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

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

Acknowledgements

Co-authors

Analysis and manuscript

Shruthi Cyriac (IFPRI)

Apurva Bamezai (IFPRI)

Funding for analysis

UNICEF, India

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

DATA and METHODS

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

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

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)

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

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).

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

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

Results

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)

Stunting by child age, NFHS-3, 2005-06

0

10

20

30

40

50

60

70

80

90

100

% Children who areModerately Stunted(-3<HAZ<-2)*

% Children Who areSeverely StuntedHAZ<-3*

Source: Authors’ estimates based on data from NFHS III (2005-06)

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

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 intogarbage

Put/rinsed intodrain or ditch

Put/rinsed intotoilet or latrine

Child used toilet orlatrine

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

Ch

ild S

too

l

Dis

po

sal

Toile

t Ty

pe

D

rin

kin

g W

ate

r

Sou

rce

Key: EBF: Exclusive Breast Feeding; CSD: Child Stool Disposal; TT: Toilet Type; DW: Drinking Water;

1= Yes; 2= No

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

Dri

nki

ng

Wat

er

Sou

rce

Toile

t Ty

pe

C

hild

Sto

ol

Dis

po

sal

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

Dri

nki

ng

Wat

er

Sou

rce

Toile

t Ty

pe

C

hild

Sto

ol

Dis

po

sal

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***

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*

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

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)



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

Summary table of regression results from linear

regression models including interactions between IYCF

and WASH variables: Dependent variable: HAZ (Contd.)

IYCF indicators


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)



Figures in table are regression coefficients, p values in parenthesis


Association between IYCF and WASH interactions and

stunting – All India (logit analyses)

IYCF indicators


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)


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)


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)


not using toilet

0.971 (0.79-1.19)

0.760** (0.63-0.92)

0.751+ (0.56-1.01)



Figures in table are regression coefficients, CIs in parenthesis


Association between IYCF and WASH interactions

and stunting – All India (logit analyses) Contd.

IYCF indicators


WASH Variable Stunting

IYCF 0

WASH 1

Stunting

IYCF 1

WASH 0

Stunting

IYCF 1

WASH 1

Minimum acceptable diet

(6-23m)


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)



1.067 (0.60-1.38)

0. 857 (0.66-1.11)

0. 914 (0.86-1.33)



Figures in table are regression coefficients, CIs in parenthesis


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

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

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.

Health & Medicine

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