Elsevier

Social Science & Medicine

Volume 157, May 2016, Pages 165-185
Social Science & Medicine

Risk factors for chronic undernutrition among children in India: Estimating relative importance, population attributable risk and fractions

https://doi.org/10.1016/j.socscimed.2015.11.014Get rights and content

Highlights

  • Research on risk factors for child undernutrition has been single-factorial and downstream.

  • We assessed the relative and joint contribution of multiple factors for growth and development.

  • Maternal stature, education, household wealth, dietary diversity, and maternal BMI were the top 5 risk factors.

  • Together these five 5 factors accounted for more than 65% of the PAR for child undernutrition.

  • Strategies focused on social circumstances and direct investments in nutrition specific-programs are required.

Abstract

Nearly 40% of the world's stunted children live in India and the prevalence of undernutrition has been persistently high in recent decades. Given numerous available interventions for reducing undernutrition in children, it is not clear of the relative importance of each within a multifactorial framework. We assess the simultaneous contribution of 15 known risk factors for child chronic undernutrition in India. Data are from the 3rd Indian National Family Health Survey (NFHS-3), a nationally representative cross-sectional survey undertaken in 2005–2006. The study population consisted of children aged 6–59 months [n = 26,842 (stunting/low height-for-age), n = 27,483 (underweight/low weight-for-age)]. Risk factors examined for their association with undernutrition were: vitamin A supplementation, vaccination, use of iodized salt, household air quality, improved sanitary facilities, safe disposal of stools, improved drinking water, prevalence of infectious disease, initiation of breastfeeding, dietary diversity, age at marriage, maternal BMI, height, education, and household wealth. Age/sex-adjusted and multivariable adjusted effect sizes (odds ratios) were calculated for risk factors along with Population Attributable Risks (PAR) and Fractions (PAF) using logistic regression. In the mutually adjusted models, the five most important predictors of childhood stunting/underweight were short maternal stature, mother having no education, households in lowest wealth quintile, poor dietary diversity, and maternal underweight. These five factors had a combined PAR of 67.2% (95% CI: 63.3–70.7) and 69.7% (95% CI: 66.3–72.8) for stunting and underweight, respectively. The remaining factors were associated with a combined PAR of 11.7% (95% CI: 6.0–17.4) and 15.1% (95% CI: 8.9–21.3) for stunting and underweight, respectively. Implementing strategies focused on broader progress on social circumstances and infrastructural domains as well as investments in nutrition specific programs to promote dietary adequacy and diversity are required to ensure a long term trajectory of optimal child growth and development in India.

Introduction

The prevalence of childhood stunting and underweight in India remains persistently high (IIPS, 1995, IIPS, 2007). In 1992–93, amongst children aged 0–47 months, 57% and 49%, were stunted and underweight, respectively, declining to 47% and 42% in 2005–2006 (Authors calculation from the 1992-93 and 2005-06 NFHS datasets, 2015), and to 39% and 29% in 2013–14 (Ministry of Women and Child Development (2015)), the most recent year for which national data are available. In 2011, India accounted for 38% of the global burden of stunting (nearly 62 million children) (UNICEF, 2013) underscoring the importance of reducing undernutrition in India. Evidence also shows that steady increases in per capita income (or economic growth) that India experienced between 1992 and 2006 did not translate into reductions in undernutrition (Subramanyam et al., 2011). In parallel, there appears to be momentum to make direct investments in programs and interventions aimed at nutrition (e.g., breastfeeding, complementary feeding, micronutrient nutrition, and therapeutic and supplementary feeding), health (e.g., prevention and management of infectious diseases) and water, sanitation, and hygiene (WASH) programmes (Bhutta et al., 2013, Dangour et al., 2013, Ruel et al., 2013). Even though conceptual models on understanding child undernutrition emphasize a multifactorial framework (Bhutta et al., 2008), interventions and factors are often considered in isolation. Further, there appears to be disproportionate focus on what can be termed ‘nutrition-specific’ interventions targeted at addressing the immediate causes of undernutrition (Ruel et al., 2013), and considerably less emphasis has been placed on more social and structural factors including poverty reduction, improvements to socioeconomic status and maternal education, and intergenerational factors, all of which have been seen to be strongly associated with child nutritional outcomes (Özaltin et al., 2010, Subramanian et al., 2009, Subramanyam et al., 2011).

Using the most recent, comprehensive, and nationally representative data, that provides objective measures of child undernutrition, based on measured anthropometry (Corsi et al., 2011b), as well as a range of known “upstream” and “downstream” risk factors, we assess the relative and joint contribution of 15 factors in predicting the risk of childhood stunting/underweight in India, and provide estimates of population attributable risks and fractions associated with each risk factor and combinations of risk factors among all children and among stunted and underweight children.

Section snippets

Data

Data for the analysis come from the 2005–2006 Indian National Family Health Survey (NFHS) (International Institute for Population Sciences, 2007), which remains the most recent nationally representative data on child anthropometry. The survey is based on a nationally representative sample of households across 29 states in India and the sampling frame covered approximately 99% of the population. Within households, the target sample was all married and unmarried women aged 15–49 years, men aged

Results

The prevalence of stunting and underweight in the study sample were 51.1% (95% confidence interval [CI]: 50.1–52.1) and 44.9% (95% CI: 43.9–45.9), respectively. Levels of risk factors were common in the sample including low household wealth (28.6%), no formal education (50.0%), short maternal stature (<145 cm, 12.1%), and poor dietary diversity (31.4%). 17.8% of the children had access to improved drinking water, and 40.9% of children were fully vaccinated (Table 1). Among mothers, 41.1% were

Discussion

This study has three salient findings. First, factors such as maternal height, BMI, education, and household wealth were highly related to child nutrition, and explained between 60 and 80% of the burden of undernutrition among stunted/underweight children. Second, among the remaining risk factors dietary diversity appears to be the major factor. Other factors including sanitation, household air quality, and vaccination showed relatively less contribution to explaining variation in child

Conflict of interest

Authors declare no conflict of interest.

Contributions

SVS and DJC conceptualized and designed the study. DJC conducted the analyses with assistance from IM and wrote the first draft of the manuscript. SVS contributed to the writing and provided overall supervision. All authors participated in writing and revising the final manuscript.

Ethics

This study was based entirely on a publicly available dataset without access to personal identifiers.

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