Umme Kulsoom Khattak  ( Shifa College of Medicine, Islamabad, Pakistan )
Saima Perwaiz Iqbal  ( Shifa College of Medicine, Islamabad, Pakistan )
Haider Ghazanfar  ( Shifa College of Medicine, Islamabad, Pakistan )

Objective:
To assess the impact of sociocultural perception on the nutritional status of children under five years of age.
Methods:
This cross-sectional study using a self-constructed questionnaire was conducted at the Shifa Rotary Clinic, Nurpur Shahan, Pakistan, from February to October 2016, and comprised mothers and children. Mothers age 18-45years having a child less than 5 years old were included. SPSS 21 was used for data analysis.
Results:
Of the 564 participants, 526(93.3%) were housewives and 38(6.5%) were working mothers. The overall mean age was 27.49±5.197 years. Mother was the decision-maker for child nutrition in 344(61.0%) cases while the father was the decision-maker for child nutrition in 106(18.8%) cases. About 64(11.3%) wasted colostrums, of which 18(28.1%) acted on their own accord 46(71.9%) on others\\\' advice. Mother as the decision-maker for child nutrition was found to be significantly associated with normal child nutritional status (p<0.05).In our study male child was 2.29 times likely to have a normal nutritional status as compared to a female child (p<0.05).
Conclusion:
Sociocultural perceptions were found to have a significant impact on nutritional status of children under the age of 5 years.
Keywords:
Perceptions, Malnutrition, Nutritional status, Child, Pakistan. (JPMA 67: 1213; 2017)

Introduction
According to a recent survey by the United Nations Food and Agriculture Organisation (FAO), almost 40% of the children under five years of age are underweight.¹ In South Asia, approximately 50% of the children under five years of age suffer from stunted growth.² Malnutrition is estimated to contribute to more than one-third of all child deaths.³ Poor feeding practice is one of the major risk factors of malnutrition in children less than 5 years of age. In Pakistan, one of the main causative risk factors is low consumption of food and foods with low nutritional value. Traditional practice and sociocultural beliefs that impede early treatment of malnutrition are dangerous and significantly contribute to under 5-year child mortality rate.⁴ According to a study done in Turkey, it was concluded that due to sociocultural influence, the duration of exclusive breastfeeding is relatively short as compared to the standard 6 months exclusive breastfeeding period.⁵ According to another study, boys are breastfed more than the girls because of the sociocultural perception that boys need to be stronger than the girls.⁶ Socially constructed gender hierarchy, the status of woman and sociocultural perception has a significant impact on the nutritional status of the child under the age of 5 years.⁷
The current study was planned to assess the impact of sociocultural perception on the nutritional status of children under five years of age.

Subjects and Methods
This cross-sectional study was conducted at the Shifa Rotary Clinic, Nurpur Shahan, Pakistan, from February to October 2016, and comprised mothers and children. Nurpur Shahan is a peri-urban community of Islamabad. The reason the study was conducted in this area was that this study sample represented various ethnic groups from different parts of Pakistan who have migrated here. Nurpur Shahan was a small area with a population of a few thousand people a decade back. Its population grew and the area became highly dense after the influx of migrants from all over the country, including the 2005 earthquake and 2010 floods because of the free land available to live on and also because of the availability of free food at the shrine of Bari Imam. The participants were selected by using convenience sampling. We used a self-constructed questionnaire comprising of 20 demographic variables and 29 variables regarding child\\\'s nutritional health



.Cronbach\\\'s alpha was measured to assess the internal consistency of the different domains of the questionnaire. Cronbach\\\'s alpha value for the questionnaire was found to be 0.87. McNemar\\\'s test was applied to assess for test-retest reliability (p>0.05). Mothers between the age of 18 and 45 years having a child less than 5 years old were included in the study. Mothers who were temporarily a resident of the community or had moved into the community during the last 6 months were not included.
The key variables of interest included the role of in-laws in decision-making, living conditions, feeding pattern, vaccination status, and associated sociocultural perceptions. Informed consent was taken from all the participants and they were assured that their identity will be kept confidential. The sample size was calculated at 551 by using World Health Organisation\\\'s (WHO) sample size calculator, keeping 6.1% as prevalence of severe malnutrition in Pakistan, confidence interval at 95% and absolute precision at 2%.8.
SPSS 21 was used for data analysis. Chi-square test was applied to assess the association between gender of the child and the nutrition status of the child. Chi-square test was also applied to assess the association between type of milk given in formula fed and child developmental milestones. P<0.05 was considered significant. Mann-Whitney U test was applied to determine the association between who made the decision related to child nutrition and nutritional status of the child, whether "ghutti" was given at birth or not and exclusive breastfeeding of the child. P<0.05 was considered significant. Ethical approval of the study was taken from Shifa International Hospital\\\'s institutional review board and ethics committee.
 

Result
Of the 600 mothers approached, 564(94%) agreed to participate. The overall mean age of participants\\\' was 27.49±5.197 years. Most of the participants were housewives 526(93.3%), while only 38(6.5%) were working mothers. About 252(44.7%) mothers were educated. Most of the participants 358(63.5%) had a joint family system while the remaining 206(36.5%) participants had a nuclear family system. Most of the participants 200(35.5%) had a family income in the range Rs5,000-10,000 while only 36(6.4%) participants had a family income greater than Rs25,000. The median number of children born per family was 3 while the mean age of the mother at the first childbirth was 20.31±4.28 years.  Moreover, the decision-maker for the family was husband in 302(53.5%) cases, while in-laws and the mother herself were the decision-makers in 190(33.7%) and 48(8.5%) cases, respectively. Mother was the decision-maker for child nutrition in most case 344(61.0%), while the father was the decision-maker for child nutrition in 106(18.8%) cases. About 64(11.3%) wasted colostrum, of whom 18(28.1%) acted on their own accord and 46(71.9%) on someone else\\\'s advice. The most common reasons that were given to support wasting colostrum were that it was harmful to the child, it was dirty milk, it was hot in nature, it had no benefit for the child, it was not good for child health, mother had diabetes or it was a traditional norm. About 114(20.2%) mothers or their elders were in favour of bottle feeding while 450(79.8%) mothers or their elders did not favour it.  Of those in favour, 48(42.1%) were mothers themselves while 42(36.8%) were mothers-in-law. Also, 54(47.36%) favoured bottle feeding due to insufficient breast milk production. Other reasons for favouring bottle feeding were that it was easy to give, due to working mother, due to caesarean section, to fulfil water requirement of a child, child was not taking mother feed, for the health of mother and child and having twin babies. About 118(20.9%) mothers or their elders restricted and 446(79.1%) did not restrict food of the child due to seasonal and cultural variations. In most cases, the restriction was recommended by the mother herself 38(32.5%) or by the mother-in-law 52(44.07%). The reason of food restrictions included banana had cold effects and resulted in sputum formation, eggs had hot effects, oranges had cold effects and caused a sore throat and chest infection so should not be given in winter, rice caused chest infection, mangoes and curry had hot effects so not given in summer, yogurt due to cold effects and tea added in milk because milk resulted in sputum formation. About 218(38.7%) mothers had restricted food to the child due to poverty despite knowing it was not good for the child health. All of the mothers took their child for check-up to a government hospital, whereas 230(40.8%) also took their child to a private hospital/clinic for check-up. Moreover, 70(12.4%) mothers took their child to spiritual healers.




In about 316(56.0%) cases the index child was male while in 248(44.0%) cases the index child was female. Also, 554(98.2%) of the pregnancies of the index child were full term. Most of the mothers 468(86.2%) got regular antenatal check-up during the pregnancy of the index child. About 282(50.0%) mothers delivered in a hospital setting while 206(36.5%) delivered at home and 76(13.5%) underwent delivery in a private clinic. About 62(11.0%) mother had a neonate which was admitted to the hospital. About 312(55.3%) of the index children were given \\\'ghutti\\\' after birth. Honey 126(40.38%) was most commonly given as "ghutti". Other things given as "ghutti" included readymade ghutti bottle, gurr water, green tea, goat milk, ghee, date, milk and Zamzam water. Moreover, 294(52.1%) children were breastfed only, 26(4.6%) were given bottle feed only, and 244(43.3%) were given both breastfeed and bottle feed. At the time of data collection, 166(29.4%) mothers were still breastfeeding their child. The mean duration of breastfeeding for the children who were given \\\'ghutti\\\' after birth was found to be 1.50±0.74 years. Buffalo milk 132(48.8%) was the most common source of milk for bottle feed followed by dry milk 94(34.8%). About 6 mothers had not started weaning yet. For the mothers who had started mean age at which weaning was started was 0.66±0.34 years. Weaning was started with banana, rice, porridge and cereals by 292(52.3%), 274(49.1%), 242(43.4%) and 116(20.8%) mothers.



About 382(67.7) participants\\\' index children were completed vaccinated according to Expanded Programme on Immunistion (EPI) schedule while 130(23.0%) were partially vaccinated. Anyone with 1 or more than 1 missed vaccine was considered as partially vaccinated. About 52(9.2%) participants\\\' index children were not vaccinated. Vaccination status was confirmed from the vaccination card. Of them, 30(57.7%) were stopped from getting their child vaccinated by someone in the family. In 428(75.9%) children, the development milestones were normal while in 136(24.1%) they were delayed. Most of the children 310(55.0%) had a normal nutritional status while 142(25.2%), 82(14.5%) and 30(5.3%) had 1st-degree malnutrition, 2nd-degree malnutrition, and 3rd-degree malnutrition, respectively.
In our study, the male child was 2.29 times likely to have a normal nutritional status as compared to a female child (p<0.05). Bottle-fed children who were given animal milk were 1.65 times more likely to have delayed child\\\'s developmental milestones as compared to children who were given formula milk. Mann-Whitney U test was applied to determine the association between who made the decision related to child nutrition and nutritional status of the child, whether "ghutti" was given at birth or not and exclusive breastfeeding of the child. Mother as the decision-maker for child nutrition was found to be significantly associated with normal child nutritional status (p<0.05). Mother as the decision-maker for child nutrition was found to be significantly associated with "ghutti" being given to the child at birth. The child was less likely to be given exclusive breastfeeding in cases where the mother was not the decision-maker of the child (p<0.05).

Discussion
Exclusive breastfeeding has been recommended for the first 4 to 6 months of life as it promotes infant and child health and also helps to minimise the damage caused by the malnutrition-infection cycle.⁹ In a study done in Nouakchott, it was concluded that the child was less likely to receive appropriate duration of exclusive breastfeeding in cases where the mother was not the sole decision-maker of the child health.¹⁰ In that study, it was also found that 50.5% of the mothers were aware of the optimal duration of exclusive breastfeeding but only 14.2% complied with the recommendation due to interference from their in-laws. Another study done in Myanmar concluded that one of the major barriers to exclusive breastfeeding was that husbands and grandmothers believed that exclusive breastfeeding was not sufficient for the child and that solid food and water were necessary.¹¹ A study done in India concluded that cultural beliefs played a significant role in determining the duration of breastfeeding.¹² According to study, the child was less likely to be given exclusive breastfeeding in cases where the mother was not the decision-maker of the child (p<0.05). 
In a study done on American Samoa, it was concluded that the convenience of formula, the perception among mothers that they were not producing enough breast milk, and pain while breastfeeding were the main barriers to exclusive breastfeeding.¹³ The most common reasons for favouring bottle feeding in our study was insufficient breast milk production 54(47.36%).  In our study, 47.9% of the mothers used formula feeding via a bottle with or without breastfeeding. About 65.19% of the children who were bottle-fed were given animal milk instead of the formula milk. Animal milk does not provide enough vitamin E, iron, and essential fatty acids. It is also hard for the baby\\\'s system to handle the high level of protein, sodium, and potassium found in cow\\\'s milk. It is also hard for the baby to digest the protein and fat in cow\\\'s milk. Greater cow\\\'s milk intake during the early years of life has been associated with increased risk of islet autoimmunity and type-1 diabetes.^14/ A double-blinded study done in Costa Rica concluded that bottle-fed infants who were given animal milk were more likely to be anaemic as compared to infants who were given breast milk.¹⁵ In our study, bottle-fed children who were given animal milk were 1.65 times more likely to have delayed child\\\'s developmental milestones as compared to children who were given formula milk.
Gender inequality is an important sociocultural predictor of malnutrition. Gender inequality leads to an inequitable distribution of food at household level.¹⁶ In many Pakistani families, boys are preferred to girls and, considering this gender bias, the male child is given sufficient food both in quality and quantity as compared to the girl child. This determinant affects the nutritional status of the girl child in two ways: by depriving them of essential nutrients and, secondly, by provoking psychological effects due to ignorance. Malnutrition in women continues across generation as nutritional deficiencies during and after pregnancy has a direct effect on the development of infants. In a study done in Bangladesh, it was concluded that females were 1.44 times more likely to be severely malnourished.¹⁷ A study done in India concluded that girls were 1.05 times more vulnerable to become malnourished as compared to boys.¹⁸ In our study male child was 2.29 times likely to have a normal nutritional status as compared to a female child. The higher rate can be explained by the fact that our study was done in a community with lower socio-economic status. According to existing literature, gender inequality is more prevalent in communities with lower socio-economic status.¹⁹ Sociocultural perceptions start in our community from the decision-maker in the house. In our study, the decision-maker was the father of the child in 53.5% cases while in laws and mother were the decision-maker of the family in 33.7% and 8.5% cases, respectively. This tells the pattern of life in the families and the hold of in-laws who have the decision power and can decide about the food given to the child. These results are similar to another study which concluded that in-laws, especially the grandmother, play a central role as advisors to younger women and as caregivers of both the mother and the child on nutrition and health-related issues.²⁰ One of the most important sociocultural perceptions is regarding food taboos, restricting food due to seasonal and cultural variations .This commonly held food belief in the Pakistani communities is the concept of hot and cold foods. Foods like egg, dates, etc. are considered as "hot foods", whereas, foods like rice, banana, oranges, etc. are considered as "cold foods". In some communities of Pakistan, it is believed that hot and cold foods should not be given. In our study, 20.9% families were restricting food as advised by the mothers-in-law and parents of the child. According to another study decreased breastfeeds, initiating bottle feeds, feeding diluted milk and reducing complementary feeds during illness was a widely common practice.²¹ An important sociocultural taboo is wasting colostrum (early breast milk). In our study, 11.3% mothers were wasting colostrum which contains immunoglobulinA (IgA) and immunoglobulinG (IgG), important for the immunity of the child. According to different studies, families who decide not to give colostrum to the baby do so because they consider that it\\\'s stale milk and will harm their child and give the child cultural food i.e. "ghutti", instead. This can have a significant impact on child\\\'s health and plays an important role in contributing to the vicious cycle of under-nutrition.²² These practices also have an impact on exclusive breastfeeding.²³ On the basis of our findings, we recommend spreading awareness about malnutrition among parents, especially females about care of women during pregnancy; the importance of antenatal visits; diet during pregnancy; importance of breastfeeding and starting it within the first hour of birth of the baby; the importance of only breastfeeding in initial 6 months; importance of vaccination; the importance of weaning; and importance of personal and environmental hygiene and cleanliness.

Conclusion
Sociocultural perceptions had a significant impact on nutritional status of children under the age of 5 years. There is an urgent need to plan community-based nutrition programmes to create awareness about the negative impact of these dietary practices with a view to uprooting these firmly rooted beliefs.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References
1. Nutritional Country Profile. United Nations Food and Agriculture Organization (FAO). [Online] [Cited 2016 Nov 15]. Available from: URL: http://www.fao.org/ag/agn/nutrition/pak_en.stm 
2. Khor GL. Update on the prevalence of malnutrition among children in Asia. Nepal Med Coll J 2003; 5: 113-22
3. Malnutrition. Maternal, newborn, child and adolescent health. World Health Organization. [Online] [Cited 2016 Nov 15]. Available from: URL: http://www.who.int/maternal_child_adolescent/topics/ child/malnutrition/en/ 
4. Senol V, Ünalan D, Çetinkaya F, Öztürk Y. Traditional practices about public nursing in the city of Kayseri. Clin Develop 2004; 17: 47-55.
5. Samli G, Kara B, Ünalan PC, Samli B, Sarper N, Gökalp AS. The applications, beliefs and knowledge of mothers regarding nutrition of foster children and breastfeeding. A qualitative study. Marmara Med J 2006; 19: 13-20.
6. Ertem G, ErgünS. Traditional practices and beliefs regarding nutrition of children in the 0-5 age group in western Turkey: a qualitative study. J Pak Med Assoc 2013; 63:173-8.
7. Mengesha AD, Ayele TT. The Impact of Culture on the Nutritional Status of Children and Mothers Durrinng Recurring Food Insecurity: The Case of Boreicha Woreda (SNNPRS). Am J Educ Res 2015; 3: 849-67.
8. STEPS Sample Size Calculator and Sampling Spreadsheet. Chronic diseases and health promotion. World Health Organization. [Online] [Cited 2016 Nov 15]. Available from: URL: http://www.who.int/chp/steps/resources/sampling/en/ 
9. Filteau SM. Role of breast-feeding in managing malnutrition and infectious disease. Proc Nutr Soc 2000; 59: 565-72.
10. Diagana MS, Kane H. Infant feeding practices in Nouakchott: between medical guidelines and grandmothers’ instructions. Sante Publique 2016; 28: 235-43
11. Thet MM, Khaing EE, Diamond-Smith N, Sudhinaraset M, Oo S, Aung T. Barriers to exclusive breastfeeding in the Ayeyarwaddy Region in Myanmar: Qualitative findings from mothers, grandmothers, and husbands. Appetite 2016; 96: 62-9. 
12. Sinha LN, Kaur P, Gupta R, Dalpath S, Goyal V, Murhekar M. Newborn care practices and home-based postnatal newborn care programme - Mewat, Haryana, India, 2013.Western Pac Surveill Response J 2014; 5: 22-9.
13. Hawley NL, Rosen RK, Strait EA, Raffucci G, Holmdahl I, Freeman JR, et al. Mothers\\\' attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa. Women Birth 2015; 28: e80-6. 
14. Lamb MM, Miller M, Seifert JA, Frederiksen B, Kroehl M, Rewers M et al. The effect of childhood cow\\\'s milk intake and HLA-DR genotype on risk of islet autoimmunity and type 1 diabetes: the Diabetes Autoimmunity Study in the Young. Pediatr Diabetes 2015; 16: 31-8. 
15. Lozoff B, Wolf AW, Jimenez E. Iron-deficiency anemia and infant development: effects of extended oral iron therapy. J Pediatr 1996; 129: 382-9.
16. Mondal N, Sen J. Prevalence of under nutrition among children (5-12 years) belonging to three communities residing in a similar habitat in North Bengal, India. Ann Hum Biol 2010; 37: 198-216.
17. Choudhury KK, Hanifi MA, Rasheed S, Bhuiya A. Gender inequality and severe malnutrition among children in a remote rural area of Bangladesh. J Health Popul Nutr 2000; 18: 123-30.
18. Tigga PL, Sen J, Mondal N. Association of some socio-economic and socio-demographic variables with wasting among pre-school children of North Bengal, India. Ethiop J Health Sci 2015; 25: 63-72.
19. Cheah WL, Wan Muda WA, Mohd Hussin ZA, Thon CC. Factors associated with under-nutrition among children in a rural district of Kelantan, Malaysia. Asia Pac J Public Health 2010; 24: 330-42
20. Aubel J. The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers. Matern Child Nutr 2012; 8: 19-35. 
21. Benakappa AD, Shivamurthy P. Beliefs regarding diet during childhood illness. Indian J Community Med 2012; 37: 20-4.
22. Bhutia DT. Protein energy malnutrition in India: the plight of our under five children. J Family Med Prim Care 2014; 3: 63-7. 
23. Chege PM, Kimiywe JO, Ndungu ZW. Influence of culture on dietary practices of children under five years among Maasai pastoralists in Kajiado, Kenya. Int J Behav Nutr Phys Act 2015; 12: 131.