International Journal of Social Economics

Understanding the health and nutritional status of children in Pakistan: A study of the
interaction of socioeconomic and environmental factors
Uzma Iram Muhammad S. Butt
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Uzma Iram Muhammad S. Butt, (2006),"Understanding the health and nutritional status of children in
Pakistan", International Journal of Social Economics, Vol. 33 Iss 2 pp. 111 - 131
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Understanding
Understanding the health and health and
nutritional status of children in nutritional status
Pakistan
111
A study of the interaction of socioeconomic
and environmental factors
Uzma Iram and Muhammad S. Butt
Applied Economics Research Centre, University of Karachi, Karachi,
Sindh, Pakistan
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Abstract
Purpose – The main purpose of this paper is to increase the level of knowledge pertaining to
nutritional status of preschoolers and to identify/quantifying the relative importance of various
socioeconomic and environmental factors which may have significant role in determining nutritional
status of preschoolers in Pakistan.
Design/methodology/approach – Household food availability, childcare practices, and child
health status being focused as proximate determinants of child nutritional status pose problems for the
simple regression analysis. An ordinary least squares (OLS) estimation of the regression with nutrition
as an outcome and these three proximate variables as determinants could be biased for two reasons.
First, there may be unobserved variables that are relegated to the error term but are correlated with the
variables included on the right side. Second, explanatory variables may exit that are endogenous or
codetermined with the outcome variable and hence are correlated with the error term. The approach to
address these problems is to use instrumental variables (IV) approach. The credibility of the IV
approach will rest on the ability to find variables that are correlated with the suspected endogenous
explanatory variables but that do not affect the outcome variable (other than through the explanatory
variable being instrumented).
Findings – The results from empirical analysis shows that factors on the maternal and household
level are more important determinants of child nutritional status. Food availability, childcare practices
and child health (diarrhea) are significantly related to child nutritional status. Household size has
negative and significant impact on child nutritional status. Household income has an important and
significant impact on child nutritional status. Childcare practices are negatively and significantly
related to child nutritional status. This may suggest that as childcare practices improve, they may
complement the need for other sources of improved energy for preschooler’s nutritional status. The
findings suggest that women’s education plays a very important role in improving children’s
nutritional status and that the nutrition status among children depends on both better sanitary
conditions and on dietary intake.
Research limitations/implications – Owing to data limitation present analysis employed child
calorie adequacy ratio (CCAR) as a proxy of child nutritional status. For that to estimate, commonly
used measures are nutrient intake, caloric adequacy ratio and relative caloric allocation.
Practical implications – A key message of this research is that significant achievement could be
made toward reducing malnutrition through actions in sectors that have not been the traditional focus
of nutritional interventions like improved hygiene conditions.
International Journal of Social
Originality/value – This could be the first ever effort in describing child nutritional status with the Economics
help relative more robust analytical technique for Pakistan. Vol. 33 No. 2, 2006
pp. 111-131
Keywords Nutrition, Children (age groups), Public health, Child welfare, Pakistan q Emerald Group Publishing Limited
0306-8293
Paper type Research paper DOI 10.1108/03068290610642210
 IJSE 1. Introduction
33,2 Poor diet and infectious disease interact to cause growth failure in children,
physiological damage especially to the immune system, and specific clinical conditions
like anemia, leading to impaired development and death. This interaction and its
biological results are called “malnutrition,” or the “malnutrition-infection complex”
(Tomkins and Watson, 1989). Malnutrition[1] is the largest risk factor in the world for
112 disability and premature mortality, especially in developing countries, and is entirely
preventable. Eliminating malnutrition would cut child mortality more than 50 percent,
and reduce the burden of disease in developing countries by 20 percent (Tomkins and
Watson, 1989; FAO/WHO, 1992; Pelletier, 1994; Murray and Lopez, 1997). The
emergence of human development[2] as a guiding principle for overall development
reflects a growing dissatisfaction with an exclusive reliance on economic growth as
means to development. “Human development” has emerged as a concept focusing the
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overall aims and aspirations of development efforts, one which “weaves development
around people, not people around development.”
Nutrition improvement plays a fundamental role in human resources development.
The effect of nutrition has received particular attention recently, in prevention of
disease, in improving educability, and in increasing productivity (ACC/SCN/IFPRI,
2000; UNICEF, 1998). A malnourished child has greater morbidity[3], mortality[4], and
developmental delays than a well-nourished child (World Bank, 1996, 1997; Pelletier,
1994; Murray and Lopez, 1997). A person malnourished in utero and in early childhood
has reduced capacity to take advantage of health, education and employment
opportunities (Pelletier, 1994; Murray and Lopez, 1997; World Bank, 1997).
This effect extends to further generations: much child development failure is
perpetuated because small girl babies grow up to become small mothers, in turn
having low birth weight (LBW)[5] infants (Figure 1). Recent studies confirm the strong
relationship between infant nutrition, cognition, and school enrollment linkages
exploited by the early childhood initiatives (Berg, 1997). In all nations, improving
people’s nutritional status is linked to economic progress, and economic progress often
helps people improve their nutritional status, creating a virtuous circle (FAO/WHO,
1992). In spite of the critical role of nutrition in development, malnutrition so frequently
escapes notice, that it is referred to as “the silent disaster” (UNICEF, 1998). Investing in
children strengthens the quality and productivity of the future labor force and results
in higher incomes for the family and permits investment in the quality of the next
generation (UNDP, 1998). Nutrition thus improves “human capital.”

Child growth
failure

Low birth- Low weight

Early teenage
weight baby and height in
pregnancy
teens

Small adult
Figure 1.
women
 Some 30 million infants are born each year in developing countries with impaired Understanding
growth caused by poor nutrition in the womb. About half the preschool children in health and
Asia are malnourished, ranging from 16 percent under weight in the People’s Republic
of China (PRC) to 64 percent in Bangladesh, and a similar percentage are deficient in nutritional status
one or more micronutrients (ADB-UNICEF, 1999). The United Nations estimates that
one out of every three preschoolers in developing countries – 180 million children
under the age of five – exhibit at least one manifestation of malnutrition 113
(ACC/SCN/IFPRI, 2000). Growth attainment studies undertaken in the Asian
continent indicate 97 million children under five years having low nutritional status
which increases their risk of dying before the first birthday by four times, as compared
with children from other continents. Furthermore, children under five years from South
Asia have the lowest nutritional status (UNICEF, 1998).
The world has been facing a paradox of widespread food insecurity[6] and
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malnutrition amid net food surpluses. Increased food supplies do not automatically
enhance access to food by the poorer groups of society. Food security measures alone
may have a limited effect on the nutritional well being of individuals, unless the
reinforcing detrimental linkages between food insecurity, disease, poor sanitation and
inadequate education are addressed (Bouis and Hunt, 1999). The dimensions and
underlying causes of food insecurity and malnutrition are often complex and extremely
location specific. They may differ widely from country to country, and from one
location or population group to another, even within the same country (Chung et al.,
1997). Current theory holds that good nutrition for preschoolers depends on household
food security, adequate health environment, and adequate maternal and childcare[7]
(ACC/SCN, 1992). However, that nutrition status is a product not only of the levels of
these three factors, but also of the interactions between them (Smit and Haddad, 1999;
Blau et al., 1996; ACC/SCN/IFPRI, 2000; Haddad et al., 1996). The importance of child
feeding practices for child nutrition is well recognized in the nutrition literature (WHO,
2000; Deolalikar, 1995). The concept of “care” as a determinant of child nutrition is still
new to many outside the nutrition field. Moreover, for those in the field to measure care
is problematic, because caregiver responses and practices vary substantially from one
culture to another (Engle and Lhotska, 1999). The care that children receive has
powerful effects on their survival, growth and development. Food, health and care are
all necessary for healthy survival, growth and development (UNICEF, 1990). All three
elements must be satisfactory for good nutrition. Even when poverty causes food
insecurity and limited health care, enhanced care giving can optimize the use of
existing resources to promote good health and nutrition in women and children (Frede,
1995; Engle and Lhotska, 1999; Patten, 1999).
Over the past two decades an increasing body of empirical research has concluded
that investment in early nutritional improvements could have powerful positive effects
on people’s health, and enhance human capital, a prerequisite for economic
development (World Bank, 1997). Reducing child malnutrition brings multiple
benefits. Eliminating malnutrition by 20-30 percent in Asia would reduce mortality and
disability (calculated as DALYs lost[8]). Economic benefits from preventing lost
production and ill-health due to malnutrition are estimated to be substantial, certainly
greater than investment required to reduce malnutrition: the benefit-cost ratios are
considerably greater than one (Behrman, 1992; AERC, 1990). Many of these economic
benefits are long term, being realized in adults from prevention of malnutrition in
 IJSE childhood. They are thus a long-term investment, analogous to other investment in
33,2 people, like education (Mason et al., 2001; Mercedes, 2000; Phillips and Sanghri, 1996;
Bouis and Hunt, 1999).
In Pakistan, during the last three decades, there has been impressive economic
and agricultural growth and also improvement in national per capita food
availability. Protein and calorie consumption per capita have also increased and food
114 intake availability is 3 percent higher than recommended average dietary allowance
in Pakistan. Despite this progress, malnutrition is a very serious health problem in
Pakistan. The nutritional status of children under five years of age is extremely poor.
At a national level almost 40 percent of these children are underweight. Over half the
children are affected by stunting and about 9 percent by wasting. A positive
relationship exists between the age of the child and the prevalence rates of stunting
and underweight. There are significant provincial variations in malnutrition rates in
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Pakistan, whereas no differences in malnutrition rates are apparent between sexes.

The anthropometric deficits are systematically higher in rural areas probably due to
the lower socioeconomic status and to very poor access to basic health services.
Further complicating the problem is the high incidence of infectious diseases in areas
of poverty, where living conditions may be crowded and/or sanitation is
substandard.
In Pakistani diet cereals, remain the main staple food providing 62 percent of total
energy. Compared to other Asian countries, the level of milk consumption is
significantly higher in Pakistan, whereas the consumption of fruits and vegetables,
fish and meat remains very low. The consumption of fruit and fresh vegetables,
which are highly dependent on local seasonal availability, is also limited by the lack
of organized marketing facilities throughout the country. Fluctuations in the
availability of these important foods is likely to be one of the factors responsible for
the micronutrient deficiency disorders observed in Pakistan. Food consumption is
just one of the multiple factors which interact and have an impact on the nutritional
status of the overall population. Other important influences include morbidity, poor
coverage of health infrastructures and socioeconomic factors. Since Pakistan’s
independence (1947), the provision of health infrastructures has improved over time
but remains inadequate particularly in rural areas. The under-five mortality rate, an
important index of health and nutritional status of a community, is high by
international standards: 92 for 1,000 births. A large number of infectious diseases
such as respiratory and intestinal infections remain responsible for up to 50 percent
of deaths of children under five, with malnutrition being an aggravating factor
especially in the most populated areas. Because improving preschooler health and
nutrition are seen to be important development objectives in their own right, many
international organizations, including the Department for International Development
(DFID) and the World Bank are prioritizing improvements in child health and
nutrition (World Bank, 2000). Better health and nutrition is both an end in itself and
a means to escape income poverty. Investing in improved nutrition is urgent both
from an economic and human rights perspective. Malnutrition among children
continuous to be one of the major problems in Pakistan despite the food and
nutrition intervention programs implemented during the last three decades. The
main objective of this research is to find out socioeconomic and environmental
determinates of child nutritional status in Pakistan.
 The reminder of the paper is divided into six sections. Theoretical framework is Understanding
given in next section. Data information is given in Section 3. The Section 4 describes health and
the empirical strategies and estimation techniques for the study. Empirical results are
presented in Section 5. The final section summarizes the results of the study and also nutritional status
presents the possible policy implications emerged from the present study.

2. Theoretical framework: the determinants of child nutrition status 115

The causes of child malnutrition are complex, multidimensional, and interrelated.
They range from factors as broad in their impacts as political instability and slow
economic growth to those as specific in their manifestation as respiratory infection and
diarrheal disease. In turn, the implied solutions vary from widespread measures to
improve the stability and economic performance of countries to efforts to enhance
access to sanitation and health services in individual communities (ACC/SCN, 1991).
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The theoretical framework underlying this study (Figure 2) is being drawn from the

Cultural, political, economic and

social context of urbanization

Access to Caregiver resources Health care and

adequate income and intrahousehold water, and sanitation
control

Household Caregiver Health care and

food security behaviors healthy environment

Dietary intake Illness

Nutritional status Figure 2.

Conceptual framework for
analyzing nutritional
status
Source: Adapted from UNICEF 1990.
 IJSE United Nations Children’s Fund’s framework for the causes of child malnutrition
33,2 (UNICEF, 1990, 1998) and its subsequent extention (Engle and Lhotska, 1999) to
incorporate childcare. The framework is comprehensive, incorporating both biological
and socioeconomic causes of malnutrition. It recognizes three levels of causality
corresponding to immediate, underlying, and basic determinants of child malnutrition.
The immediate determinants of child nutritional status manifest themselves at the
116 level of the individual human being. They are dietary intake, energy, protein, fats and
micronutrients and health status.
These factors themselves are interdependent. A child with inadequate dietary
intake is more susceptible to disease (UNICEF, 1998). In turn, disease depresses
appetite, inhibits the absorption of nutrients in food and competes for child’s energy.
Dietary intake must be adequate in quantity and quality, and nutrients must be
consumed in appropriate combinations for the human body to be able to absorb them.
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The immediate determinates of child nutritional status is, in turn, influenced by three
underlying determinants manifesting themselves at the household level. These are
food security, adequate care for mothers and children and proper health environment,
including access to health services. Associated with each is a set of resources necessary
for their achievement (Alderman and Higgins, 1992).
Energy and protein intake is influenced by household access to food acquisition
and allocation behavior, infectious disease, and the three child-related factors
mentioned above. Access to food, sanitation, water, primary health care, and
knowledge in turn influenced by household resources, that is, assets, income, and
time, as well as the prices and availability of food and non-food goods and services,
including health care services at the community level (Rabiee and Geissler, 1990).
Food security is achieved when person has access to enough food to lead an active
and healthy life (World Bank, 1996). The resources necessary for gaining access to
food are food production; income for food purchased or in kind transfers of food
whether from other private citizen, national or foreign governments, or international
institution. The aspect of child nutrition is captured by the concept of care for
children and their mothers.
Care, the second underlying determinant, is defined as “the behaviors and
practices of caregivers (mothers, siblings, fathers, and childcare providers) to
provide the food, health care, stimulation, and emotional support necessary for
children’s healthy growth and development” (Engle and Lhotska, 1999). The third
underlying determinant of child nutritional status viz; healthy environment and
services rests on the availability of safe water, sanitation, health care, and
environmental safety, including shelter. The prevalence and severity of infectious
disease are influenced by sanitary conditions, quality and quantity of water
available, access to primary health care, behavior of households and individuals,
energy and protein intake, and in the case of children, by childcare, breast feeding,
and weaning practice. Because malnutrition and infection interact and are closely
linked, it is relevant to talk about a “malnutrition-infection complex” (UN, 1996). Of
about 13 million infants and children who currently die each year in developing
countries, most of the deaths are due to infections and/or parasitic disease, and
many if not most of the children die malnourished. The malnutrition and infection
complex remains the most prevalence public health problem in the world today
(ACC/SCN/IFPRI, 2000).
 The basic determinants include the potential resources available to a country or Understanding
community, which are limited by the natural environment, access to technology, and the health and
quality of human resources. Political, economic, cultural, and social factors affect the
utilization of these potential resources and how they are translated into resources for nutritional status
food security, care, and health environments and services (UNICEF, 1990). Most
biomedical and demographic studies of the covariates of child anthropometry have
focused on the estimation of child health production functions (Martorell and Habicht, 117
1986). Anthropometric outcomes are modeled as a function of child, parent, and
environmental characteristics as well as inputs into the production process. These
inputs will include the child’s diet (such as nutrient intake, the length of breastfeeding,
age at which supplementary foods were introduced), activity level, amount of time spent
caring for child both in the home, and the utilization of health care services (such as pre-
and post-natal care). The production function is likely to change during a child’s life:
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breastfeeding will have a different impact on the weight of an infant and on the weight of
a five year old. The child’s gender and innate healthiness may also affect the shape of the
function. Parental characteristics, including healthiness, stature, and weight might have
an impact on the production process; child health is almost certainly affected by parental
education through the choice of inputs into the production function (allocative efficiency)
and also, perhaps, directly (technical efficiency). Although there is limited evidence
suggesting the latter is not very important (Rodolfs and Rosenzweig, 1999).
Estimation of the parameters of the production function requires knowledge of
inputs into the process and, since inputs and outputs are jointly determined,
instruments (such as prices) are needed to purge estimates of simultaneity bias. This is
quite demanding in terms of data and few socioeconomic surveys are sufficiently rich
or detailed to permit such estimation. As a result, much of the socioeconomic literature
has attempted to integrate the biomedical approach with a model of the family (Bound
et al., 1995) and estimate reduced form child health. The underlying theory is well
known for a discussion with applications to child health, see in particular Behrman and
Deolalikar (1989). Essentially, assuming a household maximizes a quasi-concave utility
function. Which depends on consumption of commodities and leisure as well as the
quality and quantity of children. Household utility is maximized subject to the
constraints that total expenditure is not greater than household earnings and unearned
income, a time constraints for each individual and restrictions imposed by the health
production function.
As theoretical framework as discussed earlier will guide the multivariate analysis
by identifying the multiple and complex pathways through which various factors
affect child nutritional status. The model for nutritional status will derive from the
household production model. The household maximizes the joint utility function,
which comprises the health and nutrition of each household member, goods purchased
and produced at home, and leisure (Behrman and Deolalikar, 1989; Strauss and
Thomos, 1995). Since the focus will be on the index child’s nutritional status, the utility
function is expressed as:
U ¼ U ðW i ; C i ; Li Þ;

where Wi is the nutritional status of the index child i (measured by the standardized
anthropomatric measurement of weight for age), Ci is the consumption of goods, and Li
is leisure. Wi is an outcome of the weight production function,
 IJSE W i ¼ f ðX i ; X h ; X d ; X c ; uÞ;
33,2 where Xi is a set of exogenous child-specific characteristics, Xh is a set of exogenous
household-specific characteristics, Xd is a vector of endogenous household-specific
inputs, Xc is a set of exogenous community-specific variables, and u represents
unobserved heterogeneity.
118 The input vector Xd represents outcomes of livelihood security that are inputs in to
child nutritional status. A number of inputs have been identified from the conceptual
framework presented in Section 3 (Figure 2). Data limitation will prevent the
exploration of all of these, so that the focus will be on the three most important factors
influencing child nutritional status: food, care, and health. Each input demand function
can be represented as follows:
X d ¼ gðY ; Z ; U Þ;
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where Y is a vector of exogenous household characteristics, and Z is a vector of

endogenous variable.

3. The data
The data for this study was drawn from the Pakistan integrated household survey
(PIHS)[7], carried out in 1999. During this survey 16,305 households were interviewed
across 1,150 urban and rural communities. Information was collected from household
and from rural communities on a range of social sector issues, viz basic education,
morbidity, health, housing and household’s characteristics, population welfare, water
and sanitation conditions.
4. Empirical strategy and estimation techniques
Household food availability, childcare practices, and child-health status being
focused as proximate determinants of child nutritional status pose problems for the
simple regression analysis. These inputs into nutritional status are also outcomes of
a variety of factors, one of which is income. An ordinary least squares (OLS)
estimation of the regression with nutrition as an outcome and these three proximate
variables as determinants could be biased for two reasons. First, there may be
unobserved variables that are relegated to the error term but are correlated with the
variables included on the right side. Second, explanatory variables may exit that are
endogenous or codetermined with the outcome variable and hence are correlated with
the error term.
The typical approach to deal with the first problem is fixed effects estimation at the
community, household, or individual level. Since the data are cross sectional, only
community fixed effects could be estimated. The second approach to address these
problems is to use instrumental variables (IV) approach. The credibility of the IV
approach will rest on the ability to find variables that are correlated with the suspected
endogenous explanatory variables but that do not affect the outcome variable (other
than through the explanatory variable being instrumented). The task is difficult and
challenging, especially when there are three explanatory variables to instrument. The
multivariate analysis will estimate a system of four equations explaining:
(1) household calorie availability;
(2) child health status;
 (3) child care behaviors index; and Understanding
(4) child nutritional status. health and
The primary relationship of interest here is the association between nutritional status nutritional status
and food availability, child health, and childcare practices. Nutritional status will be
measured by the child calorie adequacy. The effort to model the independent impact of
the proximate determinants of child nutritional status amounts to an estimation of a 119
structural equation for child nutrition. The estimating equation will include control for
the individual characteristics of the child and the characteristics of both the primary
caretaker and household. The estimating equation for nutritional status is:
Child nutritional status ¼ f(child’s age, age squared, sex, and health; mother’s
education, age and weight, log of household size; household income; sex of
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household head; child health status[9], childcare index[10] and log of food
availability[11]).
Various anthropometric and biochemical test are used to assess the nutritional status
of children under five years of age. Anthropometric measurements are most common to
assess child malnutrition in practice. As with most illnesses, malnutrition manifests
itself in children in varying degree. The severity of a particular case can be determined
by comparing the appropriate characteristics of the afflicted children with those of
normal children. One must select characteristics that most appropriately mirror
nutrition and specify what is normal for those characteristics as standard.
There are different indicators, which can be used to measure nutritional status of
children under the age of five. There are three ways to assess nutritional status of
children five years of age underlying anthropometric measurement. They are:
(1) stunting (height for age);
(2) wasting (weight for height); and
(3) underweight (weight for age).

Height for age or stunting is one of the three anthropometric indices commonly used
as an indicator for malnutrition. A deficit in height for age does not establish the
specific processes that lead a particular child or a group of children to be
malnourished. Height for age reflects linear growth achieved pre- and post-natally,
and its deficits indicate long term, cumulative effects of inadequacies of health, diet,
or care. Weight for height or wasting, one can compare the observed weight of a
child to the normal weight of a child of the same height-weight/weight (height).
Because weight loss could be rather sudden, this ratio is an indication of the severity
of acute (short-term) malnutrition. The third indicator is the ratio of observed weight
of a child to the normal weight of a child of the same age and weight. Deficiency
with respect to this measure reflects either acute (short-term) malnourishment or
chronic (long-term) malnourishment, or both.
Owing to data limitation present analysis employed child calorie adequacy ratio
(CCAR) as a proxy of child nutritional status. For that to estimate, commonly used
measures are nutrient intake, caloric adequacy ratio (CAR) and relative caloric
allocation (Senauer et al., 1988). Each indicator has its own advantages and
disadvantageous. Nutrient intake is the amount of nutrients taken by a person. Food
 IJSE conversion tables are used to convert the amount of food into amount of nutrients.
Usually caloric intake is expressed as the amount of kilocalories per person per day.
33,2 Though this measure is easy to calculate, it neither shows the adequacy of nutrients as
it does not compare intake and recommended levels of nutrients nor does it show
inequality of intra-household food allocation. The ratio between caloric intake and the
recommended level is known as CAR. The advantage of this indicator is that it can be
120 used to measure caloric malnutrition though it does not give any idea about inequality
of intra-household food allocation.
The CCAR is derived by dividing actual child’s caloric intake (CCI) by the children
recommended daily allowance (CRDA) for that nutrient;
CCI
CCAR ¼
CRDA
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The estimating equation includes controls for the individual characteristics of child
and the characteristics of both the primary caretaker and the household.
The OLS equation for child nutritional status is as follows:
CCAR ¼ b0 þ b1 ðCSEXÞ þ b2 ðLMEDUÞ þ b3 ðMAGEÞ þ b4 ðLHINCMÞ
þ b5 ðAWATRÞ þ b6 ðNTOILTÞ þ b7 ðINHOUSÞ þ b8 ðDPNCYÞ þ b9 ðCAREÞ
þ b10 ðCHLTHÞ þ b11 ðPCCALÞ þ b12 ðHHSIZEÞ þ b13 ðURBANÞ þ m

And the equation with IV is as follows:

CCAR ¼ b0 þ b1 ðCSEXÞ þ b2 ðLMEDUÞ þ b3 ðMAGEÞ þ b4 ðLHINCMÞ
þ b5 ðAWATRÞ þ b6 ðNTOILTÞ þ b7 ðINHOUSÞ þ b8 ðDPNCYÞ
þ b9 ðPRCAREÞ þ b10 ðPRCHLTHÞ þ b11 ðPRPCCALÞ þ b12 ðHHSIZEÞ
þ b13 ðURBANÞ þ m
where
CCAR ¼ child calorie adequacy ratio
CSEX ¼ child sex
MEDU ¼ mother’s years of schooling
MAGE ¼ mother’s age
LHINCM ¼ log of household annual income
AWATR ¼ availability of piped water
NTOILT ¼ non-availability of toilet facility
INHOUS ¼ equals one, if independent house; otherwise zero.
DPNCY ¼ dependency ratio
HHSIZE ¼ household size
CARE ¼ childcare index
 CHLTH ¼ child health status Understanding
PCCAL ¼ per capita caloric intake health and
URBAN ¼ equals one, if urban; otherwise zero nutritional status
PRCAR ¼ predicted value of childcare index
PRCHLTH ¼ predicted child health status 121
PRPCCAL ¼ predicted per capita calorie intake
In general, OLS estimates will be inconsistent in the presence of an endogenous
variable on the right side. IV estimates are consistent but less efficient. However, they
can be biased if the selected instruments are unable to explain the variance in the
predicted endogenous variables on the right (Bound et al., 1995).
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5. Empirical results
This section discusses the regression results for the child nutritional status. OLS
estimation and IVs estimation techniques are used to estimate the important of various
selected variables on child nutritional status within Pakistani families.
Table I presents descriptive statistics for the selected variables used for the present
analysis. Table II presents frequencies of these variables. Eighty-eight percent
households owned independent house and 40 percent households have access to safe
drinking water within their residence. Forty percent of the sampled households have
no proper sources to dispose off human disposable. The table shows that smaller
households are 3 percent of the total households, 26 percent are medium size
households, 71 percent belong to large family size of the sampled level household.
Twenty-nine percent households belong to low-income level groups, 54 percent belong
to medium income group and 17 percent households belong to high-income level group.
The data also reveals that, majority of the sampled households have lower number of
dependent as compared to 25 percent of their counterparts.
Table III shows the estimated coefficients of CCAR using all exogenous variables
to estimate relationships among food availability, child health and childcare
practices. While Table IV presents regression results by employing IVs to control for
the endogenity relationship among food availability, child health and childcare
practices.
The IV estimation for CCAR includes predicted values for childcare, child health
status (incidence of diarrhea) and food availability. In stage one childcare, child health
status and food availability were regressed on all exogenous variables for the given
inputs, all exogenous variables from the equation – and on a set of instruments unique to
each input. In the second stage, the predicted values for childcare, child health, food
availability and predicted household income were included in the estimated regression.
Durbin-Hausman specification test were used to check the simultaneity. The relevance
test or exogeneity test were used to check the endogenity problem. Food availability,
childcare and child health indicates that these instruments do not predict their respective
endogenous variables very well. Because the F-test reject the null hypothesis and accept
that the corresponding variables (childcare practices, child health status and food
availability) are endogenous in the equation of CCAR. Hausman specification test or
simultaneity test also reject the null hypothesis that there is no simultaneity or
 IJSE
Variables Mean SD N Description
33,2
CARa 0.56 0.26 20,837 Ratio
Mother age 33 6.2 11,226 Age in years
Mother education 7.6 2.9 11,226 Years
Household income 73,192 98,492 20,837 Rs (annual) per household
122 Independent house 0.89 0.31 20,837 Independent house: 1, otherwise: 0
Sanitation facility 0.3935 0.4885 20,837 No toilet: 1, otherwise: 0
Access to piped water 0.3996 0.4898 20,837 Piped water: 1, otherwise: 0
Household size 9.6 5.1 20,837 (#)
Room per capita 0.3079 0.1932 20,837 (#)
Dependency ratio 0.3522 0.1367 20,837 (#)
Per capita calorie intake 1615 1045 20,837 K
Urban residence 0.30 0.46 20,837 Urban: 1, Rural: 0
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Childcare practice 1.02 2.44 20,837 Index

Child health status 0.81 2.6 20,837 Days of diarrhea incidence
Predicted variables
Per capita calorie intake 7.16 0.19 20,837 Ratio
Childcare practice 1.01 0.67 20,837 Index
Child health status 0.13 0.82 20,837 Days of diarrhea incidence
Table I.
Descriptive statistics for Note: aCalorie adequacy ratio.
selected variables Source: PIHS 1998-1999.

correlation between error term and endogenous variables. This may suggests that the
instruments do not perform well, in that they are correlated with the nutrition error term.
These results indicate that, the instruments for food availability, childcare and child
health are not powerful and do not explain enough of the variations in the first stage
dependent variables for proper identification. Given the high number of potentially
endogenous variables in the CCAR equation, it was difficult to find appropriate
instruments that were correlated with the one endogenous variable but not others.
In general, present results as shown in Table III, reveals that, factors relating to the
maternal and household’s aspects appeared to be relatively more important
determinants of child calorie adequacy for preschoolers among the sampled
households than other explanatory variables. For present analysis child gender is
not significantly related to child nutritional status, indicating that there is no formal
treatment of male children within the Pakistani families, as compared to common belief
of bias toward child girl. Mother education is positively and significantly related to
child nutritional status and appeared to enhance child nutritional status among
Pakistani families. Whereas some studies have stressed the importance of mother’s
schooling, in particular as a determinant of child nutrient intake and health status.
Whereas mother’s age is negative but insignificantly associated with child nutritional
status among the sampled households. This may indicate that, motherhood
experiences have no effect on child nutritional status among the Pakistani families.
The coefficient of dependency ratio shows insignificant relationship with child
nutritional status. It appears that, child nutritional status is not being affected by
larger dependency ratio among the sampled households in Pakistan. Whereas total
household size is adversely influencing the nutritional status of preschoolers among
the sampled households. This may indicate that, as household size increases, child
 Understanding
Variables No. Percent
health and
Type of house nutritional status
Independent house 18,509 88
Compound house 2,139 10.3
Type of other house 79 0.4
Water sources 123
Water piped inside residency 8,326 40
Water piped outside residency 9,430 46
Others 2,971 14
Household size (no.)
Low (1-3) 485 3
Medium (4-6) 5,448 26
Large (7-above) 14,904 71
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Household annual income

Low income 6,000 29
Middle income 11,293 54
High income 3,544 17
Sanitation facility
No toilet 8,199 40
Flush toilet 6,254 30
No flush toilet 6,232 30
Number of dependent
Low 14,230 68
Medium 5,240 25
Large 1,367 7
Mother education (years)
Primary 2,070 18
Secondary 7,760 69
High 1,396 12 Table II.
Frequencies of selected
Source: PIHS 1998-1999 variables

nutritional status drops significantly in terms of lower availability of calorie intake.

Because, as the household size increases, then there may be lower chances among
children to take adequate amount of calories. This may be due to fact that there is not
as much as income for improving nutritional status as household size increases.
Because household income is a function of wage rates and the number of economically
active family members, thus, this may be reflecting a full income effect.
Environmental factors like availability of piped water and unavailability of proper
sanitation facility have significant and powerful effects on child nutritional status
towards prior conditions. It also appeared that household food security and better
childcare practices have significant association with better child nutritional status of
the sampled household. Child health status (incidence of diarrhea) is also negatively
and significantly associated with child nutritional status. Results shows that income is
powerful and significantly influencing the child nutritional status, indicating that
income might have other pathways to improved nutritional status outside of its effects
on food, care and health.
Table IV shows results from regression estimation with IVs. The findings for
child calorie adequacy with IVs are similar as appeared from OLS estimation
 IJSE
Without income With income
33,2 Variables Coefficients T-statistics Coefficients T-statistics

Constant 2 1.4 26.4 * 21.5 23 *

Child sex (girl) 0.005 0.76 0.005 0.8
Log of mother age 2 0.070 1.1 20.020 1.0
124 Log of mother education 2 0.006 0.79 20.009 1.1
Square log of mother education 0.007 3.6 * 0.007 3.3 *
Availability of piped water 0.05 6.6 * 0.050 6.1 *
No toilet facility 2 0.04 5.5 * 20.040 5.0 *
Log of dependency ratio 2 0.004 0.48 20.003 0.3
Independent house 0.001 0.14 20.0001 0.01
Log of household size 2 0.05 6.5 * 20.060 7.2 *
Per capita calorie intake 0.0005 147.9 * 0.0005 147.0 *
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Child health (dirrhea) 2 0.004 3.5 * 20.004 3.3 *

Childcare index 0.005 3.4 * 0.004 3.1 *
Urban 0.190 23.9 * 0.190 23.3 *
Log of household income 0.02 3.2 *
Adjusted R 2 0.56 0.56
Table III. Sample size 20,148 20,148
Estimates on F-statistics 1,965.0 1,826.3
determinates of child
nutritional status (OLS Notes: *At 1 percent level of significance; Dependent variable: log of calorie adequacy ratio.
regression) Source: PIHS 1998-1999.

Without income With income

Variables Coefficients T-statistics Coefficients T-statistics

Constant 2 2.9 9.4 * 223.8 7.3 *

Child sex (girl) 0.005 0.57 0.005 0.6
Log of mother age 0.02 0.92 0.1 4.0 *
Log of mother education 2 0.01 1.0 20.06 4.6 *
Square log of mother education 0.008 2.7 * 0.008 2.8 * *
Availability of piped water 0.07 5.4 * 0.07 5.8 *
No toilet facility 2 0.08 5.8 * 20.08 5.8 *
Log of dependency ratio 2 0.04 3.8 * 20.04 3.5 *
Independent house 0.02 1.5 * * * 20.04 2.3 * *
Log of household size 2 0.23 15.8 * 20.28 18.6 *
Urban 0.17 13.9 0.16 13.8 *
Predicted variables
Per capita calorie intake 0.35 8.9 * 0.34 8.9 *
Child health (diarrhea) 0.001 0.61 0.001 0.6
Childcare index 2 0.04 3.5 * 20.03 3.0 *
Household income 1.9 6.5 *
Adjusted R 2 0.084 0.086
Sample size 20,146 20,146
Table IV. F-statistics 142.9 136.0
Estimates on
determinates of child Notes: *At 1 percent level of significance; * *At 5 percent level of significance; * * *At 10 percent level
nutritional status of significance; Dependent variable: log of calorie adequacy ratio.
(instrumental regression) Source: PIHS 1998-1999.
 (except predicted value of childcare and diarrhea). In the IV estimates, childcare is Understanding
negatively and significantly related with CCAR. This may suggests that childcare is
most important factor for children nutritional status and breast-feeding is also most
health and
important contributor for providing care practices to their children. It is not unusual nutritional status
that the association between childcare and CCAR is negative. Because, typically, most
children under this study drive a large proportion of their energy from breast milk. So
this may suggest that as childcare practices[12] increases they may complement to 125
need for other source of energy for children nutritional status. Similarly, child health
status (incidence of diarrhea) appeared to be insignificantly associated with child
calorie adequacy in instrumental estimation. Food availability is positive and
significantly associated to child nutritional status. From the IVs estimates it appeared
that, food availability is the factor that most affects child nutritional status. While the
coefficient of childcare signifies the importance of natural sources of energy and
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better hygienic for the improvement of nutritional status of the preschoolers in the
Pakistan.
6. Conclusions and policy implications
Among children in developing countries, malnutrition is an important factor
contributing to illness and death. Malnutrition during childhood can also affect growth
potential and the risk of morbidity and mortality in later years of life. Child
malnutrition is generally caused by a combination of inadequate or inappropriate food
intake, gastrointestinal parasites and other childhood diseases, and improper childcare
practices during illness. Child malnutrition has long been recognized as a serious
problem in developing countries like Pakistan. Effective policies and programs to
alleviate malnutrition require an understanding of the underlying determinants. This
study adds to the rapidly expanding literature that, in the last several years, has
greatly increased our knowledge of the factors affecting nutrition and health status in
developing countries.
The study has examined factors that influence the child nutritional status. Two
estimating models, that is, OLS and IV regressions were used to analysis the child
nutritional status. The results from OLS regression shows that factors on the maternal
and household level are important determinants of child nutritional status. Food
availability, childcare practices and child health (diarrhea) are significantly related to
child nutritional status. Household size has negative and significant impact on child
nutritional status. Household income has an important and significant impact on child
nutritional status. Because high income level enable to household to provide required
nutrients, childcare and better health facilities to their children. With IVs the regression
coefficients are almost similar, except childcare practice and child illness. Childcare
practices are negatively and significantly related to child nutritional status. This may
suggest that as childcare practices improve, they may complement the need for other
sources of improved energy for preschooler’s nutritional status. While diarrhea is
positive but insignificant impact on child nutritional status.
Children whose mothers have little or no education tend to have a lower nutritional
status than do children of more-educated mothers, even after controlling for a number
of other – potentially confounding – demographic and socioeconomic variables. This
finding suggests that, women’s education and literacy programmes could play very
important role in improving children’s nutritional status. This analysis also suggests
that, the nutrition status among children depends on both better sanitary conditions
 IJSE and on dietary intake. The severe and moderate level of malnutrition among children
33,2 was much higher among those with poor housing and sanitary conditions even with
the same level of dietary intake whereas inspite of lower dietary intake, the level of
malnutrition was much lower for those living in better sanitary conditions. Thus to
reduce the problem of malnutrition among children in Pakistan, there should be a
comprehensive strategy to improve dietary intake as well as providing safe drinking
126 water, better sanitation and improve housing conditions and more emphasis on the
better propagation to improve childcare practices within the households. Poor housing
and sanitary conditions could represent indicators for identifying the target group
for nutritional programs. The preference should be given for those living in poor
houses, not having access to safe drinking water, and using toilet facility as
bush/fields.
A key message of this research is that significant achievement could be made
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toward reducing malnutrition through actions in sectors that have not been the
traditional focus of nutritional interventions like improved hygiene conditions. A
second key message is that any comprehensive strategy for attacking the problem of
child malnutrition must include actions to address both in underlying and basic causes.
Without improvements in national incomes, the resources and political will to invest in
the underlying – determinant factors – in health environments, women’s education
and status, and food availabilities will not be there. If improved national income is not
directed to improvements in the underlying-determinant factors, on the other hand,
they will make little difference. Investments in all of the factors will support the crucial
role of direct nutrition programs at the community level.

Notes
1. Malnutrition refers the lack of enough calories and nutrients to sustain normal growth,
health and activity.
2. Human capital refers to the combination of education, health (including nutrition), social
development, and growth but at the scales of a nation.
3. A disease condition or state, the incidence of a disease or all of diseases in a population.
4. Child mortality refers to the death of children that occur within the first five years of life. The
rate of child mortality is defined as the number of child deaths within the first five year of life
per 1,000 live births per year.
5. LBW is defined as a body weight at birth of less than 2,500 g.
6. Limited or uncertain availability of nutritionally adequate and safe foods or limited or
uncertain ability to acquire acceptable foods in socially acceptable ways.
7. Care is the provision in the household and the community of time, attention and support to
meet the physical, mental and social needs of growing child and other household members.
8. DALY refers as a measure of the burden of disease and also reflects total amount of healthy
life lost, to all causes, whether from premature mortality or from some degree of disability
during a period of time.
9. Incidence of diarrhea.
10. For the construction of care index, see Appendix 1.
11. For the construction of food availability, see Appendix 2.
12. See Appendix 1.
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Appendix 1

Score allocated to different

Descriptive statistics practices, by age group (month)
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Practices included in the index Results (percent) 4-8.9 9-17.9 $ 18

Breast-feeding and feeding practices

Only breast feeding 92 No ¼ 21 No ¼ 2 1 Yes ¼ 1
Yes ¼ 1 Yes ¼ 1
Breast feeding with milk 4 No ¼ 21 No ¼ 2 1
Yes ¼ 0.7 Yes ¼ 0.7
Breast feeding with liquid 6 No ¼ 21 No ¼ 2 1
Yes ¼ 0.5 Yes ¼ 0.5
Breast feeding with diarrhea 52 No ¼ 21 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1
Semi food given to child 73 No ¼ 21 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1
Liquid food given to child during diarrhea 88 No ¼ 21 No ¼ 2 1 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1 Yes ¼ 1
Water given to child during diarrhea 91 No ¼ 21 No ¼ 2 1 No ¼ 2 1
Yes ¼ 0.7 Yes ¼ 0.7 Yes ¼ 0.7
Boil water given to child 89 No ¼ 21 No ¼ 2 1 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1 Yes ¼ 1
Preventive health care services use
ORS 61 No ¼ 21 No ¼ 2 1 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1 Yes ¼ 1
BCG 76 No ¼ 21 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1
DPT immunization (.3 month) 77 No ¼ 21 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1
Measles immunization (.9month) 64 No ¼ 21 No ¼ 2 1
Yes ¼ 1 Yes ¼ 1
Mother care
Prenatal care 32
No ¼ 21
Yes ¼ 1
Postnatal care 9
No ¼ 21 Table AI.
Yes ¼ 1 Practices and scoring
TT injection 34 system used, by age
No ¼ 21 group, to create index
Yes ¼ 1 (child feeding and use of
preventive health care
Source: PIHS (1998-1999) practices)
 IJSE Appendix 2
33,2
Food items Kilocalorie

Cereals and cereals products

Biscuit 440
130 Bread 263
Puri 293
Wheat (atta) 357
Rice (boiled) 163
Grains legumes
Barely 339
Suji 370
Maida 350
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Dal channa (cooked) 187

Mash 363
Moong (cooked) 120
Masoor (cooked) 178
Arhar (cooked) 135
Soybean seed 411
Sunflower seed 236
Peas garden (mutter) 84
Fruits
Banana 96
Apple 57
Dates 131
Grapes 74
Mango 64
Melon water 23
Sarda 29
Guava (amrood) 73
Lemon 82
Jamon 30
Pear (nashpati) 58
Peach (auro) 47
Papaya (papita) 43
Meat, poultry and eggs
Mutton 164
Beef 244
Chicken meet 187
Eggs 155
Fish 101
Vegetables
Potato 83
Onion 44
Tomato 21
Cabbage 23
Cauliflower 27
Lady’-finger 35
Khira 16
Table AII. Tinda 23
Energy content per 100 g Pumpkin 44
of edible portions (continued)
 Food items Kilocalorie
Understanding
health and
Bottle gourd (kaddo) 15
Radish (moli) 23
nutritional status
Turnip 26
Carrots (gajor) 37
Mongra 25
Kulfa 23
131
Lettuce (salad) 18
Nuts and dry fruits
Almond (badam) 51
Raisin (kishmish) 312
Dates (chora) 293
Walnut (akhrot) 654
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Chilgoza 572
Pista 590
Peanut 552
Sesame Seed (till) 580
Coconut 321
Cashew (kajo) 528
Fats and oils
Desi ghee 900
Dalda ghee 874
Cooking oil 890
Sugar, sweets and beverages
Sugar (white) 390
Sugar (Brown) 371
Gur 310
Tea 296
Coffee 134
Milk and milk products
Milk 105
Lasi 31
Butter 721
Cream 361
Curd (Dahi) 52
Yoghurt 71
Honey 310
Barfi 384
Jaleebi 395
Halwa sohan 481
Lemon juice 43
Mango juice 74
Source: Food Composition Table for Pakistan (2001) Table AII.

Corresponding author
Uzma Iram can be contacted at: u_iram@hotmail.com

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