Individual and Ecological Variation in Child Undernutrition in India: A Multilevel Analysis

Despite the substantial burden of child undernutrition in South Asia, little is known on the relative importance and contribution of individual and micro/macro environments in shaping variation in child undernutrition. Using measures of anthropometry, we decompose the variation in child undernutrition in India to the levels of child, communities and states, quantifying the extent to which variation at each of these levels can be explained by known proximal and distal risk factors, measured at the individual (child/household) level. Data are from under-five singleton children participating in the 2005-2006 National Family Health Survey (NFHS-3). The outcome variables were: height-for-age z-score (HAZ), weight-for-age z-score (WAZ) and weight-for-height z-score (WHZ), as well as their associated measures of anthropometric failure: stunting, underweight and wasting, defined as more than two standard deviations below the median of the referred z-scores, respectively. We also considered the composite index of anthropometric failure (CIAF), defined by combinations of child anthropometric failure. After accounting for risk factors, of the total variation in HAZ, 93.2 per cent, 4.9 per cent and 1.9 per cent were attributable to the individual, community and state levels, respectively. The observed risk factors explained 6.3 per cent and 46.9 per cent of the variation at the individual and community level, respectively; however, between-state variation was not explained by these risk factors. Variability in other measures of anthropometry and anthropometric failure largely followed this pattern. Additionally, there were also considerable differences in the amount of variation at the individual and community levels among different states. Hence, there is a substantial variability at the community level compared to the state level, suggesting the presence of micro-geographies of undernutrition. Additionally, while a substantial majority of the variation in child undernutrition is at the individual level, our ability to explain variability in undernutrition at the individual-level risk factors is extremely limited. Further research is needed to explore community level or environmental factors affecting child undernutrition, generating evidence for policies to target these determinants.