Shailen Nandy

Poverty, child undernutrition and morbidity: new evidence from India

Undernutrition continues to be a primary cause of ill-health and premature mortality among children in developing countries. This paper examines how the prevalence of undernutrition in children is measured and argues that the standard indices of stunting, wasting and underweight may each be underestimating the scale of the problem. This has important implications for policy-makers, planners and organizations seeking to meet international development targets. Using anthropometric data on 24 396 children in India, we constructed an alternative composite index of anthropometric failure (CIAF) and compared it with conventional indices. The CIAF examines the relationship between distinct subgroups of anthropometric failure, poverty and morbidity, showing that children with multiple anthropometric failures are at a greater risk of morbidity and are more likely to come from poorer households. While recognizing that stunting, wasting and underweight reflect distinct biological processes of clear importance, the CIAF is the only measure that provides a single, aggregated figure of the number of undernourished children in a population.

Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey

Abstract Objective To investigate the demographic, socioeconomic, and geographical distribution of tobacco consumption in India. Design Multilevel cross sectional analysis of the 1998-9 Indian national family health survey of 301 984 individuals in 92 447 households in 3215 villages in 440 districts in 26 states. Setting Indian states. Participants 301 984 adults (≥ 18 years). Main outcome measures Dichotomous variable for smoking and chewing tobacco for each respondent (1 if yes, 0 if no) as well as a combined measure of whether an individual smokes, chews tobacco, or both. Results Smoking and chewing tobacco are systematically associated with socioeconomic markers at the individual and household level. Individuals with no education are 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. Households belonging to the lowest fifth of a standard of living index were 2.54 times more likely to consume tobacco than those in the highest fifth. Scheduled tribes (odds ratio 1.23, 95% confidence interval 1.18 to 1.29) and scheduled castes (1.19, 1.16 to 1.23) were more likely to consume tobacco than other caste groups. The socioeconomic differences are more marked for smoking than for chewing tobacco. Socioeconomic markers and demographic characteristics of individuals and households do not account fully for the differences at the level of state, district, and village in smoking and chewing tobacco, with state accounting for the bulk of the variation in tobacco consumption. Conclusion The distribution of tobacco consumption is likely to maintain, and perhaps increase, the current considerable socioeconomic differentials in health in India. Interventions aimed at influencing change in tobacco consumption should consider the socioeconomic and geographical determinants of peoples susceptibility to consume tobacco.

The Mortality Divide in India: The Differential Contributions of Gender, Caste, and Standard of Living Across the Life Course

OBJECTIVES We investigated the contributions of gender, caste, and standard of living to inequalities in mortality across the life course in India. METHODS We conducted a multilevel cross-sectional analysis of individual mortality, using the 1998-1999 Indian National Family Health Survey data for 529321 individuals from 26 states. RESULTS Substantial mortality differentials were observed between the lowest and highest standard-of-living quintiles across all age groups, ranging from an odds ratio (OR) of 4.61 (95% confidence interval [CI]=2.98, 7.13) in the age group 2 to 5 years to an OR of 1.97 (95% CI=1.68, 2.32) in the age group 45 to 64 years. Excess mortality for girls was evident only for the age group 2 to 5 years (OR=1.33, 95% CI=1.13, 1.58). Substantial caste differentials were observed at the beginning and end stages of life. Area variation in mortality is partially a result of the compositional effects of household standard of living and caste. CONCLUSIONS The mortality burden, across the life course in India, falls disproportionately on economically disadvantaged and lower-caste groups. Residual state-level variation in mortality suggests an underlying ecology to the mortality divide in India.

Role of socioeconomic markers and state prohibition policy in predicting alcohol consumption among men and women in India: a multilevel statistical analysis

OBJECTIVE To investigate the independent contribution of individual socioeconomic markers and state prohibition policy on alcohol consumption among men and women in India. METHODS The study used a multilevel cross-sectional analysis of alcohol consumption from the 1998-1999 Indian national family health survey of 301 984 adult individuals in 92 447 households in 3215 villages in 440 districts in 26 states, stratified by sex. FINDINGS Men with no education were more likely to consume alcohol that those with a post graduate education (OR, 2.28; 95% CI, 2.08-2.50). Unlike men, women showed a U-shaped association between education and alcohol consumption. Men and women living in households at the lowest standard-of-living quintile were more likely to consume alcohol (OR, 1.92; 95% CI, 1.81-2.03, and OR, 2.72, 95% CI, 2.18-3.39), respectively, than those classified as living in the top quintile. Members of scheduled tribes and castes and other backward classes were more likely to consume alcohol than members of other caste groups. There was no difference in alcohol consumption between men from states that were not under prohibition (OR, 1.36; 95% CI 0.69-2.03) and those that were. By contrast, states not under prohibition has higher alcohol use by women (OR, 3.04, 95% CI, 1.59-4.48) than those under partial or complete prohibition. CONCLUSION Caste, education and standard of living independently influence alcohol use in India. Prohibition policies appear to have little effect on alcohol use by men, but may reduce the proportion of women who consume alcohol. The socioeconomic patterning of health behaviours is likely to feed substantially into inequalities in health outcomes. Further investigation is required to understand how social and cultural factors in more localized contexts (e.g. districts) influence alcohol consumption.

Overlooking undernutrition? Using a composite index of anthropometric failure to assess how underweight misses and misleads the assessment of undernutrition in young children.

In light of current international interest in the Millennium Development Goals, this short report examines the suitability of one of the primary indicators being used to assess progress. Using anthropometric data on 46,784 children aged 0–35 months in seven developing countries, we show how the weight for age (underweight) indicator is problematic but not for the reasons conventionally cited. We show that the information it provides about the degree and direction of change in undernutrition over time sometimes contradicts that provided by other conventional indicators. We demonstrate the potential of an alternative indicator, the composite index of anthropometric failure (CIAF), which can be used to show the overall extent of undernutrition among children, and which provides an unequivocal statement on the direction and degree of change in undernutrition over time. Given the fundamental importance of undernutrition to child survival and health, the issues raised will be of interest to and have implications for policy makers and planners alike.

Improving the measurement of material deprivation at the European Union level

In June 2010, European Union (EU) Heads of State and Government adopted a social inclusion target as part of the new ‘Europe 2020 Strategy’: to lift at least 20 million people in the EU from the risk of poverty and exclusion by 2020. One of the three indicators used to monitor progress towards this target is the EU indicator of severe material deprivation (MD). A main limitation of this indicator is the weak reliability of some of the items it is based on. For this reason, a thematic module on MD was included in the 2009 wave of the EU Statistics on Income and Living Conditions (EU-SILC) survey. This article assesses the 2009 EU-SILC MD data and proposes an analytical framework for developing robust EU MD indicators. It carries out a systematic item by item analysis at both EU and country levels to identify the MD items which satisfactorily meet suitability, validity, reliability and additivity criteria across the EU. This approach has resulted in a proposed 13-item MD indicator covering some key aspects of living conditions which are customary across the whole EU covering a broad range of basic (food, clothes, shoes, etc.) as well as social (Internet, regular leisure activities, etc.) necessities.

The Composite Index of Anthropometric Failure (CIAF) : An Alternative Indicator of Malnutrition in Young Children

Malnutrition is a serious problem in many developing countries. It is one of the main causes of child morbidity and contributes significantly to premature mortality. This chapter discusses the design and use of an alternative indicator of malnutrition – the composite index of anthropometric failure (CIAF). It argues the three most commonly used anthropometric indicators of stunting, wasting and underweight, while providing valuable information about distinct biological processes, are individually unable to provide a comprehensive picture of the overall burden of malnutrition among young children in a population. They are frequently used to predict health and mortality risk, but provide quite limited information on the relationship between malnutrition and disease. The CIAF, however, can also be used to predict morbidity risk, and in its disaggregated form provides a more useful picture of the relationship between ill health and malnutrition. It can also be used to examine the relationship between different forms of malnutrition and poverty. Using the new World Health Organization (WHO) reference population norms and recent anthropometric data on 45,377 Indian children aged under 5 years, the prevalence of stunting, wasting and underweight are calculated and compared to prevalence estimates by the CIAF. Age adjusted logistic regression is used to see how well different indicators predict morbidity risk. Analysis of variance is used to see the relationship between groups of anthropometric failure and poverty. This chapter also provides information on how reliable, nationally representative anthropometric data from household surveys can be freely accessed by researchers to pursue their own study.

Applying the Consensual Method of Estimating Poverty in a Low Income African Setting

We present the first study of multidimensional poverty in Benin using the consensual or socially perceived necessities approach. There is a remarkable level consensus about what constitutes the necessities of life and an adequate standard of living. Following Townsend’s concept of relative deprivation, we show how social consensus provides the basis for a reliable and valid index of multiple deprivation, which can be used to reflect multidimensional poverty. We discuss the issue of adaptive preferences, which has previously been used to criticise the consensual approach, and provide evidence to contest the claim that the poor adjust their aspirations downwards.

Examining the changing profile of undernutrition in the context of food price rises and greater inequality

This paper examines how the profile of undernutrition among children in two African countries (Ethiopia and Nigeria) changed over the period of the 2007/08 food, fuel and financial crisis. Using the Composite Index of Anthropometric Failure (CIAF), an indicator which allows for a comprehensive assessment of undernutrition in young children, we examine what changes occurred in the composition of undernutrition, and how these changes were distributed amongst children in different socio-economic groups. This is important as certain combinations of anthropometric failure (AF), especially the experience of multiple failures (dual and triple combinations of AF) are associated with higher morbidity and mortality risks, and are also related to poverty. Our hypothesis is that increases in food prices during the crisis contributed to an increase in inequality, which may have resulted in concurrent increases in the prevalence of more damaging forms of undernutrition amongst poorer children. While both countries witnessed large increases in food prices, the effects were quite different. Ethiopia managed reduce the prevalence of multiple anthropometric failure between 2005 and 2011 across most groups and regions. By contrast, in Nigeria prevalence increased between 2008 and 2013, and particularly so in the poorer, northern states. The countries studied applied quite different policies in response to food price increases, with the results from Ethiopia demonstrating that protectionist public health and nutrition interventions can mitigate the impacts of price increases on poor children.

Inter-state differences in caste-specific risks for child deprivation in India

The issue of caste has long been an important structural cause of poverty in India, with certain groups and communities socially and physically excluded from the benefits of national economic and social development. While differences between groups are often explained at national and state levels, this paper focuses instead on the issue of inter-state caste-specific risks of child poverty and basic needs deprivation. We show that while children from schedule caste and tribe (SC/ST) communities fare poorly at the national level, it need not be so given some states manage to protect SC/ST children, ensuring outcomes for them are on a par or better than for children from higher caste groups. Caste and tribe status need not condemn children to lives of poverty, and this paper identifies for policy makers where caste and tribe status remain important drivers of poverty and disparities for children. Tackling these would be a start for making India a more equitable society in coming decades.