Menon et al india nutrition and wash iycf august 3 2013 v4(2)

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Menon et al india nutrition and wash iycf august 3 2013 v4(2)

  1. 1. DIET QUALITY, WATER AND TOILETS: WHAT ROLES FOR CHILD UNDERNUTRITION IN INDIA? Purnima Menon, PhD Senior Research Fellow Poverty Health and Nutrition Division International Food Policy Research Institute (IFPRI) New Delhi, India August 3, 2013
  2. 2. Acknowledgements  Co-authors  Analysis and manuscript  Shruthi Cyriac (IFPRI)  Apurva Bamezai (IFPRI)  Funding for analysis  UNICEF, India
  3. 3. Objectives  Examine associations between WASH practices and child anthropometric outcomes  examine the interactions between WASH and infant and young child feeding (IYCF) practices and their combined effect on child anthropometric outcomes
  4. 4. DATA and METHODS
  5. 5. Data  Data: National Family Health Survey – III, 2005-06, child data set.  Sample:  12,633 children 0-23.9 mo  Varies by sample needed for each IYCF indicator
  6. 6. Sample size for each indicator-specific age group Age Groups (in months) ALL INDIA 0-5.99 3076 6-23.99 -Minimum Acceptable Diet 8001 -Minimum Diet Diversity 9557 0-23.99 12633
  7. 7. Analysis – Descriptive analysis of patterns in IYCF, WASH and anthropometry – OLS regression analysis for mean anthropometric outcomes (height for age z-scores (HAZ), weight-for-age z-scores (WAZ), weight for height z-scores (WHZ)) – Logit regression analysis for bivariate anthropometric outcomes (stunting, wasting, underweight) – All analyses use svy commands to adjust for survey design and clustering (using Stata 11 and 12)
  8. 8. Dependent variable: Anthropometric Indicators • Height for Age Z Score(HAZ) • Weight for Age Z Score (WAZ) • Weight for Height Z Score (WHZ)  Stunting: if HAZ is “– 2” standard deviations (below) from the reference population median  Underweight: if WAZ is “– 2” standard deviations (below) from the reference population median  Wasting: if WHZ is “– 2” standard deviations (below) from the reference population median  All anthropometry indicators created using WHO International Growth Reference 2006
  9. 9. Independent variables: Key IYCF indicators INDICATOR DEFINITION Exclusive breastfeeding under 6 months Proportion of infants 0–5 months of age who are fed exclusively with breast milk Minimum dietary diversity Proportion of children 6–23 months of age who receive foods from 4 or more food groups Minimum acceptable diet Proportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breast milk).
  10. 10. Independent variables: Key WASH indicators INDICATOR DEFINITION Improved Source of Drinking water When the source of drinking water is piped into dwelling/yard/plot, public tap/standpipe, tube well/bore well/protected well, protected spring, rainwater or bottled water Improved Type of toilet facility When there is a flush connected to piped sewer system/septic tank/pit latrine, pit latrine which is ventilated improved pit/with slab or when there is a composting toilet Improved manner of disposal of child's stool when not using toilet facility When disposal is using a toilet/latrine/pit, rinsed in toilet/latrine or buried
  11. 11. Other variables in analyses Child characteristics Child age; age-squared Size of child at birth (reported); Child sex Maternal characteristics Age of mother at 1st birth Whether mother worked in last 12 months Maternal nutrition status (height, BMI) Maternal education Number of children Prenatal care visits Maternal diet diversity Frequency of reading newspaper* Frequency of listening to radio* Frequency of watch television* Household Socio-economic status (wealth quintiles)* Place of residence Caste* Religion* State State dummies *variables not included in all results in this presentation
  12. 12. Results
  13. 13. Child nutrition by age, NFHS-3, 2005-06 -2.5 -2 -1.5 -1 -0.5 0 Age (in months) HAZ WHZ WAZ Source: Data from NFHS III (2005-06)
  14. 14. Stunting by child age, NFHS-3, 2005-06 0 10 20 30 40 50 60 70 80 90 100 % Children who are Moderately Stunted (-3<HAZ<-2)* % Children Who are Severely Stunted HAZ<-3* Source: Authors’ estimates based on data from NFHS III (2005-06)
  15. 15. Coverage of essential inputs for nutrition in India 0 10 20 30 40 50 60 70 80 90 100 India Early Inititation of Breastfeeding Exclusive BF (0-6 Months) Introduction of CF at 6-9 Months 3 Expected IYCF Practices Iron-rich Foods All basic Immunisations Stools Safely disposed Vitamin A Supplementation (<3s) Adolescent Girls (15-19 Years) Non-Anemic* HH - Adequately Iodised Salt Diarrhea: Children Fed >= Usual SAM: Children with access to care The GOAL : 100% Gap Menon, Raabe & Bhaskar, 2009
  16. 16. Percentage of mothers with children under age five, who use different methods to dispose the last stools of their youngest child, NFHS India, 2005-06 1.4 2.5 6 14.1 20.8 27.8 9.3 9.6 9 8.1 8.3 9 20.2 11.3 7 3.8 2.8 2.4 33.7 38 33.5 22.8 12.8 7 28.3 34.9 42.8 49.2 53.5 52.9 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <6 6-11 12-23 24-35 36-47 48-59 Left in the open Thrown into garbage Put/rinsed into drain or ditch Put/rinsed into toilet or latrine Child used toilet or latrine
  17. 17. Percentage of wasting, by exclusive breast feeding and WASH categories 0 5 10 15 20 25 30 35 40 EBF 0, DW 0 EBF 1, DW 0 EBF 0, DW 1 EBF 1, DW 1 EBF 0, TT 0 EBF 1, TT 0 EBF 0, TT 1 EBF 1, TT 1 EBF 0, CSD 0 EBF 1, CSD 0 EBF 0, CSD 1 EBF 1, CSD 1 ChildStool DisposalToiletType DrinkingWater Source Key: EBF: Exclusive Breast Feeding; CSD: Child Stool Disposal; TT: Toilet Type; DW: Drinking Water; 1= Yes; 2= No
  18. 18. Percentage of Underweight by Minimum Diet Diversity and WASH variables 0 10 20 30 40 50 60 MDD 0, DW 0 MDD 1, DW 0 MDD 0, DW 1 MDD 1, DW 1 MDD 0, TT 0 MDD 1, TT 0 MDD 0, TT 1 MDD 1, TT 1 MDD 0, CSD 0 MDD 1, CSD 0 MDD 0, CSD 1 MDD 1, CSD 1 Key: MDD: Minimum Diet Diversity; CSD: Child Stool Disposal; TT: Toilet Type; DW: Drinking Water; 1= Yes; 2= No DrinkingWater SourceToiletType ChildStool Disposal
  19. 19. Percentage of Stunting, by Minimum Adequate Diet and WASH categories 0 10 20 30 40 50 60 MAD 0, DW 0 MAD 1, DW 0 MAD 0, DW 1 MAD 1, DW 1 MAD 0, TT 0 MAD 1, TT 0 MAD 0, TT 1 MAD 1, TT 1 MAD 0, CSD 0 MAD 1, CSD 0 MAD 0, CSD 1 MAD 1, CSD 1 Key: MAD: Minimum Adequate Diet; CSD: Child Stool Disposal; TT: Toilet Type; DW: Drinking Water; 1= Yes; 2= No DrinkingWater SourceToiletType ChildStool Disposal
  20. 20. Associations between WASH variables and child anthropometry among children 6-23.99 months, (Linear regression results) DEPENDENT VARIABLES INDEPENDENT VARIABLES↓ HAZ COEFFICIENT WAZ COEFFICIENT WHZ COEFFICIENT Diet Diversity (Continuous) 0.0876*** 0.0671*** 0.0273+ Source of drinking water -0.0270 0.00114 0.0166 Type of toilet facility 0.0992+ 0.0295 -0.0323 Disposal of child’s stool when not using toilet 0.0835 0.0623 0.0346 Child Age (Months) -0.238*** -0.0448* -0.00432 Child Age (Squared) 0.00445*** 0.000173 0.000227 Size of child at birth (reported) Larger than average vs. very large -0.193 -0.195* -0.131 Average vs. very large -0.207+ -0.210* -0.141 Smaller than average vs. very large -0.414*** -0.508*** -0.405*** Very small vs. very large -0.498*** -0.688*** -0.581***
  21. 21. Associations between WASH variables and child anthropometry among children 6-23.99 months (Linear regression results) Contd. DEPENDENT VARIABLES INDEPENDENT VARIABLES↓ HAZ COEFFICIENT WAZ COEFFICIENT WHZ COEFFICIENT Child sex (reference: male) -0.142*** -0.0398 -0.00622 Age of mother at 1st birth 0.0159* 0.00586 -0.00360 Whether mother worked in last 12 months In the past year vs. not working -0.0634 -0.103+ -0.0891 Currently working vs. not working -0.121* -0.157*** -0.123** Has a job, but on leave last 7 days vs. not working 0.0601 0.0371 0.00325 State dummies Maternal height (cms) 0.0575*** 0.0429*** 0.0168*** Maternal BMI 0.0123* 0.0289*** 0.0314*** Maternal education Primary vs. none 0.0404 0.0591 0.0538 Secondary vs. none 0.0577 0.111* 0.112*
  22. 22. Associations between WASH variables and child anthropometry among children 6-23.99 months (Linear regression results) Contd. DEPENDENT VARIABLES INDEPENDENT VARIABLES↓ HAZ COEFFICIENT WAZ COEFFICIENT WHZ COEFFICIENT Prenatal care visit 1-3 vs. none 0.108+ 0.105* 0.0646 4+ vs. none 0.195** 0.200*** 0.132* Simple asset count index 0.0231** 0.0178** 0.00850 Number of children -0.0441+ -0.0320+ -0.0119 Maternal diet diversity 0.00810 0.00986 0.00804 House type Semi-pucca vs. kachha -0.00524 0.0235 0.0267 Pucca vs. kachha 0.0413 0.154* 0.168* Constant -8.703*** -8.379*** -4.150*** N 9505 9505 9505 Significant effect: + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001
  23. 23. Summary of regression results - interactions between IYCF and WASH variables IYCF indicators Included in the model WASH Variable HAZ IYCF 0 WASH 1 HAZ IYCF 1 WASH 0 HAZ IYCF 1 WASH 1 Exclusive BF (0-5.99m) (N=3076) Source of Drinking water 0.0127 (0.92) -0.0891 (0.65) 0.1993 (0.17) Type of toilet facility 0.0496 (0.70) -0.2100* (0.04) -0.1010 (0.54) Disposal of child’s stool when not using toilet 0.0973 (0.47) -0.2195* (0.02) 0.1005 (0.60) Diet diversity – (6-23m) (N= 9557) Source of Drinking water -0.0326 (0.63) 0.1807 (0.11) 0.1430+ (0.08) Type of toilet facility 0.1312* (0.03) 0.2220** (0.01) 0.2561** (0.002) Disposal of child’s stool when not using toilet 0.1256+ (0.07) 0.2059*** (0.001) 0.1999* (0.04) Figures in table are regression coefficients, p values in parenthesis Significant effect: + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001 IYCF 0 : Unimproved feeding practice WASH 0: Unimproved source of water/sanitation IYCF 1 : Improved feeding practice WASH 1: Improved source of water/sanitation
  24. 24. Summary table of regression results from linear regression models including interactions between IYCF and WASH variables: Dependent variable: HAZ (Contd.) IYCF indicators Included in the model WASH Variable HAZ IYCF 0 WASH 1 HAZ IYCF 1 WASH 0 HAZ IYCF 1 WASH 1 Minimum acceptable diet (6- 23m) Source of Drinking water -0.0268 (0.69) 0.2027 (0.17) 0.1105 (0.24) Type of toilet facility 0.1784** (0.004) 0.2422** (0.01) 0.2133* (0.04) Disposal of child’s stool when not using toilet 0.0731 (0.30) 0.1701* (0.03) 0.1329 (0.34) IYCF 0 : Unimproved feeding practice WASH 0: Unimproved source of water/sanitation IYCF 1 : Improved feeding practice WASH 1: Improved source of water/sanitation Figures in table are regression coefficients, p values in parenthesis Significant effect: + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001
  25. 25. Association between IYCF and WASH interactions and stunting – All India (logit analyses) IYCF indicators Included in the model WASH Variable Stunting IYCF 0 WASH 1 Stunting IYCF 1 WASH 0 Stunting IYCF 1 WASH 1 Exclusive BF (0-5.99m) (N=3076) Source of Drinking water 1.344 (0.89-2.03) 1.203 (0.65-2.21) 1.522+ (0.96-2.42) Type of toilet facility 1.028 (0.68-1.55) 1.067 (0.77-1.49) 1.435 (0.88-2.33) Disposal of child’s stool when not using toilet 0.761 (0.47-1.24) 1.165 (0.86-1.57) 0.712 (0.40-1.28) Diet diversity – (6-23m) (N= 9557) Source of Drinking water 1.007 (0.83-1.23) 0.579** (0.39-0.85) 0.798+ (0.62-1.03) Type of toilet facility 0.774** (0.65-0.92) 0.811+ (0.64-1.02) 0.544*** (0.42-0.70) Disposal of child’s stool when not using toilet 0.971 (0.79-1.19) 0.760** (0.63-0.92) 0.751+ (0.56-1.01) IYCF 0 : Unimproved feeding practice WASH 0: Unimproved source of water/sanitation IYCF 1 : Improved feeding practice WASH 1: Improved source of water/sanitation Figures in table are regression coefficients, CIs in parenthesis Significant effect: + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001
  26. 26. Association between IYCF and WASH interactions and stunting – All India (logit analyses) Contd. IYCF indicators Included in the model WASH Variable Stunting IYCF 0 WASH 1 Stunting IYCF 1 WASH 0 Stunting IYCF 1 WASH 1 Minimum acceptable diet (6-23m) Source of Drinking water 1.052 (0.86-1.29) 0.700 (0.42-1.16) 0.931 (0.69-1.25) Type of toilet facility 0.734*** (0.61-0.88) 0.874 (0.64-1.20) 0.613** (0.45-0.84) Disposal of child’s stool when not using toilet 1.067 (0.60-1.38) 0. 857 (0.66-1.11) 0. 914 (0.86-1.33) IYCF 0 : Unimproved feeding practice WASH 0: Unimproved source of water/sanitation IYCF 1 : Improved feeding practice WASH 1: Improved source of water/sanitation Figures in table are regression coefficients, CIs in parenthesis Significant effect: + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001
  27. 27. Other notable results  Child size at birth strongly determines nutrition outcomes  Maternal characteristics are significantly associated with all child nutrition outcomes  Maternal height, maternal education, maternal age at first birth, maternal BMI & use of prenatal care  Household characteristics (wealth, caste) are significantly associated with almost all child nutrition outcomes  State dummies are mostly significant
  28. 28. Limitations of these analyses  Data are cross-sectional in nature; limiting claims of causality  Household level control variables are somewhat limited (e.g., no consumption-expenditure data; limited asset lists)  Data are somewhat dated (2005-06/2007) – IYCF practices could have changed over time as could nutrition indicators and associations
  29. 29. Summary Results  WASH variables reflecting sanitation conditions and hygiene practices, especially toilet type and child stool disposal, were more strongly associated with nutritional outcomes than drinking water.  IYCF practices, especially indicators of the quality of complementary feeding diets, are associated with better anthropometric outcomes in this context.  The effects of IYCF and of WASH indicators are not independent, based on the analyses in this paper. Specifically, improved IYCF practices, especially better dietary quality, are protective for HAZ and WAZ, under poor sanitary conditions.  We see some variability in the IYCF-WASH interactive effects, depending on the nutritional outcome at hand. For some combinations of IYCF-WASH, there is a larger main effect of improved sanitation; for others, IYCF is more strongly associated with nutritional outcomes than the sanitation indicators.

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