expected to increase due to the negative
impact of COVID-19 on livelihoods, the affordability of nutritious diets, and access to
essential health and nutrition services [4].
The south Asia region comprises seven countries: Afghanistan, Bangladesh, Bhutan,
India, Iran, Maldives, Nepal, Pakistan, and Sri Lanka. Regardless of the reduction in
the number of stunted children, this region continues to experience a high prevalence
of stunting (31.7%), which is significantly higher than the global average (21.3%) [1,3].
Among these seven countries, Pakistan has the second-highest prevalence of stunting after
Afghanistan [5–14]. Pakistan, an agricultural country, has a rapidly growing population
of 207 million, headed towards 300 million by 2050 [6,15]. Its population consists of a
considerable youth bulge (28% between 15 and 29 years), with 31 million children under
five years of age and 56 million women of reproductive age (15–49 years) [6,8]. With
a fertility rate of 3.56 children per woman, about 50% of young Pakistani women of
reproductive age (15–19 years) leave school, marry, and bear their first child before their
20th birthday [6]. As the main contributor to the rapidly growing population, these young
women’s ability to access education, nutritious diets, healthcare services, and maintain
adequate birth intervals and water, sanitation, and hygiene practices is a growing concern,
as these are strong drivers of healthy child growth [1]. In Pakistan, the failure to tackle
the high prevalence of stunting may severely impact economic growth and human capital
development, leading to delays in the demographic dividend anticipated for the country [6].
With the country’s efforts towards achieving the 17 Sustainable Development Goals
(S.D.G.s), especially S.D.G. 2: Zero Hunger and S.D.G. 3: Good Health and Wellbeing,
the national health and nutrition indicators have shown some progress, with stunting
prevalence decreasing from 44% to 40% from 2011 to 2018 [6,16]. Similarly, the wasting
prevalence (15% in 2011 to 7.1% in 2018), maternal mortality rate (276/100,000 live births in
2007 to 186/100,000 live births in 2019), exclusive breastfeeding rate (37.7% in 2011 to 48.4%
in 2018), and child immunization coverage (54% in 2013 to 76.5% in 2021) have improved
over the last few years [5,16,17]. No improvements have been made in the anemia rates
among women of reproductive age and the prevalence of low birth weight [16]. Against this
backdrop, we aimed to assess the most recent nationally representative data, the National
Nutrition Survey 2018, to describe the prevalence of stunting in terms of socioeconomic and
geographic characteristics. We also aimed to identify the child-, maternal-, and householdlevel determinants of stunting in Pakistan. These determinants, once identified, may help
to improve the understanding and enable the strategic strengthening of nutrition-specific
and -sensitive interventions and programs.
2. Materials and Methods
The National Nutrition Survey 2018 used a cross-sectional survey design, which
collected data at the household level using quantitative and qualitative approaches [6]. In
Pakistan, population diversity is entirely hinged on culture, influencing attitudes, practices,
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political affiliations, and social cohesion [18]. With this in mind, quantitative data were
collected at the district level (district representative), while qualitative data were collected
at the regional level (regionally representative) [6]. Data on malnutrition, dietary practices
(caloric and micronutrient intakes), and food insecurity were collected from all districts of
Punjab, Sindh, Khyber Pakhtunkhwa (including erstwhile Federally Administered Tribal
Areas (FATA)), Balochistan, Azad Jammu and Kashmir (A.J.K.), Gilgit-Baltistan (G.B.), and
Islamabad Capital Territory (I.C.T.). The target population was women of reproductive age
(15–49 years), children under five (0–59 months), school-aged children (6–12 years), and
adolescents (10–19 years).
The survey used a two-stage stratified sample design, where primary sampling units
(P.S.U.s) were provided by the Pakistan Bureau of Statistics based on the Population and
Housing Census of 2017 [6]. The households within the P.S.U.s were treated as secondary
sampling units (S.S.U.s). Moreover, the prevalence of undernutrition (wasting, stunting, and micronutrient deficiencies) among children under five, adolescents, and women
of reproductive age was used to calculate the district-specific sample size. Across the
156 districts of the country, 115,600 households (S.S.U.s) were sampled from 5780 PSUs to
obtain reliable estimates of the key survey indicators. A detailed description of the National
Nutrition Survey design, sampling methodology, and results are presented elsewhere [6].
The secondary analysis in this article presents the prevalence of stunting among
children under five years in terms of maternal age, education, and employment; child
gender, age, and presence of disease; and household socioeconomic status and place of
residence. Data from 52,602 children under five were used for the secondary analysis. Since
stunting was the primary outcome measure, children whose height for the age z-scores
was less than -2SD (standard deviation) of the World Health Organization (WHO) Child
Growth Standard median were considered to be stunted. The frequencies, along with
weighted percentages, were reported for the selected predictors. The analysis started with
a simple univariate analysis followed by a multivariate logistic regression. Unadjusted
odds ratios with their 95% CIs were reported for the bivariate analysis. Variables significant
at p < 0.25 were considered for inclusion in the multivariate model. Covariates that were
not significant at the multivariate level were dropped consecutively from the model after a
careful assessment of confounding. The final model was selected based on the theoretical
and statistical significance of the predictors. The Type 1 error was set to 0.05. The model
estimates are presented with the adjusted odds ratios (A.O.R.) and 95% CIs.
The analysis was adjusted for the child’s gender, age, and diarrhea in the last two
weeks, the mother’s education and age, the family size, sanitation facilities, household
food insecurity status, wealth status, rural/urban, and province. All the analyses were
performed using Stata statistical software (version 18).
The National Nutrition Survey’s methodology and strategy were approved by the
Ethical Review Committee (ERC) at Aga Khan University (A.K.U.) (5176-WCH-ERC-17,
dated 27 December 2017). Ethical clearance was obtained from the National Bioethics
Committee (N.B.C.) (NBC-278, dated 7 November 2017). Informed consent was obtained
from all the participants and confidentially was ensured as part of the survey. Approval for
the secondary data analysis was obtained from the ERC, A.K.U.
3. Results
3.1. Child, Maternal, and Household Characteristics
Out of the 52,602 children enrolled, 50.7% were male, with the majority aged
24–59 months (63.0%) and living in rural areas (63.4%) (Table 1). Across the provinces,
most children were from Punjab (52.8%), 27.9% were from Sindh, and 0.5% were from
Gilgit Baltistan. A larger proportion of children had no reported presence of diarrhea
(90.7%), acute respiratory infection (97.7%), or fever (85.5%) in the last two weeks. More
than 1⁄2 of the mothers of the children had no education (55.3%), while a 1⁄4 had completed
secondary (12.3%) or higher education (11.1%). Most of these women were aged 20–34
(75.0%) and were housewives (89.4%). Most households comprised ≤6 family members
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(51.7%), had <5 children under the age of five (98.0%), and had access to improved drinking
water (92.0%) and improved sanitation facilities (82.5%). Furthermore, 58.4% of households
reported being food secure, with 20.2% reporting severe food insecurity. In total, 6 out of
100 households (5.5%) reported receiving financial assistance from the government in the
last 12 months. A similar proportion of children (about 20%) were found across the five
wealth quintiles, with a 2.1% increase in the poorest quintile.
Table 1. Child, maternal, household, and community characteristics among children aged
0–59 months from the NNS 2018 (N = 52,602).
Maternal, Child, Household, and Community Characteristics
n (%)
Maternal Characteristics
Mother’s education
None
Primary
Middle
Secondary
Higher
30,883 (55.3)
5639 (12.1)
4671 (9.2)
5836 (12.3)
5573 (11.1)
Maternal working status
Housewife
Others
46,344 (89.4)
6258 (10.6)
Mother’s age
Less than 20 years
20–34 years
35–49 years
1047 (1.9)
38,368 (75.0)
13,187 (23.0)
Child Characteristics
Gender
Male
Female
26,826 (50.7)
25,776 (49.3)
Child’s age
<6 months
6–23 months
24–59 months
4388 (8.7)
14,618 (28.3)
33,596 (63.0)
Diarrhea in the last 2 weeks
Yes
No
5071 (9.3)
47,531 (90.7)
A.R.I. in the last 2 weeks
Yes
No
1652 (2.3)
50,950 (97.7)
Fever in the last 2 weeks
Yes
No
8043 (14.5)
44,559 (85.5)
Household Characteristics
Family size
≤6 members
7 or more members
26,054 (51.7)
26,548 (48.3)
Number of children under five
<5
≥5
51,612 (98.0)
990 (2.0)
Drinking water sources
Improved sources
Unimproved sources
47,203 (92.0)
5399 (8.0)
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Table 1. Cont.
Maternal, Child, Household, and Community Characteristics
n (%)
Sanitation facilities
Improved sanitation facility
Unimproved sanitation facility
41,341 (82.5)
11,261 (17.5)
Food insecurity status
Food secure
Mildly food insecure
Moderately food insecure
Severely food insecure
30,741 (58.4)
6157 (12.5)
4337 (8.9)
11,367 (20.2)
The household received financial assistance in the last 12 months
Yes
No
2853 (5.5)
49,749 (94.5)
Wealth status (quintiles)
Lowest income
Second
Middle
Fourth
Highest income
14,682 (22.1)
12,152 (20.2)
10,435 (20.2)
8817 (20.0)
6516 (17.5)
Community Characteristics
Area
Urban
Rural
15,497 (36.6)
37,105 (63.4)
Province
Punjab
Sindh
KP
Balochistan
ICT
FATA
AJK
GB
19,396 (52.8)
10,643 (27.9)
6136 (9.6)
7849 (5.4)
719 (1.1)
1043 (1.0)
3646 (1.6)
3170 (0.5)
Abbreviations: A.R.I., acute respiratory infection; K.P., Khyber Pakhtunkhwa; I.C.T., Islamabad Capital Territory;
FATA, erstwhile Federally Administered Tribal Areas; A.J.K., Azad Jammu and Kashmir; and G.B., Gilgit-Baltistan.
3.2. Determinants of Stunting in Children under Five
Of the 52,602 children under five enrolled in the survey, 40.0% were stunted. In the univariate logistic analysis, the odds of stunting were higher among male children (OR = 1.08,
95% CI [1.03–1.13], p = 0.001) from rural areas (OR = 1.43, 95% CI [1.36–1.50], p < 0.001),
with the presence of diarrhea (OR = 1.26, 95% CI [1.16–1.36], p < 0.001), respiratory infection
(OR = 1.21, 95% CI [1.06–1.38], p = 0.005), or fever (OR = 1.08, 95% CI [1.01–1.15] p = 0.017)
in the last two weeks compared to female children from urban areas with no diarrhea, respiratory infection, or fever (Table 2). Children under two years of age (<6 months: OR = 0.54,
95% CI [0.50–0.59], p < 0.001; 6–23 months: OR = 0.87, 95% CI [0.83–0.92], p < 0.001) had
lower odds of stunting compared to children aged 24–59 months. Compared to children
whose mothers had completed higher education, the odds of stunting were higher among
children born to mothers with no education (OR = 2.30, 95% CI [2.11–2.51], p < 0.001)
or lower levels of education (primary: OR = 1.62, 95% CI [1.46–1.80], p < 0.001; middle:
OR = 1.45, 95% CI [1.29–1.62], p < 0.001; and secondary: OR = 1.17, 95% CI [1.05–1.30],
p = 0.004). Children with employed mothers (OR = 1.13, 95% CI [1.05–1.21], p < 0.001) had
higher odds of stunting compared to children whose mothers were housewives. Expectedly,
the odds of child stunting decreased with an increase in the mother’s age; however, the
odds ratios were not statistically significant for mothers aged 20–34 years (OR =0.88 (95%
CI [0.76–1.03], p = 0.11) and 35–49 years (OR = 0.91, 95% CI [0.78–1.07], p = 0.26), relative
to mothers < 20 years of age. The odds of child stunting were higher in households with
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≥7 members (OR = 1.08, 95% CI [1.01–1.15], p = 0.01), with no access to improved sources
of drinking water (OR = 1.15, 95% CI [1.06–1.26], p = 0.001) and no improved sanitation
facilities (OR = 1.79, 95% CI [1.69–1.89], p < 0.001), compared to households with ≤6 members and access to improved drinking water and sanitation facilities. The odds of stunting
increased with the severity of food insecurity experienced by households. Households
experiencing severe food insecurity (OR = 1.52, 95% CI [1.43–1.61], p < 0.001) were most at
risk compared to food-secure households. Like food insecurity, the odds of child stunting
increased as the wealth status of households decreased. Across the wealth quintiles, the
lowest-income households (OR = 2.65, 95% CI [2.45–2.87], p < 0.001) were most at risk of
experiencing child stunting compared to the wealthiest households. However, unexpectedly, the odds of stunting were lower among children whose households did not receive
financial assistance in the last 12 months (OR = 0.62, 95% CI [0.56–0.68], p < 0.001) and
were located in Punjab (OR = 0.64, 95% CI [0.59–0.70], p < 0.001), K.P. (OR = 0.733, 95% CI
[0.66–0.81], p < 0.001), I.C.T. (OR = 0.54, 95% CI [0.45–0.65], p < 0.001), and A.J.K. (OR = 0.74,
95% CI [0.66–0.84], p < 0.001) compared to households who received assistance and were
located in G.B.
Table 2. Determinants of stunting among children aged 0–59 months in the NNS 2018 (N = 52,602).
Unadjusted Odd
Ratio (OR) [95%CI]
Adjusted Odd
Ratio (OR)
[95%CI]
Characteristics
Stunted
Normal
Overall
22,005 (40.0%)
30,597 (60.0%)
Mother’s education
None
Primary
Middle
Secondary
Higher
14,517 (46.1%)
2193 (37.6%)
1730 (35.0%)
1914 (30.3%)
1651 (27.0%)
16,366 (53.9%)
3446 (62.4%)
2941 (65.0%)
3922 (69.7%)
3922 (73.0%)
2.308 (2.116–2.518)
1.626 (1.462–1.809)
1.45 (1.295–1.623)
1.174 (1.053–1.308)
Ref.
Maternal working status
Housewife
Others
19,316 (39.7%)
2689 (42.7%)
27,028 (60.3%)
3569 (57.3%)
Ref.
1.134 (1.058–1.215)
<0.001
Mother’s age
Less than 20 years
20–34 years
35–49 years
456 (42.7%)
15,997 (39.8%)
5552 (40.6%)
591 (57.3%)
22,371 (60.2%)
7635 (59.4%)
Ref.
0.885 (0.76–1.032)
0.914 (0.781–1.07)
0.119
0.264
Gender
Male
Female
11,520 (41.0%)
10,485 (39.0%)
15,306 (59.0%)
15,291 (61.0%)
1.083 (1.035–1.133)
Ref.
0.001
1.089 (1.04–1.141)
Ref.
<0.001
Child’s age
<6 months
6–23 months
24–59 months
1360 (28.4%)
5899 (38.9%)
14,746 (42.1%)
3028 (71.6%)
8719 (61.1%)
18,850 (57.9%)
0.545 (0.5–0.595)
0.874 (0.83–0.921)
Ref.
<0.001
<0.001
0.534 (0.488–0.585)
0.893 (0.847–0.942)
Ref.
<0.001
<0.001
Diarrhea in the last
2 weeks
Yes
No
2366 (45.2%)
19,639 (39.5%)
2705 (54.8%)
27,892 (60.5%)
1.262 (1.169–1.363)
Ref.
<0.001
1.155 (1.067–1.25)
Ref.
<0.001
ARI. in the last 2 weeks
Yes
No
778 (44.6%)
21,227 (39.9%)
874 (55.4%)
29,723 (60.1%)
1.211 (1.061–1.383)
Ref.
0.005
Fever in last 2 weeks
Yes
No
3533 (41.6%)
18,472 (39.7%)
4510 (58.4%)
26,087 (60.3%)
1.081 (1.014–1.151)
Ref.
0.017
p-Values
p-Values
Maternal Characteristics
<0.001
<0.001
<0.001
0.004
1.571 (1.423–1.735)
1.358 (1.215–1.518)
1.293 (1.151–1.453)
1.109 (0.993–1.239)
Ref.
Ref.
0.895 (0.765–1.048)
0.783 (0.665–0.922)
<0.001
<0.001
<0.001
0.066
0.168
0.003
Child Characteristics
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Table 2. Cont.
Stunted
Normal
Unadjusted Odd
Ratio (OR) [95%CI]
Family Size
≤6 members
7 or more members
10,679 (39.1%)
11,326 (41.0%)
15,375 (60.9%)
15,222 (59.0%)
Ref.
1.081 (1.014–1.151)
0.017
Number of Children Under
Five
<5
≥5
21,567 (40.0%)
438 (39.6%)
30,045 (60.0%)
552 (60.4%)
Ref.
0.981 (0.834–1.154)
0.817
Drinking Water Sources
Improved sources
Unimproved sources
19,505 (39.7%)
2500 (43.3%)
27,698 (60.3%)
2899 (56.7%)
Ref.
1.158 (1.062–1.262)
0.001
Sanitation Facilities
Improved sanitation facility
Unimproved sanitation facility
16,276 (37.5%)
5729 (51.9%)
25,065 (62.5%)
5532 (48.1%)
Ref.
1.796 (1.699–1.898)
Food Insecurity Status
Food secure
Mildly food insecure
Moderately food insecure
Severely food insecure
11,930 (36.7%)
2670 (41.6%)
1986 (43.8%)
5419 (46.9%)
18,811 (63.3%)
3487 (58.4%)
2351 (56.2%)
5948 (53.1%)
Characteristics
p-Values
Adjusted Odd
Ratio (OR)
[95%CI]
p-Values
Household Characteristics
Ref.
1.098 (1.048–1.151)
<0.001
<0.001
Ref.
1.144 (1.068–1.226)
<0.001
Ref.
1.225 (1.14–1.317)
1.343 (1.231–1.465)
1.523 (1.439–1.612)
<0.001
<0.001
<0.001
Ref.
1.099 (1.021–1.182)
1.057 (0.968–1.156)
1.078 (1.012–1.149)
0.012
0.217
0.020
The household received financial assistance in the last 12 months
Yes
1402 (51.0%)
1451 (49.0%)
Ref.
No
20,603 (39.4%)
29,146 (60.6%)
0.625 (0.569–0.687)
<0.001
Wealth Status (quintiles)
Lowest income
Second
Middle
Fourth
Highest income
7552 (51.9%)
5429 (45.0%)
4124 (39.6%)
2972 (32.3%)
1928 (28.9%)
7130 (48.1%)
6723 (55.0%)
6311 (60.4%)
5845 (67.7%)
4588 (71.1%)
2.659 (2.455–2.879)
2.019 (1.861–2.191)
1.612 (1.483–1.752)
1.177 (1.079–1.283)
Ref.
Area
Urban
Rural
5714 (34.7%)
16,291 (43.2%)
9783 (65.3%)
20,814 (56.8%)
Ref.
1.43 (1.36–1.504)
Province
Punjab
Sindh
KP
Balochistan
ICT
FATA
AJK
GB
7146 (36.5%)
4904 (45.7%)
2536 (39.4%)
3870 (46.8%)
235 (32.6%)
463 (44.7%)
1395 (39.8%)
1456 (47.0%)
12,250 (63.5%)
5739 (54.3%)
3600 (60.6%)
3979 (53.2%)
484 (67.4%)
580 (55.3%)
2251 (60.2%)
1714 (53.0%)
0.649 (0.594–0.709)
0.95 (0.866–1.042)
0.733 (0.662–0.813)
0.992 (0.894–1.101)
0.545 (0.452–0.658)
0.911 (0.766–1.084)
0.747 (0.663–0.841)
Ref.
<0.001
<0.001
<0.001
<0.001
1.64 (1.468–1.832)
1.477 (1.341–1.627)
1.285 (1.172–1.409)
1.035 (0.946–1.132)
Ref.
<0.001
<0.001
<0.001
0.452
Community Characteristics
<0.001
<0.001
0.273
<0.001
0.887
<0.001
0.294
<0.001
Ref.
1.078 (1.016–1.144)
0.799 (0.727–0.879)
0.942 (0.852–1.041)
0.748 (0.672–0.833)
0.878 (0.785–0.982)
0.808 (0.665–0.982)
0.717 (0.599–0.858)
0.91 (0.803–1.032)
Ref.
0.014
<0.001
0.241
<0.001
0.022
0.032
<0.001
0.142
Abbreviations: CI; confidence interval; ARI, acute respiratory infection; KP, Khyber Pakhtunkhwa; ICT, Islamabad
Capital Territory; FATA, erstwhile Federally Administered Tribal Areas; AJK, Azad Jammu and Kashmir; and GB,
Gilgit-Baltistan.
In the multivariable logistic regression, male children (AOR = 1.08, 95% CI [1.04–1.14],
p < 0.001) from rural areas (AOR = 1.07, 95% CI [1.01–1.14], p = 0.014), with the presence
of diarrhea in the last two weeks (AOR = 1.15, 95% CI [1.06–1.25], p < 0.001), remained at
risk of stunting compared to female children from urban areas with no diarrhea in the last
two weeks. Younger children aged < 6 months (AOR = 0.53, 95% CI [0.48–0.58], p < 0.001)
and 6–23 months (AOR = 0.89, 95% CI [0.84–0.94], p < 0.001) continued to experience lower
odds of stunting as compared to older children aged 24–59 months. The relationship between
the risk of child stunting and maternal education remained apparent; however, the odds
ratios decreased with no maternal education (AOR = 1.57, 95% CI [1.42–1.73], p < 0.001)
or lower levels of maternal education (primary: AOR = 1.35, 95% CI [1.21–1.51], p < 0.001;
middle: AOR = 1.29, 95% CI [1.15–1.45], p < 0.001). The odds of stunting were lower among
Nutrients 2023, 15, 3480
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children whose mothers were 35–49 years old (AOR = 0.78, 95% CI [0.66–0.92], p = 0.003)
compared to mothers aged < 20 years old, which was initially found to be insignificant in
the univariate analysis. At the household level, the risk of child stunting remained higher in
households with ≥ 7 members (AOR = 1.09, 95% CI [1.04–1.15], p < 0.001), with no access to
improved sanitation facilities (AOR = 1.14, 95% CI [1.06–1.22], p < 0.001) and experiencing
severe food insecurity (AOR = 1.07, 95% CI [1.01–1.14], p = 0.02) compared to households
with ≤ 6 members, access to improved sanitation facilities, and food security. Similarly, the
lowest-income households (AOR = 1.64, 95% CI [1.46–1.83], p < 0.001) remained most at
risk of experiencing child stunting, with this risk gradually decreasing across the wealth
quintiles relative to the wealthiest households. Households located in Punjab (AOR = 0.79,
95% CI [0.72–0.87], p < 0.001), K.P. (AOR = 0.74, 95% CI [0.67–0.83], p < 0.001), and I.C.T.
(AOR = 0.80, 95% CI [0.66–0.98], p = 0.032) continued to experience higher odds of child
stunting, with the new inclusion of Balochistan (AOR = 0.87, 95% CI [0.78–0.98], p = 0.022) and
FATA (AOR = 0.71, 95% CI [0.59–0. 85], p < 0.001), compared to households located in G.B.
4. Discussion
The prevalence of child stunting in Pakistan remains very high (44%) compared to
the regional (31.7%) and global (21.3%) estimates [6]. This national stunting prevalence is
only surpassed by Afghanistan, a country that has been experiencing protracted conflict
for over 20 years [5–14]. Our study presents selected determinants associated with stunting
among children under five in Pakistan using the National Nutrition Survey 2018. The
study showed that a child’s gender, age, presence of diarrhea, and place of residence, the
mother’s age and education, the household size, food security status, wealth status, and
access to sanitation facilities were significantly associated with child stunting. Among these
determinants, household wealth status and maternal education were most significantly
associated with stunting in children under five. Children in the lowest-income households
had the highest odds of being stunted, which could be linked to their inability to access safe,
diverse, affordable, and nutritious foods and essential health services. This makes these
households more vulnerable to food insecurity and poor child growth [19–21]. Similar
findings have been reported by other studies within the region [19–21].
Our analysis found that children living in rural areas were more at risk of stunting,
which is consistent with regional surveys conducted in Bangladesh, Nepal, India, and the
Maldives [19–21]. However, the most recent National Demographic and Health Survey
conducted in 2017 found that children living in urban areas had higher odds of stunting; this
may be partly due to the rapidly growing population being accompanied by an even faster
rate of urbanization [5,22]. One third of the Pakistani population live in urban areas [23].
This urban transition is expected to continue and brings about informal settlements, where
the living conditions may be unsafe and access to affordable, nutritious food and essential
services, such as water, electricity, sanitation, and health, is very difficult [24–26].
Moreover, male children aged 24–59 months were more at risk of stunting than those
younger (<24 months) and female. This is consistent with previous research studies, which
have shown that male children are most at risk of stunting. In contrast, older children
were at risk due to the inappropriate initiation of complementary feeding practices. [19–21].
The study also found that children whose mothers had no education and were younger
(<20 years) had a higher risk of stunting than children of older mothers with a higher
education. Several studies have found a similar relationship between child stunting and
maternal education and age [19–21]. Older, educated mothers are assumed to be better
informed and, therefore, able to respond better and attain their children’s essential nutrition
and health requirements [21].
With an estimated 10.8 billion USD already invested in nutrition-specific and healthsystem-geared interventions over the past decade, the study findings indicate the need for
scaling up nutrition-sensitive interventions, which focus on improving the affordability of
locally available nutritious foods, access to safe, clean water and sanitation, and encouraging female education, in order to tackle child stunting in Pakistan [27]. Policies and
Nutrients 2023, 15, 3480
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programs focused on social protection, food, education, and water, sanitation, and hygiene
systems are critical for positive nutrition and health outcomes, female secondary education
attainment, and the transformation of local food systems.
Social protection consists of government policies and programs that prevent and protect people from poverty, vulnerability, and social exclusion throughout their lifecycle [28].
These programs can improve the access to essential services, reduce negative coping strategies in response to shocks, and improve the accessibility and affordability of nutritious
foods. Social protection is more effective and creates more remarkable change when food
and nutrition security are integrated into national policies and programs. At the same time,
the targeting of beneficiaries and the amounts and modalities of transfers are adapted to
the primary and nutritional needs of the most vulnerable populations [29].
In Pakistan, efforts are underway to address child stunting by scaling up nutritionsensitive social protection programs that integrate food security and nutrition outcomes
and target the most nutritionally vulnerable populations (women and children). In this context, and with World Bank funds, the government has implemented the Nashonuma project
(2020–2023) [30]. This project focuses on demand-side interventions delivered through
national health and social protection systems. These interventions include providing conditional cash transfers upon the consumption of locally produced specialized nutritious foods
(a lipid-based nutrient supplement), the uptake of maternal and child health services, and
maternal participation in social and behavioral change communication activities, in order
to improve dietary and hygiene practices and prevent stunting in children. However, there
is a lack of supply-side interventions across the food system, which positively influence the
food production, processing, availability, and affordability of locally produced nutritious
foods—a critical approach to achieving nutritious diets for all.
Our study also has some strengths and limitations. The strengths include using the
most recent and largest representative sample, with a high nationwide response rate (90%).
In contrast, using a cross-sectional survey design is a limitation, since it prevents the establishment of a causal relationship between child stunting and the different determinants.
5. Conclusions
In conclusion, our study found that a child’s gender, age, the presence of diarrhea,
and place of residence, the mother’s age and education, the household size, food security
status, wealth status, and access to sanitation facilities are significantly associated with
child stunting in Pakistan. These factors need an in-depth qualitative investigation in future
studies, targeting the rural areas of the country, where the child stunting prevalence is more
pronounced. Moreover, the establishment of causal relationships between child stunting
and these various determinants would benefit from longitudinal studies. By observing and
tracking these factors over time, research studies can provide insights into the true causal
influences, enabling more informed decision making and targeted policy interventions.
Furthermore, there is a need to scale up nutrition-sensitive interventions focused on improving the affordability of locally available nutritious foods and supplementation, access
to safe, clean water and sanitation, and encouraging female education to sustain reduced
child stunting in the country.
Author Contributions: Conceptualization, S.B.S. and Z.A.B.; methodology, M.A.H., S.B.S. and Z.A.B.;
validation, S.B.S. and Z.A.B.; formal analysis, M.S., A.R. and; I.A.; investigation, S.B.S. and Z.A.B.;
resources, M.A.H., J.I., I.H., S.A., A.R., S.B.S. and Z.A.B.; data curation, M.S., A.R., I.A. and S.B.S.;
writing—original draft preparation, S.K., A.K. and S.B.S.; writing—review and editing, I.H., M.U.,
S.A., K.M.A., A.B.K.A. and Z.A.B.; visualization, M.S., A.R. and I.A.; supervision, S.B.S. and Z.A.B.;
project administration, I.H., M.A.H., S.B.S. and Z.A.B.; funding acquisition, Z.A.B. All authors have
read and agreed to the published version of the manuscript.
Funding: The study was supported by UNICEF (Grant number: 51684).
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Review Committee of The Aga Khan University [5176-WCH-
Nutrients 2023, 15, 3480
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ERC-17, dated 27 December 2017] and the National Bioethics Committee (N.B.C.) [NBC-278, dated
7 November 2017].
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: We would like to thank the Aga Khan University, Pakistan, for supporting this
study, and we are immensely grateful to all participants for their cooperation during the study.
Conflicts of Interest: The authors declare no conflict of interest.
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