Edited Thesis

RISK FACTORS FOR UNDERWEIGHT AMONG UNDER
FIVE YEARS CHILDREN: A COMMUNITY BASED

CASE CONTROL STUDY IN PADAMPUR VDC,
CHITWAN
Kumar Prasad Mainali
Department of Sociology and Anthropology

Tri-Chandra Multiple Campus
Tribhuvan University
Kathmandu, Nepal
2018
I
RISK FACTORS FOR UNDERWEIGHT AMONG UNDER
FIVE YEARS CHILDREN: A COMMUNITY BASED
CASE CONTROL STUDY IN PADAMPUR VDC,
CHITWAN
In Partial Fulfillment of the Requirements of the Degree of
Masters of Sociology And Anthropology
A Thesis Submitted to
Department of Sociology And Anthropology
Tri-Chandra Multiple Campus
Tribhuvan University
Kathmandu, Nepal
2018
II
DECLARATION
To the best of my knowledge and belief I declare that this thesis entitled “Risk Factors
for Underweight among under Five Children: A Community Based Case
Control Study In Padampur VDC, Chitwan” is the result of my own research and
contains no material previously published by any other person except where due
acknowledgement has been made. This thesis contains no material, which has been
accepted for the award of any other degree or diploma in any university.
Signature: …………………..
Name: Kumar Prasad Mainali
Date:……………………
I
ACKNOWLEDGEMENT
I am very grateful to my supervisor Prof. Dr. Muni Raj Chhetri for all his continuous
inspiration, precious suggestion and valuable direction through the course as well as
during the time of doing this thesis and his invaluable contribution towards my
professional development. I would also like to express my deep thanks to my co-
supervisor Lecturer Mr. Shankar Nand Subedi for his support in the completion of this
thesis.
My sincere thanks goes to all the faculty members of Department of Sociology and
Anthropology, for suggestion in my thesis work as well as for facilitating a lot of
opportunities to students throughout the thesis preparation period.
I am thankful to all the study participants who provided their valuable time responding
to my questions. I can never forget the enthusiasm and kindness of all the respondents,
Female Community Health Volunteers and Members of Padampur Subhealth post and
Village Development Committee.
I would like to thank all my colleagues for their inspiration, cooperation and remarkable
suggestions regarding this study.
II
SUMMARY
Malnutrition is a serious obstacle to child survival, growth and development in Nepal.

Malnutrition has a variety of forms. The most common forms are protein-energy
malnutrition (PEM) i.e., stunting, underweight and wasting and micronutrient
deficiency status (iodine, iron and vitamin A deficiency). Almost one third of the
Nepalese under-5 children are underweight (weight-for-age) i.e., acute malnutrition
which is shown in the different studied but very few information are available about
risk factors. So this study aimed to identify the risk factors for underweight among
under five children. A community based case-control study was conducted to identify
the risk factors for underweight in Padampur Village Development Committee of
Chitwan district. The cases were underweight children and controls were normal
children without underweight. Required sample size was identified by simple random
sampling method among normal and underweight children of the study area. The
information was collected by interview to mothers of 93 cases and 186 controls. This
study showed that majority of underweight children were female (51.6%) and most of
the case 31.2% were in the age group 13-24 followed by 30.1% in 0-12 age group. The
mean age of cases was 22.1±14.9 and control was 22.4±15.8. Among all cases 69.9
were Hindu and 80.6% were Disadvantaged janajatis caste. 29% cases were from low
wealth quintile family and 82% cases were from food insecure family. This study found
that Children of no PNC visited mothers are 3.158 times more likely to be underweight
than the children of mothers visited PNC (95% CI 1.242-8.028). Children who were
received care from the other members of the family besides mother were 6.047 times
more likely to be case than control (95% CI 1.438-25.424). Similarly, mother who had
no income were 5.133 times higher among the cases as compared to those who had
monthly income (95% CI 1.272-20.712). This study concluded that underweight is the
result of multiple factors and all those factors should be taken in to consideration to
address underweight among children. Thus to prevent children from being underweight
mother should visit PNC, should involve in income generating activities and children
should be cared by mother herself. So, it is better to initiate income generating activities
in such a way that child could get his/her mother for care.
III
ACRONYMS
ANC Antenatal care
ANM Auxiliary nurse midwife
ARI Acute respiratory infection
CI Confidence interval
DALY Disability adjusted life year
DOHS Department of health service
EHCS Essential health care services
FCHVs Female Community Health Volunteers

HMIS Health management information system
HP Health post
MDG Millennium development goal
NDHS Nepal demographic health survey
NFHS Nepal family health survey
NMHBS Nepal multipurpose household budget survey
NMSS National micronutrient status survey
NPAN National plan for action on nutrition
OR Odds ratio
PEM Protein energy malnutrition
PHCC Primary health care center
PNC Postnatal care
SD Standard deviation
IV
SHP Sub health post
SLTHP Second long term health plan
SPSS Statistical package for social sciences
UNICEF United nations international children Emergency Fund
VDC Village development committee
WHO World health organization
V
TABLE OF CONTENTS
APPROVAL SHEET .................................................................................i
DECLARATION .......................................................................................ii
ACKNOWLEDGEMENT ........................................................................iii
SUMMARY ..............................................................................................iv
ACRONYMS .............................................................................................v
TABLE OF CONTENT ...........................................................................vii
LIST TABLES ..........................................................................................ix
LIST OF FIGURES ...................................................................................x
CHAPTER I ...............................................................................................1
INTRODUCTION ......................................................................................1
1.1 Background ..........................................................................................................1
1.2 Statement of problem ..........................................................................................2
1.3 Rationale of the study ...........................................................................................3
1.4 Objectives .............................................................................................................4
1.5 Research questions ...............................................................................................5
1.6 Study variables .....................................................................................................5
1.7 Conceptual framework .........................................................................................6
1.8 Operational definition .........................................................................................7
CHAPTER II ............................................................................................10
LITERATURES REVIEW .......................................................................10
CHAPTER III ...........................................................................................17
RESEARCH METHODOLOGY .............................................................17

3.1 Study area ...........................................................................................................17
3.2 Study design .......................................................................................................17
VI
3.3 Study population ................................................................................................17
3.4 Sample size .........................................................................................................17
3.5 Sampling Methods/Techniques ..........................................................................18
3.6 Sampling Unit ....................................................................................................19
3.7 Criteria for Sample Selection ............................................................................19
3.8 Data Collection Technique / Methods ................................................................19
3.9 Data Collection Tools.........................................................................................19
3.10 Validity and Reliability of the Study Tools .....................................................19
3.11 Plans for Data Management and Analysis .......................................................20
3.12 Ethical consideration ........................................................................................20
3.13 Plan for data collection .....................................................................................20
CHAPTER IV: RESULTS .......................................................................21
CHAPTER V: DISCUSSION ..................................................................35

CHAPTER VI: CONCLUSION AND RECOMMENDATIONS ...............................39
REFERENCES .........................................................................................41
ANNEX ......................................................................................................I
ANNEX I QUESTIONNAIRE ...................................................................................... I
LIST OF TABLE
Table 4.1.1: Socio-demographic and economic characteristics of the study 22

population
Table 4.2.1: Association between socio-demographic and economic characteristics 24
and undereight
Table 4.2.2: Association between families related characteristics and underweight 25
Table 4.2.3: Association between health service utilization related characteristics and 27
underweight
VII
Table Table 4.2.4: Association between environmental related characteristics and 29
underweight
Table 4.2.5: Association between feeding practices and underweight 31
Table 4.2.6: Association between childhood diseases and underweight 32
Table 4.3: Variables associated with underweight, multivariate analysis 34
LIST OF FIGURE
Figure 1.Conceptual Framework of the study 6
Figure 2. Sampling Procedure used in the study area 18
VIII
IX
CHAPTER I
INTRODUCTION
1.1 Background
Malnutrition is a major underlying cause of the child morbidity and mortality in Nepal.
Factors that contribute to malnutrition are many and varied, so multifaceted strategies
are required to combat it. It is therefore important to determine its causative factors
before appropriate intervention can be implemented. This analysis tries to analyze the
factors associated with nutritional status among children of under five years of age so
that nutritional intervention can be better designed.1
Nutritional status is a sensitive indicator of the quality of life in a given population.

Despite global improvement in the health of children aged 5 years in developing
countries, under-nutrition remains an important public health problem. More than half
of deaths of children in these countries are related to under-nutrition. Under-nutrition
profoundly affects human function, with both individual and transgenerational effects.
Individual effects include the well-known under-nutrition–infection vicious cycle,
while transgenerational effects refer to a similar vicious spiral that extends to
forthcoming offspring and induces permanent effects on mental, social and physical
well-being. These effects occur even in mild-to-moderate cases. Under-nutrition also
affects society at large because it leads to reduced productivity and limited ability to
escape the consequences of poverty. 2
Reduction of the prevalence of under-nutrition in under-fives is a top priority to reduce

child mortality and morbidity. Reduction of under-nutrition prevalence by 50
% between 1990 and 2015 is among the most important targets of the first Millennium
Development Goal. Nevertheless, progress remains slow, and most international goals set
for improving child nutrition and health were not met by 2000. 2
Malnutrition is usually the result of a combination of inadequate dietary intake and

infection. Malnourished children are more likely to die as a result of common childhood
diseases, to have lifetime disabilities and weakened immune systems, and to lack a full
capacity for learning. UNICEF estimates that malnutrition contributes to more than half
of the nearly 12 million under-5 deaths in developing countries each year. Underweight
or low weight-for-age, is the most widely cited of three interrelated indicators
1
commonly used to assess the nutritional status of young children. Low height-for-age,
which is termed as stunting, reflects chronic under-nutrition, while low weight-for-
height or wasting, reflects acute nutritional problems. The underweight is a composite
of the latter two aspects of under-nutrition; a child with low weight-for-age may be
either short or thin.
Global chronic under-nutrition in children is highly prevalent and remains a big

challenge. One hundred seventy-eight million and 112 million children aged less than
five years (under-five children) are stunted (<-2 height-for-age z-scores) and
underweight (<-2 weight-for-age z-scores) respectively in low-income countries. The
Millennium Development Goals (MDGs) address reducing the proportion of
underweight children by half between 1990 and 2015. The improvement of childhood
nutrition will also assist in the goal to reduce child mortality (MDG 4) because
undernutrition is an underlying cause of an estimated more than a half of all deaths of
under-five children. Nutritional status during childhood is important for human
development as it affects every phase of human life. Therefore, investment in childhood
nutrition contributes not only to improving children‟s current welfare but to enhancing
human‟s capacity in the long run. 4
1.2 Statement of the Problem

Malnutrition remains one of the most common causes of morbidity and mortality among
children throughout the world. An estimated 80 per cent of the world‟s stunted children
live in just 14 countries. Sub-Saharan Africa and South Asia have particularly high
prevalence, at almost 40 per cent and 39 per cent respectively. More than a third of
children under 5 years of age in East and South Asia are stunted. 3
Reduction of under-nutrition by 50 % between 1990 and 2015 is one of the most

important targets of the Millennium Development Goal (MDG) and this increase the
probability of achieving MDGs 4 and 5 for child and maternal mortality. Second Long
Term Health Plan identified nutrition as one of the priority areas of Essential Health
Care Services (SLTHP, 1997-2017). 3
Nepal Demography and Health Survey 2011 shows that, 29 percent of children under
age 5 are underweight (low weight-for-age), and 8 percent are severely underweight.
The proportion of underweight children is highest (37 percent) among those age 18-23
2
months and lowest (18 percent) among those under 6 months. Male children are slightly
more likely to be underweight (30 percent) than female children (28 percent). The data
show a strong correlation between underweight children and birth weight. Babies
perceived by mothers as very small and small at birth are much more likely to also be
underweight later in life (43 percent and 45 percent, respectively) than those perceived
as average or large at birth (25 percent). Children born to mothers who are thin (BMI <
18.5) are three times more likely to be underweight (40 percent) than children born to
mothers who are overweight/obese (13 percent).5 Rural children are more likely to be
underweight (30 percent) than urban children (17 percent). Children living in the
mountain zone are more likely to be underweight (36 percent) than those in the Terai
(30 percent) and hill zone (27 percent). The Mid-western region has the highest
percentage of underweight children (37 percent), while the Western region has the
lowest (23 percent). Among the subregions, the highest percentage of underweight
children is found in the Western mountain subregion (42 percent), and the lowest
percentage is found in the Western hill subregion (17 percent). 5
As with wasting and stunting, mother‟s education is associated with underweight, with
the percentage of children who are underweight being lowest among children of
mothers with an SLC and higher (13 percent) and highest among children of mothers
with no education (38 percent). A similar inverse relationship is observed between
household wealth and the percentage of underweight children: children in the poorest
households are four times as likely to be underweight (40 percent) as children in the
wealthiest households (10 percent). 5
A study carried out by Ruwali D in Padampur VDC of Chitwan district showed that
Prevalence of underweight, stunting and wasting was 37.3%, 22.7%, and 25.7%
respectively. Study indicated that the risk of stunting increases with age.
Socioeconomic status was most important factors associated with stunting, underweight
and wasting. Meeting the minimum dietary diversity, minimum meal frequency and
minimum acceptable diet was associated with better nutritional status
of children. 1
1.3 Rationale of the study
Malnutrition is a serious obstacle to child survival, growth and development in Nepal.

Malnutrition has a variety of forms. The most common forms are protein-energy
3
malnutrition (PEM) i.e., stunting, underweight and wasting and micronutrient
deficiency status (iodine, iron and vitamin A deficiency). Almost one third of the
Nepalese under-5 children are underweight i.e., acute malnutrition which is shown in
the different studied but very few information are available about risk factors.
Malnutrition places an enormous burden on children and women in Nepal. Even mildly
or moderately malnourished children are more likely to die from common childhood
illness than those adequately nourished. In addition, malnutrition constitutes a serious
threat especially to young child survival and is associated with one third of childhood
mortality. 5
Reduction of under-nutrition by 50 % between 1990 and 2015 is one of the most

important targets of the Millennium Development Goal (MDG) and this increase the
probability of achieving MDGs 4 and 5 for child and maternal mortality. Second Long
Term Health Plan identified nutrition as one of the priority areas of Essential Health
Care Services (SLTHP, 1997-2017). 6
Underweight is an underlying cause of child morbidity and mortality. The trend of

underweight has not been remarkably decreasing since 1998 (NMSS 1998 47.1%,
NDHS 2001 43%, NDHS 2006 39%, NDHS 2011 29%). 5,7
A community based cross sectional study carried out by Ruwali D in 2010 in Padampur
district showed that 37% children of this VDC were underweight.1
Various risk factors have been found responsible for under nutrition among children
aged under 5 in different studies in Nepal. But very few studies have been conducted
to identify the risk factors for only underweight and it could not be found the
community based case control study to analyze risk factors in Nepal. So this study aim
to identify whether the predictors were consistent for underweight in Nepal with
different studies carried out in Asian and African and other part of the world.
Thus, this study aims to analyze the various risk factors and identify the most important
factors of underweight. The identification of factors will help to prioritize the strategies
to address underweight in the district.
4
1.4 Objectives
1.4.1 General Objective
 To assess the risk factors for underweight among children under 5 years
of age in Padampur VDC of Chitwan district.
1.4.2 Specific objectives
 To identify socio-demographic and family related factors associated
with underweight
 To identify utilization of health services associated with underweight
 To identify environmental and hygiene factors associated with
underweight
 To determine feeding practices and childhood diseases associated with
underweight
 To assess the magnitude of the effect of determinants of underweight
1.5 Research Questions
 Are feeding practice and childhood disease factors associated with
underweight?
 Are family related factors associated with underweight?
 Are health service related factors associated with underweight?
 Are environmental factors associated with underweight?
 Are socio demographic and economic factors associated
with underweight?
1.6 Variables
1.6.1 Dependent variable (as outcome): underweight among under 5 years
children
1.6.2 Independent variables (as exposures)
Socio-demographic factors
 Age of child, sex of child, education, occupation and earning status of

mother, ethnicity, economic status and food security
Family related factors
 Birth order, birth spacing, mother’s age at marriage, age of mother at child
birth, BMI of mother, care giver, number of children,
5
Health services utilization
 Antenatal check-up, postnatal check-up, place of delivery, birth

attendance, immunization status
Environmental and hygiene factors
 Water purification, Indoor air pollution, use of pesticides, type of toilet

and defecation practice
Feeding practices
 Breast feeding and complementary feeding
Childhood diseases
 Low birth weight, Diarrhea, ARI, malaria, measles
6
1.7 Conceptual framework
The conceptual framework shows the relationship between dependent variable and
independent variables. This framework is based on the framework of UNICEF 1990
and some minor changes are made on the original framework. The variables are
changed according to the topic of the study. Conceptual framework of this study shows
that basic determinants, underlying determinants and intermediate determinants result
in underweight.29
Underweight Manifestation
Childhood diseases Feeding Practices

LBW Breast feeding
Diarrhea Complementary Immediate
ARI feeding determinants
Malaria
Measles
Health service Family related Environmental

utilization factors and hygiene
ANC Birth order factors
PNC Age of mother at Water purification Underlying
Place of delivery child birth Indoor air determinants
Birth attendance Care giver pollution
Immunization No. of children Pesticide use
BMI of mother Defecation
Socio demographic and economic factors

Age of child Earning status of mother Basic
Sex of child Economic status of family
Mother‟s education Food security determinants
Mother‟s occupation Ethnicity
Figure 1: Conceptual framework of the study
7
1.8 Operational definitions
Underweight: underweight was ascertained by using the weight-for-age indicator.
The criterion was: Z-value less than -2 standard deviations (SDs) below the median
weight-for-age according to WHO new child growth standards 2006.
Age of children: age of children was ascertained, to the nearest month, through
birth certificates, growth monitoring and immunization card or asking to mothers.
It was categorized as 0-12 months, 13-24 months, 25-36 months, 36-48 months and
49-60 months.
Mother’s education: it was categorized as, illiterate, informal education, primary

(schooling up to eight), secondary (schooling from grade nine to ten), intermediate
(10+2) and Higher education
Mother’s occupation: it was categorize as housewife, small scale business, service,

daily labor and other occupation.
Economic status: it was measured by calculating wealth quintile per family based
on the NDHS 2011 questionnaire.
Food security status: food security status of the family was identified by using
NDHS 2011 questionnaire for food security of family.
Ethnicity: it was categorized as six different ethnic groups based on Nepal

Demographic and Health Survey (NDHS) 2011.
Family related factors: in this study family related factors were age of mother at
child birth, birth order, care giver and number of children in a family.
Age of mother at child birth: age was taken as in complete years at the time of her
last delivery. It was categorize in three groups i.e., <20 years, 20-30 years and >30
years.
8
Birth order: it was the order of birth of index child that includes all live births. It
was categorized as 1-2, 3-4 and ≥5.
Care giver: it was defined as the person who cares children most of the time in a
family. It was categorized as mother, father and other member.
Antenatal care (ANC): the ANC check up by pregnant women before delivery was
categorized as 1st, 2nd, 3rd and 4th visits.
Postnatal care (PNC): the PNC check up by postnatal mother and was categorized
by 1st, 2nd and 3rd visits.
Place of delivery: it was categorize as home and institutional delivery.
Birth attendance: it was categorized as, birth assisted by relatives and others. The
delivery assisted by doctors, staff nurse, midwifes and auxiliary nurse midwives
(ANMs) was considered as skill birth attendance.
Environmental factors: environmental and hygiene factors was included water

purification, indoor air pollution, pesticide use and use of toilet.
Water purification: house hold purification of water either by boiling, filtering,

chemical disinfection and SODIS.
Indoor air pollution: it was identified by type of fuel used for cooking, cooking
stove and ventilation of kitchen.
Pesticide use: it was identified by use of chemical to kill pests in vegetable and
crop field that was categorized as use and not use.
Use of toilet: it was categorized as water seal type, dug well latrine and open
defecation.
9
Initiation of breast feeding: it was categorized as within one hour and after one
hour of child birth.
Colostrums feeding: it was categorized as whether infant was colostrums fed or

not.
Exclusive breast feeding: breast feeding practice in which infant or child was only
received breast milk from mother without any additional food or drink. It was
allowed oral rehydration solution, drops, syrups (vitamins, minerals, medicines). It
was not included children who received pre-lacteal foods before 6 months.
Complementary feeding: it was the introduction of additional food to children

other than breast milk in 6 months of child birth.
Minimum dietary diversity: it was included 7 groups of food such as; 1) Grains,
roots and tubers 2) Legumes and nuts 3) dairy products (milk, yogurt and cheese)
4) Flesh foods (meat, fish, poultry and liver/organ meats) 5) Eggs 6) vitamin A rich
fruits and vegetables 7) Other fruits and vegetables. The cut-off of at least 4 out of
the above 7 food groups was selected.
Feeding times: it was categorized as; 1) less than 3 feedings 2) 3 or more than 3
feeding to a children in a day.
Childhood diseases: it was included birth weight/size, acute respiratory infection

(ARI), diarrhea, malaria and measles.
Birth weight/size at birth: it was categorized as small or normal baby. It was

ascertained by the birth weight (cut off point 2.5 kg) or answer given by mother.
Acute respiratory infection (ARI): this was included the cough, chest pain with
fever and without fever. The episodes were taken for past 1 month.
Diarrhea: it was defined as passing loose watery stool three or more than three
times in 24 hours. The episode of diarrhea was taken for past 1 months.
10
CHAPTER II
LITERATURE REVIEW
2.1 literature search methodology
Literature related to the study topics were collected from the reviewing of available
printed documents, thesis, reports of various organizations/programs, books, journals,
newspapers etc. internet search for the electronic resources will be carried out by using
various search sites such as Google, PubMed etc.
2.2 literature review
Malnutrition in children can take the form of stunting, wasting, or underweight. 14 Children
whose weight-for-age indicator is more than two or three standard deviations below the
median for the international reference population (ages 0-59 months) are considered
moderately or severely underweight. 10 Children whose height/length-for-age indicator is
more than two or three standard deviations below the median for the international reference
population (ages 0-59 months) are considered moderately or severely stunted. 11 Children
whose weight-for-height/length indicator is more than two or three standard deviations
below the median for the international reference population (ages 0-59 months) are
considered moderately or severely wasted. 12
According to Porter and Kaplan, the initial metabolic response of malnutrition is

decreased metabolic rate. To supply energy, the body first breaks down adipose tissue.
Later, when these tissues are depleted, the body may use protein for energy, resulting
in a negative nitrogen balance. Visceral organs and muscle are broken down, 23 and a
decrease in weight occurs. Loss of organ weight is greatest in the liver and intestines,
intermediate in the heart and kidneys, and least in the nervous system.13
Children who are malnourished are at far greater risk of contracting pneumonia,
measles, diarrhoea, malaria, and HIV/AIDS, and of dying from these conditions.
Malnutrition affects a child’s growth, morbidity, mortality, cognitive development, and
physical work capacity. It also impacts on human performance, health, and survival.14
11
Nzala, Siziya, Babaniyi, Songolo, Muula and Rudatsikira conducted a cross-sectional
study with the objective to determine associations of demographic, cultural and
environmental factors with frequency and severity of malnutrition among children less
than 5 years of age in Zambia. The researchers used data from the Zambia Multiple
Indicator Cluster Survey of 1999-2000 and included 6,142 children in the survey. Their
study discovered that child malnutrition was associated with the male gender, a low
education level on the part of the householder and mother, poverty, incomplete
vaccination status, and the type of toilet used by the child.15
A population-based multicentre nested case-control study conducted by Shargi, Kamran

and Faridan (2011), which included 76 underweight children and 76 controls in the city of
Namin in Iran, showed that the female gender, poverty, short maternal height, and the use
of unhygienic latrines in the home were significantly associated with childhood
malnutrition. In an age-matched case-control study including 102 severely malnourished
under-five children and 102 well-nourished children.16Amsalu and Tigabu (2006) found
that severe acute malnutrition in Ethiopia was independently associated with a lack of
exclusive breastfeeding for the first six months of life and late initiation of complementary
diet.17
To assess the nutritional status and to determine potential risk factors of malnutrition in
children under 3 years of age in Nghean (Vietnam), Hien and Hoa (2009) conducted a cross-
sectional descriptive survey using a structured questionnaire and measurements of weight
and height of children aged 6-36 months. The research found that region of residence (urban
or rural), ethnicity, mother’s occupation, household size, mother’s body mass index,
number of children in family, weight at birth, time of initiation of breastfeeding, and
duration of breastfeeding were significantly correlated with child malnutrition.18
Turyashemererwa, Kikafunda and Agabe (2009) assessed by means of a cross-sectional

descriptive study using both qualitative and quantitative methods of data collection the
prevalence of malnutrition and the factors influencing the nutritional status of children
under 5 years of age in a peri-urban environment in Kabarole District in western Uganda.
They administered a questionnaire to 93 caretakers of children aged 6-59 months in
randomly selected households and held focus group discussions with a few selected
participants. The findings from their study revealed that education level of the
12
mother/caretaker, age of the child, receipt of information on child feeding, and time of
introduction of other foods were significantly correlated with malnutrition.19
In 2006, Mahgoub et al conducted a cross-sectional descriptive survey using a structured

questionnaire and measurements of weight and height of under-three children. Four
hundred households and mothers of children under 3 participated in the study, whose
objective it was to evaluate the level of malnutrition and the impact of some socioeconomic
and demographic factors of households on the nutritional status of children less than 3 years
of age in Botswana. The study revealed that malnutrition was significantly higher among
boys than among girls, underweight was less prevalent among children whose parents were
involved in informal business, children brought up by single parents suffered from
underweight to a significantly higher level than children living with both parents, the
prevalence of underweight decreased significantly as family income increased, the higher
the level of the mother’s education, the lower the level of child underweight observed, and
breastfeeding was found to reduce the occurrence of underweight among children.14
Previous studies on child malnutrition have had the strength of including representative
samples and using structured questionnaires and a collection of anthropometric data
through measurements of the length/height and weight of participant children by the
researchers. For example, Nzala et al (2011) included 6,142 children less than 5 years in
their study; Nnyepi et al (2010) included 742 households and 1,003 children; Hien and Hoa
(2009) selected 383 child/mother pairs for their study; Mahgoub et al (2006) included 400
households and mothers of children under 3, representing the 23 health regions of
Botswana; Rayhan and Khan (2006) had a sample of 5,419 children; Amsalu and Tigabu
(2006) included 102 cases and 102 age-matched controls and Shargi et al (2011) had a
sample of 76 children with malnutrition (the cases) and 76 children without malnutrition
(the controls) to identify risk factors for protein-energy malnutrition in children under 6
years of age in the city of Namin in Iran.14,15,17,18,20,21
In a study conducted in Bangladesh in 2006 showed that, 45 percent of the children

under age five were suffering from chronic malnutrition, 10.5 percent were acutely
malnourished and 48 percent had under-weight problem. The main contributing factors
for under five malnutrition were found to be previous birth interval, size at birth,
mother‟s body mass index at birth and parent’s education. Children with previous birth
13
interval 0-23 months and 24-47 months had respectively 1.4 times and 1.2 times higher
risk of being under weighted as compared to children with previous birth interval 48
and above months. Babies were very small in size and smaller than average had
respectively 3.93 times and 2.23 times higher risk of being underweighted than those
children who were average or larger in size at birth. Children of nourished mother were
38 percent less likely to be under-weighted compared to children of acutely
malnourished mother. Father’s education and prevalence of underweight were inversely
related. Risks of under-weight were 0.98 and 0.70 times lower for children of fathers
attended primary and secondary level respectively, comparing to the children of
illiterate fathers. 21
A community based, cross-sectional study was conducted on 541 mother-child pairs of

6-59 month old children in December 2012 in titled with Magnitude and factors
associated with malnutrition in children 6-59 months of age in pastoral community of
Dollo Ado district, Somali region, Ethiopia by Solomon Demissie and Amare Worku.
This study revealed that, that the overall prevalence of malnutrition in the community
was high with 42.3% of the children being wasted, 34.4% for stunting and 47.7% for
underweight. All three forms of malnutrition (wasting, stunting and underweight) was
more prevalent among boys than girls with a statistically significant of P<0.031.
Prevalence of wasting was higher among young children while stunting and
underweight were more likely to be observed in older children. Regression analysis
shows that the significant determinants of malnutrition were gender and age of child,
marital status, maternal education, monthly HH income, decision making, having of
livestock, presence of ARI, total number of children ever born, health status during
pregnancy, pre-lactation practice, mode of feeding, access to clean water and type of
floor in the households.22
A population-based, multicenter case-control study in titled with „Evaluating risk

factors for protein-energy malnutrition in children under the age of six years: a
casecontrol study from Iran‟ was carried out by Afshan Sharghi, Aziz Kamran and
Mohammad Faridan with 76 children with malnutrition (case) and 76 children without
malnutrition (control) shows that female gender, poverty, short maternal height, and
use of unhygienic latrines in the home were significantly associated with childhood
malnutrition (P <0.05), but there was no relationship between maternal age at child
14
birth or presence of chronic disease and childhood malnutrition. Maternal factors, those
that were directly related to childhood malnutrition were short maternal stature,
maternal unemployment, and hyper emesis of pregnancy. In addition, of the
environmental factors, age close to that of the next oldest sibling, poor latrine hygiene
in the home, passive exposure to cigarette smoke, use of kerosene instead of gas as the
main domestic fuel at home were factors that had a significant relationship with
childhood malnutrition. The socioeconomic factors in this study which had a significant
relationship with childhood malnutrition were migration during the previous 5 years
and poverty in the family. Ultimately, after logistic regression analysis, the only
variables that maintained a significant relationship with childhood malnutrition were
maternal height, female gender, poverty, and presence of unhygienic latrines in the
home.23
A cross sectional study carried out by J. Haidar, G. Abate, W. Kogi-Makau and P.

Sorensen in titled with „risk factors for child under-nutrition with a human rights edge
in rural villages of north Wollo, Ethiopia‟ in One hundred-forty four sampled
households with under five year old children (n=200) comprising of 96 male-headed,
24 female-headed and 24 landless with children aged between six and 59 months
showed that; The overall prevalence rate of under nutrition as determined by stunting,
underweight and wasting was 44.5%, 25.0% and 9.0% respectively with more
preponderance among the toddlers. The proportion of under nutrition was higher in
female-headed households. Shortage of farmland, lack of irrigation, dispossession of
livestock, shortage of non-farm employment options, parental illiteracy, high number
of children, water inadequacy, food taboos and wrong eating habits of families, poor
child feeding practices, deprivation of health nutrition education as well as maternal
attributes such as young motherhood, low body mass index and short stature of mothers.
The most important risk factors for underweight were lower maternal stature and child
feeding practices specifically; the practice in which the child ate from the same platter
with the rest of the household members. A significantly high proportion of children
who were introduced to complementary foods before or after six months of age were
stunted while those whose feeding frequency was low were at a higher risk of stunting
and underweight.24
15
Protein-energy malnutrition (PEM) is a serious health problem among young children
in Bangladesh. PEM increases childhood morbidity and mortality. Information is
needed on the major risk factors for PEM to assist with the design and targeting of
appropriate prevention programs. To compare the underlying characteristics of
children, aged 6-24 months, with or without severe underweight, reporting to the Dhaka
Hospital of ICDDRB in Bangladesh, a case-control study was conducted among 507
children with weight-for-age z-score (WAZ) <-3 and 500 comparison children from the
same communities with WAZ >-2.5. There were no significant differences between the
groups in age [overall mean±standard deviation (SD)
12.6±4.1 months] or sex ratio (44% girls), area of residence, or year of enrollment.
Results of logistic regression analysis revealed that severely-underweight children were
more likely to have: undernourished mothers [body mass index (BMI) <18.5, adjusted
odds ratio (AOR)=3.8, 95%CI 2.6-5.4] who were aged <19 years (AOR=3.0, 95% CI
1.9-4.8) and completed <5 years of education (AOR=2.7, 95% CI 1.9-3.8), had a history
of shorter duration of predominant breastfeeding <4 months, (AOR=2.3, 95% CI 1.6-
3.3), discontinued breastfeeding (AOR=2.0, 95% CI 1.1-3.5), and had higher birth-
order >3 (OR=1.8, 95% CI 1.2- 2.7); and fathers who were rickshawpullers or unskilled
day-laborers (AOR=4.4; 95% CI 3.1-6.1) and completed <5 years of education
(AOR=1.5; 95% CI 1.1-2.2), came from poorer families (monthly income of <5,000,
AOR=2.7, 95% CI 1.9-3.8) and Teen-aged mother (AOR=2.86; 95% CI1.99-4.12).
Parental education, economic and nutritional characteristics, childfeeding practices,
and birth-order were important risk factors for severe underweight.24
A study carried out by Ruwali D in titled „Nutritional Status of Children Under Five
Years of Age and Factors Associated in Padampur VDC, Chitwan‟, a cross sectional
study among 150 under five children showed that Prevalence of stunting, underweight
and wasting was 22.7%, 37.3% and 25.7% respectively. Study indicated that the risk of
stunting increases with age. Socioeconomic status was most important factors
associated with stunting, underweight and wasting. Meeting the minimum dietary
diversity, minimum meal frequency and minimum acceptable diet was associated with
better nutritional status of children. 1
The researcher has noticed the following limitations from the above mentioned studies. In
some of the studies, participants were restricted to children under 3 years of age. Hien and
16
Hoa; Mahgoub et al, Nnyepi et al, Nzala et al, Hien and Hoa, Mahgoub et al,
Turyashemererwa et al, and Rayhan and Khan applied a cross-sectional study design to
investigate the factors associated with child malnutrition in their respective investigations.
However, Joubert and Ehrlich report that although cross-sectional studies are relatively easy
and economical to conduct, and are useful for evaluating the relationships between
exposures that are relatively fixed characteristics of individuals, they also have some
limitations. Cross-sectional studies are not able to distinguish between factors that cause
the disease and factors that prolong the period with the disease. Compared to cohort studies
and case-control studies, cross-sectional studies provide weaker evidence about disease
causation and do not assess and compare the occurrence of new cases of disease (incidence)
in the group of people with the disease and the group of people without the disease.
In the current study, the researcher extended the age of participant children up to 59 months
and applied a case-control study design because of budget and time constraints (a cohort
study is costly and time-consuming). Another reason in the choice of this study design is
that the researcher wanted to provide stronger evidence about the causation of malnutrition
than has been the case in previous cross-sectional studies. He also wanted to assess and
compare the occurrence of new cases of underweight (incidence) in two groups.
CHAPTER III
METHODOLOGY
3.1 Study Area

This study was conducted in Padampur VDC of Chitwan district, one of the rural
VDC where various ethnic groups of people were resided.
3.2 Study Design

The study design was case control with matching age and community of children.
The data was collected by interviewing mothers of both case and control children
of age under 5 years
Cases: Cases were underweight children (low weight for age). The criterion for
underweight was: Z-value less than -2 standard deviations (SDs) below the median
weight-for-age. Underweight was ascertained by using weight-for-age indicator
according to WHO new growth standards 2006.
17
Controls: Controls were children without underweight: Z-value equal to or above
-2 SDs. It was also ascertained by using weight-for-age indicator according to WHO
new growth standards 2006.
3.3 Study Population

Study populations were children under 5 years and their mothers in Padampur VDC
of Chitwan district.
3.4 Sample size:

The sample size has been calculated by using Epi Info 7 StatCalc with following
values based on a study9: confidence level = 95%, power (1-β) = 80%, case control
ratio = 1:2, percentage of control exposed = 10.5%, odds ratio = 2.86. The total
sample size is 258 i.e. Cases=86 and control= 172. Assuming 10% non response
rate, 284 samples were approached for study. Among 284 children that were
approached for study. 5 questionnaires were incomplete and not included in
analysis. Finally there were 279 children in the study (93 cases and 186 controls).
3.5 Sampling Methods / Techniques:

Padampur VDC of Chitwan district was selected purposively. There were 1154
children who were under five years of age. At first, among all households having
under five children, underweight and normal children were identified by doing
household survey. Three days household survey was carried out by using FCHVs,
SHP representative and researcher himself. During household survey, only
youngest children of the family were included so that only 1085 children were
included for the study. At the time of survey only age and weight of children were
measured by using standard measuring instruments and categorized all children into
underweight and normal group by using weight-for-age indicator according to
WHO new growth standards 2006. That household survey found that there were
326 underweight children and remaining 759 children were normal. Among these
underweight and normal children, required cases (93) and controls (186) were
selected by doing simple random probability sampling.
18
Total under five children
(1154)
No of eligible children for the

study (1085)
Household survey
Underweight Normal children

children (759)
Simple Random Sampling

Case Control
(93) (186)
Fig: sampling methods/technique
3.6 Sampling Unit:
Children under 5 years of age and their mothers of Padampur VDC of Chitwan
district were the sampling units for the study.
3.7 Criteria for Sample Selection (Inclusion and Exclusion Criteria):
Inclusion Criteria
Children under five years of age were included. Only one child from each
family was included. If there were more than one child in the same house,
youngest one was selected for the study. Exclusion Criteria
Child with physical disability was excluded from the study
3.8 Data Collection Technique / Methods:
19
Data collection technique was interview and anthropometric measurement of
weight of children. The respondents were mothers of children under five years
of age. Data was collected by direct involvement of researcher himself although
FVHVs were used during household survey prior to the data collection.
3.9 Data Collection Tools:
The pretested structured questionnaire in Nepali language was used for the data
collection. Well established measuring instruments were used for
anthropometric measurement (weight) of the children. These instruments were
available from the Department of Community Medicine and Public Health,
Chitwan Medical College, Bharatpur, Chitwan.
3.10 Validity and Reliability of the Study Tools

Validity
Pre-testing of the tools was done in Jutpani VDC of the Chitwan district.
Precision in age was maintained as it was calculated using date of birth. Weight
was measured by using valid measuring instrument which were available from
the Department of Community Medicine and Public Health, Chitwan Medical
College, Bharatpur, Chitwan.
Reliability
Measuring tool was checked for their consistency. Standard questionnaire and
questions without ambiguity was used. Researcher himself was collected data.
3.11 Plans for Data Management and Analysis:

Data processing
Data compiling, checking and editing was done manually. Data cleaning,
entry and analysis was done in SPSS software 16.0 version. Data
analysis
Chi-square test was carried out to assess the association between different
independent variables and dependent variable. Those variables significantly
associated with underweight (p-value<0.05) were further subjected to bivariate
analysis. Similarly variables that were found significant in the bivariate analysis
were further analyzed in the multiple regression analysis to identify the strong
20
predictor of underweight by adjusting the confounding effects of other
variables.
3.12 Ethical consideration

National ethical guidelines developed by Nepal Health Research Council
(NHRC) and the suggestions from the thesis committee (CMC-IRC) were
followed for respecting the ethical issues in research. Permission from DPHO
and VDC was taken before starting the data collection. Complete voluntarism
for the participation of respondents in the study process was ensured.
Confidentiality of the information obtained was maintained and assured to all
the participants during the process of data collection. Purpose of the study,
potential benefits and harms were explained and ensured during the process.
3.13 Plan for data collection

The process of data collection was initiated after getting approval from thesis
committee of department of community medicine and Public Health
(CMCIRC). Tools for data collection (questionnaire) was developed and
pretested before starting data collection. The comments from feedback were
incorporated in the final tools. Collected data were verified and edited on the
same day to minimize mistakes and to maintain consistency.
CHAPTER IV FINDINGS
This chapter presents the result of the study obtained from the analysis and
interpretation of the data. This study was conducted to identify the risk factors for
underweight among children under 5 years. Underweight children were identified at
field level by using WHO simplified field tables. It was calculated by using the
reference median and classified according to the standard deviation (expressed as
Zscore) which is based on WHO new standard 2006. For this indicator two standard
deviation below the reference median (i.e. <-2SD) was considered as underweight
(weight for age).
21
4.1 Descriptive analysis
4.1.1 Socio-demographic and economic characteristics
Table 4.1.1 shows that among 279 children, higher proportion (31.2%) of children was
in the age group 13-24 months and lower proportion (5.4%) in age group 49-60 months.
Mean age of children was 22.3±15.5. Age group of cases and controls were more or
less similar with mean age of total children. Mean age of cases and controls were
22.1±14.9 and 22.4±15.8. Among all children 57.3% were male and 42.7% were
female. Likewise 80.3% children had birth order 1-2 followed by birth order 34(14.5%)
and more than 5(2.7%).
Regarding the religion status of family, more family (66.1%) were Hindu followed by
Buddhist (19.9%) and Christian (14.0%). Most of the children (77.8%) were from
Disadvantaged janajatis group of ethnicity where as 10.4%, 8.2% and 3.6% from Dalit,
Upper cast and Relatively advantaged janajaties respectively. Among mothers, 21.5%
were illiterate, 48.7% had primary level education and 14.0% had secondary level
education. In case of mother’s occupation, 85.7% mothers were house wife and only
14.3% mother had some means of income. Among them, 7.5% had small business type
occupation like tailoring and small shop.
Economic status of family were measured by two indicators i.e. wealth quintle and food
security condition of the family. Regarding the wealth quintle, 19.6% family had low
wealth quintle whereas all others level (second, middle, fourth and highest) includes
similar 20.1% family. Majority (66.3%) of the households had insecure whereas only
33.7% had secured status of food security.
Table 4.1.1: Socio-demographic and economic characteristics of the study

population
Nutritional Status (weight for age)

Total n=279
Characteristics Case n=93(%) Control (%)
n=186(%)
Age of children(month)
0-12 28(30.1) 61(32.8) 89(31.9)

13-24 29(31.2) 44(23.7) 73(26.2)
22
25-36 19(20.4) 43(23.1) 62(22.2)
36-48 12(12.9) 23(12.4) 35(12.5)
49-60 5(5.4) 15(8.1) 20(7.2)
Mean age (in months) 22.1±14.9 22.4±15.8 22.3±15.5
sex of the children
Male 45(48.4) 115(61.8) 160(57.3)
Female 48(51.6) 71(38.2) 119(42.7)
Birth order
1-2 70(75.3) 154(82.8) 224(80.3)
3-4 20(21.5) 27(14.5) 47(16.8)
≥5 3(3.2) 5(2.7) 8(2.9)
Religion
Hindu 65(69.9) 123(66.1) 188(67.4)
Buddhist 12(12.9) 37(19.9) 49(17.6)
Christian 16(17.2) 26(14.0) 42(15.1)
Ethnicity
Dalit 11(11.8) 18(9.7) 29(10.4)
Disadvantaged janajatis 75(80.6) 142(76.3) 217(77.8)
Relatively advantaged 3(3.2)
janajaties 7(3.8) 10(3.6)
Upper cast groups 4(4.3) 19(10.2) 23(8.2)
Nutritional Status (weight for age)

Total n=279
Characteristics Case n=93(%) Control (%)
n=186(%)
[[[ Educational status of the mother
Illitrate 30(32.3) 30(16.1) 60(21.5)

Informal education 12(12.9) 19(10.2) 31(11.1)
Primary education 47(50.5) 89(47.8) 136(48.7)
Secondary education 3(3.2) 36(19.4) 39(14.0)
23
Inter-mediate (10+2) 1(1.1) 9(4.8) 10(3.6)
Higher education 0(0.0) 3(1.6) 3(1.1)
Occupation of mother
Housewife 87(93.5) 152(81.7) 239(85.7)
Business 1(1.1) 20(10.8) 21(7.5)
Labor 4(4.3) 4(2.2) 8(2.9)
Service 0(.0) 3(1.6) 3(1.1)
Others 1(1.1) 7(3.8) 8(2.9)
Wealth Quintile
Low 27(29.0) 28(15.1) 55(19.6)
Second 26(28.0) 30(16.1) 56(20.1)
Middle 19(20.4) 37(19.9) 56(20.1)
Fourth 12(12.9) 44(23.7) 56(20.1)
Highest 9(9.7) 47(25.3) 56(20.1)
Food Security status
Insecure 77(82.8) 108(58.1) 185(66.3)
Secure 16(17.2) 78(41.9) 94(33.7)
4.2 Bivariate analysis
4.2.1. Association of socio-demographic and economic characteristics and

underweight.
The association between independent variables such as sex of children, education of

mother, income status of mother, occupation of mother, wealth quintile and household
food security showed significant association when comparing case and control groups.
But some variables such as age of children, birth order, ethnicity and religion did not
showed significant association with underweight.
According to the bivariate analysis, female children were 1.728 times more likely to be
case than male children (95% CI 1.045-2.857). The illiteracy was 2.476 times higher
among the mothers of cases than controls (95% CI 1.380-4.443). Likewise mother who
had no income were 3.723 times higher among the cases as compared to those who had
24
monthly income (95% CI 1.512-9.164). Mother‟s occupation as housewife was 3.243
times higher among cases as compared to controls (95% CI 1.309-8.034). Household
food security and wealth quintle of the family were also significantly associated with
the underweight. The families with no food security were 3.476 times higher risk to
have underweight children as compared to families with food security (95% CI 1.867-
5.777). It was also found that children from low, second and middle wealth quintle level
family are more likely to be underweight as compared to children from fourth and
highest level family (OR=3.284,95% CI 1.867-5.777).
Table 4.2.1: Association between socio-demographic and economic

characteristics and underweight
Case Control Total P- Unadjusted OR

Characteristics
n=93(%) n=186(%) n=279(%) value (95% CI)
Sex of children
Female
48(51.6) 71(38.2) 119(42.7) 0.032 1.728(1.045-2.857)*
Male 45(48.4) 115(61.8) 160(57.3) 1
Education of mother
Illiterate 30(32.3) 30(16.1) 60(21.5) 0.002 2.476(1.380-4.443)*
Literate 63(67.7) 156(83.9) 219(78.5) 1

Characteristics
n=93(%) n=186(%) n=279(%) value (95% CI)
Incoming mother
No 87(93.5) 148(79.6) 235(84.2) 0.003 3.723(1.512-9.164)*
Yes 6(6.5) 38(20.4) 44(15.8) 1
Occupation of
mother
Others 87(93.5) 152(81.7) 239(85.7) 0.008 3.243(1.309-8.034)*
25
House wife 6(6.5) 34(18.3) 40(14.3) 1
Household food security

Insecure 77(82.8) 108(58.1) 185(66.3) <0.001 3.476(1.884-6.411)**
Secure 16(17.2) 78(41.9) 94(33.7) 1
Wealth Quintle
Low, Second and
Middle 72(77.4) 95(51.1) 167(59.9) <0.001 3.284(1.867-5.777)**
Fourth and Highest 21(22.6)) 91(48.9) 112(40.1) 1
*significant at <0.05, ** significant at <0.001, 1reference category
4.2.2: Association between families related characteristics and underweight
In case of birth order, 80.3% children had birth order second and less among them
68.7% were not underweight. Almost one fifth of children (19.7%) had birth order three
and more among them 41.8% were underweight. Most of the mothers 52.7% were under
age group 20-30 years likewise 47.3% mothers were under the age group below 20 and
more than 30 years. More than half mothers (58.4%) had height 150 cm and more
among them 61.1% had normal children. And 41.6% mothers had height less than 150
cm among them 35.3% had underweight children. Most of the children were received
care from their mothers (91%) and only 9% children were received care from other
members of the family beside mothers.
From the binary logistic regression analysis of family related variables and
underweight, birth order of children and height of mothers were not significantly
associated with underweight. But some variables like age of the mothers and care giver
of children were significantly associated with underweight. Children from mothers age
below 20 and more than 30 years were more likely to be case than the control
(OR=2.343, 95% CI 1.407-3.902). Children who were received care from the other
members of the family besides mother were 3.385 times more likely to be case than
control (95% CI 1.456-7.867)
Table 4.2.2: Association between families related

26
Characteristics
n=93(%) n=186(%) n=279(%) value (95% CI)
Birth order Third
and more 23(24.7) 32(17.2) 55(19.7) 0.136 1.581(0.863-2.898)
Second and less 70(75.3) 154(82.8) 224(80.3) 1
Age of mother at child birth

<20 and >30 years 57(61.3) 75(40.3) 132(47.3) 0.001 2.343(1.407-3.902)*
20-30 years 36(38.7) 111(59.7) 147(52.7) 1
Height of mother
Less than 150 cm 41(44.1) 75(40.3) 116(41.6) 0.548 1.167 (.705-1.930)
150 cm and more 52(55.9) 111(59.7) 163(58.4) 1
Care giver of children

Others
25(9.0)
15(16.1) 10(5.4) 0.003 3.385(1.456-7.867)*
Mother 78(83.9) 176(94.6) 254(91) 1
*significant at <0.05, 1reference category
4.2.3: Association between health service utilization related characteristics and

underweight
Among all mothers 88.9% mothers were visited health institution for ANC service
among them 57.3% mothers did not completed the course of four ANC visit and 42.7%
mothers had completed. In case of TT vaccine taken, 91.8% mothers completed the two
course of TT vaccine during their pregnancy where as 8.2% mothers did not taken TT
vaccine. Likewise, only 39.8% mothers had completed iron tablet course of intake, 52%
mothers had not completed and 8.2% mothers had never intake. Among all deliveries,
55.9% deliveries were in health facilities and remaining 44.1% deliveries were in home
or other places. 67% mothers had not visited PNC where as 33% mothers visited PNC
among visited mothers 80.4% mothers had not completed three PNC visits and only
19.6% mothers had completed the three or more PNC visits.
In the binary logistic regression analysis, ANC visit, number of ANC visits, place of
delivery, PNC visit and TT vaccine taken had significantly associated with underweight
27
whereas number of PNC visits and iron tablet intake are not significantly associated.
Those children whose mothers had not visited ANC were 2.369 times more likely to be
case than the control (95% CI 1.114-5.035). Among ANC visited mothers, children
with less than four ANC visited mother are more likely to be underweight in
comparison to children of four and more ANC visited mothers (OR=2.636,95% CI
1.469-4.728). Children who were delivered in house and other places are 2.054 times
higher in case than the control. Children of no PNC visited mothers are 2.860 times
more likely to be case than control (95% CI 1.655-5.515). Children of no TT vaccine
taken mothers are 2.860 times more likely to be case than control (95%CI 1.203-6.797).
Table 4.2.3: Association between health service utilization related characteristics

and underweight
Control
Case n=186( Total Unadjusted OR

Characteristics n=93(%) %) n=279(%) P-value (95% CI)
ANC visit
No 16(17.2) 15(8.1) 31(11.1) 0.022 2.369(1.114-5.035)*
Yes 77(82.8) 171(91.9) 248(88.9) 1

Numbers of ANC visit (n=248)
Less than 4 visits 56(72.7) 86(50.3) 142(57.3) 0.001 2.636(1.469-4.728)*
4 and more visits 21(27.3) 85(49.7) 106(42.7) 1
TT vaccine Taken
No 13(14.0) 10(5.4) 23(8.2) 0.014 2.860(1.203-6.797)*
Yes 80(86.0) 176(94.6) 256(91.8) 1
Iron tablet intake (n=256)

Incomplete 50(61.7) 95(54.3) 145(56.6) 0.264 1.358(.793-2.326)
Complete 31(38.3) 80(45.7) 111(43.4) 1
Place of delivery
Home and other
place 52(55.9) 71(38.2) 123(44.1) 0.005 2.054(1.240-3.404)*
Health Facility 41(44.1) 115(61.8) 156(55.9) 1
28
PNC visit
No 76(81.7) 111(59.7) 187(67.0) <0.001 3.021(1.655-5.515)**
Yes 17(18.3) 75(40.3) 92(33.0) 1

Numbers of PNC visit (n=92)
Less than 3 visits 15(88.2)
59(78.7) 74(80.4) 0.369 2.034(0.421-9.830)
Three or more
2(11.8) 16(21.3) 18(19.6) 1
visits
4.2.4: Association between environmental related

Regarding the environmental characteristics of the house, 87.5% households had wood
as a cooking fuel and only 12.5% households had LPG gas as a cooking fuel. Likewise
87.8% household had not improved cooking stove whereas only 12.2% household had
improved cooking stove. Among those house where wood was the cooking fuel, 77.1%
house had no ventilation in kitchen. More than half of the household (53.4%) had
separate kitchen and 46.6% had no separate kitchen. 64.2% household had no
ventilation in house whereas only 35.8% households had ventilation in house. In case
of toilet presence, 90.7% households had toilet in their house whereas only 9.3%
households had no toilet. Among households having toilet, 50.6% had dug well toilet
and remaining 49.4% had modern toilet.
Among all environmental factors, fuel for cooking, type of cooking stove, separate
kitchen and ventilation in house showed the significant association with underweight
but some factors like ventilation in kitchen, presence of toilet and type of toilet did not
showed significant association. The odds of having underweight children were 9.814
times higher in the house where wood was used as cooking fuel than those who used
LPG gas (OR= 9.814, 95% CI 2.300-41.865). The odds of underweight children were
9.455 times higher in the house where cooking stove was not improved (OR=9.455,
95% CI 2.214-40.381). The odds of underweight children were 2.811 times higher in
29
those houses where kitchen had been separated than those houses where kitchen had
not been separated (OR=2.811, 95% CI 1.679-4.706). Similarly the odds of getting
underweight children were more likely where
Table 4.2.4: Association between environmental related characteristics and

underweight
Unadjusted OR (95%
Case Control Total
Characteristics n=93(%) n=186(%) n=279(%) Pvalue CI)
Fuel used for cooking
Woods 91(97.8) 153(82.3) 244(87.5) <0.001 9.814(2.300-41.865)**
LPG gas 2(2.2) 33(17.7) 35(12.5) 1
Type of cooking stove

Not improved 91(97.8) 154(82.8) 245(87.8) <0.001 9.455(2.214-40.381)**
Improved 2(2.2) 32(17.2) 34(12.2) 1
Ventilation in kitchen (if wood as fuel) n=245)

(
No 117(76.0) 1.198 (0.641-2.242)
72(79.1) 189(77.1) 0.571
Yes 19(20.9) 37(24.0) 56(22.9) 1
Separate kitchen
No 59(63.4) 71(38.2) 130(46.6) <0.001 2.811(1.679-4.706)**
Yes 34(36.6) 115(61.8) 149(53.4) 1
Ventilation in house
No 79() 100() 179(64.2) <0.001 4.853(2.566-9.178)**
Yes 14() 86() 100(35.8) 1
30
Presence of toilet
No 11(11.8) 15(8.1) 26(9.3) 0.308 1.529(.673-3.477)
Yes 82(88.2) 171(91.9) 253(90.7) 1
Types of toilet
Dug Well Latrine
45(54.9) 83(48.5) 128(50.6) 0.345 1.289(.760-2.187)
Modern 37(45.1) 88(51.5) 125(49.4) 1

4.2.5: Association between feeding practices and underweight
Among all respondents 40.1% initiated breast feeding after one hour but 91%
respondents fed colostrum to their children after birth. 52% respondents had not
practice exclusive breast feeding for 6 months and more than half (60.2%) respondents
fed their children with complementary food during 6 months. Similarly, 40.3%
respondents fed complementary food to their children less than three times per day and
39.8% respondents had not fed protein rich animal foods (meat, egg and fish) weekly
to their children. Likewise 81% of children had consumed minimum diversified food
below the standard of WHO. Children who had less than usual feeding during illness
were 89.8% and only 10.2% of children had fed as usual during illness.
Among all variables time of breast feeding start, exclusive breast feeding period,
complementary feeding times, meat egg fish intake and minimum food diversity are
significantly associated with the underweight. But some variables like colostrum
feeding, complementary feeding, times of meat egg fish intake and feeding during
illness are not significantly associated with underweight. Breast feeding start practice
after one hour was significantly higher among underweight children (OR=2.033, 95%
CI 1.225-3.375). Children who had exclusively breast fed less than and more than 6
months are 2.018 times more likely to be underweight in comparison with children who
had exclusively breast fed up to 6 months (OR=2.018, 95% CI 1.210-3.364). Similarly
31
children who had fed complementary food less than 3 times per day are 2.769 times
more likely to be underweight (OR=2.769, 95% CI 1.568-4.890). Children who had not
fed meat, egg and fish weekly are more likely to be underweight (OR=3.694, 95% CI
2.071-6.590). Likewise minimum food diversity was highly associated with
underweight status of children. Minimum food diversity below standard were 13.917
times higher among underweight children (OR=13.917, 95% CI 3.266-59.313).
Table 4.2.5: Association between feeding practices and underweight

Total
Case Control P- Unadjusted OR (95%
Characteristics n=279(%
n=93(%) n=186(%) value CI)
)
Breast feeding start
After one hour 48( 51.6) 64( 34.4) 112(40.1) 0.006 2.033(1.225-3.375)*
Within one hour 45( 48.4) 122( 65.6) 167(59.9) 1

Colostrums feeding
No 12( 12.9) 13( 7.0) 25(9.0) 0.103 1.972(0.862-4.511)
Yes 81( 87.1) 173( 93.0) 254(91.0) 1
Exclusive breast feeding
<6 and >6 Months 59( 63.4) 86( 46.2) 145(52.0) 0.007 2.018(1.210-3.364)*
Up to 6 months 34( 36.6) 100( 53.8) 134(48.0) 1

Complementary feeding
Before and after 6 months 39(41.9) 72(38.7) 111(39.8) 0.604 1.144(0.689-1.898)
During 6 months 54(58.1) 114(61.3) 168(60.2) 1
Feeding times (per day)
Less than 3 times 43(56.6) 48(32.0) 91(40.3) <0.001 2.769(1.568-4.890)**
3 or more times 33(43.4) 102(68.0) 135(59.7) 1
Meat, egg, fish intake (per week)
No 46(60.5) 90(39.8) <0.001 3.694(2.071-6.590)**
44(29.3)
Yes 30(39.5) 106(70.7) 136(60.2) 1
Times of meat, egg, fish intake (per week) (n=136) 71(
67.0)
Less than 3 times 21( 70.0) 0.755 1.150(.477-2.772)
92(67.6)
3 or more times 9( 30.0) 35( 33.0) 44(32.4) 1
32
Minimum food diversity
(n=226)
Below standard 183(81.0)
74( 97.4) 109( 72.7) <0.001 13.917(3.266-59.313)**
Standard 2( 2.6) 41( 27.3) 43(19.0) 1
Feeding during illness
(n=226)
Less than usual 203(89.8)
71( 93.4) 132( 88.0) 0.203 1.936(.690-5.434)
As usual and more 5( 6.6) 18( 12.0) 23(10.2) 1
4.2.6: Association between childhood diseases and underweight
Occurrences of childhood diseases are important factors for underweight among

children. Among all children 37.3% children had no ARI and 62.7% children had one
and more times ARI in past 2 months. Similarly 62% children had no diarrhea and 38%
children had one or more times diarrhea in past 2 months.
Among these two childhood diseases, diarrhea had significantly associated with
underweight. Diarrhea was 2.354 times higher among cases as compared to controls
(OR=2.354 95% CI 1.411-3.926).
Table 4.2.6: Association between childhood diseases and underweight
Case Control Total Unadjusted OR

Characteristics n=93(%) n=186(%) n=279(%) Pvalue (95% CI)
Birth Weight
(n=178)
<2.5 kg 5(11.1) 15(11.3) 20(11.2) 0.976 0.983(0.336-2.878)
2.5 kg and more 40(88.9) 118(88.7) 158(88.8)
ARI
One or more times 64(68.8) 111(59.7) 175(62.7) 0.137 1.491(0.880-2.527)
No illness 29(31.2) 75(40.3) 104(37.3) 1
Diarrhoea
One or more times 48(51.6) 58(31.2) 106(38.0) 0.001 2.354(1.411-3.926)*
33
No illness 45(48.4) 128(68.8) 173(62.0) 1
4.3 Multi-variate logistic regression analysis

Simple cross tabulation may lead to the misleading information as the relationship
between dependent and independent variable may be confounded by other variables.
From the bi-variate analysis we examined that the relationship exist between certain
independent variables and the dependent variable. So, to identify the independent effect
of each of the independent variables and to identify the most significant factors of the
underweight, multiple regression analysis was done.
The variables which are significant at 95% confidence interval (p<0.05) in bivariate
analysis were put into multivariate analysis. Adjusted odds ratio was calculated to
measure the net effect size of variables. Hosmer and Lemeshow Chi-square test was
used to test the goodness-of-fit.
The values of multivariate regression analysis of this study were fitted on regression
equation, y= b0+b1X1+b2X2+………..+bkXk17, where y is the log of the dependent
variable, b0 is the constant and k independent x variables which is shown as,
Underweight= -5.480 + 1.80 (care giver of children) + 1.15 (PNC) + 1.636 (income of
mother)
Table 4.3 presents the final explanatory models for each after adjusting established risk
factors. Further analysis with logistic regression model revealed that the risk for
underweight was independently associated with PNC visits, caretaker of children and
income of mother.
Children of no PNC visited mothers are 3.158 times more likely to be underweight than
the children of mothers visited PNC (95% CI 1.242-8.028). Children who were received
care from the other members of the family besides mother were 6.047 times more likely
to be case than control (95% CI 1.438-25.424). Similarly, mother who had no income
were 5.133 times higher among the cases as compared to those who had monthly
income (95% CI 1.272-20.712).
34
Table 4.3: variables associated with underweight, multivariate analysis
Unadjusted OR Adjusted OR
Variables (95% CI) (95% CI)
PNC Visits
No 3.021(1.655-5.515) 3.158(1.242-8.028)*
Yes 1 1
Care giver of children

Others 3.385(1.456-7.867) 6.047(1.438-25.424)*
Mother 1 1
Income of mother
No 3.723(1.512-9.164) 5.133(1.272-20.712)*
Yes 1 1
Nagelkerke R Square= 0.379
Hosmer and Lemeshow Test= 0.847
35
CHAPTER V DISCUSSION
The aim of the study was to identify the risk factors of underweight among under five
children in Padampur VDC of Chitwan district. For the validity of the result of the
study, researcher himself was involved in every steps of research activity. Various
things used in research such as questionnaire, measuring standards, conceptual
framework etc. were adopted from articles of index journals and are modified in the
context of Nepal. Well established measuring instruments were available from the
Department of Community Medicine and Public Health, Chitwan Medical College,
Bharatpur, Chitwan. The validity of the study was ensured by selecting controls which
were comparable to the cases for their age and community setting. Although the
information was collected in cross-section of time, it was ensured that exposures were
happening before the outcome. All the procedures and methods were implemented
carefully, thus the results shown by this study are valid.
This study showed that there was no association of age with underweight. But Nepal
Demographic and Health Survey 2011 showed that underweight is higher among 1823
months children and lowest in under 6 months childrens.5 The study conducted in
Vietnam also shows the significant association between age of children and
underweight. Where children more than one year are more likely to be underweight in
comparison with children of age group 0-11 months.25 this study showed this type of
finding because mean age and standard deviation of case and control were almost same
i.e. case were 22.1±14.9 months and control were 22.4±15.8 months.
This study showed that sex of children was significantly associated with underweight
(OR=1.728, 95% CI 1.045-2.857). This finding is resemble with a case-control study
conducted by Shargi et al (2011) to determine the risk factors for protein-energy
malnutrition in children under the age of 6 years in Iran. That study showed that
malnutrition was significantly associated with the female gender.23 But a study
conducted in Ethiopia showed that male children were 1.70 times more likely to be
36
underweight (AOR=1.70 95%CI 1.15-2.51).22 Another study conducted in Vietnam
showed that female are protective than male (OR=0.49. 95% CI 0.31-0.78).25
The study conducted in Zambia concluded that children had illiterate mother were more
likely to be underweight (OR=1.12 95% CI 1.11-1.12).15 Another study in Ethiopia also
showed that children having basic education attended mother were protective than no
education mother (OR=0.18, 95% CI 0.08-0.41).22 All these finding are resemble with
this study where the illiteracy was 2.476 times higher among the mothers of
underweight children (OR=2.476, 95% CI 1.380-4.443).
The study conducted in kailali district of Nepal showed that risk factors for stunting
comprised mothers without earning (OR=3.11, 95% CI 1.26-7.65) and care taker of the
children other than mother (OR=3.02, 95% CI 1.19-7.70). These findings are resembled
with the findings of this study. These both studies shows that nutritional status of
children is highly associated with the earning status of mother and care giver of
children.28
This study showed that income status of mother and occupation of mothers and
caretaker of children was associated with underweight. Mothers who had no income
were 3.723 times higher among the cases as compared to those who had monthly
income (95% CI 1.512-9.164). Mother‟s occupation as housewife was 3.243 times
higher among cases as compared to controls (95% CI 1.309-8.034). Children who were
received care from the other members of the family besides mother were 3.385 times
more likely to be case than control (95% CI 1.456-7.867). These findings are resembled
with the study conducted in Botswana, which showed that children of unemployed
parents were more likely to be underweight (AOR=50.3 95% CI 4.8652.1) and children
raised by other members of house were more likely to be underweight than raised by
their own mothers (AOR= 5.67 95% CI 1.30-24.73). 8
Wealth quintile of the family and food security condition of family both was significantly
associated with underweight in bivariate analysis. The families with no food security were
3.476 times higher risk to have underweight children as compared to families with food
security (95% CI 1.867-5.777). It was also found that children from low, second and
middle wealth quintile level family are more likely to be underweight as compared to
children from fourth and highest level family (OR=3.284,95% CI 1.8675.777). Families
37
from low wealth quintile were unable to produce and purchase a food that‟s why they
became insecure from food. This study provides the basis for this statement. Another
study conducted in Zambia also concluded that decreasing the wealth quintile level of
family increases the underweight children in house.15 but a contradictory finding was
showed by study conducted in Kailali district of Nepal. In that study food insecurity
was not significantly associated with underweight (OR=0.96, 95% CI 0.49-1.88).26
This study showed that age of mother at the time of child birth was a risk factor for
child underweight. This finding is resembled with the result of study conducted in
Bangladesh. In that study, children of mothers aged below 19 years are more likely to
be underweight (AOR=3.0, 95% CI 1.9-4.8). That study also showed that the mother‟s
BMI below 18.5 was also predominant factor for underweight of children (AOR= 3.8,
95% CI 2.6-5.4).24 But these findings are not resembled to this study. In this study
mother‟s BMI was not significantly associated with the underweight of children.
In this study mother related variables like no ANC visit, less than 4 ANC visits, home
delivery, no PNC visit and no TT taken condition showed significant association with
underweight in the bivariate logistic regression analysis. Among them, PNC visit was
highly associated with underweight in multivariate logistic regression analysis. Study
showed that children of no PNC visited mothers are 3.158 times more likely to be
underweight than the children of mothers visited PNC (95% CI 1.242-8.028). These
findings were resembled with the study conducted in Kunchha VDC of Nepal. In that
study children of no ANC visited mother were 7.54 times more likely to be
malnourished (OR=7.54, 95% CI 1.37-41.41).27
In this study environment related variables like wood as fuel (OR=9.814, 95% CI 2.300-
41.865), not improved oven (OR=9.455, 95% CI 2.214-40.381), no separate kitchen
(OR=2.811, 95% CI 1.679-4.706) and no ventilation in house (OR=4.853, 95% CI
2.566-9.178) are showed significant association with underweight in bivariate
regression analysis. But after confounding the other variables no one variables of
environment of house showed significant association with underweight. From above
findings it was concluded that there were some sort of effects of environmental factors
on the children underweight.
Childhood feeding practices like breast feeding start after 1 hour, exclusive breast
feeding <6 months and >6 months, less than 3 times feeding per day, no protein rich
38
animal food intake per months and low standard minimum food diversity showed
significant association with underweight. These results are resembled with the finding
of the study carried out in Vietnam. That study showed that exclusive breast feeding
below 6 months is significantly associated with underweight (OR=5.98 95% CI
2.5713.91). But that study did not showed the significant association between initiation
of breast feeding within 1 hour after birth and underweight (OR=1.74, 95% CI
0.704.26).25
Among various childhood illness like diarrhea, ARI, malaria and measles, this study
showed that only diarrhea had the significant association with underweight. One or
more times diarrhea was 2.354 times higher among underweight children as compared
to children having no diarrhea (OR=2.354 95% CI 1.411-3.926). This result is resemble
with the finding of the study conducted in Vietnam which showed that children with
diarrhea in last 2 weeks are 2.33 times more likely to be underweight (OR=2.33 95%
CI 1.10-4.90). further, that study also showed that there was no significant association
between cough in last 8 weeks and underweight (OR=1.41, 95% CI 0.89-2.22).25
Likewise another study conducted in Botswana also revealed that child illness had
significant relationship with underweight of children (OR=20.95 95% CI 7.55-58.10).8
39
CHAPTER VI CONCLUSION AND
RECOMMENDATIONS
6.1 Conclusion
The findings of this study showed that main risk factors of underweight among under
five years children were mother‟s income, PNC visits and caretaker of children.
The study showed that 84.2% mothers had no income. Among them 37% mother had
underweight children. Mothers with no income had 5.133 times higher risk of having
underweight children. This study also found that 91% children were most of the time
cared by mother. This practice seemed to be very good because the children cared by
mothers were 6.047 times less likely to be underweight than those children cared by
other members of the family.
Among all respondent mothers 67% had not visited PNC. Among them 40.6% had
underweight children. Mothers who had not visited PNC were 3.158 times higher risk
of having underweight children than those mothers who had visited PNC.
This study concluded that underweight is the interaction of different factors and might
not occur in isolation. The happening of one factor may influence the occurrence of
another factor. Tackling a single factor may not necessarily address the underweight
among children. So, underweight is the result of multiple factors and all those factors
should be taken in to consideration to address underweight among children.
Thus to prevent children from being underweight mother should visit PNC, should
involve in income generating activities and children should be cared by mother herself.
So, it is better to initiate income generating activities in such a way that child could get
his/her mother for care.
6.2 Recommendations
In light of the findings of this study, the following recommendations are offered:
Similar research should be conducted on a large sample of under-five children to detect

the effects of some of the factors that could not be observed by the current study. The
40
government of Nepal and local authorities should conduct and encourage researcher to
conduct various study regarding child nutrition.
Health education should be reinforced at community level and at health facilities to

improve PNC visit among mothers. To reinforce at community level, various IEC
materials should be used and health education programs should be conducted in the
community settings. Most of the mothers had been consulting with FCHVs for the
maternity care so that training regarding maternity care should be provided to FCHVs.
The government of Nepal and local authorities should provide more job opportunities
in local setting. So that mother could involve in income generating activities and also
provide care to their children. For this, government should provide training to mothers
regarding household income generating activities like tailoring, vegetable farming,
animal husbandry, hand crafting etc.
Inter-sectoral coordination among health sector, agricultural sector, administrative

bodies, I/NGOs, mother groups, youth club should be done to strengthen the health,
education and economic condition of family.
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43
44
ANNEX
ANNEX I: QUESTIONNAIRE
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!_ cfdf @_ afa' #_ cGo -v'nfpg]_ =====
!) s] tkfO{Fn] w'd|kfg ug'{x'G5 < !_ u5'{ @ _ klxn] uy{] #_ slxNo} u/]sf] 5}g
!!_ s] tkfO{Fn] dWokfg ug'{x'G5 < !_ u5'{ @ _ klxn] uy{] #_ slxNo} u/]sf] 5}g
:jf:Yo ;]jfsf] pkof]u ;DaGwL k|ZgfjnL
!@_ tkfO{n] of] aRrf k]6df x'Fbf ue{hfFr u/fpg' eof] < s_ u/fP v_ u/Og
!@=!_ olb u/fPsf] eP, !_ ! k6s @_ @ k6s #_ # k6s $_ $ jf ;f]eGbf a9L
!#_ of] aRrf hGdfpFbf sxfF hGdfpg' ePsf] lyof] <
!_ 3/df @_ :jf:Yo ;+:yfdf #_ cGo -v'nfpg'xf];\_ ========
!#=!_ tkfO{+n] of] aRrf hGdfpFbf s;n] ;xof]u u/]sf] lyof] < -:jf:Yo ;+:yf eGbf aflx/ ePdf_
!_ tflnd k|fKt :jf:YosdL{ @_ cfkmGt #_ cGo -v'nfpg'xf];\_ ========
!$_ of] aRrf hlGdPkl5 ;'Ts]/L hfFr u/fpg'eof] < !_ u/fP @_ u/Og
!$=! olb u/fPsf] eP, !_ ! k6s @_ @ k6s #_ # k6s
!%_ tkfO{+n] of] aRrfnfO{ ;a} vf]k nufpg' eof] <
!_ nufP @_ nufOg #_ slxn]sflxF
!%=!_ olb nufPsf] eP

qm=;+= aRrfsf] pd]/ BCG DPT Hep-b Polio Measles JE
! I II III I II III
@
!^_ tkfO{+n] TT vf]k nufpg' ePsf] lyof] < !_ lyPF @_ lyOg
!&_ tkfO{+n] cfO/grSsL ;]jg ug{] u'g{ePsf] lyof] <
!_ lyPF @_ lyOg #_ slxn]sflxF===============-dlxgf_
jftfj/0fLo ;/;kmfO ;DaGwL

ii
!*_ s] tkfO{+ kfgL z'l4s/0f u/]/ lkpg] ug'{x'G5 <
!_ u5'{ @_ ulb{g
!*=!_ olb z'l4s/0f ug'{x'G5 eg] s'g ljlw k|of]u ug'{x'G5 <
!_ pdfNg] @_ lkmN6/ ug{] #_ Snf]l/g÷s]ldsn k|of]u
$_ 3fddf ;'sfpg] $_ cGo -v'nfpg'xf];\ _==================
!(_ vfgf ksfpgsf nflu s'g OGwgsf] k|of]u ub{} cfpg' ePsf] 5 <
!_ bfp/f @_ dl§t]n -:6f]e_
#_ uf]j/UofF; $_ UofF; -l;n]G8/_ %_ cGo pNn]v ug{]==============
@)_ tkfO{sf] 3/df s'g k|sf/sf] rNxf] 5 < - cjnf]sg ug{]_
!_ ;'wfl/Psf] @_ g;'wfl/Psf]
@!_ efG;faf6 w'jf aflx/ hfg] 7fpF 5 < -cjnf]sg ug{]_
!_ 5 @_ 5}g
@@_ tkfO{Fsf] 3/df s/];faf/L 5 <
!_ 5 @_ 5}g
@#_ tkfO{F s/];faf/L÷v]taf/Ldf ls6gfzs cf}ifwL k|of]u ug'{x'G5 <
!_ u5'{ @_ ulb{g #_ slxn]sflxF dfq
@$_ olb k|of]u ug'{x'G5 eg], s] tkfO{ s/];faf/L÷v]taf/Ldf cf}ifwL 5bf{ aRrfnfO{ ;fydf n}hfg'x'G5 <
!_ n}hfG5' @_ n}hfGg
@%_ tkO{Fsf] 3/df s'g k|sf/sf] rkL{ 5 <
!_ 5 @_ 5}g
@%=! olb 5 eg] M !_ cfw'lgs rlk{ @_ vfN8] rlk{ #_ cGo - v'nfpg'xf];\ _===================
@%=@ olb 5}g eg] M lbzf sxf ug'{x'G5 < !_ h+un @_ gbL
#_ v]taf/L tyf t/sf/L af/L $_ cGo -v'nfpg]_===
aRrfsf] vfglkg ;DaGwL
@^_ tkfO{Fn] of] aRrfnfO{ hGd]sf] slt ;do kl5 cfkm\gf] b'w v'jfpg' eof] <
!_ ! 306f leqdf @_ ! 306f kl5
@&_ tkfO{Fn] of] aRrfnfO{ ljuf}tL b'w v'jfpg' eof] <
!_ v'jfP @_ v'jfOg
@*_ tkfO{n] of] aRrfnfO{ slxn];Dd cfkm\gf] b'w dfq v'jfpg' eof] <
iii
pQ/ ====================================== dlxgf
@(_ tkfO{Fn] clxn] of] aRrfnfO{ b'w v'jfO/fVg' ePsf] 5 <
!_ 5' @_ 5}g
#)_ gv'jfPsf] eP aRrf slt pd]/sf] x'Fbf v'jfpg 5f8\g' ePsf] lyof] <
pQ/ M ============================================== dlxgf
#!_ aRrfsf] eftv'jfO{ -kf:gL_ slxn] ug'{ eof] <
pQ/ M ================================================dlxgf
#@_ aRrfnfO{ cfkm\gf] b'w afx]s lbgsf] slt k6s cGo vfgf v'jfpg' x'G5 <
!_ ! k6s @_ @ k6s #_ # k6s $_ $ jf ;f] eGbf a9L
##_ of] aRrfnfO{ x/]s xKtf df5f, df;', c08f cflb v'jfpg] ug'{ ePsf] 5 < !_ v'jfpF5' @_ v'jfpFlbg
##=! olb v'jfpg'x'G5 eg] M !_ ! k6s @_ @ k6s #_ # k6s $_ $ jf ;f] eGbfa9L
#$_ laut @$ 306fdf tkfO{Fn] of] aRrfnfO{ s] s] vfg]s'/f v'jfpg' eof] <
pNn]v ug'{xf];\=========================================================================================
!_ cGg, ufh/, d'nf, cfn', lu7f, Eofu'/ @_ u]8fu'8L, abfd, cf]v/ cflb
#_ b'Uw kbfy{ -b'w, blx, l3pm cfbL_ $_ df5f df;'
%_ c08f ^_ le6fldg o'Qm kmnkm'nx? / t/sf/Lx?
&_ cGo kmnkm"n tyf t/sf/Lx?
#%_ aRrf la/fdL x'Fbf slt k6s vfgf v'jfpg'x'G5 <

!_ ;fljs h:t} @_ ;fljs eGbf sd #_ ;fljs eGbf a9L
afn/f]ux? ;DaGwL
#^_ of] aRrf hGdLbf slt lsnf] lyof] <

pQ/ M ===================================================== s]=lh=
#^=!_ of] aRrf hlGdbf sqf] lyof] < !_ ;fgf] lyof] @_ l7s} jf 7'nf lyof]
#&_ ljut ! dlxgfdf aRrfnfO{ ?vfvf]ls nfu]sf] lyof] < !_ lyof] @_ lyPg
#&=! olb lyof] eg] M================================================== k6s
#*_ ljut ! dlxgfdf aRrfnfO{ kvfnf nfu]sf] lyof] M !_ lyof] @_ lyPg
#*=!_ olb lyof] eg] M ===========================================k6s
#(_ ljut ! dlxgfdf aRrfnfO{ dn]l/of nfu]sf] lyof] M !_ lyof] @_ lyPg
$)_ ljut ! dlxgfdf aRrfnfO{ bf?jf nfu]sf] lyof] M !_ lyof] @_ lyPg
3/kl/jf/sf] vfBfGg ;'/Iff cj:yfsf] ljj/0f

iv
$!_ laut !@ dlxgfdf tkfO{nfO{ slt k6s vfg]s'/f ck'u xf]nf eg]/ slt lrGtf nfUof]<
!= slxNo} klg nfu]g @= slxn]sflx
#= la/n}÷ w]/} yf]/} #= ;w}h;f]
$@= laut !@ dlxgfdf tkfO{ jf tkfO{sf] kl/jf/n] OR5ofOPsf] vfg]s'/f >f]tsf] cefjsf] sf/0f slt k6s vfg
kfpg' ePg <
!= ;w}h;f] kfO{of] @= la/n}÷ w]/} yf]/} k6s kfO{Pg
#= slxn]sflx kfO{Pg $= slxNo} klg kfO{Pg
$#_ laut !@ dlxgfdf tkfO{ jf tkfO{sf] kl/jf/n] >f]tsf] cefjsf] sf/0f slt k6s l;ldt k|sf/sf] vfg
vfg'k¥of] <
!= slxNo} klg vfg' k/]g @= slxn]sflx vfg'k¥of]
#= la/n}÷ w]/} yf]/} k6s vfg'k¥of] $= ;w}h;f] vfg'k¥of]
$$_ laut !@ dlxgfdf vfg]s'/fsf] cefjsf sf/0f tkfO{ jf tkfO{sf] kl/jf/n] cfkm'nfO{ rflxPsf] eGbf sd
vfgf slt k6s vfg'k¥of] <
$%_ laut !@ dlxgfdf slt k6s >f]tsf] cefjsf sf/0f tkfO{ jf tkfO{sf] kl/jf/n] lbgdf yf]/} k6s vfg'k¥of]
<
$^_ laut !@ dlxgfdf tkfO{ jf tkfO{sf] kl/jf/n] >f]tsf] cefjsf sf/0f 3/df vfg]s'/f g} gePsf] cj:yf slt
k6s cfof] <
!= slxNo} klg cfPg @= slxn]sflx cfof]
#= la/n}÷ w]/} yf]/} k6s cfof] $= ;w}h;f] cfof]
$&_ laut !@ dlxgfdf tkfO{ jf tkfO{sf] kl/jf/n] vfg]s'/fsf] cefjsf sf/0f /ftfLsf] vfgf g} gvfP/ /ftL ef]s}
;'Tg' kg{] cj:yf slt k6s cfof] <
!= slxNo} klg cfPg @= slxn]sflx cfof]
#= la/n}÷ w]/} yf]/} k6s cfof] $= ;w}h;f] cfof]
kl/jf/sf] cfly{s cj:Yfsf] ljj/0f
$*=tkfO{sf] kl/jf/sf] d'Vo cfDbfgLsf] >f]t s] xf] <
!= s[lif %= Hofnfbf/L
@=;fgf] k;n ^= j}b]lzs /f]huf/

v
#= Jofkf/ -v'nfpg]_ ========== &= cGo -pNn]v ug{'xf];\_==========
$= hflu/
$(= ljleGg cfDbfgLsf] >f]tx?af6 cf};tdf dfl;s slt k};f hDdf x'G5 -?k}ofdf_
!= s[lif ==================== %= Hofnfbf/L ===================

@=;fgf] k;n============== ^= j}b]lzs /f]huf/ ============
#= Jofkf/ -v'nfpg]_ ========== &= cGo -pNn]v ug{'xf];\_==========
$= hflu/ =======================
%)= s] tkfO{sf] v]tLof]Uo hUuf÷hdLg 5 <

!= 5 @= 5}g
%)=! olb 5 eg] slt hUuf÷hdLg 5<
ljuf ================================s7\7f ===========================w'/================================
%!= tkfO{x?n] s'g} lsl;dsf] kz'÷k+IfL kfng klg ug'{ ePsf] 5 <
!= 5 @= 5}g
%!=! olb 5 eg] tnsf dWo] s'g s'g kz'÷k+IfL] 5g\ <
!= e}+;L========================= % afv|f, v;L================
@= ufO{÷uf]? ================ ^= ;'Fu'/, aF'u'/================
#= s'v'/f================ ====== &= cGo========================
$= xfF; ======================
%@= tkfO{sf] kl/jf/df oftfoftsf] s'g} ;fwgx? 5g\ < -5 jf 5}gdf uf]nf] nufpg]_
5 5}g
s=;fOsn÷l/S;f ! ) v= df]6/;fOsn ! )
u= uf8f ! )
3=6]Dkf] ! )
ª= uf8L÷6«s÷6«ofS6/ ! )
%#= tkfO{sf] 3/df ePsf 3/fo;L ;fdfgx? atfO{lbg ;Sg' x'G5 < -5 jf 5}gdf uf]nf] nufpg]_
5 5}g
s= /]l8of] ! )
v= 6]lnlehg ! )
vi
u= df]afOn÷kmf]g ! )
3= /]lkm|lh/]6/÷lkm|h ! )
ª= knª ! ) r=
6]jn ! ) 5= s';L{
! ) h=;f]kmf
! ) em=sDKo'6/
! )
`=cGo ! )
%$= tkfO{sf] kl/jf/df÷3/df tn pNn]lvt s] s] ;'lawfx? 5g<-atfO{ lbg' xf]nf_
!= lah'nL @= vfg]kfgL
#= af6f]÷lgsf; $= 6]lnkmf]g
%= s]a'n ^= cGo
%%= 3/÷3/sf] 5fgfsf] k|sf/ -cjnf]sg u/]/ n]Vg]_
!= sRrf
@= sRrf kSsf
#= kSsf
%^= 3/sf] e'Osf] agfj6sf k|sf/ -cjnf]sg u/]/ n]Vg]_
!= df6f] $= l;d]G6
@= 6fon %= cGo -pNn]v ug{'xf];\_==================
#= sf7
%&= tkfO{sf] 3/df hDdf sltj6f sf]7fx? 5g\ < =================================== sf]7f
%*= 3/df Emofn sf] Joj:yf 5 <-cjnf]sg u/]/ n]Vg]_ != 5 @= 5}g
%(= s] 3/df 5'§} efG;fsf]7f 5 <-cjnf]sg u/]/ n]Vg]_ != 5 @= 5}g
;f]lwPsf k|Zgsf] pQ/ lbP/ ;xof]u ug'{ePsf]df wGojfb

;dfKt
vii

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RISK FACTORS FOR UNDERWEIGHT AMONG UNDER

FIVE YEARS CHILDREN: A COMMUNITY BASED

Kumar Prasad Mainali

Department of Sociology and Anthropology

Kumar Prasad Mainali

In Partial Fulfillment of the Requirements of the Degree of

Masters of Sociology And Anthropology

Department of Sociology And Anthropology

Tri-Chandra Multiple Campus

Name: Kumar Prasad Mainali

Kumar Prasad Mainali

Malnutrition is a serious obstacle to child survival, growth and development in Nepal.

ANC Antenatal care

ANM Auxiliary nurse midwife

ARI Acute respiratory infection

DALY Disability adjusted life year

DOHS Department of health service

EHCS Essential health care services

FCHVs Female Community Health Volunteers

MDG Millennium development goal

NDHS Nepal demographic health survey

NFHS Nepal family health survey

NMHBS Nepal multipurpose household budget survey

NMSS National micronutrient status survey

NPAN National plan for action on nutrition

PEM Protein energy malnutrition

PHCC Primary health care center

PNC Postnatal care

SLTHP Second long term health plan

SPSS Statistical package for social sciences

UNICEF United nations international children Emergency Fund

VDC Village development committee

WHO World health organization

APPROVAL SHEET .................................................................................i

TABLE OF CONTENT ...........................................................................vii

LIST TABLES ..........................................................................................ix

LIST OF FIGURES ...................................................................................x

LITERATURES REVIEW .......................................................................10

CHAPTER III ...........................................................................................17

RESEARCH METHODOLOGY .............................................................17

CHAPTER IV: RESULTS .......................................................................21

CHAPTER V: DISCUSSION ..................................................................35

Table 4.1.1: Socio-demographic and economic characteristics of the study 22

Figure 1.Conceptual Framework of the study 6

Figure 2. Sampling Procedure used in the study area 18

Nutritional status is a sensitive indicator of the quality of life in a given population.

Reduction of the prevalence of under-nutrition in under-fives is a top priority to reduce

Malnutrition is usually the result of a combination of inadequate dietary intake and

Global chronic under-nutrition in children is highly prevalent and remains a big

1.2 Statement of the Problem

Reduction of under-nutrition by 50 % between 1990 and 2015 is one of the most

1.3 Rationale of the study

Malnutrition is a serious obstacle to child survival, growth and development in Nepal.

Reduction of under-nutrition by 50 % between 1990 and 2015 is one of the most

Underweight is an underlying cause of child morbidity and mortality. The trend of

 Age of child, sex of child, education, occupation and earning status of

Family related factors

 Antenatal check-up, postnatal check-up, place of delivery, birth

Environmental and hygiene factors

 Water purification, Indoor air pollution, use of pesticides, type of toilet

 Breast feeding and complementary feeding

 Low birth weight, Diarrhea, ARI, malaria, measles

Childhood diseases Feeding Practices