Determinants of Stunting among Children under Five in Pakistan
Authors: Soofi Sajid Bashir , Khan Ahmad , Kureishy Sumra , Hussain Imtiaz , Habib Muhammad Atif , Umer Muhammad , Ariff Shabina , Sajid Muhammad , Rizvi Arjumand , Ahmed Imran , Iqbal Junaid , Ahmed Khawaja Masuood , Achakzai Abdul Baseer Khan , Bhutta Zulfiqar A. 
Published: August 2023

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.