The Impact of the Central Asia Stunting Initiative on Stunting Among Children Under Five Years Old in Gilgit Baltistan and Chitral, Pakistan

1. Introduction

Stunting, a form of chronic malnutrition, poses a significant public health challenge worldwide, especially in developing countries [1,2]. It is marked by impaired linear growth in children under five due to prolonged nutritional deficiencies, repeated infections, and insufficient psychosocial stimulation [3]. The World Health Organization (WHO) estimates that approximately 22% of children under five globally suffer from stunting, with the burden disproportionately affecting low- and middle-income countries [1,4]. Stunting has immediate health implications and long-term consequences on cognitive development, economic productivity, and overall well-being, thereby perpetuating cycles of poverty and underdevelopment [5,6,7].

The impact of stunting is especially severe in South Asia, where malnutrition remains a significant challenge despite economic growth and development initiatives [1,4]. Pakistan, the fifth most populous country in the world, has one of the highest rates of childhood stunting, with nearly 40.2% of children under five affected, according to the National Nutrition Survey [8]. Among various regions in Pakistan, Gilgit-Baltistan and Chitral face unique geographical and socio-economic challenges that aggravate malnutrition and stunting rates [8,9]. The survey indicated that the prevalence of stunting in Gilgit-Baltistan is 46%, surpassing the national average. While specific data for Chitral is not separately reported in the study, it falls within Khyber Pakhtunkhwa (KP), where the stunting rate is 40% [8,9]. These figures highlight the potential for targeted nutritional interventions to address the high rates of stunting in these regions.

Stunting during childhood has far-reaching consequences that extend beyond physical growth. Research shows that children who experience stunting are at a greater risk of poor educational outcomes due to impaired cognitive development [10]. This, in turn, affects their economic potential in adulthood, leading to lower earnings and productivity, thereby contributing to the cycle of poverty [11]. Furthermore, stunting is linked to an increased susceptibility to non-communicable diseases (NCDs) in adulthood, including obesity, diabetes, and cardiovascular diseases [12]. According to Soofi et al. [9], male children and those from households lacking access to improved sanitation facilities are particularly vulnerable to stunting. Given these long-term effects, addressing stunting is not merely a matter of child health but is also crucial for sustainable development [7].

Tackling stunting in Gilgit-Baltistan and Chitral requires a multi-sectoral approach that integrates health, nutrition, education, and social protection programs. The Government of Pakistan, in collaboration with international organizations such as UNICEF and the World Food Programme (WFP), has initiated initiatives like the Pakistan Multi-Sectoral Nutrition Strategy (2018-2025) to combat malnutrition [13,14]. However, these regions' unique geographical challenges and socio-cultural barriers require localized, community-driven interventions.

Studies have demonstrated that nutrition interventions based on the 1000-day approach and supplementation strategies significantly improve nutrition indicators among women and children [15,16], promising a healthier future generation. It has also been recognized that adequate maternal nutrition through iron and folic acid supplementation lowers the risk of maternal anemia and low birth weight. At the same time, early initiation of breastfeeding and exclusive breastfeeding contribute to improved child survival and development [17]. Similarly, Vitamin A supplementation, ready-to-use therapeutic foods (RUTF), and micronutrient powders have been shown to reduce childhood wasting, stunting, morbidity, and mortality [17]. Community-based programs implementing this approach, such as those in South Asia and sub-Saharan Africa, have successfully lowered malnutrition rates and improved maternal and child health [16,18,19].

Acknowledging the pressing need to address malnutrition, Pakistan has rolled out targeted programs for mothers and children to improve nutrition. One such effort is the Central Asia Stunting Initiative (CASI), spearheaded by the Aga Khan Development Network and the Aga Khan Foundation (AKF) in partnership with essential government agencies [20]. The CASI project aims to decrease stunting and enhance maternal and child health through community-driven interventions that focus primarily on women of reproductive age and children under five, particularly those under two years old (Table 1) [20]. This initiative is being implemented in Gilgit Baltistan and Chitral, which were chosen for their alarming stunting rates [8]. This study examines the effect of nutritional interventions under CASI on reducing stunting rates among children under five years of age in Gilgit-Baltistan and Chitral.

2. Methodology

The Aga Khan Development Network (AKDN) implemented the intervention package detailed in Table 1. An independent group of researchers from Aga Khan University in Pakistan evaluated these interventions. Given that CASI interventions were applied to a broad population in the Gilgit Baltistan province and Chitral district, and due to the nature of the intervention, no demographic segment could be excluded from receiving benefits; thus, our study does not include a control group. To address this issue, we adopted a Single-Group Pre-Post Test Design [21] for assessing the effectiveness of the CASI intervention package. In our study, participants served as their own controls, comparing baseline (pre-intervention) data with mid-intervention data to evaluate shifts in nutritional indicators.

Our baseline and midline survey evaluation focused on children aged 0-59 months, with stunting as the primary outcome. Given a 45% prevalence of stunting among children under five, we estimated a sample size of 500 households with at least one child under five to meet the primary objective of reducing stunting. A 95% confidence level and a 5% margin of error were utilized, including a 20% non-response rate, to achieve this sample size [22]. We used a two-stage stratified sampling design, treating villages as primary sampling units (PSUs) and households within those villages as secondary sampling units (SSUs). Villages were selected using probability proportional to size sampling (PPS), while households were identified through systematic random sampling. A new household listing was conducted to ensure an accurate selection, prioritizing those with children under the age of five. Respondent selection followed specific criteria. Household heads or knowledgeable individuals aged 18 or older contributed data on demographics, socioeconomic conditions, and food security. Women in selected households were surveyed for reproductive health and dietary information. Data for children aged 0-59 months were gathered from mothers or caretakers, including anthropometric measurements for a randomly chosen child (6-59 months) per household during the baseline survey and all available children under five during the midline survey. Height-for-age z-scores (HAZ) were calculated for children over two years, while length-for-age z-scores (LAZ) were derived for those under two. According to WHO classifications, children were designated as stunted, wasted, and underweight, ensuring alignment with global standards [23].

The research and evaluation team at Aga Khan University created and reviewed an extensive survey protocol. Data collection tools were designed, translated, and pre-tested for accuracy. The survey was conducted by independent teams from Aga Khan University, trained in data collection, anthropometry, and Hb testing. Survey quality was monitored at various levels, with team leaders supervising data collection, anthropometry, and Hb testing in the field. AKU's Data Management Unit (DMU) provided real-time dashboard tracking and data validation. Regular feedback was given to supervisors to address inconsistencies and improve data quality. Data collection employed Computer-Assisted Personal Interviews (CAPI) using handheld tablets. At the same time, paper-based personal interviews (PAPI) were conducted in security-sensitive areas, with the subsequent data being transcribed into the system. Data entry utilized a custom Android application featuring built-in validation checks, and a web-based dashboard facilitated real-time oversight. Data security was upheld through encryption and limited access. The analysis was performed using STATA, considering stunting (height/length-for-age z-score of < −2) as an outcome variable for children under five. Statistical tests, including chi-square tests for categorical variables and t-tests for continuous variables, assessed pre- and post-intervention differences, determining significance with p-values (p < 0.05). Cohen’s h [24] was utilized to measure effect size, quantifying the magnitude of change between proportions.

The Ethical Review Committee at Aga Khan University approved the study. The research team ensured confidentiality by obtaining informed consent from all participants. They referred children with severe malnutrition or illnesses to health facilities for necessary treatment.

3. Results

The study provides a comparative analysis of baseline and midline data, highlighting the progress and challenges in household, maternal, and child health indicators. The size of households remained stable during both periods. However, socioeconomic disparities grew, evident in a slight increase in the proportion of the poorest families (from 20.1% to 21.5%) and a decrease in the wealthiest households (from 19.9% to 18.7%). Housing conditions showed mixed results; while the percentage of homes with finished walls rose (from 50.5% to 65.4%), finished roofing experienced a significant decline (from 41.9% to 11.1%), accompanied by a sharp rise in rudimentary roofing (from 28.5% to 88.8%). Access to safe drinking water decreased slightly (99.1% to 98.2%), whereas improved sanitation facilities increased from 96.8% to 99.0%. The most concerning change was the drastic drop in food security, with the proportion of food-secure households plummeting from 95.2% to 11.9%. Meanwhile, moderate to severe food insecurity rose from 3.5% to 51.6%, indicating a significant decline in food availability and access.

Maternal indicators showed notable educational improvements, as maternal literacy rose from 50.0% to 67.9%, and paternal literacy increased from 64.2% to 79.7%. However, maternal employment remained low, with only a slight rise from 4.9% to 5.2%. Child health indicators demonstrated positive trends, especially in breastfeeding rates, which increased from 71.3% to 88.3%, and dietary diversity among children aged 6-24 months, improving from 4.0% to 26.8%. Immunization coverage remained consistently high, with fully immunized children representing 99.1% at midline, although a small proportion of partially (0.6%) and non-immunized (0.4%) children appeared in the midline data. Despite improvements in education, sanitation, and child nutrition, the decline in food security and worsening housing conditions underscore significant economic challenges, emphasizing the urgent need for policy interventions Table 2.

The comparative analysis of baseline and midline data on child nutritional status in Gilgit-Baltistan & Chitral (GBC), revealed notable improvements in nutrition indicators, especially regarding underweight, stunting, and wasting. In GBC, the rate of underweight children decreased from 20.8% to 15.5% (p=0.004, effect size=0.14), while severe underweight cases dropped from 7.0% to 2.9% (p<0.001, effect size=0.19). Stunting rates fell from 40.9% to 35.4% (p=0.02, effect size=0.11), and severe stunting significantly reduced from 17.8% to 10.9% (p<0.001, effect size=0.20). Similarly, the prevalence of wasting significantly decreased from 9.8% to 4.9% (p<0.001, effect size=0.19), with severe wasting dropping from 5.0% to 1.5% (p<0.001, effect size=0.21). However, concurrent stunting and wasting rates changed little (from 1.4% to 1.6%, p=0.752, effect size=0.02), Table 3. These patterns indicate significant progress in combating both acute and chronic malnutrition in GBC, likely due to enhanced healthcare, dietary programs, and food security measures.

In Chitral, similar positive trends were noted, with underweight prevalence decreasing from 21.5% to 17.9%, even though this change was not statistically significant (p=0.125, effect size=0.09). Severe underweight rates, however, declined significantly from 8.4% to 3.7% (p=0.001, effect size=0.20). Stunting prevalence dropped from 46.0% to 38.8% (p=0.016, effect size=0.15), while severe stunting saw a considerable decline from 22.3% to 13.1% (p<0.001, effect size=0.24). Wasting prevalence was reduced from 10.9% to 5.1% (p=0.001, effect size=0.22), and severe wasting decreased from 5.0% to 1.3% (p=0.001, effect size=0.22). Nonetheless, concurrent stunting and wasting rates showed no significant shift (from 1.7% to 2.0%, p=0.694, effect size=0.02). These results indicate notable reductions in severe forms of malnutrition in Chitral, likely due to targeted interventions, improved maternal health, and better infant feeding practices (Table 3).

In GB, underweight prevalence fell from 19.8% to 11.9% (p=0.007, effect size=0.22), and severe underweight cases dropped from 4.9% to 1.7% (p=0.026, effect size=0.18). The stunting prevalence reflected only a minor decrease from 33.1% to 30.3% (p=0.456, effect size=0.06), while severe stunting declined from 10.9% to 7.6% (p=0.166, effect size=0.11). Wasting prevalence fell from 8.2% to 4.6% (p=0.08, effect size=0.15), and severe wasting significantly reduced from 4.9% to 1.7% (p=0.031, effect size=0.18). Conversely, concurrent stunting and wasting rates remained stable at 1.0% (p=0.98, effect size=0.00) Table 3. While GB showed some improvement in acute malnutrition, the ongoing levels of stunting highlight a continued problem with chronic malnutrition, underscoring the necessity for enduring nutrition programs and long-term strategies.

4. Discussion

The findings of this study demonstrate that the CASI has significantly reduced rates of stunting, underweight, and wasting among children under five in Gilgit-Baltistan and Chitral. This progress in nutrition indicators highlights the effectiveness of targeted nutritional initiatives, maternal health education, and improved child-feeding practices. However, persistent high stunting rates, declining food security, and deteriorating housing conditions reveal ongoing socioeconomic challenges that continue to affect child nutrition outcomes.

These results align with trends observed in similar nutritional interventions across South Asia. In Bangladesh, programs prioritizing maternal nutrition, dietary diversity, and community healthcare have successfully reduced stunting despite ongoing food security challenges [25]. In India, the Integrated Child Development Services (ICDS) program has improved underweight and wasting rates, but poverty and sanitation concerns have hindered progress in reducing stunting [26]. Meanwhile, Nepal’s Multi-Sector Nutrition Plan (MSNP) has achieved more substantial success by integrating food security initiatives, sanitation improvements, and social protection measures [27]. CASI stands out for its community-driven approach and rigorous monitoring, which sets it apart from these programs. However, economic challenges and food insecurity continue to limit its overall impact.

Our analysis of the findings confirms that CASI has successfully reduced severe stunting and wasting by enhancing access to healthcare, promoting maternal education, and encouraging healthier dietary behaviours. Despite these improvements, the prevalence of stunting in Gilgit-Baltistan (30.3%) remains higher than in Nepal (25.8%) and certain parts of India (27.5%), highlighting the persistence of structural barriers such as geographic isolation and economic disparities [26,27]. Although CASI has improved nutritional outcomes, the decline in food security (from 95.2% to 11.9%) raises concerns about the program’s long-term sustainability. This trend underscores the need to complement health-focused interventions with strategies that address food security, economic empowerment, and agricultural policies for lasting impact.

The potential causal interactions between CASI interventions and observed improvements can be explored through various pathways. Improved maternal nutrition and dietary diversity lead to better birth outcomes, resulting in reduced neonatal morbidity and improved child growth [17]. Increased access to fortified foods and dietary supplementation directly improves nutrient intake, decreasing malnutrition and micronutrient deficiency and supporting cognitive and physical development [28]. Community education and awareness programs enhance knowledge on appropriate infant and young child feeding practices, improving exclusive breastfeeding rates and better child nutritional status [29]. Moreover, improved sanitation and hygiene reduce exposure to infections, which can exacerbate malnutrition [30].

Our study employs a single-group pre-post-test design, allowing for a direct comparison between baseline and midline data. The substantial sample size and stratified sampling method enhance the reliability of the findings, while Computer-Assisted Personal Interviews (CAPI) improve data accuracy. However, the absence of a control group prevents definitive causal inferences, and the study’s short duration limits insights into long-term effects. Additionally, the analysis does not fully account for regional differences in dietary practices and healthcare access, which may affect the broader applicability of the conclusions.

To sustain progress, future efforts must integrate economic development with nutritional initiatives. Policymakers should strengthen food security by introducing subsidies, expanding agricultural programs, and improving market access. At the same time, enhancing sanitation and hygiene education can help combat malnutrition related to infections. Strengthening social safety nets and promoting community-led livelihood programs could also build resilience against economic hardship and food shortages. Long-term monitoring and adopting multi-sectoral strategies, such as Nepal’s MSNP, could further enhance CASI’s effectiveness.

5. Conclusions

In conclusion, CASI has made a significant improvement in child nutrition in Gilgit-Baltistan and Chitral. The reductions in severe malnutrition demonstrate the success of maternal education, child-feeding practices, and healthcare improvements. However, persistent food security and economic challenges indicate the need for more integrated policies. A comparative review with neighbouring countries suggests that incorporating food security measures and long-term financial support could amplify CASI’s impact. Future strategies should prioritize holistic, multi-sectoral approaches to ensure sustained improvements in child nutrition.