1. Introduction

Good nutrition is a prerequisite for the optimal health and growth, cognitive development, academic performance, productivity, socioeconomic development of individuals and national development of countries, however problems related to poor nutrition affect the entire population [1]. Malnutrition is a serious public health problem throughout the developing world predominantly in South Asian countries [2]. It is one of the most widespread causes of morbidity and mortality among children and adolescents throughout the world [3, 4]. Malnutrition in children is mainly due to unbalanced diet, inadequate or excessive food intake, non-potable water, poor and unhygienic food quality as well as sanitary practice [5–7], severe and repeated infectious diseases [7]. Malnutrition is a major contributing factor to disease, disability and early deaths for women and children [8–10]. Poverty, literacy and social status of mother are key factors contributing to malnutrition in children and this factors significantly contribute to the cause of propensity for malnutrition in an individual [11, 12]. Malnourished children who survive may suffer from recurrent illness and faltering growth, with permanent damage to their development and cognitive abilities [13]. Infants and young children bear the brunt of chronic malnutrition and suffer the greatest consequences, that is, the highest risks of morbidity and mortality [14]. Malnutrition early in life clearly has major consequences for future educational, income and productivity outcomes [15]. Adults who were malnourished during their early childhood have impaired intellectual performance [16]. Under nutrition during childhood followed by later overweight increases the risk of having non communicable diseases and for women increase the risk of childbirth complications [17]. Indicators of over nutrition such as overweight and obesity in children and adolescents now occur simultaneously with underweight, stunting and wasting [18–20]. The inconsistency of these two boundaries, repeatedly referred to as the “double burden of malnutrition” [20, 21].

Globally, in 2020, it was anticipated that 149 million children under the age of five were stunted, 45 million were wasted and 38.9 million were overweight or obese [22]. More than half of all stunted and more than two thirds of all wasted under-five children remained in Asia [23]. In South Asia, the prevalence of child wasting remains a serious public health issue as it exceeds the critical level of 15%. [24, 25]. The pooled prevalence of underweight and overweight in South Asia 28% and 17% respectively whereas in South East Asia both underweight and overweight was 20% [26]. According to national level survey in Nepal, 36% of children under age 5 are stunted, 10% are wasted, 27% are underweight, and 1% are overweight [27]. The study conducted among under five years children in Dolakha and Kavre districts of Nepal revealed that 18.9%, 39.9% and 7.0% children were underweight, stunted and wasted respectively [28].

The Muslim population constitute of 4.4% of the overall population in Nepal, putting them in eighth position numerically. Rautahat, Bara, Parsa, Kapilvastu and Banke are the five districts which have highest number of Muslim populations [29]. The Muslim populations in Nepal was given a lower marginal status in the legal code, and they were shunned, discriminated against, and attacked violently [30]. Muslims, as a vulnerable demographic group, demanded social justice and the establishment of a Muslim branch of the National Inclusion Commission [31]. Muslim populations in Nepal have poor health outcomes and highest mortality rate [32]. Kapilvastu district of Lumbini province is one among the five districts of Nepal which have highest number (18.2%) of Muslim populations [29]. Malnutrition is a silent emergency and one of the most common causes of morbidity and mortality among children throughout the world especially in developing countries like Nepal. If unanswered, this challenge will endanger poverty reduction measures taken by governments, civil society, and aids based organizations and threaten their long-term growth prospects. In order to eliminate or reduce the risk of malnutrition, it is crucial to first understand and identify the causes and underlying factors of malnutrition. Among the Muslims community in Nepal in relation to health very few studies had been conducted which includes studies in family planning and maternal fertility [33–35]. However, according to researcher knowledge no research has been conducted to investigate the causes/reason of having malnutrition among Muslim children in Nepal. Hence this study aim to find out nutritional status and its associated factors among under 5 Muslim children of Kapilvastu district Nepal.

2. Materials and methods

2.3. Sample size determination and sampling technique

The sample size was calculated by using the formula: n = Z²pq/L² with 95% level of confidence interval, 6% margin of error and the prevalence of underweight was taken as 72.3% among the children in marginalized Chepang community of Chitwan district, Nepal [36]. As multistage probability random sampling technique was used, the calculated sample size 213 was multiplied by the design effect of 1.5. Hence the sample size was 213*1.5 = 319.5 that was 320. Additional 5% non-response rate was added in the above sample size; 5% of 320 = 16. Hence, final sample size of the study was 320 + 16 = 336. Multistage probability random sampling was used for the study. There are altogether ten local units (municipalities and rural municipalities) in Kapilvastu district of Nepal, out of which six are municipalities and four are rural municipalities. Among ten units, three units were selected randomly to generalize the Muslim community of the district. Then from selected three units, two wards from each local unit which covers a large proportion of Muslim population were selected purposively. After entering the selected wards, listing of the household (HH) having children of 6 months to 59 months in Muslim community was done from each ward with the help of Female Community Health Volunteers (FCHV)/community leaders. Than in order to select the respondents, equally fifty six mothers and their children of 6 months to 59 months from each selected wards were taken by using simple random sampling technique (Fig 1). Data were collected from mothers through face to face interview and anthropometric measurement of their children was done through door to door visit.

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Fig 1. Sampling technique.

https://doi.org/10.1371/journal.pone.0280375.g001

3. Results

The median age of the children was 39 months. Among 336 children, nearly one-fifth (19.3%) of the children were less than equal to 24 months. More than half (50.3%) of the mothers had more than two children. One-third of the respondents (33.3%) were from rural municipality. The median number of living children was three and size of family members was nine. Additionally, less than one fifth (19.3%) were from nuclear family. More than three fourth of the children were living with both mother and father in the family (Table 1).

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Table 1. Socio-demographic characteristics of mothers of under-five Muslim children in Kapilvastu district Nepal.

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Nearly one third (32.4%) of the child’s mother and more than one fifth (20.8%) of child’s father were illiterate. On the other hand, less than one fifth of both child’s mother and father got informal education. More than one third (34.5) of the children started going to school. Regarding the occupation, 86.0% of childs’ mother were involved in household chores and more than one fifth (21.4%) of their father were involved in agriculture. Less than half (48.2%) of the respondents had their own land and among them 41.3% had food sufficiency for only up to nine months (Table 2).

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Table 2. Socio-economic characteristics of mothers of under-five Muslim children in Kapilvastu district Nepal.

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Table 3 represents the nutritional status of the under-five Muslim children in Kapilvastu district of Nepal. About half (50.3%) of the Muslim children were underweight, very few (0.9%) were overweight, 17.3% were wasted and nearly two third (63.1%) were stunted. The mean Z- score for weight for age (underweight) was -3.23 (95 percent CI: -3.369, -3.084), for weight for age (overweight) was 2.22 (95 percent CI: 1.940, 2.494), for weight for height (wasting) was -0.28 (95 percent CI: -0.505, -0.052) and for height for age (stunting) was -3.04 (95% CI:-3.254, -2.820) (Table 3).

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Table 3. Prevalence of Nutritional Status of under-five Muslim children in Kapilvastu district Nepal.

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Several factors were found significantly associated with underweight in the bivariate analysis as shown in Table 4. The multivariate regression analysis model identified size of family, type of family, living status of child, mother’s education, father’s education, child school going status, own agricultural land and history of child chronic disease as associated factors with underweight. Children who were living in family having more than four members were nearly 3 times more likely (AOR = 2.82, CI: 1.25–6.38) to have underweight than their counterpart. Similarly, odds of having underweight among children living in joint or extended family were 33% less likely (AOR = 0.33, CI: 0.16–0.68) than those living in nuclear family. Children who were living with other than both parents such as with only mother or only father or with their relatives were 2.68 times more likely (AOR = 2.68, CI: 1.38–5.21) to have underweight than those who were living with both parents. Children whose mother had primary level education; that is who had grade one to five classes were 2.59 times more likely (AOR = 2.59, CI: 1.09–6.10) to have underweight. However, regarding father’s education; those who had completed SLC and above education were 41% less likely (AOR = 0.41, CI: 0.19–0.89) to have underweight than those who were illiterate and had informal classes. School going children were 27% less likely (AOR = 0.27, CI: 0.15–0.48) to have underweight than non-school going children. The children of the respondents who did not have their own land were 2.68 times more likely (AOR = 2.68, CI: 1.55–4.65) to have underweight than those who had their own agricultural land. Children who had the history of chronic disease were 3.01 times more likely (AOR = 3.01, CI = 1.06–08.54) to have underweight than those who did not have history of chronic diseases. After subjected to multivariate model, father’s occupation and history of parent’s chronic disease were found as confounders for having underweight (Table 4).

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Table 4. Factors associated with underweight in using bivariate and multivariate regression model.

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After adjustment in multivariate analysis, variables such as mother’s education, father’s education, child school going status, having own agricultural land, family monthly income and children who had history of chronic disease are found as associated factors of wasting. Children whose mother had secondary level education (6 to 10 classes) were 30% less likely (AOR = 0.30, CI: 0.10–0.88) to be wasted than those who were illiterate and had informal classes. However, regarding father’s education; those who had primary level education (1–5 classes) were 3.50 more likely (AOR = 3.50, CI: 1.26–9.74) to have wasting than those who were from illiterate and had informal classes. School going children were 16% less likely (AOR = 0.16, CI: 0.06–0.41) to have wasting than non-school going children. The children of the respondents who did not have their own land were 4.73 times more likely (AOR = 4.73, CI: 2.13–10.48) to have wasting than their counterparts. The children of the respondents with family monthly income more than NRs. 20,000 were 21% less likely (AOR = 0.21, CI: 0.08–0.57) to have wasting. Children who had history of chronic disease were 3.55 times more likely (AOR = 3.55, CI = 1.38–9.12) to be wasted. After subjected to multivariate model, age of children, number of living children, residential status and living status of children were found as confounders for having wasting (Table 5).

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Table 5. Factors associated with wasting in using bivariate and multivariate regression model.

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The bivariate analysis revealed several factors were significantly associated with stunting, as shown in Table 6. The multivariate logistic regression analysis model identified sex of child, residential status, type of family, living status of child, father’s education and having own agricultural land as associated factors with stunting. Male were 1.7 times more likely (AOR = 1.70, CI: 1.01–2.85) to be stunted than female. The odds of having stunting were reduced by 17% (AOR = 0.17, CI = 0.09–0.31) among children who were living in rural areas than those who were living in urban areas. Regarding the type of family, the children who were living in joint and extended family were 28% (AOR = 0.28, CI = 0.13–0.64) less likely to be stunted than those who were living in nuclear family. Similarly, the odds of having stunting were 3.71 times more likely (AOR = 3.71, CI = 1.84–7.49) among the children who lived with other than both parents (either with only mothers or with only fathers or with relatives) than those who were living with both parents. The odds of having stunting were reduced by 50% (AOR = 0.50, CI = 0.27–0.94) among those children whose mothers had secondary education than those who were illiterate or had informal classes. Children who were from the family who did not have their own agricultural land were 1.95 times more likely (AOR = 1.95, CI = 1.13–3.37) to be stunted than those who had their own agricultural land (Table 6).

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Table 6. Factors associated with Stunting in using bivariate and multivariate regression model.

https://doi.org/10.1371/journal.pone.0280375.t006

4. Discussion

The finding of this study revealed that 50.3% of the under-five Muslim children were underweight, 17.3% were wasted, 0.9% were overweight and 63.1% were stunted. The findings of this study were above the cutoff point from the significant level of public health i.e ≥ 30% for underweight and ≥ 40% for stunting and ≥ 15% for wasting [44, 45]. The under nutritional indicators such as underweight, wasting and stunting in this study was higher than in the national level data, however over nutritional indicators (overweight) is similar with Nepal Demographic and Health Survey 2016 [27]. These discrepancy might be due to the variances in dietary intake, socioeconomic and sociocultural factors prevalent in the marginalized Muslim children. The study conducted in Janakpurdham, Nepal among 161 Muslim people found that Muslim communities in Nepal have poor health outcomes and highest mortality rate [32].

The finding of this study revealed that half of the children were underweight which is in line with another community based cross-sectional study conducted among two hundred ninety two under five children in Rupandehi district of Nepal which found that nearly half (45.9%) of the children were underweight [40]. However, in contrast to this study, several other studies conducted in Nepal such as study conducted by analyzing 12, 674 data from Nepal Demographic and Health Survey (NDHS 2011) focusing severely food-insecure households in Nepal [46], rural and urban Nepal [28, 47–52]. Similarly, several studies conducted in India such as community-based cross-sectional study conducted among 500 children of tribal population in Assam India [53], community-based cross-sectional study conducted at urban slums and rural area in two districts of Maharashtra, India among 3671 under five children [54]. Similar studies conducted around the world such as cross-sectional study conducted at semi-pastoral communities of Tanzania among 310 children of 6 to 59 months [7], community based cross sectional study conducted in eastern Ethiopia among 791 under five years children [55] found lower proportion of under five children were underweight. However, higher proportion of underweight among under five children was also found in some studies, such as study case-control conducted at a Teaching Hospital in Bobo-Dioulasso, Burkina Faso among 164 HIV infected and 164 HIV uninfected under five children found more than three fourth of HIV infected children were underweight [56]. The prevalence of overweight in this study is found to be lower than another community based descriptive cross-sectional study conducted in Chitwan district of Nepal among 167 under five children which found 5.39% were overweight [50]. The prevalence of wasting in the present study was nearly one fifth which is in line with another community-based cross-sectional study conducted at urban slums and rural area of Maharashtra, India [54] and secondary analysis of Nigeria Demographic and Health Survey NDHS, Nigeria [57]. In contrast to this study, several other studies conducted in Nepal [48–50], cross-sectional study conducted at semi-pastoral communities of Tanzania among 310 children [7], eastern Ethiopia among 791 [55] and community based cross sectional study conducted in Sudan among 411 under five children [4] found lower proportion of under five children were wasted. However, in contrast to this study, several other studies conducted in Nepal [47, 51], community based cross-sectional study conducted among 500 children of tribal population in Assam India [53], cross- sectional household survey conducted among 1635 under five children in North Sudan [58] and case-control study conducted taking 164 HIV infected and 164 HIV uninfected under five years children in Burkina Faso found more than one fifth of the children were wasted [56]. Nearly two third of the children in this study were stunted which is in line with another study conducted in Rupandehi [40] and Kapilvastu district of Nepal [47]. However, in contrast to this study other studies such as study conducted in severely food-insecure households in Nepal [46], rural and urban Nepal [28, 48–51], tribal population in Assam India [53], urban slums and rural area of Maharashtra, India [54], semi-pastoral communities of Tanzania, eastern Ethiopia [55] found lower proportion of under five children were stunted [7]. However, higher proportion of underweight was also found in some studies, such as study conducted at a Teaching Hospital in Bobo-Dioulasso, Burkina Faso found more than three fourth of HIV infected under five years children were stunted [56].

In the present study, the prevalence of under nutrition particularly underweight was greater than that of wasting. Similar results were also found in other studies such as study conducted in Nepal [47, 59]. tribal population in Assam India [53], urban slums and rural area of Maharashtra, India [54]. Underweight was shown to be more prevalent than wasting in this study, which is in line with several other studies such as study Nepal [47, 50, 59], tribal population in Assam India [53], urban slums and rural area of Maharashtra, India [54], Eastern Ethiopia [55]. These divergence on the prevalence of under nutrition might be due to the variances in study population, study setting, and dietary intake as well as socioeconomic and cultural factors. This study was conducted in marginalized Muslim children, and Muslim populations in Nepal have poor health outcomes and highest mortality rate [32].

Size of family was significantly associated with underweight in this study, which is in line with another study conducted among tribal population in Assam India [53], cross-sectional descriptive study conducted in Kenya among 144 children [60] cross- sectional household survey conducted among 325 children in, Ethiopia [61] and north Sudan [58] which founds that underweight is more prevalent in the children living in greater than four members in the family. The present study revealed that type of family had statistically significant association with the underweight. This result is consistent with result of study conducted in Chitwan district of Nepal [50]. In this study children living with other than both the parents were more likely to be underweight than their counterparts, this results is similar to another study conducted North Ethiopia [61] which found that children not living with their both parents were 3.6 times more likely to be underweight. Similarly another study conducted by analyzing data from demographic and health surveys of 17 Sub-Saharan Africa found that overall malnutrition is more prevalent in west and Sub-Saharan African under five children who were not living with any of the parents [62]. In the present study, mother’s education was significantly associated with underweight of under five children. This result is consistent with result of study conducted among under five children residing in rural area of Maharashtra, India [54], Nigeria [57], community based cross-sectional survey conducted in Iran [63], Indonesia [64] and south Ethiopia [65]. Children’s from the fathers having SLC and above education were less likely to be underweight than from illiterate fathers which is in accordance to the finding of other studies such as study from Nigeria [57] and Sri Lanka [66] which found that fathers having secondary and above education were less likely to be underweight than illiterate fathers. In the present study ownership of own agricultural land is positively associated with having children underweight and wasting which is similar to the review conducted for finding the nutritional status of south Asia [67]. The present study revealed that child suffering from chronic diseases were more likely to be underweight which is in line with another study conducted by pooled analysis of 2416 population-based measurement studies [68]. Children’s from the mother having secondary education were less likely to be wasted than from illiterate mothers which is in accordance to the finding of another study from Nigeria [57] which found that mothers having secondary and above education were 0.79 times less likely to be wasted than illiterate mothers. In this study father’s education is also found to be significantly associated with wasting, this finding is in accordance to the finding of another study from Nigeria [57]. Family monthly income in this study was found to be significantly associated with wasting which is in concordance with another cross-sectional descriptive study conducted among 99 under five children in Zambia [69].

The present study showed that male were 1.70 times more likely to be stunted than female, similar result was also found in other studies such as study conducted in urban slums area of Maharastra India [54], slums area of Nairobi [70], cross-sectional study conducted among 341 under five children in Tanzania [71] and community based cross-sectional study conducted in south Ethiopia among 796 children [65] where male were 1.77, 1.60, 1.89 and 2.8 times more likely to be stunted than their counterparts respectively. Similarly female were 0.82 times less likely to be stunted in another study conducted in Ethiopia by using 2016 Ethiopia demographic and health survey [72]. Residential status in this study was significantly associated with stunting which is in concordance with several other studies [51, 63, 64, 71, 73]. In the present study stunting was less prevalent in the children who were living in joint and extended family, however in contrast to this study another study conducted in urban slums of Maharastra India [54] found less prevalent of stunting among children living in nuclear family. Similarly, stunting in under five children is more prevalent among those mothers who do not have their own agriculture land, this result is similar to the result from Zambia [74]. In the present study having own agriculture land is significantly associated with stunting which is line with another descriptive cross-sectional study conducted among 423 under five children in Nigeria, where food insecure mothers were more likely to be stunted [75]. This variations might be due to variations in study populations, dietary diversity, socio cultural and socio economic factors.

5. Conclusions

The key nutritional indicators such as underweight, wasting and stunting in under-five Muslim children were above the cutoff point from the significant level of public health given by WHO, as well as higher than the national level data from Nepal Demographic and Health Survey 2016 hence this study suggests a collaborative and immediate attention should be taken from the responsible governmental and non-governmental organizations such as local government, municipalities, rural municipality, local NGOs/INGOs and public health authorities working in nutrition and health.

Children having greater than four members in the family, nuclear family, who are living with other than their parents, mother’s having primary education, illiterate fathers, children who were not going school, who do not have their own agricultural land and history of child’s chronic disease were found to be independent predictors of increased risks for underweight. Illiterate mothers, father’s having primary education, children who were not going school, who do not have their own agricultural land, family monthly income of lesser than 10000 Nepalese rupees and history of child’s chronic disease were found to be independent predictors of increased risks for wasting. Similarly, male children, living in urban area, nuclear family, who are living with other than their parents, having illiterate fathers, who do not have their own agricultural land were found to be independent predictors of increased risks for stunting. Based on these findings, efforts should be done to promote the women and men education by providing informal learning opportunity, intervention regarding parental support to child, children school enrolment at appropriate age, prevention and treatment of children chronic diseases, intervention for income generating activities and intervention addressing the problems of household food insecurity should be emphasized among the Muslim communities. Similarly, large-scale research within Muslim communities should be recommended using qualitative approaches to investigate perceptions cultural practice, belief, and value system related to nutritional status among under five children of underprivileged and unserved Muslim communities.

6. Strengths and limitations of the study

This study may have a few limitations that might affect the validity of the results. The cross-sectional study design restricts the ability to examine the temporal relationship of the findings. Besides, information bias is possible as the respondents had to recall some of the information regarding independent variables. This study has a significant asset in that it was conducted in a specific marginalized Muslim community, where information about nutritional status is very scare. Besides, it was community based study in which interview and anthropometric measurement was done by house to house visit, it represent the real Muslim community.

Supporting information

Acknowledgments

Authors would like to express their deepest gratitude to public health graduates Mr. Sudarshan Gautam, Adolescent and youth Program Officer in Kapilvastu Integrated Development Services, Mr. Rajan Gupta NAMUNA Integrated Development Council (NAMUNA) District Coordinator/Field Supervisor for support in field level coordination and data collection, Mr. Jaan Mohammad Pathan, BPH 4^th year student, Ms. Madhu Chaudary and Ms. Kumari Sweta Gupta Kalwar BPH 3^rd year students and Ms. Pooja Gupta, Adolescents Youth Community Mobilizer in Kapilvastu Integrated Development Services for their support in data collection. Last but not least, we would like to thank all the respondent mothers and children for their valuable time and support for providing inevitable information for the study.