POSHAN District Nutrition Profiles_Guide to DNPs

Shruthi Cyriac, Abhilasha Vaid, Elisa Knebel, Srabashi Ray,
Suman Chakrabarti, Parul Tyagi and Purnima Menon
District Nutrition Profiles
A Quick Guide

BACKGROUND
India is land to millions of undernourished
children, however, little is known about
undernutrition and its multiple determinants at
the district level. To create awareness, facilitate
evidence-based discussions, and mobilize action
for nutrition at the district level, POSHAN,
created District Nutrition Profiles (DNP). These
short profiles present a snapshot on the state
of nutrition and its multiple determinants in
selected districts, identify areas for action,
and identify key data gaps and challenges.
They were conceptualized to enable local
leaders and civil society to understand what
it takes to effectively tackle undernutrition
in their communities. The available data on
the nutritional status of children in India is
often only available at the national and state
levels with very little data at the district level,
so this series is one step toward bridging this
knowledge gap.
To date, POSHAN has developed 46 DNPs for
the states of Bihar, Jharkhand, Madhya Pradesh,
Odisha, and Uttar Pradesh. POSHAN is now
supporting its partners Vatsalya, Vikas Samvad
and Public Health Resource Network (PHRN), to
develop DNPs for all districts of Uttar Pradesh,
Odisha and Madhya Pradesh.

CONCEPTUAL FRAMEWORK: Causes of undernutrition at three levels—immediate, underlying, and basic
1
OVERVIEW OF THE DISTRICT
NUTRITION PROFILES
A conceptual framework developed by UNICEF in 1990
and modified by Black et al. (2008)1
, lays out the causes
of nutrition at three levels—immediate, underlying, and
basic. (See Graphic Below.)
The profiles feature data, when available, on over 50
indicators, which are grouped according to these three
levels along with state-level indicators as comparisons.
The indicators include the following:
„ Nutritional outcomes: percentages of children
who are stunted, wasted, underweight, and anemic
Optimum fetal and child nutrition and development
IMMEDIATE
• Breastfeeding, nutrient rich foods, and eating routine
• Feeding and caregiving practices, parenting stimulation
• Low burden of infectious diseases
UNDERLYING
• Food security: availability, economic access and use of food
• Feeding and caregiving resources (maternal, household and community level)
• Access to and use of health services, a safe and hygienic environment
BASIC
• Knowledge and evidence
• Politics and governance
• Leadership, capacity and financial resources
• Social, economic, political, and environmental context (national and global)
„ Immediate causes of undernutrition: rates for
infant and young child feeding, immunization,
supplementation, disease burden, and adolescent
and maternal health services
„ Underlying causes of undernutrition: data on
women’s status; water, hygiene, and sanitation; food
security; and socioeconomic conditions
„ Basic causes of undernutrition: percentage of
births attended by skilled health personnel
The four-page profiles are drawn from various data
sources including data from the Government of India
Census, district-level surveys conducted by State
Nutrition Missions, Hungama Survey, and the National
Sample Survey.

2
„ Using profiles from Kandhamal, Dumka, and
Paschimi Singhbhum districts in the states of Odisha
and Jharkhand, PHRN, together with Professional
Assistance for Development Action (PRADAN), used
the profiles in combination with a qualitative field
assessment to identify critical areas for PRADAN to
begin engaging in supporting actions for nutrition.
The profiles are easy to read,
with few technical terms and
an abundance of infographics
to facilitate understanding
among the diverse stakeholders
working in nutrition. Some of
the profiles are translated into
local language to enable a wide
reach.
The profiles are created and
used at district-level nutrition-
sensitization workshops. These
workshops are attended by
various district officials (District
Panchayati Raj Officers, District
Program Officers, Medical
Officers etc.) and provide all
participants the opportunity
to understand and discuss the
contents of the DNPs, as well as
determine workable solutions/
action points informed by the
data. For example, POSHAN
and its partners have used the
profiles in the following ways:
„ In Uttar Pradesh, Vatsalya
brought together district-
level officials at a meeting
convened by the District
Development Officer
to discuss the state of
nutrition in Lucknow district
based on the profile and
identify areas for immediate
action.
„ In Odisha, PHRN convened
a state-level meeting to
present the first set of
district profiles and launch
a process for district-level
meetings.
„ In Madhya Pradesh, Vikas Samvad is in the process of
conducting district workshops in Shivpuri, Khandwa,
and Balaghat districts, and using the district profiles
to discuss the state of nutrition.
PAGE 1: Nutritional Outcomes
51.4
13.1
42.6
96.2
30.8
53.0
31.8
57.9
97.6
45.1
30.6
Children stunted
(%)1,2,^
Children wasted
(%)1,2,^
Children
underweight
(%)1,2,^
Children with any
anemia (%)3,^^
Women with
BMI<18.5 (%)2
Infants with
birthweight
<2500gms (%)4,#
Adults who are
obese in the
district (%)
Gaya Bihar
30.4% 0.1% 69.5%
^Children aged <5years; ^^Children aged <6years;
#Infants 0-2 months old
Source: Data source provided on Page 4
Gaya, Bihar
DISTRICT NUTRITION PROFILE
Page 1
THE STATE OF NUTRITION IN GAYA
DISTRICT DEMOGRAPHIC PROFILE
Total Population 4,391,418
MALE FEMALE
RURALURBAN
SC ST OTHERS
CHANGES OVER TIME
Bihar
(Children aged <5 years)
Gaya
(Children aged < 5 years)
2002-04
(DLHS-2)
2005-06
(NFHS-3)
2002-04
(DLHS-2)
2011
(HUNGaMA)
Stunting No data 53.0% No data 51.4%
Wasting No data 31.8% No data 13.1%
Underweight 49.9% 57.9% 57.3% 42.6%
CHILDREN
STUNTED1
CHILDREN
WASTED1
NO DATA ON
WOMEN’S
NUTRITIONAL
STATUS
CHILDREN
UNDERWEIGHT11
51.4%
13.1%
42.6%
THE PREVALENCE OF
UNDERWEIGHT HAS
DECREASED IN THE
DISTRICT BETWEEN
2002 AND 2011+
!
INSERT MAP
+Indicators reported are specific to rural areas as HUNGaMA survey data is based on rural population
NoData
NoData
NoData
Data based on rural population
Gaya ranks 562nd amongst
599 districts in India
(District Development Index)13
51.6% 48.4%
13.2% 86.8%

3
‚ Page 2: Immediate Causes of Undernutrition
Page 2 of the profiles present the status of interventions
and practices that promote better nutrition (see image
below).
As shown on page 2 of Gaya’s profile, over a half of
children are breastfed within 1 hour from birth but only
21.8 percent of 3–5 month olds are exclusively breastfed.
In terms of adolescent and maternal health, levels of
anemia among adolescent girls and pregnant women
(98.5 percent and 97.4 percent respectively) in Gaya are
alarming, and only 38.5 percent of women report having
access to at least 1 ANC check-up.
Just over a half of children in Gaya are fully immunized
(57.7 percent). Only 29.6 percent of children under 2
reported having diarrhea 4 weeks prior to the survey but,
22.1 percent of children with diarrhea were treated with
oral rehydration salts (ORS).
READING A DISTRICT
NUTRITION PROFILE
ƒ Page 1: Nutritional Outcomes
Page 1 of the profiles provides information on the
demographics of and nutritional status of the district
(see image at left).
Using the example of Gaya’s DNP, page 1 of the profile
shows that Gaya is predominantly rural, with less than
a third of people belonging to scheduled castes and a
majority belonging to other minority groups.
Gaya ranks 562nd out of 599 districts in India, in the
District Development Index (an index which averages
district economic development, material wellbeing,
educational development, and health indices).
The DNP also shows that over half of the district’s
children are stunted and over 40 percent are
underweight.
The DNP compares each district to its respective state. In
Gaya’s case, roughly the same
percent of children under 5
are stunted in Gaya and Bihar,
but Gaya has significantly less
wasting (13.1 percent) than
Bihar (31.8 percent). The profile
also shows that anemia rates
for children under 6 in Gaya
and in Bihar are also very high,
reaching over 95 percent in
both areas.
The DNP shows changes
in nutrition over time. One
promising evolution has
been that the prevalence of
underweight in Gaya decreased
by 14.7 percent between 2002
and 2011.
PAGE 2: Immediate Causes of Undernutrition
60.0
39.5
21.8
37.9
55.2 57.7
48.3
29.6
22.1
35.5
57.0
67.7
43.5 42.4 42.8
65.9
51.8
31.1 32.5
39.1
Early initiation of
breastfeeding
(%)
Exclusive
breastfeeding
(0-2 months old)
(%)
Exclusive
breastfeeding (3-
5 months old)
(%)
Children (6-8
months) who
received any
solid/semi solid
food in the last
24 hours (%)
Children (9-11
months old) who
achieve
minimum diet
diversity (%)
Full
immunization
coverage (%)^
Children who got
vitamin A
supplementation
(%)^^
Children who
suffered from
diarrhoea in
previous 4 weeks
(%)^
Children with
diarrhoea who
were treated
with ORS (%)^
Children who
suffered from
ARI in the
previous 4 weeks
(%)^
DISEASE
BURDEN4^
Page 2
Child undernutrition is caused by inadequacies in food, health and care for infants and young children, especially in
the first two years of life (immediate causes). Inadequate food, health and care arise from food insecurity, unsanitary
living conditions, low status of women, and poor health care (underlying causes). These are, in turn, caused by social
inequity, economic challenges, poor political will and leadership to address these causes (basic causes). Interventions
to address undernutrition must address these multiple causes of undernutrition and do so in an equitable manner.
IMMEDIATE CAUSES OF UNDERNUTRITION
IMMEDIATE CAUSES
Breastfeeding, nutrient rich foods, and eating routine
Feeding and caregiving practices, parenting stimulation
Low burden of infectious diseases
Optimum fetal and child nutrition and development
WHAT FACTORS CAUSE UNDERNUTRITION?6
UNDERLYING CAUSES
Food security: availability, economic access and use of food
Feeding and caregiving resources (maternal, household and
community level)
Access to and use of health services, a safe and hygienic environment
BASIC CAUSES
Knowledge and evidence
Politics and governance
Leadership, capacity and financial resources
Social, economic, political, and environmental context
(national and global)
The most crucial period for child nutrition is
from pre-pregnancy to the second year of life2
HOW CAN NUTRITION IMPROVE?
ADOLESCENT &
MATERNAL HEALTH3,5
INFANT AND YOUNG
CHILD FEEDING4
0
10
20
30
40
50
60
70
80
90
100
Age of child (in months)
Percentageofchildstunting(%)
Window of
opportunity
Too late
IMMUNIZATION &
SUPPLEMENTATION4,5
^Children aged 12-23 months; ^^Children aged 12-35 months;
# Girls aged 10-19 years;
38.5
97.4 98.5
59.1
97.1 99.2
Women with access to
any antenatal care (at
least 1 visit) (%)
Any anemia among
pregnant women (%)
Any anemia among
adolescent girls (%)#
Gaya Bihar
• Poor state of infant and young child feeding: low
rates of diet diversity amongst infants
• Low rates of immunization and vitamin A
supplementation, which needs urgent attention
• Alarming levels of anaemia among pregnant women
and adolescent girls
Areas for action:
Data challenges:
• Out-dated data; poor availability of data on key
immediate determinants of under nutrition from
national surveys
• Where data are available, indicator definitions are
non-standardized and often differ from World Health
Organisation recommendations

4
Page 3: Underlying
and Basic Causes of
Undernutrition „
Page 3 of the profiles present
the status of women, water
and sanitation, food security,
and socioeconomic conditions,
which are strongly linked to
nutrition (see image at right).
In the case of Gaya, early
marriage of girls is highly
prevalent, with over half of girls
married by the age of 18.
In the area of water and
sanitation, only 20.8 percent
of households in Gaya have
access to improved sanitation
facilities, which may be the
primary cause of high rates of
open defecation (74.8 percent).
Alarmingly, only less than half
of households report washing
their hands with soap before
consuming a meal, although
a majority of households have
access to improved drinking
water sources (87.9 percent).
In terms of food security, more
than half of households in Gaya
spend half of their income
on food. Out of total food
expenditure, 39 percent is spent
on cereals.
Socioeconomic conditions
in Gaya are poor, with
24.6 percent of households
living below the poverty
line, only 16.3 percent of
households having access
to electricity, and less than half of the households
(42.5 percent) living in a permanent house.
Additionally, over half of the adults in Gaya are illiterate,
and only less than a half of households avail of bank
services.
PAGE 3: Underlaying and Basic Causes of Undernutrition
51.1
87.9
20.8
74.8
42.745.9
7.8 9.2
93.3
19.5
75.8 73.3
57.2
Girls married
when <18years
old (%)
Ever married
women/mothers
who completed
primary school
(%)
Women who
completed
middle school
(%)
Women's
ownership of
land (%)
Women's
ownership of
livestock (%)
Access to
improved
drinking water
sources (%)
Access to
improved
sanitation
facilities (%)
Open defecation
(%)
Child stool
disposal in a
sanitary manner
(%)
Households who
washed hands
with soap before
a meal (%)^
52.8
39.0
53.3
24.6
51.1
42.5
16.3
49.4
34.8
53.2
34.1
50.9 48.1
16.4
Household share of
expenditure on food
(%)
Household share of
food expenditure on
cereals (%)
Households in the
district involved in
agriculture (%)
Below Poverty Line
households (%)
Households ownership
of agricultural land (%)
Households living in a
permanent house (%)
Access to electricity (%)
Gaya Bihar
SOCIO ECONOMIC CONDITIONS7,9
Page 3
UNDERLYING CAUSES OF UNDERNUTRITION
BASIC CAUSES OF UNDERNUTRITION
• Per capita gross district domestic product of Gaya ranked 13th amongst 38 district of Bihar in 2011-1214.
• Bihar’s per capita income ranks last amongst 32 major States/UTs in India in 2011-1215.
NoData
NoData
NoData
NoData
NoData
NoData
NoData
WOMEN’S STATUS5 WATER, SANITATION AND HYGIENE2,4,7
FOOD SECURITY8
^Household with a child aged 6-8 months;
52.3
25.8
100.0
25.6
81.4
38.4
47.450.4
31.7
91.7
32.7
91.7
57.2
44.4
Adult literacy rate (%)12 Births attended by
skilled health personnel
(%)5
Household has access to
Anganwadi Worker (%)5
a Sub Health Centre
(%)5
Primary/Middle School
(%)5
Households who
demanded and received
work through NREGA
(%)11
Households availing
Bank services (%)7
Gaya Bihar
Areas for immediate action:
• Very high rates of open defecation; critical need to increase awareness about washing hands with soap and
ensuring access to using improved sanitation facilities
• Early marriage of girls less than 18 years is highly prevalent; early marriage is related to poor health and
nutrition outcomes for mothers and babies
• Food insecurity, especially diet quality, is a challenge that can holdback improvements in nutrition
• Very few households live in a permanent house and have access to electricity
Data challenges:
• Difficult to compare indicators of water, sanitation and hygiene over time as census data do not provide data
on child stool disposal or on hand washing
• Access to skilled health personnel and Sub-Health Centres is very limited
• Action needs to be taken to improve adult literacy which is low
• No data available on indicators of governance and political will to address nutrition

5
Page 4: Evaluation of Health and
Nutrition Schemes
The last section of the profile will differ among states. In
some cases it will be a space for participants in nutri-
tion-sensitization workshops to note action points to
improve nutrition in their communities, while in others
it will present a set of indicators on the performance of
health and nutrition schemes in the state and district,
from state-level surveys. In Gaya’s case, it is the latter
(see image above).
Less than half of the eligible households in Gaya, with
children 0–2 months old, receive any take home ration
(31.4 percent), and financial assistance for delivery and
child care (23 percent).
On a positive note, a majority of households
(62.6 percent) report having institutional deliveries and
85 percent of households with a 12–23 month old
child are equipped with an immunization/MCP card.
PAGE 4: Evaluation of Health and Nutrition Schemes
Data sources
1. Author’s estimates based on HUNGaMA: Fighting Hunger & Malnutrition: the HUNGaMA Survey Report. 2011. Naandi Foundation.
2. Author’s estimates based on National Family Health Survey (NFHS-3), 2005-06, India. Mumbai: International Institute for Population Studies.
3. Author’s estimates based on District Level Household Survey on Reproductive and Child Health (DLHS-2), 2002-04, India. International Institute for Population Studies.
(IIPS). 2006. District Level Household Survey on Reproductive and Child Health (DLHS-2), 2002-04, India: Nutritional Status of Children and Prevalence of Anemia among
Children, Adolescent Girls and Pregnant Women. Mumbai: IIPS. March 18, 2015, www.rchiips.org/pdf/rch2/National_Nutrition_Report_RCH-II.pdf
4. Concurrent Household Health and Nutrition Survey (Round-6), Concurrent Monitoring and Learning Unit, CARE India – Bihar
5. International Institute for Population Studies (IIPS). 2010. District Level Household Survey and Facility Survey (DLHS-3), 2007-08, India, Uttar Pradesh. Mumbai: IIPS.
Accessed March 18, 2015, http://www.rchiips.org/pdf/rch3/report/bh.pdf
6. Robert E Black, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, Sally Grantham-McGregor, Joanne Katz, Reynaldo
Martorell, Ricardo Uauy, and the Maternal and Child Nutrition Study Group. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-
Income Countries”. The Lancet 382 (9890), 427-451.
7. Census of India. 2011. Houselisting and Housing Census Data. Accessed March 18, 2015, www.censusindia.gov.in/2011census/hlo/HLO_Tables.html
8. Author’s estimates based on Household Consumption Expenditure, National Sample Survey Office (NSSO) 68th Round, 2011-12. Ministry of Statistics and Program
Implementation. Government of India.
9. Planning Commission. 2013. Press note on poverty estimates, 2011-12. Government of India. Accessed March 18, 2015.
http://planningcommission.nic.in/news/pre_pov2307.pdf
10. Finance Department, Government of Bihar. Economic Survey Report 2011-12: Gross District Domestic Product at Constant Prices (2005-06). Accessed March 18, 2015,
http://finance.bih.nic.in/Documents/Reports/Economic-Survey-2012-EN.pdf
11. Author’s estimates based on Employment and Unemployment, National Sample Survey Office (NSSO) 68th Round, 2011-12. Ministry of Statistics and Program
Implementation. Government of India.
12. Census of India. 2011. Primary Census Abstract. Accessed June 6, 2015, www.censusindia.gov.in/pca/default.aspx
13. Us-India Policy Institute. 2015. District Development and Diversity Index. Accessed July 2, 2015, http://www.usindiapolicy.org/updates/general-news/225-district-
development-and-diversity-index-report
14. Government of Bihar. 2015. Economic Survey 2014-15. Accessed July 2,2015, http://finance.bih.nic.in/Documents/Reports/Economic-Survey-2015-EN.pdf
15. Government of India. 2014. State-wise Per Capita Income and Gross Domestic Product at current prices. Accessed July 2, 2015,
http://pib.nic.in/archieve/others/2014/aug/d2014070801.pdf
This District Nutrition Profile was developed by Srabashi Ray for POSHAN. This version, dated 20-07-
2015 is a draft intended for use in a district-level workshop in Gaya, and will be revised following
workshop discussions
EVALUATION OF HEALTH AND NUTRITION SCHEMES
FLW visits4
^Infants aged 0-2 months; ^^2 recommended visits; *3 recommended visits;
Last Trimester^^ Within 1 week of delivery*
Within 24
hours of
delivery*No Visit
Less than
recommended
Equal to
recommended
More than
recommended
No Visit
Less than
recommended
Equal to
recommended
More than
recommended
Bihar 58.9% 5.8% 10.1% 25.3% 67.3% 21.3% 4.8% 6.6% 27.4%
Gaya 58.2% 7.1% 7.9% 26.7% 60.4% 27.9% 4.5% 7.3% 33.6%
62.6
85.0
31.4
23.0
71.8
83.2
42.0
26.4
Institutional deliveries
(%)^
Households (with a 12-
23 month old child) with
an immunization/MCP
card (%)
Households that receive
any take home ration
(%)^
Any financial assistance
to households for
delivery and childcare
(%)^
Gaya Bihar
Source:SavetheChildren/India/2009
Areas for immediate action:
• Less than half of the eligible household
receive any take home ration
• A majority of households with a pregnant
woman/new-born child were not visited
by any FLW
• Only a few households receive financial
assistance for delivery and child care
Data challenges:
• Lack of data on assessing the
implementation of government schemes
Frequency of frontline worker (FLW) visits to house-
holds with a pregnant woman/new born child
however, is poor. In Gaya, 58.2 percent of women are
not visited by FLWs in the last trimester. Even fewer
women are visited within 1 week of delivery, with only
27.9 percent receiving at least three recommended
visits. Alarmingly, only 33.6 percent of women are
visited 24 hours prior to delivery.
LESSONS AND CHALLENGES
IN PREPARING THE DISTRICT
NUTRITION PROFILE
The lack of recent and reliable district-level data
on nutrition is the biggest challenge in preparing
these profiles. None of the profiles has all the data
on nutrition, and often, the data that does exist is
outdated. In the case of Gaya, data on recommended

6
CONCLUSION
POSHAN is excited to be supporting such a diverse
set of knowledge mobilization partners in convening
nutrition conversations using the District Nutrition
Profiles. These profiles are a foundation for transforming
the nutrition situation in any district. The challenge for
all districts will be to collect timely and relevant data
on nutrition-related indicators through surveys. To
make this happen, strong governance and leadership is
required. The absence of data, highlighted in the profiles
can be used to initiate policy dialogue and engagement
among policymakers at the district, state, and national
levels to take action.
IYCF practices, women’s status, low birth weight infants,
adult obesity, and governance and political will to
address undernutrition, is all currently unavailable.
For the data that is available, indicator definitions are
not standardized, varying across surveys and reports,
and often differ from the World Health Organization’s
recommendations. This makes it challenging to make
comparisons over time.
„ Sampling differences: Some of the data sources
provided only rural data and used smaller samples.
This made it difficult to compare indicators from
these data sources with data available from national
level surveys.
„ Data skills: Some data, e.g., on food security and
diet diversity, require the use of unit-level data
from large, complex data sources such as National
Sample Survey Organization (NSSO) data. Others
are less challenging e.g., water-sanitation indicators
and access to services, which can be almost directly
obtained from the census reports.

7
ANNEX 1: INDICATOR DEFINITION AND SOURCES
Choice of Indicators
District Nutrition Profiles feature a set of indicators on the state of nutrition and its multiple determinants in India
based on diverse sources of data. A conceptual framework developed by UNICEF in 1990 and modified by Black
et al. (2008) lays out the causes of nutrition at three levels—immediate, underlying, and basic. The profiles feature
district-level indicators that are grouped by these three levels and an associated state-level indicator as a comparison
as well as overall indicators for district demographics and nutrition status.
POSHAN is regularly tracking data sources as they are released and updating the profiles accordingly. These are all
featured at: http://poshan.ifpri.info/district-nutrition-profiles/.
PLEASE NOTE: Indicator definitions and sources will vary among states. The following indicators and sources are
specific to Bihar.
District Profile Indicators
DEMOGRAPHICS
Indicator Indicator Definition Unit State Source District Source Additional
Information
Total Population Number of individuals living in the district Persons
Government of
India 2011
Government of
India 2011
Census 2011
URL: http://www.
censusindia.gov.
in/2011census/
population_
enumeration.html
Population
Enumeration Data
(Final Population)
>> Primary
Census Abstract
Data (Final
Population)>>
Primary Census
Abstract Data
Tables (India
& States/UTs -
District Level)
(Excel Format)
Male Population Numerator: number of males living in the
district
Denominator: total population
Persons
Female Population Numerator: number of females living in the
district
Persons
Urban Population Numerator: number of individuals living in
urban areas
Persons
Rural Population Numerator: number of individuals living in
rural areas
Persons
Scheduled Caste
Population
Numerator: number of individuals belonging
to a scheduled caste living in the district
Percentage
Scheduled Tribe
Population
Numerator: number of individuals belonging
to a scheduled tribe living in the district
Percentage
Other Population Numerator: number of individuals belonging
to a other backward classes or general
(non-disadvantaged castes) living in the
district
Percentage

8
NUTRITION STATUS
Indicator Indicator Definition Unit State Source District Source Additional Information
Children
stunted
Numerator: number of children aged 0–5
years who are stunted
Denominator: all children aged 0–5 years
Stunting: height-for-age less than –2
standard deviations of the WHO Child
Growth Standards2
median
Percentage National Family
Health Survey 3
(NFHS3) 2005–06
HUNGaMA
20113
/NO DATA
CURRENTLY
AVAILABLE
Author’s estimates from
NFHS3 and HUNGaMA 2011
datasets
NO DATA CURRENTLY
AVAILABLE at the district level
for non-HUNGaMA districs
Children
wasted
years who are wasted
Wasting: weight-for-height less than –2
standard deviations of the WHO Child
Growth Standards median
Percentage NFHS3 2005–06 HUNGaMA
2011/NO DATA
CURRENTLY
AVAILABLE
datasets
NO DATA CURRENTLY
AVAILABLE at the district level
for non-HUNGaMA districs
Children
underweight
years who are underweight
who are underweight
Underweight: weight-for-age less than
–2 standard deviations of the WHO Child
Growth Standards median
Percentage NFHS3 2005–06 HUNGaMA
2011/District
Level Household
Survey 2 (DLHS2)
2002–04
datasets
For non-HUNGaMA districts,
author estimate from DLHS2
dataset
Children
with any
anemia
months (of mothers aged 15–44 years)
classified as having iron-deficiency anemia
Denominator: all children aged 0–71
months (of mothers aged 15–44 years)
Anemia: Hemoglobin (Hb) <12 g/dL (mild/
moderate/severe)
Percentage District Level
Household
Survey 2 (DLHS2)
2002–04
DLHS2 2002–04 Url: http://www.rchiips.org/
pdf/rch2/National_Nutrition_
Report_RCH-II.pdf
APPENDIX A
‘District-wise Indicators of
Nutritional Status, Anaemia
among Children: Mild+
Moderate+ Severe’
Women
underweight
Numerator: number of women aged
15–49 years with body mass index (BMI)
<18.5
Denominator: all women aged 15–49
years
BMI: mass (kilograms)/ height2
(meters)
Percentage NFHS3 2005–06
State Report
NO DATA
CURRENTLY
AVAILABLE
URL: http://www.rchiips.org/
nfhs/NFHS-3%20Data/Bihar_
report.pdf
TABLE 56 NUTRITIONAL
STATUS OF ADULTS
Under column ‘total thin’
Children
with low
birth weight
months with birth weight of less than
2500 grams
months
Percentage Concurrent
Household Health
and Nutrition
Survey, 6th Round
(CHHNS6) 2014
CHHNS6 2014 Author’s estimates from
CHHNS6 2014 dataset
Obesity
among
adults
Prevalence of obesity among adults (Body
Mass Index ≥ 30)
Percentage NO DATA
CURRENTLY
AVAILABLE
NO DATA
CURRENTLY
AVAILABLE
NOT APPLICABLE

9
IMMEDIATE CAUSES
Early
initiation of
breastfeeding
months who were breastfed within 1 hour
of birth
Denominator: all children aged 0–2 months
Percentage CHHNS6 2014 CHHNS6 2014 Author’s estimates from
CHHNS6 2014 dataset
Exclusive
breastfeeding
(0–2 months)
months who were exclusively breastfed for
in the last 24 hours
Note: Based on mother’s report for their
youngest child
CHHNS6 2014 dataset
Exclusive
breastfeeding
(3–5 months)
months who were exclusively breastfed for
in the last 24 hours
Note: Based on mother’s report for their
youngest child
CHHNS6 2014 dataset
Children aged
6–8 months
who received
any solid/semi
solid food in
the last 24
hours
months who received any solid, semi-solid,
or soft foods in the last 24 hours
CHHNS6 2014 dataset
Children aged
9–11 months
who achieve
minimum diet
diversity
months whose diet included foods from at
least four or more food groups
Note: Food groups include grains; roots and
tubers; legumes and nuts; dairy products
(milk, yogurt, cheese); flesh foods (meat,
fish, poultry and liver/organ meats); eggs;
vitamin-A rich fruits and vegetables; other
fruits and vegetables
CHHNS6 2014 dataset
Full
immunization
coverage
months who received Bacille Calmette-
Guerin (BCG), three injections of diphtheria,
pertussis and tetanus (DPT), three doses
of Polio (excluding Polio 0) and measles
immunizations
months
CHHNS6 2014 dataset

10
IMMEDIATE CAUSES continued
Children aged
12–35 months
who received
vitamin A
Numerator: number of children (of mothers
aged 15–49 years) aged 12–35 months who
received at least one dose of vitamin A
Denominator: all children (of mothers aged
15–49 months) aged 12–35 months
Percentage District Level
Household
Survey 3
(DLHS3)
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
TABLE 5.7 CHILDHOOD
VACCINATION BY DISTRICTS
Under column ‘Percentage
received at least one dose of
vitamin A’
Acute diarrhea
in children
months who suffered from diarrhea 4 weeks
prior to the survey
CHHNS6 2014 dataset
Children
with diarrhea
treated with
ORS
months who suffered from diarrhea and were
given ORS
CHHNS6 2014 dataset
Children who
suffered from
ARI
months who suffered from Acute Respiratory
Infections (ARI) 4 weeks prior to the survey
years aware of danger signs of pneumonia
CHHNS6 2014 dataset
Women with
access to any
antenatal
care (at least
1 visit)
Numerator: number of women aged 15–49
years who received any antenatal care (ANC)
during pregnancy
Denominator: all women aged 15–49 years
Note: Based on women who had their last
live/still birth since 01-01-2004
Percentage DLHS3
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
TABLE 4.2 ANTENATAL
CARE BY DISTRICT
Under column ‘Any ANC’
Any anemia
among
pregnant
women
Numerator: number of pregnant women
aged 15–44 years classified as having iron-
deficiency anemia
Denominator: all pregnant women aged
15–44 years
Iron-deficiency anemia: Hb <12 g/dL (mild/
moderate/severe)
Percentage DLHS2
2002–04
DLHS2 2002–04 Url: http://www.rchiips.
org/pdf/rch2/National_
Nutrition_Report_RCH-II.pdf
APPENDIX A
among Pregnant Women:
Mild+ Moderate+ Severe’
Any anemia
among
adolescent
girls
Numerator: number of adolescent girls
aged 10–19 years classified as having iron-
deficiency anemia
Denominator: all adolescent girls aged 10–19
years
Iron-deficiency anemia: Hb <12 g/dL (mild/
moderate/severe anemia)
Percentage DLHS2
2002–04
DLHS2 2002–04 Url: http://www.rchiips.
org/pdf/rch2/National_
Nutrition_Report_RCH-II.pdf
APPENDIX A
among Adolescent Girls:
Mild+ Moderate+ Severe’

11
UNDERLYING CAUSES
Indicator Indicator Definition Unit State Source District
Source
Additional Information
Women’s status
Girls married
when <18years
old
Numerator: number of women aged
15–18 years who were married below
legally prescribed minimum age
Denominator: all women aged 15–18
years
Legally prescribed minimum age: 18
years
Percentage DLHS3
2007–08
State Report
DLHS-3
2007–08 State
Report
DLHS-3 State Report
TABLE 2.3 AGE AT MARRIAGE
Under column ‘Percentage of
marriages below legal age at
marriage- Girls (<18 years)’
Women who
completed
primary school
Numerator: number of ever-married
women aged 15–49 years who have
completed primary school education
Denominator: all ever-married women
aged 15–49 years
Primary school: 0–5 years of schooling
Percentage DLHS3
2007–08
State Report
NO DATA
CURRENTLY
AVAILABLE
DLHS-3 State Report
TABLE 3.2 LEVEL OF
EDUCATION OF EVER-MARRIED
WOMEN
Under column ‘Years of
schooling 0–5 years’
Women who
completed
secondary
school
Numerator: ever-married women aged
15–49 years who have completed
secondary school education
Denominator: all ever-married women
aged 15–49 years
Secondary school: 6–8 years of
schooling
Percentage DLHS3
2007–08
State Report
NO DATA
CURRENTLY
AVAILABLE
DLHS-3 State Report
TABLE 3.2 LEVEL OF
EDUCATION OF EVER-MARRIED
WOMEN
Under column ‘Years of
schooling 6–8 years’
Women's
ownership of
land
Numerator: number of women that own
any land
Denominator: all women
Percentage NO DATA
CURRENTLY
AVAILABLE
NO DATA
CURRENTLY
AVAILABLE
NOT APPLICABLE
Women's
ownership of
livestock
Numerator: number of women who own
livestock
Denominator: all women
Percentage NO DATA
CURRENTLY
AVAILABLE
NO DATA
CURRENTLY
AVAILABLE
NOT APPLICABLE
WASH (Water, Sanitation, and Hygiene)
Access to
improved
drinking-water
sources
Numerator: number of households using
improved drinking water source
Denominator: total number of
households in the area
Improved drinking water sources: Piped
water into dwelling, plot or yard, public
tap/stand pipe, tube well/borehole,
protected dug well, protected spring and
rainwater collection
Percentage Government of
India 2011
Government of
India 2011
Census 2011
HH-6: HOUSEHOLDS BY MAIN
SOURCE OF DRINKING WATER
AND LOCATION
URL: http://www.censusindia.
gov.in/2011census/hlo/District_
Tables/Distt_table/10/HH2206-
1000CRCD.pdf
Access to
improved
sanitation
facilities
Numerator: number of households in
the district using improved sanitation
facilities
households in the area
Improved sanitation facilities: Piped
sewer system, septic tank, pit latrine
with slab
India 2011
Government of
India 2011
Census 2011
HH-8: HOUSEHOLDS BY
AVAILABILITY OF TYPE OF
LATRINE FACILITY
gov.in/2011census/hlo/District_
Tables/Distt_table/10/HH2808-
1000DCRC.pdf

12
UNDERLYING CAUSES continued
Source
WASH (Water Sanitation Hygiene) continued
Open
defecation
Numerator: number of households that
defecate in the open
Denominator: total number of households
in the area
India 2011
Government of
India 2011
Census 2011
HH-8: HOUSEHOLDS BY
AVAILABILITY OF TYPE OF
LATRINE FACILITY
gov.in/2011census/hlo/
District_Tables/Distt_table/10/
HH2808-1000DCRC.pdf
Child stool
disposal in
a sanitary
manner
Numerator: mothers who have a child
aged 0–5 years whose stools are disposed
safely
Denominator: all mothers in the sample
Percentage NFHS3
2005–06
NO DATA
CURRENTLY
AVAILABLE
Author’s estimate from
NFHS-3 dataset
Hand washing
with soap
before meals
reported washing their hands with soap
before a meal
in the area
CHHNS6 2014 dataset
Socio Economic Conditions
Population
living below
the poverty line
in the district
Numerator: number of persons who live
below the state and sector specific poverty
line
Denominator: total population of the area
Note: The poverty lines are taken from
the Tendulkar estimates of the planning
commission4
. Sector implies rural or
urban areas.
Percentage National
Sample Survey,
68th Round
(NSS68)
2011-12
consumption
expenditure
NSS68 2011-12
consumption
expenditure
Author’s estimate from NSSO
data
State / District probability
weighted mean (not
representative at district level)
Households
who own
agricultural
land
own and cultivate land in rural areas
in the area
Percentage NSS68 2011-12
employment
and
unemployment
NSS68 2011-12
employment
and
unemployment
data
weighted mean (not
Households
living in a
‘pucca’ house
have a ‘pucca’ house
in the area
pucca= permanent
India 2011
Government of
India 2011
Census 2011- HH-13 :
HOUSEHOLDS BY TYPE OF
STRUCTURE OF THE CENSUS
HOUSES OCCUPIED
DDW-HH4313-1000.pdf
Household
access to
electricity
have access to and use electricity as their
main source of lighting
in the area
India 2011
Government of
India 2011
Census 2011- HH-7:
HOUSEHOLDS BY MAIN
SOURCE OF LIGHTING
HH2507-1000CRCD.pdf

13
UNDERLYING CAUSES continued
Source
Food Security
Household
share of
expenditure on
food
Numerator: food expenditure per-capita
Denominator: total consumption
expenditure per-capita
consumption
expenditure
NSS68 2011-12
consumption
expenditure
data
weighted mean (not
Household
share of food
expenditure on
cereals
Numerator: cereal expenditure per-capita
Denominator: total food expenditure
per-capita
consumption
expenditure
NSS68 2011-12
consumption
expenditure
data
weighted mean (not
Households
involved in
agriculture
Numerator: number of households who
are either self-employed or casual laborers
in agriculture
in the area
consumption
expenditure
NSS68 2011-12
consumption
expenditure
data
weighted mean (not
Other Indicators
Adult literacy
rate
Numerator: number of persons aged 7
years and above who can both read and
write in any language
Denominator: total number of persons
aged 7 years and above
India 2011
Government of
India 2011
gov.in/2011census/
population_enumeration.html
Population Enumeration Data
(Final Population) >> Primary
Census Abstract Data (Final
Population)>> Primary Census
Abstract Data Tables (India
& States/UTs - District Level)
(Excel Format)
[Total literates/Total
Population]*100
District rank
of Per Capita
Gross District
Domestic
Product (GDDP)
Gross District Domestic Product (GDDP)
2011–12
Note: Deflated to 2004–2005 prices
Rank Directorate of
Economic and
Statistics, State
Government
Directorate of
Economic and
Statistics, State
Government
Table A 1.7
URL: http://finance.bih.nic.
in/Documents/Reports/
Economic-Survey-2015-EN.pdf
District
Development
Index (DDI)
rank
Rank based on overall index of all socio-
religious communities (SRCs). The overall
index is calculated by taking the average
of a district’s Economic Development
Index, Material Wellbeing Index,
Educational Development Index, and
Health Index
Note: From well-performing districts to
poor-performing districts
Rank
(1–599)
NOT
APPLICABLE
District
Development
and Diversity
Index, Report
for India and
Major States,
US-India Policy
Institute and
CRDDP
URL: http://www.
usindiapolicy.org/updates/
general-news/225-district-
development-and-diversity-
index-report

14
BASIC CAUSES
Access to Services
Births
attended by
skilled health
personnel
Numerator: number of women
aged 15–49 years who had a safe
delivery
Denominator: all women aged
15–49 years
Safe delivery: institutional or
home delivery assisted by skilled
personnel
Percentage DLHS3
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
TABLE 4.9 PLACE OF
DELIVERY AND ASSISTANCE
CHARACTERISTICS BY DISTRICT
Under column: ‘Percentage of
safe delivery’
Household
has access to
Anganwadi
Worker
Numerator: number of households
that have access to an Anganwadi
worker
households
Percentage DLHS3
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
TABLE 2.12 AVAILABILITY OF
FACILITY AND HEALTH PERSONNEL
BY DISTRICT
Household has
access to a sub
health center
that have access to a health center
households
Percentage DLHS3
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
BY DISTRICT
Household
has access to
primary/middle
school
that have access to a primary/
middle school
households
Percentage DLHS3
2007–08 State
Report
DLHS3 2007–08
State Report
DLHS-3 State Report
BY DISTRICT
Households
who demanded
and received
work through
NREGA
that received an NREGA job
households that demanded an
NREGA job
Note: NREGA= National Rural
Employment Guarantee Act
employment
and
unemployment
NSS68 2011-12
employment and
unemployment
Author’s estimates from NSSO data
State / District probability weighted
mean (not representative at
district level)
Households
availing bank
services
availing bank services
households
India 2011
Government of
India 2011
Census 2011
HH-12: NUMBER OF HOUSEHOLDS
AVAILING BANKING SERVICES AND
NUMBER OF HOUSEHOLDS HAVING
EACH OF THE SPECIFIED ASSETS
URL: http://www.censusindia.gov.
in/2011census/hlo/District_Tables/
Distt_table/10/HH4012-1000DCRC.
pdf

15
EVALUATION OF HEALTH AND NUTRITION SCHEMES
Indicator Indicator Definition Unit State Source District Source Additional
Information
Policy
Institutional
delivery
months who were delivered in a medical
institution
CHHNS6 2014 dataset
Households
with an MCP
card
Numerator: number of households with a
12–23 months old child who has a MCP card
Denominator: all households with a 12–23
months old child
CHHNS6 2014 dataset
Households
receiving take
home ration
Numerator: number of households with a 0–2
month child who receives any take home ration
months old child
CHHNS6 2014 dataset
Households
receiving
any financial
assistance
Numerator: number of households with a 0–2
months old child who received any financial
assistance for child delivery and care
months old child
CHHNS6 2014 dataset
FLW visits
Frequency
of FLW visits
compared
with the
recommended
number of
visits during
a. Last
trimester
b. First week of
delivery
Numerator: number of household with
a 0–2 months old baby where no visits
were conducted/less than recommended/
recommended/more than recommended in the
last trimester/first week of birth
months old baby
Note: The calculations were done separately
for two periods – last trimester; one week after
delivery (home visits)/one week of the mother’s
return home (institutional delivery)
CHHNS6 2014 dataset;
Recommended number
of visits in the last
trimester = 2
Recommended number
of visits in the first
week of delivery (home
delivery)/mother’s return
(institutional delivery)
= 3
Any FLW visit
within 24 hours
of delivery in
case of home
delivery
Numerator: Number of households with a
0–2 months old baby where a home visit was
conducted on the day of the delivery in case of
a home delivery
months old baby who was delivered at home
CHHNS6 2014 dataset

16
NOTES
1. Robert E. Black, Cesar G. Victora, Susan P. Walker, Zulfiqar A. Bhutta, Parul Christian, Mercedes de Onis, Majid
Ezzati, Sally Grantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child
Nutrition Study Group. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-
Income Countries”. The Lancet 382 (9890), 427-451.
2. WHO (World Health Organization). 2006. WHO Child Growth Standards. Geneva. Available at
http://www.who.int/childgrowth/standards/Technical_report.pdf
3. For districts with HUNGaMA data, only rural comparisons are made. Only the rural averages are reported from
the NFHS-3 at the state level (because HUNGaMA data was based on rural regions only). For Non-HUNGaMA
districts there is no data currently available at the district level for stunting and wasting. There is however data
for underweight at the district level. For such districts date is reported for both rural and urban regions. Please
note that the DLHS-2 figures for child underweight are computed and sourced from the report because by
definition it pertains to children who are 0–5 years.
4. Planning Commission. 2013. Press note on poverty estimates, 2011-12. Government of India. Accessed March
18, 2015. http://planningcommission.nic.in/news/pre_pov2307.pdf

17
REFERENCES
Author’s estimates based on HUNGaMA: Fighting Hunger & Malnutrition : the HUNGaMA Survey Report. 2011.
Naandi Foundation.
Author’s estimates based on National Family Health Survey (NFHS-3), 2005-06, India. Mumbai: International Institute
for Population Studies.
Author’s estimates based on District Level Household Survey on Reproductive and Child Health (DLHS-2), 2002-04,
India. International Institute for Population Studies. (IIPS). 2006. District Level Household Survey on Reproductive
and Child Health (DLHS-2), 2002-04, India: Nutritional Status of Children and Prevalence of Anemia among
Children, Adolescent Girls and Pregnant Women. Mumbai: IIPS. March 18, 2015, www.rchiips.org/pdf/rch2/
National_Nutrition_Report_RCH-II.pdf
Concurrent Monitoring and Learning Unit, CARE. 2014. Concurrent Household Health and Nutrition Survey, 6th
Round. Bihar, India.
International Institute for Population Studies (IIPS). 2010. District Level Household Survey and Facility Survey
(DLHS-3), 2007-08, India, Uttar Pradesh. Mumbai: IIPS. Accessed March 18, 2015, http://www.rchiips.org/pdf/
rch3/report/bh.pdf
Robert E Black, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati,
Sally Grantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child Nutrition
Study Group. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income
Countries”. The Lancet 382 (9890), 427-451.
Census of India. 2011. Houselisting and Housing Census Data. Accessed March 18, 2015, www.censusindia.gov.
in/2011census/hlo/HLO_Tables.html
Author’s estimates based on Household Consumption Expenditure, National Sample Survey Office (NSSO) 68th
Round, 2011-12. Ministry of Statistics and Program Implementation. Government of India.
Planning Commission. 2013. Press note on poverty estimates, 2011-12. Government of India. Accessed March 18,
2015. http://planningcommission.nic.in/news/pre_pov2307.pdf
Author’s estimates based on Employment and Unemployment, National Sample Survey Office (NSSO) 68th Round,
2011-12. Ministry of Statistics and Program Implementation. Government of India.
Census of India. 2011. Primary Census Abstract. Accessed June 6, 2015, www.censusindia.gov.in/pca/default.aspx
Us-India Policy Institute. 2015. District Development and Diversity Index. Accessed July 2, 2015, http://www.usin-
diapolicy.org/updates/general-news/225-district-development-and-diversity-index-report
Finance Department, Government of Bihar. 2015. Economic Survey 2014-15. Accessed July 2, 2015, http://finance.
bih.nic.in/Documents/Reports/Economic-Survey-2015-EN.pdf
Government of India. 2014. State-wise Per Capita Income and Gross Domestic Product at current prices. Accessed
July 2, 2015, http://pib.nic.in/archieve/others/2014/aug/d2014070801.pdf

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