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Factors Influencing Malnutrition Among School-Age Children in Rural Areas of India: A Qualitative Systematic Review Protocol
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  • University: Birmingham City University
  • Country: United Kingdom

1. Background

1.1. Introduction

Malnutrition is severe problem in rural India, and it is making the school age children suffer, as result of which it has a bad effect on both children and society. This problem is also brought to the attention of the discourse by some recent studies that have investigated the impact of malnutrition on academic performance in school-going children.

One such study was conducted by Shree and Murthy (2021) and it showed how malnutrition can affect academic performance in children from Mysuru. Poor nutrition can affect my academic performance. This study by Shree and Murthy (2021) reveals that malnutrition is directly linked to academic performance. If children do not eat well, their health might suffer which lead to not being able to go to school regularly and getting poor grades.

The report also stated that a significant number of India's children are underweight, which is a major problem that needs to be addressed immediately (Shree and Murthy, 2021). According to a report, almost half of children in India face malnutrition issues.

This has a huge impact on their studying, socializing, and prospects in life. In their review published in 2022, Zerga et al. (2022) pointed out how students who are affected by malnutrition, specifically those who are stunted, undernourished, and lacking iodine, perform poorly in their academic pursuits.

1.2. Scope of the Problem

The problem of malnutrition in school age children from rural areas in India is really huge and it needs a lot of investigation to know it in more details. In Bankura, West Bengal according to Karak et al. (2018), a study shows that several school-going children are facing nutritional issues. According to Karak et al.'s (2018) research, children living in rural areas faced major health issues like bad skin, hair fall and underdeveloped bones.

Reports show that children living in urban areas are much healthier and sound than children from the countryside, as access to improved nutrition is different for them.

According to a recent study, children who belong to the lower class and live in rural areas have shown malnutrition symptoms. Thus, it is important to design suitable diet strategies to counter this issue in an effective way.

In their study, Verma et al. (2021) assess this issue that concerns about malnutrition by children at Punjab in India. The study found that a lot of children in the age group of 5-9 were severely underweight, underdeveloped and thin.

According to the research done on teenagers between the ages of 10 and 18, being stunted and underweight still remains as significant health issues that can impact them negatively in the long run due to malnutrition.

This research reveals that a considerable number of school children suffer from undernutrition. In order to break the chain of malnutrition that has been inherited from parents to offspring, focused nutrition policies need to be designed and put into action.

The research paper by Pal et al. (2021) takes a look into the Comprehensive National Nutrition Survey conducted in India, and it reveal that a lot of school children are becoming more concerned about their nutrition status. It seems logical that a child’s background, the level of education of their parents, the neighbourhood they grow up in have an impact on their overall health.

The study by Pal et al. (2021) showed that these factors have a strong impact on children' growth and weight. This clearly depicts how hard it is to address the problem of malnutrition.

Additionally, a study done by Tiwari et al. in 2022 highlights the growing issue of malnutrition amongst adolescents. Thus, in order to solve this problem effectively, we've to adopt a strategy that includes all the factors that contribute towards it. In the context of education, research show that Is it confirmed that the child's nutritional level and parent's educational statuses also indicate his/her type of living. This implies that financial status affects nutrition quality, and this is very concerning.

The study by Narayana et al. (2021) highlights the issue of malnutrition among rural school students in the Anantapur district of Andhra Pradesh. Additionally, it was discovered that several factors led to malnutrition. These included parents' lack of education, extended families, and jobs that were not related to healthcare.

The fact that children still get malnutrition, despite the government's food programs, highlights the significance of educational initiatives aimed at children (Narayana et al., 2021).

School-going children in rural India are experiencing a severe issue of malnutrition which highlights the need to take immediate action. This study shows that there are a variety of reasons for malnutrition. That means, we need economic, regional as well as intergenerational interventions to address this problem.

1.3. Literature Review

The problem of malnutrition among school-age children in India is quite complex. According to the research, various factors contributes towards it which makes it a challenging issue.

According to Katoch’s (2022) review, global Child malnutrition is a problem and several factors including maternal education, household income, maternal nutritional status, age of the child, sanitation facilities, family size, birth order, birth weight, breastfeeding, caring practices, cooking area, fuel used, sex and socioeconomic status have been identified as key contributors.

These research findings offer a broad overview of the different ways malnutrition can occur.The study done by Pal et al. (2021) focused on calculating the frequency of stunted, undernourished, emaciated, and overweight children in the age bracket of five to fourteen in India.

This research found out that malnutrition is linked to many things like how much education a person has, how much money they make, how old the mother is, and where they live. The statement insinuates the significance of supplementing our meal plans to cater to the demands of children who face a risk of malnutrition before the age of fifteen, as per Pal et al. (2021).

The study by Prangthip et al. (2019) looks into the link between eating habits and school performance among adolescents. This paper says that a lot of things like knowing how to eat right, how often they eat, what they eat, where they live, and how much they eat, can affect how well they do in school (Prangthip et al., 2019).

The study conducted by Wangaskar et al. (2021) revealed that urban adolescents in Puducherry are more likely to suffer from malnutrition due to several societal and medical issues. While a lot of children suffer from malnutrition, it's also alarming how many of them consume too much food. It is also important to have personalized interventions tailored to the specific demands of both men and women.

In their study, Khanra et al. (2023) looked at the issue of stunting among girls in Purba Medinipur, West Bengal. That research found many connections between low growth and factors like low birth weight or getting younger siblings, the number of family members, or where a baby is born. This research highlights the significance of nutrition campaigns that target pregnant women and children to reduce malnutrition.

The report by Singh et al. (2018) highlights the severity of malnutrition among primary school children in Bareilly district, Uttar Pradesh, India. There is evidence that malnutrition is a crucial issue, especially among children.

This research by Singh and Sharma (2021) collected data from numerous studies, and they discovered that there is a huge variation in the percentage of children who are underweight. The theme of the content is that we need to take more care of the problem of undernutrition in children in India. According to Singh and Sharma (2021), this issue requires immediate attention and action.

1.4. Critical Analysis

In India, school-age children are often subjected to malnutrition that can greatly impact their growth and development. There is plentiful literature available that sheds light on this issue, but upon closer examination, some limitations become apparent.

The study done by Katoch (2022) is very informative and detailed. It focuses on the impact that maternal education, household income, and socio-demographics have on people's health.

In other words, since the studies were conducted in different locations, it might be difficult to apply the results to other situations. The variety of causes involved makes the problem more intricate, yet it becomes challenging to pinpoint precise resolutions for it.

They found out that there is a strong relationship between school-aged children and their schooling status, mother's age, education, and other socio-economic factors.

However, because the research relies on self-reported data and is cross-sectional in nature, it is difficult to establish causal relationships. Longitudinal studies could provide more solid proof of the order of these connections over a period of time.

The article by Prangthip et al. (2019) stressed upon the importance of maintaining a balanced diet for better academic performance. Nevertheless, the review mainly depends on observational research, which could make it difficult to determine a direct correlation between diet and academic achievement.

According to a study conducted by Wangaskar et al. (2021) on malnutrition in urban Puducherry, they found out that the prevalence of malnutrition is quite high and it is particularly affecting boys. This research mentions that males are at a greater risk. However, there are cultural and behavioral factors that we need to analyze more deeply to have a better understanding of this problem.

Khanra et al.'s study (2023) offers significant information about how specific demographic characteristics impact stunting in Bengalee girls. But the regional specificity of this study limits its appropriate applicability to a broader context. The study by Singh et al. (2018) on malnutrition among primary school children is really good, but it is not clear whether the risk factors identified have any causal relationship with malnutrition.

Sing and Sharma’s (2021) work is valuable because they've gathered information from many studies, which gives us a good understanding of how common malnutrition is. But, the different rates of disease occurrence mentioned in studies make the discourse question the reliability of the findings.

2. Objectives/Systematic Review Question

2.1. Systematic Review Question

What are the factors (Exposure) impacting malnutrition (Outcome) among school-going children in rural areas of India (Population)?

2.2. Question Structure

Population Exposure Outcome
School-going children in rural areas of India Socio-demographic characteristics (e.g., maternal education, household income) and influencing factors (e.g., sanitation facilities, nutritional practices) Prevalence of malnutrition, including indicators such as stunting, underweight, thinness, overweight, and obesity

Table 1: Research Question Structure
(Source: Researcher)

Type of Question

The research on school-going children's malnutrition in rural parts of India will have a qualitative approach. A comprehensive research approach is required as there are numerous factors contributing to malnutrition, and the systematic review wants to understand all of them. Using this technique, the review can learn about the characteristics and factors that impact malnutrition, which is a complex issue, so that the discourse can develop a detailed view of the problem (Gerring, 2017).

2.3. Objectives

The research objectives are crafted to align seamlessly with the qualitative nature of the inquiry:
1.    To find the determinants of malnutrition among students in rural India.
2.    To find out how the diet of school-age children affects their health.
3.    To understand how various factors are related and affect malnutrition.

Philosophical Underpinning

This research has a philosophical base that is anchored in constructivism. This viewpoint recognizes that reality is built through society and that people interpret things differently based on their own perspectives (Van der Walt, 2020). When studying the causes of malnutrition, it is crucial to look at the various points of view and experiences of the individuals affected, in order to have a more comprehensive and accurate knowledge on the matter. The study is intended to understand the complex interplay of social, cultural, and economic factors that affect the nutritional status of children who attend schools in rural areas of India.

3. Methods of Review

3.1 Search Strategy

Choosing the right databases while formulating the search strategy of a focused, systematic review is a vital step. It ensures that all relevant literature is thoroughly examined. The three most important databases—Scopus, Medline and Embase—has been selected to gather information from various scholarly articles about various factors leading to malnutrition among school going children in rural areas of India.


Scopus was selected because it covers a broad range of literature across various fields of study (Schotten et al., 2017). Scopus can be used to find health-related articles because it gives a comprehensive abstract and citation database of various health, social sciences and nutrition-related disciplines (Zhu and Liu, 2020). It helps to understand the various reasons for malnutrition by including everyone.

Medline (PubMed):

Biomedical and life sciences research is extensively covered in Medline, which can be accessed through the PubMed interface (Bramer et al., 2017). Since the research question is about health, it's really important to use Medline to find studies related to nutrition, health outcomes and factors that affect malnutrition among school children.


The reason why Embase is included is because it specializes in pharmacology and biomedical literature (Li et al., 2019). Malnutrition has significant impacts in the context of health. Therefore, Embase is an ideal source for such studies and practices that can help you overcome malnutrition.

PEO Framework for Key Terms:

The PEO framework helps identify important terms (Morgan et al., 2018). "School-age children" and "India" are some of the terms related to the term "Population." In the context of the 'Exposure' component, we come across terms like "malnutrition," "nutritional status," and "socioeconomic factors." Furthermore, 'Outcome' encompasses concepts such as "health outcomes," "dietary practices," and "nutritional interventions."

Use of Boolean Operators:

The use of Boolean operators can make the search more accurate and comprehensive (Atkinson and Cipriani, 2018). The use of "AND" in the query limits the search results to only include articles that have content related to both Population and Exposure or Outcome categories (Bramer et al., 2018). Explanation of OR: OR operator expands the search by considering the synonyms of the terms present in various categories. "NOT" is used only when necessary.


Population Exposure Outcome
School-age children Malnutrition Health outcomes
Rural areas Nutritional status Dietary practices
India Socioeconomic factors Nutritional interventions

Table 2: Search Terms
(Source: Researcher)

3.2. Study Selection – Inclusion and Exclusion Criteria

Criteria Inclusion Exclusion
Publication Period Studies published between 2013 and 2023. Studies published before 2013 or after 2023.
Geographic Scope Studies conducted in rural areas of India. Studies conducted in urban areas, studies outside India, or studies not specifying the geographical location.
Population School-going children in the age range of 5 to 18 years. Studies focusing on preschoolers (below 5 years) or adults (above 18 years).
Study Design Qualitative and quantitative research studies, including observational studies, cross-sectional studies, cohort studies, and intervention studies. Case reports, reviews, editorials, and studies lacking primary data.
Language Studies published in the English language. Studies published in languages other than English.
Full Text Availability Full-text articles or reports available. Abstract-only publications or studies without publicly accessible full texts.
Relevance to Malnutrition Studies explicitly addressing factors influencing malnutrition, nutritional status, or dietary practices among school-going children. Studies unrelated to malnutrition or nutritional status, studies focusing on general health without specific attention to malnutrition, or studies not directly relevant to the research question.

Table 3: Inclusion and Exclusion Criteria
(Source: Researcher)

3.2.1 Population

The target group for this research will include school children aged 5 to 18 years living in rural areas of India, who follow the given conditions. This age bracket makes sure the people investigate the reasons of malnutrition in school years (Gultekin et al., 2020). The research was done within the period of 2013 to 2023, making it up to date.

The reason for that was to make sure that the research findings are applicable today. Because most people live in rural areas, they have to deal with special problems. English-language publications are given extra weightage during the selection process in order to ensure that the writing is consistent throughout the analysis.

By using these criteria, the researcher can make sure that the selected studies accurately match the research goals, and therefore contribute to a more detailed analysis of the factors that contribute to malnutrition in the chosen population.

3.2.2. Exposure

Exposure criteria for the systematic review are about factors that affect malnutrition among school-going children in rural areas of India. The inclusion criteria state that the research should have a clear description of the reasons that lead to malnutrition, such as the food habits, the financial situation and the family education of the respondents (Caleychetty, 2018).

Additionally, the studies should show the relation between malnutrition and health behavior of people (Ahmad et al., 2018). It's about 10 years ago from now and the identified exposures are evaluated according to the current context.

By including these exclusion criteria, the researcher can focus our research on only those studies that are relevant to the topic and were conducted recently. The aim of this evaluation is to evaluate all the factors that lead to malnutrition in rural India by following certain rules.

3.2.3. Outcome

The goal of this review is to critically evaluate the nutrition levels of rural children in India. We have to make sure that the studies being included in the research meet certain requirements, like the ones mentioned in the inclusion criteria (Das et al., 2018). It is mentioned in the guidelines that for a study to be included, it must contain information about the occurrences of malnutrition or the factors contributing to it, especially emphasizing on stunted growth, underweight children and wasting (Chandrashekhar et al., 2017).

Other associated issues are also to be reported. The paper aims to clearly explain the various forms of malnutrition found within the study sample in order to improve our understanding and enable us to develop effective measures to combat it. Moreover, the exclusion criteria exclude the research papers which are not having a clear objective and also the outcome of the research is not being presented here in a structured way.

3.3. Study Quality Assessment

The researcher will use the criterion checklist provided in the Critical Appraisal Skills Programme (CASP) to evaluate the quality of the methodology in the studies being selected.
The CASP method helps in assessing the overall quality of different research studies (Long et al., 2020). To determine the methodological quality the systematic review must follow the CASP checklist that includes a systematic route for each study analysed. The aspects to focus on are accurate way of defining objectives, appropriately selecting methods, reliably collecting data, and clearly stating the findings (Majid and Vanstone, 2018).

Malnutrition is a major problem faced by children in rural areas of India. Hence, the CASP checklist is helpful as it aligns with the research objectives and pinpoints significant factors to assess the credibility of evidence related to this issue. This tool makes it easier to understand the complexity of research evidence by analyzing both its positive and negative aspects (Buccheri and Sharifi, 2017).

The CASP instrument is used to assess research studies that are conducted in the field of health and social sciences. This tool can help analysts evaluate the strengths and weaknesses of different types of research design. Its practical use in assessing the efficiency of research's outcomes is why it's common among scholars. By using CASP, anyone can create multiple categories so that they will be able to evaluate the quality of their content easily and efficiently (Maeda et al., 2023).

4. Data Extraction

Data Extraction is the process in which we gather different informations from various platforms to achieve the desired results. This data is opted to be used because it fits the research's aims. Organization and tracking through references are possible with the help of published year in this way we will get to know how old they are (Chen, 2017).

The study design is crucial for studying as it helps in the examination of evidence and data through various methods. Determining the most appropriate sample size is a crucial thing for any survey, it should be there to gather precise and accurate results (Munn et al., 2018).

Data collected from outcomes shows that the research is majorly about children residing in rural areas and it focuses on how nutritional inadequacy impacts them. Finally, it is important to take into account the country in which the findings were made and how they differ from one nation to another (Thomas et al., 2020).

The inclusion and exclusion criteria were very detailed and the researcher was very careful in selecting the participants for the study (Munn et al., 2018b). The research should have taken place in India between 2013 and 2023 for it to be taken into account. The children that are being examined are the ones who go to school in the rural areas.

The thing about exposure is that it includes things like lack of food and clean water, which can cause people to become malnourished. And the result of this can be different problems, like stunted growth, weak immune system, and so on. The table is a useful thing which can help students to extricate the information quickly and systematically (Boland et al., 2017).

This technique is in accordance with recognized norms and also adapts concepts from the Critical Appraisal Skills Programme (CASP) standardized list. Normally the quality specific design is being used by facilitating a standardized assessment, it ensures that the results of the systematic review are reliable and aim to be valid (Majid and Vanstone, 2018).

The purpose of this study is to maintain strict quality standards through the use of a reputable tool for data extraction, and to ensure that the subsequent analysis and interpretation of evidence is thorough and trustworthy.

Study Identification Publication Year Study Design Sample Size Outcome

Table 4: Sample Data Extraction Table
(Source: Researcher)

5. Data Synthesis

For this systematic review, the researcher will apply thematic synthesis, an effective strategy for extracting, categorizing and interpreting relevant data from various qualitative and quantitative sources (Clarke and Braun, 2017). The researcher decided to use thematic synthesis because it can adjust to all kinds of study types and data (Terry et al., 2017). This makes it suitable for all types of information provided.

The selection of thematic synthesis reflects the variety of research methods utilized in the chosen studies. As the research uses various research methods such as qualitative, quantitative and mixed methods research, it is vital to use an adaptable approach to analyze the data entirely.

Thematic synthesis gives an all-inclusive understanding of the factors affecting malnutrition among students who study outside cities in India by recognizing reoccurring themes, patterns and relationships among the studies (Castleberry and Nolen, 2018).

In addition, thematic synthesis helps to create higher-level themes that go beyond the findings of individual research, allowing for the creation of new ideas and theories (Maguire and Delahunt, 2017). This methodology is a good fit for examining and pulling apart the variables that contribute to malnutrition in the given population.

Through using thematic synthesis, the review aims to provide a comprehensive and relevant analysis of the existing research, resulting in more reliable and practical results (Braun and Clarke, 2022).

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