Determinants and district-level variation in childhood undernutrition in Sindh, Pakistan: evidence from MICS 2018

Childhood undernutrition remains a persistent public health challenge in low- and middle-income countries, particularly in South Asia. In Pakistan, both chronic (stunting) and acute (wasting) forms of undernutrition continue to affect a substantial proportion of children. Sindh province faces pronounced socioeconomic, environmental, and health-related disparities that may influence child nutritional outcomes. This study aimed to examine the determinants of stunting and wasting among children aged 0-23 months and to assess district-level variations using Sindh Multiple Indicator Cluster Survey (MICS) 2018 data.

This cross-sectional study utilized secondary data from MICS 2018, including 5,985 children with valid anthropometric measurements. Stunting and wasting were defined as height-for-age z-score (HAZ) and weight-for-height z-score (WHZ) below - 2 standard deviations, respectively, based on WHO standards. Analyses were conducted using the complex samples module in SPSS to account for sampling weights, clustering, and stratification. Weighted descriptive statistics were computed, and bivariate associations were assessed using the Rao-Scott chi-square test. Multivariable logistic regression models were applied to identify determinants, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) reported. District-level prevalence estimates were also generated.

The prevalence of stunting and wasting was 38.4% and 17.4%, respectively. In bivariate analysis, both outcomes increased with age; however, after adjustment, younger children aged 0-5 months exhibited significantly lower odds of wasting compared with children aged 12-23 months, indicating comparatively higher odds among older children. Household socioeconomic status was significantly associated with stunting, with children from poorer households having significantly higher odds. Access to improved drinking water was associated with reduced odds of stunting (AOR = 0.70; 95% CI: 0.49-0.98). Male children showed relatively higher odds of wasting, although the association was not statistically significant after adjustment. while other factors, including sanitation, feeding practices, and recent illness, were not statistically significant after adjustment. The apparent association between vaccination and wasting observed in bivariate analysis was attenuated in multivariable analysis, suggesting confounding, particularly by child age. Substantial district-level disparities were observed, with higher burdens in interior districts compared to urban areas.

Childhood undernutrition remains a significant concern in Sindh, with distinct determinants for stunting and wasting. Socioeconomic inequalities and environmental conditions remain important factors associated with childhood under nutrition. While geographic disparities highlight the need for targeted, context-specific interventions. Strengthening nutrition programs with a focus on vulnerable populations and high-burden districts is essential to reduce undernutrition in the province.