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

BACKGROUNDIndia 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 PROFILESA 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,^

Childrenunderweight

(%)1,2,^

Children with anyanemia (%)3,^^

Women withBMI<18.5 (%)2

Infants withbirthweight

<2500gms (%)4,#

Adults who areobese in thedistrict (%)

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, BiharDISTRICT NUTRITION PROFILE

Page 1

THE STATE OF NUTRITION IN GAYA

DISTRICT DEMOGRAPHIC PROFILETotal Population 4,391,418

MALE FEMALE

RURALURBAN

SC ST OTHERS

CHANGES OVER TIMEBihar

(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

No D

ata

No D

ata

No D

ata

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� Page 1: Nutritional OutcomesPage 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

29.622.1

35.5

57.0

67.7

43.5 42.4 42.8

65.9

51.8

31.1 32.539.1

Early initiation ofbreastfeeding

(%)

Exclusivebreastfeeding

(0-2 months old)(%)

Exclusivebreastfeeding (3-

5 months old)(%)

Children (6-8months) whoreceived any

solid/semi solidfood in the last

24 hours (%)

Children (9-11months old) who

achieveminimum dietdiversity (%)

Fullimmunizationcoverage (%)^

Children who gotvitamin A

supplementation(%)^^

Children whosuffered fromdiarrhoea in

previous 4 weeks(%)^

Children withdiarrhoea whowere treatedwith ORS (%)^

Children whosuffered from

ARI in theprevious 4 weeks

(%)^

DISEASEBURDEN4^

Page 2

Child undernutrition is caused by inadequacies in food, health and care for infants and young children, especially inthe first two years of life (immediate causes). Inadequate food, health and care arise from food insecurity, unsanitaryliving conditions, low status of women, and poor health care (underlying causes). These are, in turn, caused by socialinequity, economic challenges, poor political will and leadership to address these causes (basic causes). Interventionsto address undernutrition must address these multiple causes of undernutrition and do so in an equitable manner.

IMMEDIATE CAUSES OF UNDERNUTRITION

IMMEDIATE CAUSESBreastfeeding, nutrient rich foods, and eating routine

Feeding and caregiving practices, parenting stimulationLow burden of infectious diseases

Optimum fetal and child nutrition and development

WHAT FACTORS CAUSE UNDERNUTRITION?6

UNDERLYING CAUSESFood security: availability, economic access and use of foodFeeding and caregiving resources (maternal, household and

community level)Access to and use of health services, a safe and hygienic environment

BASIC CAUSESKnowledge and evidencePolitics and governance

Leadership, capacity and financial resourcesSocial, 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)

Perc

enta

ge o

f chi

ld s

tunt

ing

(%)

Window of opportunity

Too late

IMMUNIZATION & SUPPLEMENTATION4,5

^Children aged 12-23 months; ^^Children aged 12-35 months;# Girls aged 10-19 years;

Source: Data source provided on Page 4

38.5

97.4 98.5

59.1

97.1 99.2

Women with access toany antenatal care (at

least 1 visit) (%)

Any anemia amongpregnant women (%)

Any anemia amongadolescent 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 marriedwhen <18years

old (%)

Ever marriedwomen/motherswho completedprimary school

(%)

Women whocompleted

middle school(%)

Women'sownership of

land (%)

Women'sownership oflivestock (%)

Access toimproved

drinking watersources (%)

Access toimprovedsanitation

facilities (%)

Open defecation(%)

Child stooldisposal in a

sanitary manner(%)

Households whowashed hands

with soap beforea meal (%)^

52.8

39.0

53.3

24.6

51.142.5

16.3

49.4

34.8

53.2

34.1

50.9 48.1

16.4

Household share ofexpenditure on food

(%)

Household share offood expenditure on

cereals (%)

Households in thedistrict involved in

agriculture (%)

Below Poverty Linehouseholds (%)

Households ownershipof agricultural land (%)

Households living in apermanent 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.

No

Dat

a

No

Dat

a

No

Dat

a

No

Dat

a

No

Dat

a

No

Dat

a

No

Dat

a

WOMEN’S STATUS5 WATER, SANITATION AND HYGIENE2,4,7

FOOD SECURITY8

^Household with a child aged 6-8 months; Source: Data source provided on Page 4

52.3

25.8

100.0

25.6

81.4

38.447.450.4

31.7

91.7

32.7

91.7

57.244.4

Adult literacy rate (%)12 Births attended byskilled health personnel

(%)5

Household has access toAnganwadi Worker (%)5

Household has access toa Sub Health Centre

(%)5

Household has access toPrimary/Middle School

(%)5

Households whodemanded and received

work through NREGA(%)11

Households availingBank 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 SchemesThe 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 – Bihar5. 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.pdf6. 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.html8. 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.pdf10. 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.pdf11. 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.aspx13. 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-report14. Government of Bihar. 2015. Economic Survey 2014-15. Accessed July 2,2015, http://finance.bih.nic.in/Documents/Reports/Economic-Survey-2015-EN.pdf15. 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;Source: Data source provided on Page 4

Last Trimester^^ Within 1 week of delivery* Within 24 hours of delivery*No Visit Less than

recommendedEqual to

recommendedMore 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

31.423.0

71.883.2

42.0

26.4

Institutional deliveries(%)^

Households (with a 12-23 month old child) withan immunization/MCP

card (%)

Households that receiveany take home ration

(%)^

Any financial assistanceto households for

delivery and childcare(%)^

Gaya Bihar

Sour

ce: S

ave

the

Child

ren/

Indi

a/20

09

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 PROFILEThe 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

CONCLUSIONPOSHAN 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 IndicatorsDistrict 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


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


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

Numerator: number of children aged 0–5 years who are wasted

Denominator: all children aged 0–5 years

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


NO DATA CURRENTLY AVAILABLE at the district level for non-HUNGaMA districs

Children underweight

Numerator: number of children aged 0–5 years who are underweight

Denominator: all children aged 0–5 years 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


For non-HUNGaMA districts, author estimate from DLHS2 dataset

Children with any anemia

Numerator: number of children aged 0–71 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

Numerator: number of children aged 0–2 months with birth weight of less than 2500 grams

Denominator: all children aged 0–2 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


NOT APPLICABLE

9

IMMEDIATE CAUSES


Early initiation of breastfeeding

Numerator: number of children aged 0–2 months who were breastfed within 1 hour of birth


Percentage CHHNS6 2014 CHHNS6 2014 Author’s estimates from CHHNS6 2014 dataset

Exclusive breastfeeding (0–2 months)

Numerator: number of children aged 0–2 months who were exclusively breastfed for in the last 24 hours


Note: Based on mother’s report for their youngest child


Exclusive breastfeeding (3–5 months)

Numerator: number of children aged 3–5 months who were exclusively breastfed for in the last 24 hours


Note: Based on mother’s report for their youngest child


Children aged 6–8 months who received any solid/semi solid food in the last 24 hours

Numerator: number of children aged 6–8 months who received any solid, semi-solid, or soft foods in the last 24 hours



Children aged 9–11 months who achieve minimum diet diversity

Numerator: number of children aged 9–11 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


Full immunization coverage

Numerator: number of children aged 12–23 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



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

Numerator: number of children aged 12–23 months who suffered from diarrhea 4 weeks prior to the survey



Children with diarrhea treated with ORS

Numerator: number of children aged 12–23 months who suffered from diarrhea and were given ORS



Children who suffered from ARI

Numerator: number of children aged 12–23 months who suffered from Acute Respiratory Infections (ARI) 4 weeks prior to the survey years aware of danger signs of pneumonia



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


Note: Based on women who had their last live/still birth since 01-01-2004

Percentage 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


APPENDIX A ‘District-wise Indicators of Nutritional Status, Anaemia 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


APPENDIX A ‘District-wise Indicators of Nutritional Status, Anaemia 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


Legally prescribed minimum age: 18 years


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



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



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



NOT APPLICABLE

Women's ownership of livestock

Numerator: number of women who own livestock

Denominator: all women



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


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


Improved sanitation facilities: Piped sewer system, septic tank, pit latrine with slab



Census 2011

HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY

URL: http://www.censusindia.gov.in/2011census/hlo/District_Tables/Distt_table/10/HH2808-1000DCRC.pdf

12

UNDERLYING CAUSES continued



WASH (Water Sanitation Hygiene) continued

Open defecation

Numerator: number of households that defecate in the open




Census 2011

HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY


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


Author’s estimate from NFHS-3 dataset

Hand washing with soap before meals

Numerator: number of households that reported washing their hands with soap before a meal



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

Numerator: number of households that own and cultivate land in rural areas


Percentage NSS68 2011-12 employment and unemployment

NSS68 2011-12 employment and unemployment



Households living in a ‘pucca’ house

Numerator: number of households that have a ‘pucca’ house


pucca= permanent



Census 2011- HH-13 : HOUSEHOLDS BY TYPE OF STRUCTURE OF THE CENSUS HOUSES OCCUPIED

URL: http://www.censusindia.gov.in/2011census/hlo/District_Tables/Distt_table/10/DDW-HH4313-1000.pdf

Household access to electricity

Numerator: number of households that have access to and use electricity as their main source of lighting




Census 2011- HH-7: HOUSEHOLDS BY MAIN SOURCE OF LIGHTING

URL: http://www.censusindia.gov.in/2011census/hlo/District_Tables/Distt_table/10/HH2507-1000CRCD.pdf

13

UNDERLYING CAUSES continued



Food Security

Household share of expenditure on food

Numerator: food expenditure per-capita

Denominator: total consumption expenditure per-capita

Percentage NSS68 2011-12 consumption expenditure




Household share of food expenditure on cereals

Numerator: cereal expenditure per-capita

Denominator: total food expenditure per-capita





Households involved in agriculture

Numerator: number of households who are either self-employed or casual laborers in agriculture






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



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)

[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


Safe delivery: institutional or home delivery assisted by skilled personnel



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

Denominator: total number of households



DLHS-3 State Report

TABLE 2.12 AVAILABILITY OF FACILITY AND HEALTH PERSONNEL BY DISTRICT

Household has access to a sub health center

Numerator: number of households that have access to a health center




DLHS-3 State Report


Household has access to primary/middle school

Numerator: number of households that have access to a primary/middle school




DLHS-3 State Report


Households who demanded and received work through NREGA

Numerator: number of households that received an NREGA job

Denominator: total number of households that demanded an NREGA job

Note: NREGA= National Rural Employment Guarantee Act

Percentage NSS68 2011-12 employment and unemployment

NSS68 2011-12 employment and unemployment

Author’s estimates from NSSO data


Households availing bank services

Numerator: number of households availing bank services




Census 2011

HH-12: NUMBER OF HOUSEHOLDS AVAILING BANKING SERVICES AND NUMBER OF HOUSEHOLDS HAVING EACH OF THE SPECIFIED ASSETS


15

EVALUATION OF HEALTH AND NUTRITION SCHEMES


Policy

Institutional delivery

Numerator: number of children aged 0–2 months who were delivered in a medical institution



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


Households receiving take home ration

Numerator: number of households with a 0–2 month child who receives any take home ration



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



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

Denominator: all households with a 0–2 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)

Percentage CHHNS6 2014 CHHNS6 2014 Author’s estimates from 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

Denominator: all households with a 0–2 months old baby who was delivered at home


16

NOTES1. 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

REFERENCESAuthor’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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POSHAN District Nutrition Profiles_Guide to DNPs