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Spatial heterogeneity and correlates of child malnutrition in districts of India.

ABSTRACT: Despite sustained economic growth and reduction in money metric poverty in last two decades, prevalence of malnutrition remained high in India. During 1992-2016, the prevalence of underweight among children had declined from 53% to 36%, stunting had declined from 52% to 38% while that of wasting had increased from 17% to 21% in India. The national average in the level of malnutrition conceals large variation across districts of India. Using data from the recent round of National Family Health Survey (NFHS), 2015-16 this paper examined the spatial heterogeneity and meso-scale correlates of child malnutrition across 640 districts of India.Moran's I statistics and bivariate LISA maps were used to understand spatial dependence and clustering of child malnutrition. Multiple regression, spatial lag and error models were used to examine the correlates of malnutrition. Poverty, body mass index (BMI) of mother, breastfeeding practices, full immunization, institutional births, improved sanitation and electrification in the household were used as meso scale correlates of malnutrition.The univariate Moran's I statistics was 0.65, 0.51 and 0.74 for stunting, wasting and underweight respectively suggesting spatial heterogeneity of malnutrition in India. Bivariate Moran's I statistics of stunting with BMI of mother was 0.52, 0.46 with poverty and?-?0.52 with sanitation. The pattern was similar with respect to wasting and underweight suggesting spatial clustering of malnutrition against the meso scale correlates in the geographical hotspots of India. Results of spatial error model suggested that the coefficient of BMI of mother and poverty of household were strong and significant predictors of stunting, wasting and underweight. The coefficient of BMI in spatial error model was largest found for underweight (??=?0.38, 95% CI: 0.29-0.48) followed by stunting (??=?0.23, 95% CI: 0.14-0.33) and wasting (??=?0.11, 95% CI: 0.01-0.22). Women's educational attainment and breastfeeding practices were also found significant for stunting and underweight.Malnutrition across the districts of India is spatially clustered. Reduction of poverty, improving women's education and health, sanitation and child feeding knowledge can reduce the prevalence of malnutrition across India. Multisectoral and targeted intervention in the geographical hotspots of malnutrition can reduce malnutrition in India.

SUBMITTER: Khan J

PROVIDER: S-EPMC6098604 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Project description:In India, districts serve as central policy unit for program development, administration and implementation. The one-size-fits-all approach based on average prevalence estimates at the district level fails to capture the substantial small area variation. In addition to district average, heterogeneity within districts should be considered in policy design. The objective of this study was to quantify the extent of small area variation in child stunting, underweight and wasting across 36 states/Union Territories (UTs), 640 districts (and 543 PCs), and villages/blocks in India. We utilized the 4th round of Indian National Family Health Survey (NFHS-4) conducted in 2015-2016. The study population included 225,002 children aged 0-59 months whose height and weight information were available. Stunting was defined as height-for-age z-score below 2 SD from the World Health Organization child growth reference standards. Similarly, underweight and wasting were each defined as weight-for-age < -2 SD and weight-for-height < -2 SD from the age- and sex-specific medians. We adopted a four-level logistic regression model to partition the total variation in stunting, underweight and wasting. We computed precision-weighted prevalence of child anthropometric failures across districts and PCs as well as within-district/PC variation using standard deviation (SD) measures. For stunting, 56.4% (var: 0.237; SE: 0.008) of the total variation was attributed to villages/blocks, followed by 25.8% (var: 0.109; SE: 0.030) to states/UTs, and 17.7% (Var: 0.074; SE: 0.006) to districts. For underweight and wasting, villages/blocks accounted for 38.4% (var: 0.224; SE: 0.007) and 50% (var: 0.285; SE: 0.009), respectively, of the total contextual variance in India. Similar findings were shown in multilevel models incorporating PC as a geographical unit instead of districts. We found high positive correlations between mean prevalence and SD for stunting (r = 0.780, p < 0.001), underweight (r = 0.860, p < 0.001), and wasting (r = 0.857, p < 0.001) across all districts in India. A similar pattern of correlation was found for PCs. Within-district and within-PC variation are the primary source of variation for child malnutrition in India. Our results suggest the importance of considering heterogeneity within districts and PCs when planning and administering child nutrition policies.

Project description:BackgroundThe conventional indicators of infant and under-five mortality are aggregate deaths occurring in the first year and the first five years, respectively. Monitoring deaths by <1 month (neonatal), 1-11 months (post-neonatal), and 12-59 months (child) can be more informative given various etiological causes that may require different interventions across these three mutually exclusive periods. For optimal resource allocation, it is also necessary to track progress in robust estimates of child survival at a smaller geographic and administrative level.MethodsData on 259 627 children came from the 2015-2016 Indian National Family Health Survey. We used a random effects model to account for the complex survey design and sampling variability, and predicted district-specific probabilities of neonatal, post-neonatal, and child mortality. The resulting precision-weighted estimates are more reliable as they pool information and borrow strength from other districts that share the same state membership. The Pearson correlation and Spearman's rank correlation were assessed for the three mortality estimates, and the Moran's I measure was used to detect spatial clustering of high burden districts for each outcome.ResultsThe majority of under-five deaths was disproportionately concentrated in the neonatal period. Across all districts, the predicted probability of neonatal, post-neonatal, and child mortality varied from 6.0 to 63.9 deaths, 3.8 to 47.6 deaths, and 1.7 to 11.8 deaths per 1000 live births, respectively. The overall correlation between district-wide probabilities of mortality for the three mutually exclusive periods was moderate (Pearson correlation = 0.47-0.58, Spearman's rank correlation = 0.58-0.64). For each outcome, a relatively strong spatial clustering was detected across districts that transcended state boundaries (Moran's I = 0.61-0.76).ConclusionsSufficiently breaking down the under-five mortality to distinct age groups and using the precision-weighted estimations to monitor performances at smaller geographic and administrative units can inform more targeted interventions and foster accountability to improve child survival.

Project description:BackgroundGlobally, India is home to every third child affected by stunting. While numerous studies have examined the correlates of childhood stunting (CS) in India, most of these studies have focused on examining the role of proximal factors, and the role of contextual factors is much less studied. This study presents a comprehensive picture of both proximal and contextual determinants of CS in India, expanding the current evidence base. The present study is guided by the WHO conceptual framework, which outlines the context, causes, and consequences of CS.Data and methodsThe study used exploratory spatial data analysis tools to analyse the spatial pattern and correlates of CS, using data from the fourth round (2015-16) of the National Family Health Survey (NFHS-4) and the 2011 Census of India.ResultsThe study findings reiterate that CS continues to be high in India, with several hot spot states and districts, and that children from the central and eastern region of the nation, namely, Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh are particularly vulnerable. Our analysis has identified six risk factors-maternal short stature, large household size, closely spaced births, prevalence of hypertension among women, household poverty, open defecation, and extreme temperature-and four protective factors-female education, access to improved drinking water, dietary diversity among children, and iron and folic acid (IFA) supplementation during pregnancy.ConclusionsThe study highlights the need for investing in pre-conception care, addressing both demand- and supply-side barriers to increase the coverage of nutrition-specific interventions, implementing programmes to promote the intake of healthy foods from an early age, providing contraceptive counselling and services to unmarried and married adolescents and young women and men, and universalizing quality primary and secondary education that is inclusive and equitable to avert the burden of childhood stunting in India.

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Spatial heterogeneity and correlates of child malnutrition in districts of India.

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