Relationship Between Women’s Financial Inclusion and Children’s Nutritional Status in Rulindo District, Rwanda

Relationship Between Women’s Financial Inclusion and Children’s Nutritional Status in Rulindo District, Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationship Between Women’s Financial Inclusion and Children’s Nutritional Status in Rulindo District, Rwanda Philomene Niyibizi, Augustave Rukundo Micomyiza, Pacifique Ishimwe, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6453648/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted 19 You are reading this latest preprint version Abstract Background Childhood malnutrition remains a critical public health issue in Rwanda, with stunting rates at 33%, underweight at 8%, and wasting at 1%. Stunting rates are particularly high in rural areas with 36.7% of children compared to 20% in urban areas. Women are the primary caregivers for children, and their financial inclusion could play a significant role in improving child nutritional status. Objectives The primary aim of this research was to investigate the relationship between women's financial inclusion and children’s nutritional status in Rulindo District. Methodology A cross-sectional study was conducted in Rulindo District (February 2024) among 315 households with children aged 6–59 months. Researchers collected data on financial inclusion through questionnaires and assessed children's nutritional status using anthropometric tools. WHO Anthro software, and SPSS version 25.0 were used to analyze the collected data. Results The study found that stunting rates are lower than national averages, where 29.5% were stunted 7.6% of the children were underweight, and 1% were wasted which was higher than national level. On the other hand, Agriculture was identified as the primary source of income for 92.4% (291) of participants. Over half, 54.6% (172), had a monthly income between 5,000 and 50,000 Rwandan francs. More than half, 54% (172), held personal bank accounts primarily used for savings related to childcare. While 74.8% (235) of participants knew where to obtain loans and 64.3% (151) had previously borrowed, 73.6% (231) were unaware of loans specifically for food purchases The study highlights income stability as key factor of women’s financial inclusion as women with consistent income are less likely to have stunted children COR (95%CI) were 3.701(95% CI: 1.363–10.44), with P-value = 0.010. Over half of women have bank account (54%) and saving for the future was associated with a significant decrease in stunting were 0.481(95% CI: 0.281–0.818,), with P-value = 0.007 and wasting 0.284(95% CI: 0.993 − 0.873), with P-value = 0.028. Microfinance membership offered a mixed picture; it is linked to a 2.67 times lower risk of stunting 2.667(95% CI:1.329–5.351), with P-Value: 0.006, but also a higher risk of underweight were 4.711(95% CI:1.171–18.95), with P-value = 0.029. Conclusion This study implies that financial inclusion enhances children's nutritional well-being, particularly among households with stable incomes. However, it highlights the need to address financial literacy gaps and explore the complexities of microfinance use. Children Financial inclusion Nutritional status Rwanda Women Introduction Despite significant global progress, child undernutrition remains a persistent threat, particularly in low- and middle-income countries (LMICs). Children under five are the most vulnerable, casting a long shadow on individual’s health, cognitive development, and future economic productivity( 1 ). This translates into a vicious cycle of stunted growth, impaired cognitive development, and decreased future earning potential, perpetuating poverty across generations. According to the World Health Organization (WHO), global estimates from 2020 reported that 149 million children under the age of 5 were stunted(too short for their age), 45 million were wasted (too thin for their height), and 38.9 million children were classified as overweight or obese ( 2 ). Alarmingly, undernutrition is linked to approximately 45% of deaths among children under 5 years, predominantly in LMICs( 3 ). Globally, Africa has high stunting rates among children under five, with a prevalence of 29.1%. This rate escalates in sub-Saharan Africa, where the stunting rates reaches 34% and is highest in East Africa at 37% ( 3 ). Rwanda, while experiencing remarkable economic progress, faces a similar challenge. The 2019–2020 Rwanda Demographic and Health Survey (RDHS) indicated that 33% of children under five are stunted, 8% are underweight, and 1% are wasted. Rural areas in Rwanda exhibit even higher rates, with 36.7% of children under five stunted, 9.7% underweight, and 6.2% wasted ( 4 ). Financial inclusion encompasses the access to and effective use of financial services such as bank accounts, credit facilities, and mobile money platforms which empowers individuals to manage their finances, invest in their well-being, and make informed decisions( 5 ). In Rwanda, agriculture plays a vital role in the national economy, with women significantly contributing to farming and related activities. Despite their critical role, women often encounter barriers to financial services, including limited access to credit, savings and insurance( 4 ). Rwanda has historically implemented policies and programs that promote financial inclusion as a cornerstone of economic progress, as emphasized in Vision 2020 and subsequent development strategies. The country has made significant strides in increasing financial access, particularly among women, narrowing the gender gap in financial inclusion ( 6 ). However, various socio-economic factors, including education, employment, and household decision-making dynamics play significant role in shaping both women's financial inclusion and child nutrition( 7 ). Additionally, cultural norms influence women's financial behaviors and access to financial services, which may directly impact child nutrition outcomes( 8 ). Financial literacy is essential for women's empowerment, as it enables them to utilize financial services effectively. Study demonstrates that financial literacy programs contribute to improved economic empowerment for women( 9 ), which in turn positively affects family welfare. Further studies identify both challenges and effective strategies in advancing financial inclusion and child nutrition( 10 ). The impact of financial inclusion on household nutrition and health outcomes in rural Rwanda is well-documented. For example, study have shown that microfinance program, such as Vision Fund Rwanda's Village Banking Program, have led to increased household income and improved food security among rural women( 11 ). Moreover, financial inclusion enhances access to essential health and nutrition services, such as vaccination, maternal health care, and community nutrition education ( 12 ). Although Rwanda has made notable progress in women’s financial inclusion with a relatively small gender gap of (4%), disparities exist. Currently,74% of men versus 63% of women use formal financial services, and only 3% of women obtain loans from commercial banks, compared to 5% of men( 13 ). Similarly, gender gaps in mobile money usage reveal that 46% of men in contrast to 33% of women, have or use mobile money accounts. While informal financial mechanisms do not show significant gender gaps, women are more likely excluded on the informal sector (24% versus 17%). Disparities also exist in specific financial products: fewer women than men hold bank accounts (24% versus 29%) or seek loans from formal institutions (69% versus 71%) (( 13 ). On the other hand, women are more inclined to participate in informal savings groups ( 14 ). This trend underscores a critical improtance to enhance women’s engagement with formal financial institutions which could contribute to increased financial empowerment and inclusion of women in Rwanda ( 15 ). This study assessed the relationship between women's financial inclusion and children's nutritional status in Rwanda’s Rulindo district. Insights gained from this study will inform broader development strategies beyond Rulindo district context, contributing to other national initiatives focused on improving child health and well-being. Materials and methods Study design and setting A cross-sectional study was conducted in February 2024 in Rulindo District, Rwanda, to assess the relationship between women’s financial inclusion and nutritional status of children aged under five years. Rulindo district was purposively selected due to its high poverty and undernutrition among children aged under 5 years. Within the district, Mbogo sector was randomly chosen as the study site by drawing a piece of paper from 17 labelled papers each presenting one of Rulindo sectors. Study population, sample determination and sampling process The study population comprised residents of Mbogo Sector in Rulindo district. To ensure geographic and demographic representation, all four cells of the Mbogo sector were included in the study. Within each cell, all villages were considered, and only one woman from each household who had at least one child aged under five years were considered as the study population. According to the information data manager's office in Mbogo sector, who gave us the number from their records, the total number of women per household having at least one child under five years were 1482 as per the sector’s records. The sample was calculated using Taro Yamane’s formula: n= \(\:\frac{\varvec{N}}{1+\varvec{N}\left({\varvec{e}}^{2}\right)}\) ( 16 ) Where: n is the sample size, N is the total population of women per household with children aged under 5 years old in Mbogo Sector and is equal to N = 1482 (according to the information data manager's office in Mbogo sector, who gave us the number from their records.) e is expected sampling error (0.05, when the confidence interval is 95%). Then the sample n = \(\:\frac{1482}{1+1482\left({o.o5}^{2}\:\right)}\) = 315 women per household To ensure an equitable distribution of the 315 households across the four study cells, the Excel RAND function was employed based on the sector’s records. This function generated random values which were systematically allocated into four cells, with each cell getting approximately equal numbers of women per household. Three cells were finally given 79 women per households while one was given 78 women per household only. Women with at least one child aged five or under per household were eligible to participate, regardless of their access to financial services. Data collection methods Data collectors ensured procedural adherence by thoroughly explaining the study’s objectives, significance and methodology to mothers and caregivers prior to initiating data collection. Then informed consent was obtained from all participating mothers. Primary quantitative data were collected using a questionnaire that was developed for this study. The instrument included sections assessing children's nutritional status, socio-demographic characteristics, and indicators of women’s financial inclusion to enhance data comprehensiveness. The questionnaire, initially developed in English language, was translated into the local language of Kinyarwanda and digitalized using Kobo collect to facilitate efficient data collection and secure storage. The questionnaire was also pretested on 6 women from households located in another area which was not part of the study. The pretest was important in ensuring the tool clarity and comprehension, estimate completion time and logical flow of items. Anthropometric measurements were taken using Portable length boards, Seca 876 - Flat scales and MUAC tapes Children vaccination cards were reviewed to confirm age. Data collection was conducted at each selected household by the study team of nutritionists using (tablets) with guidance on field by local Community Health Workers (CHWs). All data were collected using tablets/telephones and transmitted daily to the data manager of the study for monitoring and quality assurance. Data analysis Following data collection, data were cleaned, coded, and analyzed using IBM SPSS Statistics version 25.0. Data were downloaded in excel format and then imported into IBM SPSS Statistics version 25.0. Children's height-for-age, height-for-weight, and weight-for-age z-scores were calculated using the WHO Anthro software. Stunting was defined as a height-for-age z-score below − 2 standard deviations (SD), Wasting as a weight-for-height z-score below − 2 SD, and underweight as a weight-for-age z-score below-2 SD. Descriptive statistics including frequencies and percentages, were used to summarize the characteristics of the children, women, and financial inclusion variables. The Chi-square test was employed to assess whether there was a significant association between financial inclusion and nutritional status. However, the Fisher exact test was applied for variables where more than 20% of the cells had expected counts less than 5. Variables with P-values deemed statistically significant (less than or equal to 0.05) were selected and subjected to multivariate analysis using binary logistic regression modeling to ascertain the nature of the association. Ethical considerations The University of Rwanda granted approval for the study through the College of Medicine and Health Sciences Institutional Review Board (IRB) (CMHS/IRB/489/2023). The research was conducted in accordance with the ethical principles of the Declaration of Helsinki of October 2013 and relevant national guidelines for research involving human participants including Rwanda National Ethics Committee-RNEC- Standard Operating Procedures of August 2021. Additionally, authorization for data collection was obtained from local administrative authorities. Prior to participation, all participants were provided with information regarding the study objectives and procedures. Participants were also assured that participation is voluntary and that they can withdraw from the study any time they want without consequence. Informed consent was obtained from all participants. For individuals who were unable to read or write, the consent process was verbally explained and documented using thumbprints, in the presence of a witness chosen by the participant and in line with the national research guidelines and parents consented on behalf of their children. And each participant willingly gave their permission for us to share findings in this publication. To ensure confidentiality and privacy, data collectors refrained from recording personal identification information. Instead, they assigned codes in place of names. This practice was implemented before commencing interviews and anthropometric measurement. Results Participants’ Socio-demographic and financial inclusion Characteristics Among 315 participants, 42.2% (133) were between 25 and 31 years. Most participants, 70.8% (223), were married or partnered, and 66% (208) completed primary education. Additionally, a large majority, 84.8% (267), resided in male-headed households. Agriculture was identified as the primary source of income for 92.4% (291) of participants, with property ownership being common. Only 0.6% (2) reported not having community-based health insurance. Over half, 54.6% (172), had a monthly income between 5,000 and 50,000 Rwandan francs. More than half, 54% (172), held personal bank accounts primarily used for savings related to childcare. While 74.8% (235) of participants knew where to obtain loans and 64.3% (151) had previously borrowed, 73.6% (231) were unaware of loans specifically for food purchases. Details of these characteristics of the study population are presented in Table 1 Table 1 : Socio-demographic and financial inclusion characteristics of the participant (n=315) (See appendix) Child Nutritional Status Table 2 shows that 7.6% (24) of the children were underweight, while 29.5 % (93) were stunted, and 4.1% (13) were wasted. The prevalence of underweight among boys was 11.4% (18) and girls was 3.8% (6), while the prevalence of stunting among boys was 33.5% (53) and girls was 25.5% (40), where the prevalence of wasting among boys was 6.3% (10) and girls was 1.9% (3). Regarding age, underweight, stunting and wasting were more prominent in children aged under 24 months with prevalence of 8.5% (17), 30.5% (61), and 4.0% (8) respectively. Table 2: Children’s nutritional status per sex and age group in months(n=315) Nutritional status Sex Age(months) Male Female <24 24-47 48-59 Total Underweight Yes 18(11.4) 6(3.8) 17(8.5) 4(4.9) 3(8.8) 24(7.6) No 140(88.6) 151(96.2) 183(91.5) 77(95.1) 31(91.2) 291(92.4) Stunted Yes 53(33.5) 40(25.5) 61(30.5) 22(27.2) 10(29.4) 93(29.5) No 105(66.5) 117(74.5) 139(69.5) 59(72.8) 24(70.6) 222(70.5) Wasted Yes 10(6.3) 3(1.9) 8(4.0) 2(2.5) 3(8.8) 3(1) No 148(93.7) 154(98.1) 192(96.0) 79(97.5) 31(91.2) 312(99) Association between socio-demographic factors, women’s financial inclusion and children’s nutritional status To understand how women's financial situation impacts children's nutritional status, we examined the relationship between socioeconomic factors, financial inclusion, and child nutritional status. A significant association was found between additional income sources and child stunting (p=0.012). Additionally, Women's participation in microfinance institutions was statistically significantly associated with stunting (p = 0.007) and underweight (p = 0.035) and their practice of saving for the future was significantly associated with stunting (p = 0.008) and wasting (p = 0.028). Table 3: Bivariate Analysis of socio-demographic and financial inclusion characteristics and nutrition status (See appendix ) Multivariate Analysis of Factors Associated with Child nutritional status The factors that were significant associated with child underweight, stunting, and wasting such as saving for future use, microfinance and other source of income as variable were analyzed in multivariate. Results of those factors showed that mothers with diverse income sources were more likely to have stunted children (COR: 3.701, p=0.010), while those saving for the future had a lower risk of stunting (COR: 0.481, p=0.007). Additionally, not belonging to a microfinance institution increased the risk of stunting (COR: 2.667, p=0.006) however it also increased the risk of underweight (COR: 4.711, p=0.029). After adjusting for other factors, the positive association between diverse income sources and stunting persisted (AOR: 4.039, p=0.022), Additionally microfinance membership on stunting remained significant (AOR: 2.587, p=0.009). However, the relationship between saving for the future and stunting was no longer significant (AOR: 0.501, p=0.179). Table 4: The results of the binary logistic regression include the crude odds ratio (COR), adjusted odds ratio (AOR), and corresponding 95% confidence intervals. (See appendix ) DISCUSSION The study unveiled significant progresses in financial inclusion among women residing in the Mbogo sector, Rulindo district. A substantial increase in bank account ownership (54%) compared to the national average of 24% is indicative of enhanced access to formal financial services. Moreover, the widespread adoption of mobile money (56.5%) has empowered women to manage their finances with greater autonomy and security( 13 ). These financial advancements have fostered a positive impact on women's economic empowerment, as evidenced by the high savings rate of 73% among the study participants( 17 ). While the progress in financial inclusion is commendable, the study highlighted a concerning gap in financial literacy among women in the Mbogo sector, Rulindo district. Only 11.7% of participants reported receiving trainings on financial inclusion, suggesting a need for intensified efforts to educate women about financial management. Enhancing financial literacy is crucial for maximizing the benefits of financial inclusion, as it empowers women to make informed financial decisions, reduce financial risks, and improve their overall financial inclusiveness well-being( 18 ). The study also revealed a notable expansion of financial inclusion among women in the Mbogo sector, Rulindo district characterized by increased access to formal banking services and the widespread adoption of mobile money services as one of digital financial services. This development has empowered women to manage their finances independently, leading to higher savings rates. Key findings include a 54% bank account ownership rate among women, surpassing the national average of 24%, and a 56.5% mobile money usage rate. However, the study underscores a critical gap in financial literacy, with only 11.7% of women having received trainings on financial inclusion financial training. This disparity hinders women's ability to fully capitalize on financial opportunities. To optimize the benefits of financial inclusion, concerted efforts are necessary to enhance financial education and awareness. While mobile money has revolutionized financial transactions, facilitating easier access to funds and reducing financial vulnerabilities ( 19 )( 14 ). The nutritional status indicators examined in this study included stunting, underweight, and wasting. The prevalence rates for stunting, underweight, and wasting were found to be respectively 29.5%, 7.6%, and 4.1%. Additionally, on both indicators of malnutrition boys were more malnourished than girls as shown in Table 2 . The study has identified significant differences in nutritional status among children under five in the Mbogo sector. While overall malnutrition rates have declined, as indicated by lower prevalence of stunting, underweight, and wasting compared to the RDHS 2019–2020 data, specific vulnerabilities persist. Children under 24 months exhibited higher rates of underweight (9.1%), stunting (29%), and wasting (1%) compared to older children. These findings revealed the critical importance of early childhood nutrition interventions that are being implemented in Mbogo sector, Rulindo district. A range of nutrition initiatives, from community-based programs like growth monitoring and supplementary feeding to larger-scale interventions such as the GIKURIRO program ( 20 ), and World Vision's efforts have contributed to the observed decline in stunting ( 21 ). However, the varying impact of these programs highlights the need for more in-depth evaluations to identify effective strategies. Additionally, the study emphasizes the importance of addressing underlying determinants of malnutrition, such as poverty, food insecurity, inadequate care practices, and more sessions of raising awareness on both financial inclusion and good eating habits. The study also found a significant association between women's financial inclusion and children's nutritional status in the Mbogo sector. While child malnutrition rates have declined compared to national averages, as discussed earlier, the study identified specific vulnerabilities, particularly among children under 24 months. Financial factors, such as other income sources, savings, and microfinance membership, were associated with child nutritional outcomes. Stunting was linked to income diversity, savings, and microfinance participation, while wasting and underweight were correlated with savings and microfinance membership. These findings suggest that financial empowerment can positively impact child nutrition ( 22 ). Moreover, the study found an association between income stability and child nutritional status. Mothers with consistent income sources were less likely to have stunted children, highlighting the importance of economic security for child health. While savings were initially linked to reduced stunting, further analysis revealed that saving is more likely a consequence of stable income rather than a direct cause of improved child nutrition. This emphasizes the critical role of income diversification and empowerment for women in ensuring optimal child nutrition. By investing in women's economic capabilities, policymakers can effectively address malnutrition and improve overall child health outcomes( 23 ). The study revealed a relationship between microfinance and child nutrition. While being a member of was associated with a reduced risk of stunting, indicating improved household financial security, a surprising link to underweight was observed as case study of Ghana on child nutrition and health outcomes relieved( 24 ). This suggests that the impact of microfinance on child nutrition is multifaceted and requires further investigations to understand the mechanisms underlying these effects. Additionally, combining the belongingness to microfinance and using its services with targeted nutrition interventions, such as dietary education, may enhance the overall impact on child health outcomes. Limitations This study relied on women's self-reported data on financial inclusion, which may not accurately reflect individual financial management or household spending. Additionally, the cross-sectional design and small sample size prevented establishing causal relationships. Despite these limitations, the findings offer valuable insights into the connection between women's financial inclusion and child nutritional status. Conclusion This study establishes a positive correlation between women's financial inclusion and improved child nutrition in Mbogo, Rwanda. While women's access to banking and savings has increased during this study, financial literacy remains a significant gap. Income security emerged as a key factor influencing child nutrition, with microfinance playing a complex role. To optimize child health outcomes, targeted interventions should focus on enhancing financial literacy, promoting income stability, and exploring the nuanced impact of microfinance on child nutrition. Declarations Acknowledgments All the study participants deserve special recognition; they are the ones who made this study successful, we are also indebted to mothers and their children and the local government board, who have contributed to this study. Author's contribution PN was responsible for study design, funding acquisition, ethics submissions, and contributed significantly to manuscript writing. ARM assisted with tool adaptation, data collection, analysis, and manuscript preparation. PI organized and led the manuscript writing process, adapted tools, and contributed to the discussion. PNw contributed to writing and the presentation of findings in figures and tables. AN provided writing insights and reviewed the manuscript. IND supervised data collection and analysis and reviewed the manuscript. FXS provided overall guidance, supervising and reviewing the manuscript for rigor and quality. Funding This study did not receive any specific funding from public, commercial, or not-for-profit agencies. Data availability The data used for writing this paper is available to whoever needs it for research purposes, it can be accessed by direct contact to authors for promoting transparency, collaboration and advancement of knowledge. Ethics approval and consent to participate Not applicable. Consent for publication Informed consent to publish identifying details was obtained from all participants. Conflict of interest The authors declare that they have no competing interests. References United Nations Children’s Fund. The State of the World’s Children 2023: For every child, vaccination [Internet]. UNICEF Innocenti – Global Office of Research and Foresight. 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SSRN Electron J [Internet]. 2013;(October 2020). Available from: http://www.ssrn.com/abstract=2343160 Peprah JA, Microcredit. Child Education, and Health Outcomes: A Case Study from Ghana. In: Financing Sustainable Development in Africa [Internet]. Cham: Springer International Publishing; 2018. pp. 339–65. Available from: http://link.springer.com/ 10.1007/978-3-319-78843-2_13 Additional Declarations No competing interests reported. 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Niyibizi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDACZgaGwwwGDAls7BC+HIg48IAoLcwQvjFYSwJhixgSGKBaEhsYwFzcwJydx/BwQcGdPD5m5qMbPu6wSZ8fdvgh0BY7Od0G7Fosm3kMDs8weFbMxsyWdnPmmbTcjbfTDIBako3NDmDXYnCYB4wS25h5zG7zth3O3Tg7AaTlQOI2orT8bfufbjg7/QMJWhjbDiTIS+cQsoWtAOQXoBagX3rbkg03SOcUHEgwwOOX84c3fy74cydxfnvzsRs/2+zk5Wenb/7wocJODpcWBgYOAyCBJGsAZhvgUg4C7A9Qtcg34FM9CkbBKBgFIxEAAJqWZiLnGVESAAAAAElFTkSuQmCC","orcid":"","institution":"University of Rwanda","correspondingAuthor":true,"prefix":"","firstName":"Philomene","middleName":"","lastName":"Niyibizi","suffix":""},{"id":458228014,"identity":"ae01e34c-aa6e-497b-9ed9-5268dd1db9bd","order_by":1,"name":"Augustave Rukundo Micomyiza","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Augustave","middleName":"Rukundo","lastName":"Micomyiza","suffix":""},{"id":458228015,"identity":"ef9845ba-45e0-4fa9-b23d-9fd28ca23ac5","order_by":2,"name":"Pacifique Ishimwe","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Pacifique","middleName":"","lastName":"Ishimwe","suffix":""},{"id":458228016,"identity":"0edf3605-d9af-4169-8291-aeca5b010a42","order_by":3,"name":"Philomene Niwemugeni","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Philomene","middleName":"","lastName":"Niwemugeni","suffix":""},{"id":458228018,"identity":"f2af6fa3-b9e1-4db3-a612-6cafa6a9f8f6","order_by":4,"name":"Alphonsine Nyirahabineza","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Alphonsine","middleName":"","lastName":"Nyirahabineza","suffix":""},{"id":458228019,"identity":"89a657cb-e9e6-4519-b4dc-f1c3d9c5e1b3","order_by":5,"name":"Delice Niyigena Ilinde","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Delice","middleName":"Niyigena","lastName":"Ilinde","suffix":""},{"id":458228020,"identity":"bf52c163-09bf-40b3-ae97-9def74227f58","order_by":6,"name":"Francois Xavier Sunday","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Francois","middleName":"Xavier","lastName":"Sunday","suffix":""}],"badges":[],"createdAt":"2025-04-15 10:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6453648/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6453648/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24643-7","type":"published","date":"2025-10-09T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93419624,"identity":"ef3174be-9cdb-478e-8ffb-692710c27d25","added_by":"auto","created_at":"2025-10-13 16:04:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":901201,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6453648/v1/5702a8ec-03bd-426b-93df-3e71f73e6f49.pdf"},{"id":83076821,"identity":"5b5fb7dc-a29d-43d7-a65f-7dc0af8cf595","added_by":"auto","created_at":"2025-05-19 18:22:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":224493,"visible":true,"origin":"","legend":"","description":"","filename":"QUESTIONNAIREENGLISHVERSION.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6453648/v1/0b50445dc1b06656f61a3f6c.pdf"},{"id":83076820,"identity":"e580883a-fecf-4a70-8127-73dd23d1fa90","added_by":"auto","created_at":"2025-05-19 18:22:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":63104,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIX.docx","url":"https://assets-eu.researchsquare.com/files/rs-6453648/v1/84258a966d00a0412eee8cc8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship Between Women’s Financial Inclusion and Children’s Nutritional Status in Rulindo District, Rwanda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite significant global progress, child undernutrition remains a persistent threat, particularly in low- and middle-income countries (LMICs). Children under five are the most vulnerable, casting a long shadow on individual\u0026rsquo;s health, cognitive development, and future economic productivity(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This translates into a vicious cycle of stunted growth, impaired cognitive development, and decreased future earning potential, perpetuating poverty across generations. According to the World Health Organization (WHO), global estimates from 2020 reported that 149\u0026nbsp;million children under the age of 5 were stunted(too short for their age), 45\u0026nbsp;million were wasted (too thin for their height), and 38.9\u0026nbsp;million children were classified as overweight or obese (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Alarmingly, undernutrition is linked to approximately 45% of deaths among children under 5 years, predominantly in LMICs(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Globally, Africa has high stunting rates among children under five, with a prevalence of 29.1%. This rate escalates in sub-Saharan Africa, where the stunting rates reaches 34% and is highest in East Africa at 37% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Rwanda, while experiencing remarkable economic progress, faces a similar challenge. The 2019\u0026ndash;2020 Rwanda Demographic and Health Survey (RDHS) indicated that 33% of children under five are stunted, 8% are underweight, and 1% are wasted. Rural areas in Rwanda exhibit even higher rates, with 36.7% of children under five stunted, 9.7% underweight, and 6.2% wasted (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinancial inclusion encompasses the access to and effective use of financial services such as bank accounts, credit facilities, and mobile money platforms which empowers individuals to manage their finances, invest in their well-being, and make informed decisions(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Rwanda, agriculture plays a vital role in the national economy, with women significantly contributing to farming and related activities. Despite their critical role, women often encounter barriers to financial services, including limited access to credit, savings and insurance(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRwanda has historically implemented policies and programs that promote financial inclusion as a cornerstone of economic progress, as emphasized in Vision 2020 and subsequent development strategies. The country has made significant strides in increasing financial access, particularly among women, narrowing the gender gap in financial inclusion (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, various socio-economic factors, including education, employment, and household decision-making dynamics play significant role in shaping both women's financial inclusion and child nutrition(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, cultural norms influence women's financial behaviors and access to financial services, which may directly impact child nutrition outcomes(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinancial literacy is essential for women's empowerment, as it enables them to utilize financial services effectively. Study demonstrates that financial literacy programs contribute to improved economic empowerment for women(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which in turn positively affects family welfare. Further studies identify both challenges and effective strategies in advancing financial inclusion and child nutrition(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The impact of financial inclusion on household nutrition and health outcomes in rural Rwanda is well-documented. For example, study have shown that microfinance program, such as Vision Fund Rwanda's Village Banking Program, have led to increased household income and improved food security among rural women(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Moreover, financial inclusion enhances access to essential health and nutrition services, such as vaccination, maternal health care, and community nutrition education (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough Rwanda has made notable progress in women\u0026rsquo;s financial inclusion with a relatively small gender gap of (4%), disparities exist. Currently,74% of men versus 63% of women use formal financial services, and only 3% of women obtain loans from commercial banks, compared to 5% of men(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Similarly, gender gaps in mobile money usage reveal that 46% of men in contrast to 33% of women, have or use mobile money accounts. While informal financial mechanisms do not show significant gender gaps, women are more likely excluded on the informal sector (24% versus 17%). Disparities also exist in specific financial products: fewer women than men hold bank accounts (24% versus 29%) or seek loans from formal institutions (69% versus 71%) ((\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). On the other hand, women are more inclined to participate in informal savings groups (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This trend underscores a critical improtance to enhance women\u0026rsquo;s engagement with formal financial institutions which could contribute to increased financial empowerment and inclusion of women in Rwanda (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study assessed the relationship between women's financial inclusion and children's nutritional status in Rwanda\u0026rsquo;s Rulindo district. Insights gained from this study will inform broader development strategies beyond Rulindo district context, contributing to other national initiatives focused on improving child health and well-being.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted in February 2024 in Rulindo District, Rwanda, to assess the relationship between women\u0026rsquo;s financial inclusion and nutritional status of children aged under five years. Rulindo district was purposively selected due to its high poverty and undernutrition among children aged under 5 years. Within the district, Mbogo sector was randomly chosen as the study site by drawing a piece of paper from 17 labelled papers each presenting one of Rulindo sectors.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population, sample determination and sampling process\u003c/h3\u003e\n\u003cp\u003eThe study population comprised residents of Mbogo Sector in Rulindo district. To ensure geographic and demographic representation, all four cells of the Mbogo sector were included in the study. Within each cell, all villages were considered, and only one woman from each household who had at least one child aged under five years were considered as the study population. According to the information data manager's office in Mbogo sector, who gave us the number from their records, the total number of women per household having at least one child under five years were 1482 as per the sector\u0026rsquo;s records.\u003c/p\u003e \u003cp\u003eThe sample was calculated using Taro Yamane\u0026rsquo;s formula:\u003c/p\u003e \u003cp\u003e \u003cb\u003en=\u003c/b\u003e \u003cspan class=\"InlineEquation\"\u003e \u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\varvec{N}}{1+\\varvec{N}\\left({\\varvec{e}}^{2}\\right)}\\)\u003c/span\u003e \u003c/span\u003e (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhere: \u003cb\u003en\u003c/b\u003e is the sample size, \u003cb\u003eN\u003c/b\u003e is the total population of women per household with children aged under 5 years old in Mbogo Sector and is equal to \u003cb\u003eN\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1482 (according to the information data manager's office in Mbogo sector, who gave us the number from their records.)\u003c/p\u003e \u003cp\u003e \u003cb\u003ee\u003c/b\u003e is expected sampling error (0.05, when the confidence interval is 95%).\u003c/p\u003e \u003cp\u003eThen the sample \u003cb\u003en\u003c/b\u003e= \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{1482}{1+1482\\left({o.o5}^{2}\\:\\right)}\\)\u003c/span\u003e\u003c/span\u003e = 315 women per household\u003c/p\u003e \u003cp\u003eTo ensure an equitable distribution of the 315 households across the four study cells, the Excel RAND function was employed based on the sector\u0026rsquo;s records. This function generated random values which were systematically allocated into four cells, with each cell getting approximately equal numbers of women per household. Three cells were finally given 79 women per households while one was given 78 women per household only. Women with at least one child aged five or under per household were eligible to participate, regardless of their access to financial services.\u003c/p\u003e\n\u003ch3\u003eData collection methods\u003c/h3\u003e\n\u003cp\u003eData collectors ensured procedural adherence by thoroughly explaining the study\u0026rsquo;s objectives, significance and methodology to mothers and caregivers prior to initiating data collection. Then informed consent was obtained from all participating mothers. Primary quantitative data were collected using a questionnaire that was developed for this study. The instrument included sections assessing children's nutritional status, socio-demographic characteristics, and indicators of women\u0026rsquo;s financial inclusion to enhance data comprehensiveness. The questionnaire, initially developed in English language, was translated into the local language of Kinyarwanda and digitalized using Kobo collect to facilitate efficient data collection and secure storage. The questionnaire was also pretested on 6 women from households located in another area which was not part of the study. The pretest was important in ensuring the tool clarity and comprehension, estimate completion time and logical flow of items. Anthropometric measurements were taken using Portable length boards, Seca 876 - Flat scales and MUAC tapes Children vaccination cards were reviewed to confirm age. Data collection was conducted at each selected household by the study team of nutritionists using (tablets) with guidance on field by local Community Health Workers (CHWs). All data were collected using tablets/telephones and transmitted daily to the data manager of the study for monitoring and quality assurance.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFollowing data collection, data were cleaned, coded, and analyzed using IBM SPSS Statistics version 25.0. Data were downloaded in excel format and then imported into IBM SPSS Statistics version 25.0. Children's height-for-age, height-for-weight, and weight-for-age z-scores were calculated using the WHO Anthro software. Stunting was defined as a height-for-age z-score below \u0026minus;\u0026thinsp;2 standard deviations (SD), Wasting as a weight-for-height z-score below \u0026minus;\u0026thinsp;2 SD, and underweight as a weight-for-age z-score below-2 SD. Descriptive statistics including frequencies and percentages, were used to summarize the characteristics of the children, women, and financial inclusion variables. The Chi-square test was employed to assess whether there was a significant association between financial inclusion and nutritional status. However, the Fisher exact test was applied for variables where more than 20% of the cells had expected counts less than 5. Variables with P-values deemed statistically significant (less than or equal to 0.05) were selected and subjected to multivariate analysis using binary logistic regression modeling to ascertain the nature of the association.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e The University of Rwanda granted approval for the study through the College of Medicine and Health Sciences Institutional Review Board (IRB) (CMHS/IRB/489/2023). The research was conducted in accordance with the ethical principles of the Declaration of Helsinki of October 2013 and relevant national guidelines for research involving human participants including Rwanda National Ethics Committee-RNEC- Standard Operating Procedures of August 2021. Additionally, authorization for data collection was obtained from local administrative authorities. Prior to participation, all participants were provided with information regarding the study objectives and procedures. Participants were also assured that participation is voluntary and that they can withdraw from the study any time they want without consequence. Informed consent was obtained from all participants. For individuals who were unable to read or write, the consent process was verbally explained and documented using thumbprints, in the presence of a witness chosen by the participant and in line with the national research guidelines and parents consented on behalf of their children. And each participant willingly gave their permission for us to share findings in this publication. To ensure confidentiality and privacy, data collectors refrained from recording personal identification information. Instead, they assigned codes in place of names. This practice was implemented before commencing interviews and anthropometric measurement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u0026rsquo; Socio-demographic and financial inclusion Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 315 participants, 42.2% (133) were between 25 and 31 years. Most participants, 70.8% (223), were married or partnered, and 66% (208) completed primary education. Additionally, a large majority, 84.8% (267), resided in male-headed households. Agriculture was identified as the primary source of income for 92.4% (291) of participants, with property ownership being common.\u003c/p\u003e\n\u003cp\u003eOnly 0.6% (2) reported not having community-based health insurance. Over half, 54.6% (172), had a monthly income between 5,000 and 50,000 Rwandan francs. More than half, 54% (172), held personal bank accounts primarily used for savings related to childcare. While 74.8% (235) of participants knew where to obtain loans and 64.3% (151) had previously borrowed, 73.6% (231) were unaware of loans specifically for food purchases. Details of these characteristics of the study population are presented in Table 1\u003c/p\u003e\n\u003cp id=\"_Toc168993402\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Socio-demographic and financial inclusion characteristics of the participant\u003c/strong\u003e (n=315) (See appendix)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild Nutritional Status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows that 7.6% (24) of the children were underweight, while 29.5 % (93) were stunted, and 4.1% (13) were wasted. The prevalence of underweight among boys was 11.4% (18) and girls was 3.8% (6), while the prevalence of stunting among boys was 33.5% (53) and girls was 25.5% (40), where the prevalence of wasting among boys was 6.3% (10) and girls was 1.9% (3). Regarding age, underweight, stunting and wasting were more prominent in children aged under 24 months with prevalence of 8.5% (17), 30.5% (61), and 4.0% (8) respectively.\u003c/p\u003e\n\u003cp id=\"_Toc168993404\"\u003e\u003cstrong\u003eTable 2: Children\u0026rsquo;s nutritional status per sex and age group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;in months(n=315)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNutritional status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e24-47\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e48-59\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderweight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 493px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e18(11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e6(3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e17(8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e4(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e3(8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e24(7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e140(88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e151(96.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e183(91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e77(95.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e31(91.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e291(92.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStunted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 493px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e53(33.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e40(25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e61(30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e22(27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e10(29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e93(29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e105(66.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e117(74.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e139(69.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e59(72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e24(70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e222(70.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWasted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" style=\"width: 493px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e10(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e3(1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e8(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e3(8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e3(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e148(93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e154(98.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e192(96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e79(97.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e31(91.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e312(99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between socio-demographic factors, women\u0026rsquo;s financial inclusion and children\u0026rsquo;s nutritional status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo understand how women\u0026apos;s financial situation impacts children\u0026apos;s nutritional status, we examined the relationship between socioeconomic factors, financial inclusion, and child nutritional status. \u0026nbsp; A significant association was found between additional income sources and child stunting (p=0.012). Additionally, Women\u0026apos;s participation in microfinance institutions was statistically significantly associated with stunting (p = 0.007) and underweight (p = 0.035) and their practice of saving for the future was\u0026nbsp;significantly associated with stunting (p = 0.008) and wasting (p = 0.028).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Bivariate Analysis of socio-demographic and financial inclusion characteristics and nutrition status\u0026nbsp;\u003c/strong\u003e(See appendix\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc168993337\"\u003e\u003cstrong\u003eMultivariate Analysis of Factors Associated with Child\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003enutritional status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe factors that were significant associated with child underweight, stunting, and wasting such as saving for future use, microfinance and other source of income as variable were analyzed in multivariate. Results of those factors showed that mothers with diverse income sources were more likely to have stunted children (COR: 3.701, p=0.010), while those saving for the future had a lower risk of stunting (COR: 0.481, p=0.007). Additionally, not belonging to a microfinance institution increased the risk of stunting (COR: 2.667, p=0.006) however it also increased the risk of underweight (COR: 4.711, p=0.029). After adjusting for other factors, the positive association between diverse income sources and stunting persisted (AOR: 4.039, p=0.022), Additionally microfinance membership on stunting remained significant (AOR: 2.587, p=0.009). However, the relationship between saving for the future and stunting was no longer significant (AOR: 0.501, p=0.179).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: The results of the binary logistic regression include the crude odds ratio (COR), adjusted odds ratio (AOR), and corresponding 95% confidence intervals.\u003c/strong\u003e (See appendix\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe study unveiled significant progresses in financial inclusion among women residing in the Mbogo sector, Rulindo district. A substantial increase in bank account ownership (54%) compared to the national average of 24% is indicative of enhanced access to formal financial services. Moreover, the widespread adoption of mobile money (56.5%) has empowered women to manage their finances with greater autonomy and security(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These financial advancements have fostered a positive impact on women's economic empowerment, as evidenced by the high savings rate of 73% among the study participants(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the progress in financial inclusion is commendable, the study highlighted a concerning gap in financial literacy among women in the Mbogo sector, Rulindo district. Only 11.7% of participants reported receiving trainings on financial inclusion, suggesting a need for intensified efforts to educate women about financial management. Enhancing financial literacy is crucial for maximizing the benefits of financial inclusion, as it empowers women to make informed financial decisions, reduce financial risks, and improve their overall financial inclusiveness well-being(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study also revealed a notable expansion of financial inclusion among women in the Mbogo sector, Rulindo district characterized by increased access to formal banking services and the widespread adoption of mobile money services as one of digital financial services. This development has empowered women to manage their finances independently, leading to higher savings rates. Key findings include a 54% bank account ownership rate among women, surpassing the national average of 24%, and a 56.5% mobile money usage rate. However, the study underscores a critical gap in financial literacy, with only 11.7% of women having received trainings on financial inclusion financial training. This disparity hinders women's ability to fully capitalize on financial opportunities. To optimize the benefits of financial inclusion, concerted efforts are necessary to enhance financial education and awareness. While mobile money has revolutionized financial transactions, facilitating easier access to funds and reducing financial vulnerabilities (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe nutritional status indicators examined in this study included stunting, underweight, and wasting. The prevalence rates for stunting, underweight, and wasting were found to be respectively 29.5%, 7.6%, and 4.1%. Additionally, on both indicators of malnutrition boys were more malnourished than girls as shown in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The study has identified significant differences in nutritional status among children under five in the Mbogo sector. While overall malnutrition rates have declined, as indicated by lower prevalence of stunting, underweight, and wasting compared to the RDHS 2019\u0026ndash;2020 data, specific vulnerabilities persist.\u003c/p\u003e \u003cp\u003eChildren under 24 months exhibited higher rates of underweight (9.1%), stunting (29%), and wasting (1%) compared to older children. These findings revealed the critical importance of early childhood nutrition interventions that are being implemented in Mbogo sector, Rulindo district. A range of nutrition initiatives, from community-based programs like growth monitoring and supplementary feeding to larger-scale interventions such as the GIKURIRO program (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and World Vision's efforts have contributed to the observed decline in stunting (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, the varying impact of these programs highlights the need for more in-depth evaluations to identify effective strategies. Additionally, the study emphasizes the importance of addressing underlying determinants of malnutrition, such as poverty, food insecurity, inadequate care practices, and more sessions of raising awareness on both financial inclusion and good eating habits.\u003c/p\u003e \u003cp\u003eThe study also found a significant association between women's financial inclusion and children's nutritional status in the Mbogo sector. While child malnutrition rates have declined compared to national averages, as discussed earlier, the study identified specific vulnerabilities, particularly among children under 24 months. Financial factors, such as other income sources, savings, and microfinance membership, were associated with child nutritional outcomes. Stunting was linked to income diversity, savings, and microfinance participation, while wasting and underweight were correlated with savings and microfinance membership. These findings suggest that financial empowerment can positively impact child nutrition (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, the study found an association between income stability and child nutritional status. Mothers with consistent income sources were less likely to have stunted children, highlighting the importance of economic security for child health. While savings were initially linked to reduced stunting, further analysis revealed that saving is more likely a consequence of stable income rather than a direct cause of improved child nutrition. This emphasizes the critical role of income diversification and empowerment for women in ensuring optimal child nutrition. By investing in women's economic capabilities, policymakers can effectively address malnutrition and improve overall child health outcomes(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study revealed a relationship between microfinance and child nutrition. While being a member of was associated with a reduced risk of stunting, indicating improved household financial security, a surprising link to underweight was observed as case study of Ghana on child nutrition and health outcomes relieved(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This suggests that the impact of microfinance on child nutrition is multifaceted and requires further investigations to understand the mechanisms underlying these effects. Additionally, combining the belongingness to microfinance and using its services with targeted nutrition interventions, such as dietary education, may enhance the overall impact on child health outcomes.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study relied on women's self-reported data on financial inclusion, which may not accurately reflect individual financial management or household spending. Additionally, the cross-sectional design and small sample size prevented establishing causal relationships. Despite these limitations, the findings offer valuable insights into the connection between women's financial inclusion and child nutritional status.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study establishes a positive correlation between women's financial inclusion and improved child nutrition in Mbogo, Rwanda. While women's access to banking and savings has increased during this study, financial literacy remains a significant gap. Income security emerged as a key factor influencing child nutrition, with microfinance playing a complex role. To optimize child health outcomes, targeted interventions should focus on enhancing financial literacy, promoting income stability, and exploring the nuanced impact of microfinance on child nutrition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All the study participants deserve special recognition; they are the ones who made this study successful, we are also indebted to mothers and their children and the local government board, who have contributed to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor's contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePN was responsible for study design, funding acquisition, ethics submissions, and contributed significantly to manuscript writing. ARM assisted with tool adaptation, data collection, analysis, and manuscript preparation. PI organized and led the manuscript writing process, adapted tools, and contributed to the discussion. PNw contributed to writing and the presentation of findings in figures and tables. AN provided writing insights and reviewed the manuscript. IND supervised data collection and analysis and reviewed the manuscript. FXS provided overall guidance, supervising and reviewing the manuscript for rigor and quality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific funding from public, commercial, or not-for-profit agencies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used for writing this paper is available to whoever needs it for research purposes, it can be accessed by direct contact to authors for promoting transparency, collaboration and advancement of knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent to publish identifying details was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUnited Nations Children\u0026rsquo;s Fund. 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Child Education, and Health Outcomes: A Case Study from Ghana. In: Financing Sustainable Development in Africa [Internet]. Cham: Springer International Publishing; 2018. pp. 339\u0026ndash;65. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://link.springer.com/\u003c/span\u003e\u003cspan address=\"http://link.springer.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-319-78843-2_13\u003c/span\u003e\u003cspan address=\"10.1007/978-3-319-78843-2_13\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Financial inclusion, Nutritional status, Rwanda, Women","lastPublishedDoi":"10.21203/rs.3.rs-6453648/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6453648/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildhood malnutrition remains a critical public health issue in Rwanda, with stunting rates at 33%, underweight at 8%, and wasting at 1%. Stunting rates are particularly high in rural areas with 36.7% of children compared to 20% in urban areas. Women are the primary caregivers for children, and their financial inclusion could play a significant role in improving child nutritional status.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe primary aim of this research was to investigate the relationship between women's financial inclusion and children\u0026rsquo;s nutritional status in Rulindo District.\u003c/p\u003e\u003ch2\u003eMethodology\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted in Rulindo District (February 2024) among 315 households with children aged 6\u0026ndash;59 months. Researchers collected data on financial inclusion through questionnaires and assessed children's nutritional status using anthropometric tools. WHO Anthro software, and SPSS version 25.0 were used to analyze the collected data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found that stunting rates are lower than national averages, where 29.5% were stunted 7.6% of the children were underweight, and 1% were wasted which was higher than national level. On the other hand, Agriculture was identified as the primary source of income for 92.4% (291) of participants. Over half, 54.6% (172), had a monthly income between 5,000 and 50,000 Rwandan francs. More than half, 54% (172), held personal bank accounts primarily used for savings related to childcare. While 74.8% (235) of participants knew where to obtain loans and 64.3% (151) had previously borrowed, 73.6% (231) were unaware of loans specifically for food purchases The study highlights income stability as key factor of women\u0026rsquo;s financial inclusion as women with consistent income are less likely to have stunted children COR (95%CI) were 3.701(95% CI: 1.363\u0026ndash;10.44), with P-value\u0026thinsp;=\u0026thinsp;0.010. Over half of women have bank account (54%) and saving for the future was associated with a significant decrease in stunting were 0.481(95% CI: 0.281\u0026ndash;0.818,), with P-value\u0026thinsp;=\u0026thinsp;0.007 and wasting 0.284(95% CI: 0.993\u0026thinsp;\u0026minus;\u0026thinsp;0.873), with P-value\u0026thinsp;=\u0026thinsp;0.028. Microfinance membership offered a mixed picture; it is linked to a 2.67 times lower risk of stunting 2.667(95% CI:1.329\u0026ndash;5.351), with P-Value: 0.006, but also a higher risk of underweight were 4.711(95% CI:1.171\u0026ndash;18.95), with P-value\u0026thinsp;=\u0026thinsp;0.029.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study implies that financial inclusion enhances children's nutritional well-being, particularly among households with stable incomes. However, it highlights the need to address financial literacy gaps and explore the complexities of microfinance use.\u003c/p\u003e","manuscriptTitle":"Relationship Between Women’s Financial Inclusion and Children’s Nutritional Status in Rulindo District, Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 18:22:06","doi":"10.21203/rs.3.rs-6453648/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-02T06:29:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-01T20:23:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104865066586336184963426387733691022892","date":"2025-05-30T09:33:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T10:07:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212486686436175312501443565877138091580","date":"2025-05-29T09:54:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178481211980833661710496682829257754583","date":"2025-05-29T07:16:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38835786887176918338096861345355500144","date":"2025-05-29T00:21:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-27T13:45:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234519032043990493212510040798950013006","date":"2025-05-19T06:17:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T12:45:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289721515272399237349184595858204437892","date":"2025-05-18T12:26:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202769699842598582215202072687097676548","date":"2025-05-17T16:18:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74516445604086543357309100649572750746","date":"2025-05-15T06:29:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149639225877312637117542769481899962378","date":"2025-05-15T05:28:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-15T05:17:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-06T10:05:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T09:54:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-03T17:03:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-03T17:02:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1514edf1-394b-4d0f-aded-8e450fb2cb4c","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T15:59:23+00:00","versionOfRecord":{"articleIdentity":"rs-6453648","link":"https://doi.org/10.1186/s12889-025-24643-7","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-09 15:57:03","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-05-19 18:22:06","video":"","vorDoi":"10.1186/s12889-025-24643-7","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24643-7","workflowStages":[]},"version":"v1","identity":"rs-6453648","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6453648","identity":"rs-6453648","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}