Abstract
This study comprehensively analyses and maps the spatial variability and spatial spread (inequality) in nutritional outcomes among young children residing in the 277 high-focus districts in the EAG region. We used data from the fourth update of National Family Health Survey (NFHS-4), from 2015 to 2016, and adopted a Bayesian distributional structured additive regression (STAR) approach to quantify the variations in the mean level and dispersion in the undernutrition indicators across space and based on other demographic and socioeconomic indicators available to the child, mother, and household. Markov random field and Bayesian P-splines were used as prior distributions for the spatial and nonlinear effects, respectively. Substantial intra-district heterogeneity in childhood nutritional deficiency found in EAG region; the districts where dispersions are huge, are predominantly located in three states: Uttar Pradesh, Madhya Pradesh, and Bihar. Our findings provide evidence of strong spatial structure that suggests neighbouring districts from different states have similar pattern of distribution in terms of undernourished children. The effects of child's age, mother’s age and her BMI were found to be non-linear. Furthermore, we find significant linear effects of several categorical covariates, such as, gender, birth order, birth size, maternal schooling, household wealth and sanitary condition, on indicators of undernutrition in young children. Findings strongly recommend that nutrition improvement programmes in the EAG states need to account for internal spatial heterogeneity evident across the districts of this region. Efforts are needed in assessing the district-specific causes of nutritional deficiency among the young children.
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Code Availability
Software codes used for statistical modelling are available upon request.
Abbreviations
- EAG:
-
Empowered Action Group
- NFHS:
-
National Family Health Survey
- STAR:
-
Structured additive regression
- MCMC:
-
Markov chain Monte Carlo
- IWLS:
-
Iteratively weighted least square
- DIC:
-
Deviance information criterion
- BMI:
-
Body mass index
- 95% CI:
-
95% Credible interval
- SCs:
-
Scheduled castes
- STs:
-
Scheduled tribes
- OBC:
-
Other backward classes
References
Adair, L. S. (2007). Size at birth and growth trajectories to young adulthood. American Journal of Human Biology, 19(3), 327–337. https://doi.org/10.1002/ajhb.20587
Agho, K. E., Akombi, B. J., Ferdous, A. J., Mbugua, I., & Kamara, J. K. (2019). Childhood undernutrition in three disadvantaged East African Districts: A multinomial analysis. BMC Pediatrics, 19, 118. https://doi.org/10.1186/s12887-019-1482-y
Aguayo, V. M., Badgaiyan, N., & Dzed, L. (2017). Determinants of child wasting in Bhutan. Insights from nationally representative data. Public Health Nutrition, 20(2), 315–324. https://doi.org/10.1017/S1368980016002111
Aksan, A. M. (2021). Son preference and the fertility squeeze in India. Journal of Demographic Economics, 87(1), 67–106. https://doi.org/10.1017/dem.2020.5
Akseer, N., Bhatti, Z., Mashal, T., Soofi, S., Moineddin, R., Black, R. E., & Bhutta, Z. A. (2018). Geospatial inequalities and determinants of nutritional status among women and children in Afghanistan: An observational study. The Lancet Global Health, 6(4), e447–e459. https://doi.org/10.1016/S2214-109X(18)30025-1
Amin, R., Shah, N. M., & Becker, S. (2010). Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: A cross-sectional analysis. International Journal for Equity in Health, 9, 9. https://doi.org/10.1186/1475-9276-9-9
Arokiasamy, P., & Gautam, A. (2008). Neonatal mortality in the empowered action group states of India: Trends and determinants. Journal of Biosocial Science, 40(2), 183–201. https://doi.org/10.1017/S0021932007002623
Atsbeha, D. M., Nayga, R. M., & Rickertsen, K. (2015). Can prolonged breastfeeding duration impair child growth? Evidence from rural Ethiopia. Food Policy, 53, 46–53. https://doi.org/10.1016/j.foodpol.2015.03.010
Augustine, J. M., Cavanagh, S. E., & Crosnoe, R. (2009). Maternal education, early child care and the reproduction of advantage. Social Forces, 88(1), 1–29. https://doi.org/10.1353/sof.0.0233
Bawdekar, M., & Ladusingh, L. (2008). Contextual correlates of child malnutrition in rural Maharashtra. Journal of Biosocial Science, 40(5), 771–786. https://doi.org/10.1017/S0021932008002757
Belitz, C., Brezger, A., Klein, N., Kneib, T., Lang, S., & Umlauf, N. (2015). BayesX - Bayesian inference in structured additive regression models. Professuren für Statistik und Ökonometrie, Georg-August-Universität Göttingen. http://www.uni-goettingen.de/de/bayesx/550513.html
Bhandari, P., Gayawan, E., & Yadav, S. (2021). Double burden of underweight and overweight among Indian adults: Spatial patterns and social determinants. Public Health Nutrition, 24(10), 2808–2822. https://doi.org/10.1017/S1368980021001634
Bharati, S., Pal, M., & Bharati, P. (2008). Determinants of nutritional status of pre-school children in India. Journal of Biosocial Science, 40(6), 801–814. https://doi.org/10.1017/S0021932008002812
Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., et al. (2008). Maternal and child undernutrition: Global and regional exposures and health consequences. The Lancet, 371(9608), 243–260. https://doi.org/10.1016/S0140-6736(07)61690-0
Boyle, M. H., Racine, Y., Georgiades, K., Snelling, D., Hong, S., Omariba, W., et al. (2006). The influence of economic development level, household wealth and maternal education on child health in the developing world. Social Science and Medicine, 63(8), 2242–2254. https://doi.org/10.1016/j.socscimed.2006.04.034
Calder, P. C., & Jackson, A. A. (2000). Undernutrition, infection and immune function. Nutrition Research Reviews, 13(1), 3–29. https://doi.org/10.1079/095442200108728981
Caulfield, L. E., de Onis, M., Blössner, M., & Black, R. E. (2004). Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. The American Journal of Clinical Nutrition, 80(1), 193–198. https://doi.org/10.1093/ajcn/80.1.193
Chirande, L., Charwe, D., Mbwana, H., Victor, R., Kimboka, S., Issaka, A. I., et al. (2015). Determinants of stunting and severe stunting among under-fives in Tanzania: Evidence from the 2010 cross-sectional household survey. BMC Pediatrics, 15, 165. https://doi.org/10.1186/s12887-015-0482-9
Chungkham, H. S., Marbaniang, S. P., & Narzary, P. K. (2021). Childhood Anemia in India: An application of a Bayesian geo-additive model. BMC Pediatrics, 21, 529. https://doi.org/10.1186/s12887-021-03008-0
Das, S. (2008). Childhood undernutrition: A comparative analysis of Scheduled Tribes and others in the mid-Indian Tribal Region. Social Change, 38(1), 64–83. https://doi.org/10.1177/004908570803800104
Deaton, A., & Drèze, J. (2009). Food and nutrition in India: Facts and interpretations. Economic and Political Weekly, 44(7), 42–65.
Degarege, D., Degarege, A., & Animut, A. (2015). Undernutrition and associated risk factors among school age children in Addis Ababa, Ethiopia Global Health. BMC Public Health, 15, 375. https://doi.org/10.1186/s12889-015-1714-5
Delgado, C., & Matijasevich, A. (2013). Breastfeeding up to two years of age or beyond and its influence on child growth and development: A systematic review. Cadernos De Saúde Pública, 29(2), 243–256. https://doi.org/10.1590/s0102-311x2013000200012
Deshpande, A. (2011). The grammar of caste. Oxford University Press.
Dewey, K. G., & Cohen, R. J. (2007). Does birth spacing affect maternal or child nutritional status? A systematic literature review. Maternal and Child Nutrition, 3(3), 151–173. https://doi.org/10.1111/j.1740-8709.2007.00092.x
Dorey, E., & McCool, J. (2009). The role of the media in influencing children’s nutritional perceptions. Qualitative Health Research, 19(5), 645–654. https://doi.org/10.1177/1049732309334104
Dubois, L., Girard, M., Girard, A., Tremblay, R., Boivin, M., & Pérusse, D. (2007). Genetic and environmental influences on body size in early childhood: A twin birth-cohort study. Twin Research and Human Genetics, 10(3), 479–485. https://doi.org/10.1375/twin.10.3.479
Eilers, P. H. C., & Marx, B. D. (1996). Flexible smoothing with B-splines and penalties. Statistical Science, 11(2), 89–102. https://doi.org/10.1214/ss/1038425655
Espasandín-Domínguez, J., Benítez-Estévez, A. J., Cadarso-Suárez, C., Kneib, T., Barreiro-Martínez, T., Casas-Méndez, B., & Gude, F. (2018). Geographical differences in blood potassium detected using a structured additive distributional regression model. Spatial Statistics, 24(4), 1–13. https://doi.org/10.1016/j.spasta.2018.03.001
Fahrmeir, L., Kneib, T., Lang, S., & Marx, B. (2013). Regression: Models, methods and application. Springer.
Fenske, N., Burns, J., Hothorn, T., & Rehfuess, E. A. (2013). Understanding child stunting in India: A comprehensive analysis of socio-economic, nutritional and environmental determinants using additive quantile regression. PLoS ONE, 8(11), e78692. https://doi.org/10.1371/journal.pone.0078692
Galgamuwa, L. S., Iddawela, D., Dharmaratne, S. D., & Galgamuwa, G. L. S. (2017). Nutritional status and correlated socio-economic factors among preschool and school children in plantation communities, Sri Lanka. BMC Public Health, 17, 377. https://doi.org/10.1186/s12889-017-4311-y
Gayawan, E., Adebayo, S. B., Komolafe, A. A., & Akomolafe, A. A. (2019a). Spatial distribution of malnutrition among children under five in Nigeria: A Bayesian quantile regression approach. Applied Spatial Analysis and Policy, 12(2), 229–254. https://doi.org/10.1007/s12061-017-9240-8
Gayawan, E., Adebayo, S. B., & Waldmann, E. (2019b). Modeling the spatial variability in the spread and correlation of childhood malnutrition in Nigeria. Statistics in Medicine, 38(10), 1869–1890. https://doi.org/10.1002/sim.8077
Gayawan, E., Fasusi, O. D., & Bandyopadhyay, D. (2020). Structured additive distributional zero augmented beta regression modeling of mortality in Nigeria. Spatial Statistics, 35, 100415. https://doi.org/10.1016/j.spasta.2020.100415
Gewa, C. A., & Yandell, N. (2012). Undernutrition among Kenyan children: Contribution of child, maternal and household factors. Public Health Nutrition, 15(6), 1029–1038. https://doi.org/10.1017/S136898001100245X
Ghosh, S., & Varerkar, S. A. (2019). Undernutrition among tribal children in Palghar district, Maharashtra, India. PLoS ONE, 14(2), e0212560. https://doi.org/10.1371/journal.pone.0212560
Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P., Richter, L., & Strupp, B. (2007). Developmental potential in the first 5 years for children in developing countries. Lancet, 369(9555), 60–70. https://doi.org/10.1016/S0140-6736(07)60032-4
Guilmoto, C. Z., Saikia, N., Tamrakar, V., & Bora, J. K. (2018). Excess under-5 female mortality across India: A spatial analysis using 2011 census data. The Lancet Global Health, 6(6), e650–e658. https://doi.org/10.1016/S2214-109X(18)30184-0
International Institute for Population Sciences (IIPS) & ICF. (2017). National Family Health Survey (NFHS-4), 2015–16: India. Mumbai: IIPS. http://rchiips.org/nfhs/NFHS-4Reports/India.pdf
Jayachandran, S., & Pande, R. (2017). Why are Indian children so short? The role of birth order and son preference. American Economic Review, 107(9), 2600–2629. https://doi.org/10.1257/aer.20151282
Jelenkovic, A., Yokoyama, Y., Sund, R., Hur, Y. M., Harris, J. R., Brandt, I., et al. (2018). Associations between birth size and later height from infancy through adulthood: An individual based pooled analysis of 28 twin cohorts participating in the CODATwins project. Early Human Development, 120, 53–60. https://doi.org/10.1016/j.earlhumdev.2018.04.004
Jeyakumar, A., Nikam, S., & Nayak, S. (2019). Prevalence and risk factors of undernutrition among children less than 2 years in Urban Slums of Pune, Maharashtra, India. Ecology of Food and Nutrition, 58(5), 456–469. https://doi.org/10.1080/03670244.2019.1613985
Kandala, N.-B., Madungu, T. P., Emina, J. B. O., Nzita, K. P. D., & Cappuccio, F. P. (2011). Malnutrition among children under the age of five in the Democratic Republic of Congo (DRC): Does geographic location matter? BMC Public Health, 11, 261. https://doi.org/10.1186/1471-2458-11-261
Kanjilal, B., Mazumdar, P. G., Mukherjee, M., & Rahman, M. H. (2010). Nutritional status of children in India: Household socio-economic condition as the contextual determinant. International Journal for Equity in Health, 9, 19. https://doi.org/10.1186/1475-9276-9-19
Khan, J., & Mohanty, S. K. (2018). Spatial heterogeneity and correlates of child malnutrition in districts of India. BMC Public Health, 18, 1027. https://doi.org/10.1186/s12889-018-5873-z
King, J. C. (2003). The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. The Journal of Nutrition, 133(5), 1732S-1736S. https://doi.org/10.1093/jn/133.5.1732s
Klein, N., Kneib, T., & Lang, S. (2013). Bayesian structured additive distributional regression. Faculty of Economics and Statistics, University of Innsbruck.
Lakew, Y., Bekele, A., & Biadgilign, S. (2015). Factors influencing full immunization coverage among 12–23 months of age children in Ethiopia: Evidence from the national demographic and health survey in 2011. BMC Public Health, 15, 728. https://doi.org/10.1186/s12889-015-2078-6
Lang, S., & Brezger, A. (2004). Bayesian P-Splines. Journal of Computational and Graphical Statistics, 13(1), 183–212. https://doi.org/10.1198/1061860043010
Liu, L., Johnson, H. L., Cousens, S., Perin, J., Scott, S., Lawn, J. E., et al. (2012). Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. The Lancet, 379(9832), 2151–2161. https://doi.org/10.1016/S0140-6736(12)60560-1
Lutter, C. K., & Lutter, R. (2012). Fetal and early childhood undernutrition, mortality, and lifelong health. Science, 337(6101), 1495–1499. https://doi.org/10.1126/science.1224616
Marquis, G. S., Habicht, J. P., Lanata, C. F., Black, R. E., & Rasmussen, K. M. (1997). Association of breastfeeding and stunting in Peruvian toddlers: An example of reverse causality. International Journal of Epidemiology, 26(2), 349–356. https://doi.org/10.1093/ije/26.2.349
Mazumdar, S. (2010). Determinants of inequality in child malnutrition in India: The poverty-undernutrition linkage. Asian Population Studies, 6(3), 307–333. https://doi.org/10.1080/17441730.2010.512763
McDonald, C. M., McLean, J., Kroeun, H., Talukder, A., Lynd, L. D., & Green, T. J. (2015). Household food insecurity and dietary diversity as correlates of maternal and child undernutrition in rural Cambodia. European Journal of Clinical Nutrition, 69(2), 242–246. https://doi.org/10.1038/ejcn.2014.161
Menon, P., Headey, D., Avula, R., & Nguyen, P. H. (2018). Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from 2015 to 2016. Maternal and Child Nutrition, 14, e12620. https://doi.org/10.1111/mcn.12620
Mia, M. N., Rahman, M. S., & Roy, P. K. (2018). Sociodemographic and geographical inequalities in under- and overnutrition among children and mothers in Bangladesh: A spatial modelling approach to a nationally representative survey. Public Health Nutrition, 21(13), 2471–2481. https://doi.org/10.1017/S1368980018000988
Mishra, V., Roy, T. K., & Retherford, R. D. (2004). Sex differentials in childhood feeding, health care, and nutritional status in India. Population and Development Review, 30(02), 269–295. https://doi.org/10.1111/j.1728-4457.2004.013_1.x
Ngure, F. M., Reid, B. M., Humphrey, J. H., Mbuya, M. N., Pelto, G., & Stoltzfus, R. J. (2014). Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: Making the links. Annals of the New York Academy of Sciences, 1308(1), 118–128. https://doi.org/10.1111/nyas.12330
Nguyen, P. H., Keithly, S. C., Nguyen, N. T., Nguyen, T. T., Tran, L. M., & Hajeebhoy, N. (2013). Prelacteal feeding practices in vietnam: Problems and determinant factors. BMC Public Health, 13, 932. https://doi.org/10.1159/000354245
Patel, A., Pusdekar, Y., Badhoniya, N., Borkar, J., Agho, K. E., & Dibley, M. J. (2012). Determinants of inappropriate complementary feeding practices in young children in India: Secondary analysis of National Family Health Survey 2005–2006. Maternal and Child Nutrition, 8(Suppl. 1), 28–44. https://doi.org/10.1111/j.1740-8709.2011.00385.x
Paul, V. K., Sachdev, H. S., Mavalankar, D., Ramachandran, P., Sankar, M. J., Bhandari, N., et al. (2011). Reproductive health, and child health and nutrition in India: Meeting the challenge. The Lancet, 377(9762), 332–349. https://doi.org/10.1016/S0140-6736(10)61492-4
Petrou, S., & Kupek, E. (2010). Poverty and childhood undernutrition in developing countries: A multi-national cohort study. Social Science and Medicine, 71(7), 1366–1373. https://doi.org/10.1016/j.socscimed.2010.06.038
pib.gov.in. (2017). NITI Aayog calls renewed focus on Nutrition, launches the National Nutrition Strategy. Retrieved February 25, 2021, from https://pib.gov.in/newsite/PrintRelease.aspx?relid=170549
Pingali, P., & Aiyar, A. (2018). Diversity in development: Inter-state differences in the India growth story. World Food Policy, 4(2), 57–77. https://doi.org/10.18278/wfp.4.2.5
Pongou, R., Ezzati, M., & Salomon, J. A. (2006). Household and community socioeconomic and environmental determinants of child nutritional status in Cameroon. BMC Public Health, 6, 98. https://doi.org/10.1186/1471-2458-6-98
Puri, P., Khan, J., Shil, A., & Ali, M. (2020). A cross-sectional study on selected child health outcomes in India: Quantifying the spatial variations and identification of the parental risk factors. Scientific Reports, 10, 6645. https://doi.org/10.1038/s41598-020-63210-5
Rajan, S. I. (2005). District level fertility estimates for hindus and muslims. Economic and Political Weekly, 40(5), 437–446.
Registrar General & Census Commissioner of India. (2011). Census of India: Provisional Population Totals. New Delhi, India. http://censusindia.gov.in/2011-prov-results/data_files/india/paper_contentsetc.pdf
Rue, H., & Held, L. (2005). Gaussian Markov random fields: Theory and applications. Chapman & Hall/CRC.
Rutstein, S. O. (2015). Steps to constructing the new DHS wealth index. ICF International.
Sachdev, H. S., Fall, C. H. D., Osmond, C., Lakshmy, R., Biswas, S. K. D., Leary, S. D., et al. (2005). Anthropometric indicators of body composition in young adults: Relation to size at birth and serial measurements of body mass index in childhood in the New Delhi birth cohort. American Journal of Clinical Nutrition, 82(2), 456–466. https://doi.org/10.1093/ajcn/82.2.456
Shrimpton, R., Victora, C. G., Onis, M. D., Lima, C., Blo, M., de Onis, M., et al. (2001). Worldwide Timing of Growth Faltering : Implications for Nutritional Interventions. Pediatrics, 107(5), e75. https://doi.org/10.1542/peds.107.5.e75
Somo-Aina, O., & Gayawan, E. (2019). Structured additive distributional hurdle Poisson modelling of individual fertility levels in Nigeria. Genus, 75, 20. https://doi.org/10.1186/s41118-019-0067-9
Spiegelhalter, D. J., Best, N. G., Carlin, B. P., & Van Der Linde, A. (2002). Bayesian measures of model complexity and fit. Journal of the Royal Statistical Society. Series B: Statistical Methodology, 64(4), 583–616. https://doi.org/10.1111/1467-9868.00353
Srivastava, A., Mahmood, S. E., Srivastava, P. M., Shrotriya, V. P., & Kumar, B. (2012). Nutritional status of school-age children: A scenario of urban slums in India. Archives of Public Health, 70, 8. https://doi.org/10.1186/0778-7367-70-8
Tarozzi, A., & Mahajan, A. (2007). Child nutrition in India in the nineties. Economic Development and Cultural Change, 55(3), 441–486. https://doi.org/10.1086/511195
Tiwari, R., Ausman, L. M., & Agho, K. E. (2014). Determinants of stunting and severe stunting among under-fives: Evidence from the 2011 Nepal Demographic and Health Survey. BMC Pediatrics, 14, 239. https://doi.org/10.1186/1471-2431-14-239
Van De Poel, E., & Speybroeck, N. (2009). Decomposing malnutrition inequalities between Scheduled Castes and Tribes and the remaining Indian population. Ethnicity and Health, 14(3), 271–287. https://doi.org/10.1080/13557850802609931
Victora, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L., et al. (2008). Maternal and child undernutrition: Consequences for adult health and human capital. The Lancet, 371(9609), 340–357. https://doi.org/10.1016/S0140-6736(07)61692-4
Victora, C. G., De Onis, M., Hallal, P. C., Blössner, M., & Shrimpton, R. (2010). Worldwide timing of growth faltering: Revisiting implications for interventions. Pediatrics, 125(3), e473–e480. https://doi.org/10.1542/peds.2009-1519
Victora, C. G., Wagstaff, A., Schellenberg, J. A., Gwatkin, D., Claeson, M., & Habicht, J. P. (2003). Applying an equity lens to child health and mortality: More of the same is not enough. Lancet, 362(9379), 233–241. https://doi.org/10.1016/S0140-6736(03)13917-7
Wachs, T. D. (2000). Nutritional deficits and behavioural development. International Journal of Behavioral Development, 24(4), 435–441. https://doi.org/10.1080/016502500750037982
Ware, H. (1984). Effects of maternal education, women’s roles, and child care on child mortality. Population and Development Review, 10(Suppl.), 191–214. https://doi.org/10.2307/2807961
World Health Organization. (2021). Infant and young child feeding. Retrieved January 15, 2022, from https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding
World Health Organization (WHO). (2017). Progress on drinking water, sanitation and hygiene: 2017 update and SDG baseline. World Health Organization.
Yadav, A., Ladusingh, L., & Gayawan, E. (2015). Does a geographical context explain regional variation in child malnutrition in India? Journal of Public Health, 23(5), 277–287. https://doi.org/10.1007/s10389-015-0677-4
Yisak, H., Gobena, T., & Mesfin, F. (2015). Prevalence and risk factors for under nutrition among children under five at Haramaya district, Eastern Ethiopia. BMC Pediatrics, 15, 212. https://doi.org/10.1186/s12887-015-0535-0
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PB and EG conceived and designed the study. PB and EG involved to statistical analysis and data interpretation. PB wrote the first draft of the manuscript. EG critically revised the manuscript. Both the authors read and approved the final manuscript.
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Bhandari, P., Gayawan, E. Examining Spatial Heterogeneity and Potential Risk Factors of Childhood Undernutrition in High-Focus Empowered Action Group (EAG) States of India. Spat Demogr 10, 447–486 (2022). https://doi.org/10.1007/s40980-022-00108-y
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DOI: https://doi.org/10.1007/s40980-022-00108-y