Determinants of nutritional status of under-five children

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Determinants of nutritional status of under-five children receiving Integrated Child

Development Services (ICDS) in India

Authors

Manas Ranjan Pradhan, PhD1 and Mahesh Rajendra Shete2

1 Assistant Professor, Department of Fertility & Social Demography, International Institute for

Population Sciences (IIPS), Govandi Station Road, Deonar, Mumbai, 400088, Maharashtra,

India. Email: [email protected]

2 Data Analyst, Max Institute of Healthcare Management, Indian School of Business, Mohali,

India. Email: [email protected]

Abstract

Background: Undernutrition is a significant public health problem and the leading risk factor

for India's disease burden.

Aim: To understand the determinants of nutritional status of under-five children receiving

services under Integrated Child Development Services (ICDS) in India.

Methods: The study used data from the National Family Health Survey–4 (NFHS–4) conducted

during 2015–16. The present analysis was carried out for under-five children who have availed

of any ICDS services in the 12 months preceding the survey (n=1,27,813). Stunting, wasting,

and underweight were estimated following the WHO guideline and used as the primary

outcome variables. The binary logistic regression was carried out to examine the adjusted effect

of ICDS utilization and socioeconomic-demographic predictors of under-five children's

nutritional status. STATA (V 13) was used for statistical analyses.

Results: A sizable proportion of under-five children receiving any ICDS services suffer from

undernutrition. The undernutrition prevalence varied considerably by socioeconomic and

demographic characteristics, plus the frequency of ICDS utilization. Logistic regression found

insignificant role of ICDS on the nutritional status of under-five children. The child's age and

gender, maternal education and nutrition status, wealth index of the household, social group,

region, place of residence and region were significant determinants of undernutrition among

ICDS beneficiaries.

Conclusion: The study suggests the need to ensure all available services to children enrolled in

the ICDS/Anganwadi Centre (AWC). More importantly, the program should also emphasize

feeding practices and educating parents about improving child health and nutrition.

mailto:[email protected]

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Introduction

Undernutrition is a significant public health problem and the leading risk factor for India's

disease burden. The prevalence of undernutrition among under-five children is high and vary

widely depending on the assessment methodology adopted (Sahu et al., 2015). India is the

home to the highest number of children under five years wasted and found to have made no

progress in meeting the 2025 global nutrition target for wasting (Global Nutrition Report,

2020). Again, 35% of the under-five children are stunted, higher than the Asia region average

(21.8%). Malnutrition was the principal risk factor for death in under-five children in every

state of India in 2017, accounting for 68% of the total under-five deaths (Swaminathan et al.,

2019). Earlier studies found various socioeconomic and demographic factors such as age and

gender of the child (Bharati et al., 2008), maternal education (Meshram et al., 2012; Mukherjee

et al., 2008; Sen et al., 2011) and Body Mass Index-BMI (Corsi et al., 2016), family size (Rehan

et al., 2020; Swami et al., 2000), household wealth status (Corsi et al., 2016; Kanjilal et al.,

2010; Meshram et al., 2012), housing condition (Som et al., 2007), religion & caste (Rehan et

al., 2020), place of residence and region (Bharati et al., 2008), and state-level dietary diversity

(Borkotoky et al., 2018) affecting the nutritional status of under-five children in the country.

In India, the policy and programme to facilitate the delivery of nutrition‐specific interventions

is broadly in place but varies by the intervention (Avula et al., 2016). The Integrated Child

Development Services (ICDS) scheme implemented by the Ministry of Women and Child

Development (MoWCD) and the National Health Mission (NHM) implemented by the

Ministry of Health and Family Welfare (MoHFW) are the primary nutrition programs that

operate across the country. They are designed to deliver nutrition‐specific interventions

through their frontline workers (Avula et al., 2016). The ICDS, launched in 1975, is one of the

world's largest programmes for early childhood care and development. The beneficiaries under

the ICDS scheme are children in the age group of 0-6 years, pregnant women, and lactating

mothers. One of the primary objectives of the scheme is to improve the nutritional and health

status of children in the age group 0-6 years, which also aims to reduce the incidence of

mortality, morbidity, malnutrition and school dropout; lay the foundation for proper

psychological, physical and social development of the child; to enhance the capability of the

mother to look after the health and nutritional needs of the child through proper nutrition and

health education, and to achieve effective coordination of policy and implementation amongst

the various departments to promote child development. Supplementary nutrition, pre-school

non-formal education, nutrition & health education, immunization, health check-up and

referral services are provided under the scheme (MoWCD, Government of India). These

services are delivered through Anganwadi Centers (AWCs). An AWC is part of the Indian

public healthcare system. The AWCs are managed by Anganwadi Workers (AWWs), a

community-based frontline worker.

Most of the earlier studies evaluating the impact of ICDS on the nutritional status of children

have found little impact, except a few, that revealed positive contribution on the nutritional

status of children from a specific age or socioeconomic groups. Thakur et al. (2011), analyzing

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the data of 803 under-five children in Chandigarh, revealed an insignificant difference in the

prevalence of underweight among children registered under ICDS and those not registered.

Dutta and Ghosh (2015), using primary data of 390 households in West Bengal, found no

impact of enrollment and utilization of supplementary feeding from ICDS on child stunting

measures. Concerns with infrastructure and delivery of services like health check-ups,

immunization, referral slip availability, and referral of sick children by AWC were found in

the assessment study in Gujurat (Chudasama et al., 2015). Analyzing data of 60 women ICDS

beneficiaries in Jammu & Kashmir, another study found problems with the provision of

supplementary nutrition throughout the year, plus lack of coordination between health and

AWW staff affecting child immunization (Bashir et al., 2018). Past studies based on DHS data

of 2005-06 reveals a mixed effect of ICDS on child nutrition. Kandpal (2011) found significant

treatment effects of ICDS, particularly for the most malnourished children. This study further

revealed that ICDS effectively targets poor areas but failed to target areas with low levels of

average education and those with unbalanced sex ratios. Another study found a positive effect

of daily supplementary feeding on the nutritional status of children aged 0-2 years in rural India

(Jain, 2015). However, using propensity score matching in the same dataset, Dixit et al. (2018)

revealed that women who received nutrition and health education from the ICDS had a higher

chance of institutional delivery. However, this service has no positive impact on children's

nutritional status.

An insightful assessment of the role of ICDS utilization in influencing child undernutrition

among different subgroups using a large representative recent sample will have better policy

implications to improve the ICDS service utilization and reduce child morbidity and mortality.

Based on a nationally representative sample, this study aims to understand the determinants of

nutritional status of under-five children receiving ICDS services in India. Specifically, the

paper attempts to study the association of specific ICDS services with child nutrition.

Moreover, the frequency/extent of utilization of the ICDS services is expected to influence

children's nutritional status and hence studied. The study results deemed to provide the

evidence required to formulate/strengthen strategies and programs for appropriate nutrition-

focused interventions. This paper's essence may also be considered for assessing the

effectiveness of ICDS services in reducing undernutrition in the country.

Methods

Data

The study used data from the National Family Health Survey–4 (NFHS–4) conducted during

2015–16. The NFHS-4 provides information for a wide range of monitoring and impact

evaluation indicators of population, health, and nutrition. A total of 699,686 women aged 15-

49, 112,122 men aged 15-54, and 243,867 children under-five years were surveyed from

601,509 households covering all districts in the country. The Primary Sampling Unit (PSUs),

i.e., the survey villages in rural areas and Census Enumeration Blocks (CEBs) in urban areas,

were selected using probability proportional to size (PPS) sampling. The households were

randomly selected with systematic sampling in each of the selected PSU for the survey. Trained

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research investigators using computer-assisted personal interviewing (CAPI) gathered the data.

Informed consent procedures were followed, and only those respondents who voluntarily

consented (written or oral) to participate in the survey were interviewed. A detailed survey

design, questionnaire, quality control measures, and survey management information can be

obtained from the published national report (International Institute for Population Sciences and

ICF, 2017). The present analysis was carried out for under-five children who have availed of

any ICDS services in the 12 months preceding the survey (n=1,27,813). Specifically, the survey

gathered information on the frequency of receiving food, any health check-ups, immunization,

and weight measurement for children under-five, which was considered for analysis. In

addition, the survey asked the following questions to capture the utilization of ICDS services:

During the last 12 months, has (NAME) received any benefits from the anganwadi or ICDS

centre?

Those responding yes to the above question were asked the following questions:

In the last 12 months, how often has (NAME) received food from the anganwadi/ICDS centre?

(Pre-coded as: not at all (0), almost daily (1), at least once a week (2), at least once a month

(3), less often (4), don’t know (8)

In the last 12 months, how often has (NAME) had a health check-up from the anganwadi/ICDS

centre? (Pre-coded as: not at all (0), at least once a month (1), less often (2), don’t know (8)

In the last 12 months, has (NAME) received any immunizations through the anganwadi/ICDS

centre? (Pre-coded as: yes (1), no (2), don’t know (8)

In the last 12 months, how often has (NAME’s) weight been measured by the anganwadi/ICDS

centre? (Pre-coded as: not at all (0), at least once a month (1), at least once in 3 months (2),

less often (3), don’t know (8)

Outcome variables

In NFHS-4, information about the age, height and weight of the children born in the last five

years was collected from their mothers or any eligible individual in the household. This

information was used to estimate stunting, wasting, and underweight among the under-five

children following WHO guideline (WHO, 2019) and used as the present study's primary

outcome variables. Stunting: Children whose height-for-age Z-score was below minus two

standard deviations (-2 SDs) from the reference population's median were considered short for

their age (stunted), or chronically undernourished. Wasting: Children whose weight-for-height

Z-score was below minus two standard deviations (-2 SDs) from the median of the reference

population were considered thin (wasted), or acutely undernourished. Underweight: Children

whose weight-for-age Z-score was below minus two standard deviations (-2 SDs) from the

reference population's median were classified as underweight. All three dependent variables

were converted into dichotomous binary variable with categories defined as 1= yes (Z-score<

-2 SDs), 0= no (Z-score>= -2 SDs).

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Predictor variables

The primary predictor variables used in the analysis were the utilization of ICDS services.

Specifically, frequency of receiving food (almost daily, at least once a week, at least once a

month, less often, not at all), health check-ups (at least once a month, less often, not at all),

immunization (yes, no), and weight measurement (at least once a month, at least once in 3

months, less often, not at all) from the ICDS were included. The food supplements are expected

to be provided daily, although the modalities might differ. AWW provide it as regular lunch

for those aged 3-6 years attending the AWC or as a take-home-ration for those aged 0-3 years.

The children aged 0-6 are provided various health check-ups in AWC, including regular health

check-ups, management of malnutrition, treatment of diarrhoea, and de-worming. These

services are provided with support from Auxiliary Nurse Midwife (ANM) and once every

month. Although children are free to take vaccination from any health facility, the aim was to

capture whether they receive an immunization from AWC, which provides immunization

services through support from the ANM. The children aged 0-3 years are expected to be

weighed once a month and those aged 3-6 years once in three months. However, there is a

possibility of those mal-nutritious children getting weighed every month irrespective of age.

To assess the adjusted effect of ICDS utilization on nutritional status of under-five children,

selected additional potential predictors such as child’s age in months (<6, 6-11, 12-23,24-35,

36-47, 48-59), gender (male, female), mother's years of schooling (illiterates, less than ten

years, ten years and above), mother’s BMI (Normal underweight, overweight), social groups

(scheduled caste-SC, scheduled tribe-ST, other backward classes-OBC, Non-SC/ST/OBC),

religion (Hindu, Muslim, others) wealth quintile (poorest, poorer, middle, richer, richest), place

of residence (urban, rural), and geographical regions (north, central, east, northeast, west,

south) were also considered for the analysis. The wealth quintile is a measure of a household's

living standard and was calculated using data on the household's ownership of selected assets,

materials used for housing construction, and types of water access and sanitation facilities. The

southern region consists of Andaman Nicobar Islands, Andhra Pradesh, Karnataka, Kerala,

Lakshadweep, Puducherry, Tamil Nadu and Telangana; western consists of Dadra Nagar and

Haveli, Daman and Diu, Goa, Gujarat and Maharashtra; northern consists of Chandigarh,

Haryana, Himachal Pradesh, Jammu and Kashmir, New Delhi, Punjab, Rajasthan and

Uttarakhand; central consists of Chhattisgarh, Madhya Pradesh and Uttar Pradesh; eastern

consists of Bihar, Jharkhand, Odisha and West Bengal; and north-eastern consists of Arunachal

Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. These

included socioeconomic and demographic variables are well-established factors of child

nutrition in India. “Do not know” responses in all the predictor variables wherever applicable

were excluded from the analysis.

Statistical analysis

Descriptive analysis was conducted to assess the percentage distribution of the socioeconomic

and demographic characteristics of under-five children. The independent association of the

predictor variables with the outcome variables was examined using the Chi-square method.

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Further, since the outcome variables were dichotomous, binary logistic regression was

employed to examine the adjusted effect of socioeconomic and demographic predictors on

under-five children's nutritional status. The variables included for regression analysis was

finalized based on their significant individual association with the outcome variables and

checking multicollinearity among the predictor variables. Multicollinearity was examined

through Variance Inflation Factor (VIF) method. It was found that all the predictor variables

used in the model had a VIF value below two, ruling out collinearity (Gareth et al., 2013). The

goodness of fit of the regression models was assessed using Pearson χ2 goodness-of-fit test.

National sample weight available in the data set was used in the analysis. STATA (V 13) was

used for statistical analyses.

Results

Sample characteristics

Table 1 presents the socioeconomic and demographic characteristics of under-five children

who had utilized ICDS services in the last 12 months preceding the survey. Of the children,

36% received food supplements from the ICDS centre almost daily, 22% received it at least

once a week, 27% received it at least once a month, 5% received it less often, and 11% did not

receive it at all. More than a half (54%) of these children received health check-ups at least

once a month, and about a quarter (26%) of them never had any health check-ups in AWC.

Nearly three-fourths (74%) of these children had received immunization in AWC. Of the

children, 46% were weighed at least once in a month, 22% once in three months, 10% less

often, and 22% never, in the AWC. Of the sample children, 7% were less than six months old,

11% were 6-11 months old, 23% were 12-23 months old, 21% were 24-35 months old, 20%

were 36-47 months old, and the rest aged 48-59 months. Boys comprised 52% of the total

children. Nearly three out of every ten mothers were non-literates. Twenty-seven per cent of

the mothers were underweight, 60% were of normal weight, and the remaining were

overweight. Economically, 26% of these children belong to poorest, 25% to poorer, 22% to

middle income, 18% to richer, and 10% to richest households. Of the total children, 45% were

from OBC, 37% from SC/ST, and 18% from the non-SC/ST/OBC category. Eighty-one per

cent of the children were Hindus, 14% were Muslims and the rest from other religions. A

majority (79%) of the children reside in rural areas. Twenty-nine per cent of the children belong

to the eastern region, 25% to the central region, 20% to the southern region, 12% to the western

region, 11% to the northern region, and 3% to the northeast region.

Socioeconomic and demographic differential in nutritional status

Table 2 presents the nutritional status of under-five children who had utilized ICDS services in

the last 12 months by background characteristics. Of these children, 40% were found stunted,

22% were wasted, and 37% were underweight. Thirty-eight per cent of the children receiving

food supplements almost daily were stunted compared to 41% of children who never had

received any food supplements from ICDS centre. Thirty-eight per cent of the children whose

health was checked-up at least once a month was found stunted, as against 42% of those who

never went through health check-ups in ICDS centre. A similar result was found so far as

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weight measurement was concerned. Forty per cent of the children immunized in ICDS centre

were stunted as against 38% of their counterparts not immunized in that place. Wasting

prevalence also varied by sociodemographic and economic characteristics, plus the frequency

of ICDS utilization. Twenty per cent of the children receiving food supplements less often were

wasted than 22% of children who had received it almost daily from ICDS centre. Twenty-three

per cent of the children receiving health check-ups were wasted as against 21% of their

counterparts not receiving any health check-ups in the ICDS centre. Twenty-three per cent of

the children immunized in ICDS centre were wasted as against 20% of their counterparts not

immunized in that source. The wasting prevalence did not vary much with the frequency of

receiving weight measurement at ICDS centre (22-23%). Thirty-nine per cent of the children

receiving food supplements less often were underweight than 37% of children who had

received it almost daily from ICDS. Thirty-eight per cent of the children immunized in ICDS

centre were underweight against 35% of their counterparts not immunized in that place. The

underweight prevalence did not vary much with the frequency of receiving health check-ups

and weight measurement at ICDS centre (37-38%).

The proportion of stunted and underweight children increased with the increase in the age of

the children, while wasting was inversely associated. Nearly a half of the children of non-

literate mothers were found stunted (51%) and underweight (48%), while the corresponding

figures were 28% and 26% for those children whose mothers had ten plus years of schooling.

A higher percentage of children with underweight mothers (46%) were stunted, wasted (28%),

and underweight (48%) than their peers whose mothers were of normal weight (39%, 21% and

35%). The proportion of children with stunting, wasting and underweight found to decrease

with the uptrend of the economic status of the household. In the poorest households, 51% were

stunted, 28% were wasted, and 50% were underweight compared to 23% stunted, 15% wasted

children and 20% underweight children from the richest households. Forty-four per cent of the

SC/ST children were stunted, and 42% were underweight. The corresponding figures were 33%

and 31% among Non-SC/ST/OBC children. Higher percentages of the children from the central

region were stunted (45%) and underweight (42%).

Determinants of nutritional status

Table 3 presents the result of logistic regression of factors affecting the nutritional status of

under-five children receiving ICDS services. Model 1, comprising variables of ICDS

utilization, found that children who received food supplements at least once a month was more

likely to be stunted (OR: 1.04; P<0.10) than those who received it almost daily. The association

remained significant (OR: 1.06; P<0.05) even after adjusting the effects of other background

characteristics used in model 2. The chances of wasting were significantly lower (OR: 0.92;

P<0.05) among children who never received any food supplements than those who received it

almost daily after adjusting the variables. Children without any food supplements from ICDS

had higher odds of being underweight than those who received it almost daily (OR: 1.06;

P<0.10) when adjusted for other sociodemographic and economic predictors.

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The children without any health check-ups in the ICDS centre had higher odds of being stunted

(OR: 1.11; P<0.01) and underweight (OR: 1.09; P<0.01) than those undergone health check-

ups. However, the significance of these associations disappeared when adjusted for other

variables. Children not immunized in ICDS centre were less likely to be stunted (OR: 0.89;

P<0.01), wasted (OR: 0.84; P<0.01) and underweight (OR: 0.84; P<0.01) than their

counterparts immunized in that centre. This association persisted significant (P<0.01) after

adjusting other variables' effects in model 2. Children never weighed in the ICDS centre had

higher chances of stunting than those weighed at least once a month (OR: 1.08; P<0.01). The

significant association between stunting and frequency of weight measurement disappeared

when adjusted for other variables. However, the likelihood of wasting was less among the

children never weighed in the ICDS centre (OR: 0.95; P<0.10), controlling the effects of

socioeconomic and demographic variables.

Age of child revealed a significant (P<0.01) inverse association with wasting and direct

association with stunting and underweight among under-five children. Girls were less likely to

be stunted (OR: 0.94; P<0.01), wasted (OR: 0.86; P<0.01) and underweight (OR: 0.93; P<0.01).

Children of educated mothers had lesser odds of stunting, wasting, and underweight than non-

literate mothers. For example- children of mothers with ten plus years of schooling had a 39%

lower chance of being stunted and 34% lower chance of being underweight than mothers with

no schooling. Children whose mothers had normal weight or were overweight had a lower

probability of stunting (OR: 0.83, OR: 0.67; P<0.01), wasting (OR: 0.71, OR: 0.52; P<0.01)

and underweight (OR: 0.63, OR: 0.43; P<0.01) as against those with underweight mothers. The

household's economic condition had a significant inverse association with undernutrition-

children from the richest quintile of households had lower odds of being stunted by 58%, waste

by 33% and underweight by 60% from the poorest quintile households. The children from non-

SC/ST/OBC category had lower chances of stunting (OR: 0.78, P<0.01), wasting (OR: 0.90,

P<0.01) and underweight (OR: 0.80, P<0.01) than those from SC/ST category. Muslim

children were more likely to be stunted (OR: 1.14; P<0.01) and underweight (OR: 1.09; P<0.01)

than Hindu children. Children from rural areas had lower odds of stunting (OR: 0.91; P<0.01),

wasting (OR: 0.92; P<0.01) and underweight (OR: 0.89; P<0.01) than their urban counterparts.

Under-five children from the northeast region were less likely to be stunted (OR: 0.72; P<0.01),

wasted (OR: 0.70; P<0.01) and underweight (OR: 0.59; P<0.01) compared with peers from the

northern region.

Discussion

The study found that a sizable number of under-five children receiving any ICDS services

suffer from undernutrition, and the prevalence varied considerably by socioeconomic and

demographic characteristics plus the frequency of ICDS utilization. The utilization of ICDS

had a weak association with the nutritional status of under-five children. The child's age and

gender, maternal education and nutrition status, wealth index of the household, social group,

region, place of residence and region were significant determinants of undernutrition among

ICDS beneficiaries' in the country.

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Utilization of all available child-centric ICDS services was not universal among the under-five

children who had received any services. A recent study also revealed that among all the benefits

offered under ICDS, services related to health and nutrition and pre-school were relatively

lesser utilized and a high concordance between service utilization by mothers and their children

(Rajpal et al., 2020). Another past study found that the mean proportion of respondents using

ICDS services has increased between 2006 and 2016; nevertheless, the population's poorest

quintiles were still left behind (Chakrabarti et al., 2019). It was also observed that having an

ICDS centre in the village does not affect the nutritional status of children due to poor delivery

of ICDS benefits (Jain, 2015).

The ICDS utilization had a negligible effect on the nutritional status of children. Most of the

earlier studies assessing the impact of ICDS on child nutrition had similar findings (Dixit et

al., 2018; Dutta and Ghosh, 2017; Thakur et al., 2011). Even the planning commission report

on the evaluation of ICDS was inconclusive about its impact on nutritional outcomes (Planning

Commission, 2011). This finding question the effectiveness of the ICDS to improve child

nutrition, although the direct approach in many large-scale programs has been found ineffective

(Das Gupta et al., 2005). One possibility is that the designated amount of food supplements

and food diversity might be insufficient to mark significant changes in under-five children's

nutritional condition. A past study among 1286 pre-school children also revealed a higher

prevalence of protein-energy malnutrition among ICDS beneficiaries than non-beneficiaries

(Swami et al., 2000).

Moreover, the insignificant effect of health check-ups, weight measurement, and immunization

at the ICDS centre on undernutrition might be due to the beneficiaries' profile. A sizable

proportion of the beneficiaries were from socio-economically underprivileged groups and

probably could not fully utilize the benefits/learnings to improve children's nutritional status

due to their disadvantageous status. Literature suggests shifting focus to improve

environmental hygiene and child feeding practices and enhancing nutritional awareness of

caregivers from the mere provision of supplementary feeding to improve child nutritional status

(Dixit et al., 2018). Dutta and Ghosh (2015) recommend that child stunting may be improved

if the child receives supplementary food and the caregiver is provided information on the

nutrition and growth trajectory of the child. Another study found caregiver's knowledge,

attitudes, and practices regarding hygiene and infant feeding as major determinants of child

nutrition (Kalid et al., 2019). Athavale et al. (2020) recommend engaging all family members

and strengthening maternal self-efficacy for following IYCF recommended guidelines to

improve nutritional status.

Stunting and underweight prevalence found to increase with the increasing age of under-five

children. This result may be because of inadequate complementary feedings once breast milk

alone becomes insufficient. Moreover, low-quality foods and lack of food and water safety

might have affected the older children. Boys were more undernourished than girls, and the

finding conformed to a recent systematic review that attributed both biological and social

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factors as possible reasons (Thurstans et al., 2020). As found in many past studies (Corsi et al.,

2016; Meshram et al., 2012; Mukherjee et al., 2008; Sen et al., 2011), this study also found that

better education and nutritional status of mothers significantly reduce the likelihood of

undernutrition among under-five children. An earlier study revealed that educated mothers

have a better awareness of the available health services, and the acceptance of utilizing the

same is more among them (Murarkar et al., 2020). A recent study also found higher odds of

MAD feeding among children with educated mothers exposed to mass media (Acharya et al.,

2021). Children from affluent households had improved nutritional status. One possible reason

may be that these children had higher odds of MAD feeding, which was found in many earlier

studies (Patel et al., 2012; Senarath et al., 2012). Moreover, the higher MAD feeding among

the children from wealthy households could be attributed to their ability to afford food diversity

and required meal frequency to maintain a diet diversity (Rohner et al., 2013). Mothers from

poor households were again more likely to focus on food quantity than wealthy households

who give their children highly nutritious foods (Joshi et al., 2012).

The study found that children from socially backward communities (SCs/STs) more likely to

be undernourished. A past study decomposing malnutrition inequalities between SCs/STs and

the remaining population attributed the gap primarily caused by the former’s lower wealth,

education, and healthcare services (Van de Poel and Speybroeck, 2009). Additionally, their

ignorance about the importance of diet diversity and incapacity to afford the required diet

diversity and meal frequencies might also be a factor. An earlier study revealed a lower

probability of MAD feeding among children from the SCs community (Acharya et al., 2021).

There is again enough evidence to suggest lower literacy among the SC/ST people and their

economically weaker status (International Institute for Population Sciences (IIPS) and ICF,

2017; Ministry of Social Justice and Empowerment Government of India, 2004-05; Registrar

General and Census Commissioner of India, 2011). Moreover, social-group based inequalities

in accessing health services and health services utilization measures- SC/ST communities being

the disadvantaged group, might be another possibility (Balarajan et al., 2011; Baru et al., 2010;

Shaikh et al., 2018). The differences in the effects of religion on stunting may be attributed to

the variations in values and norms that guide lifestyles and beliefs concerning health and well-

being (Parekh and Pillai, 2016). In contrast to past studies that found a better nutritional status

of urban children (Bharati, 2009; Ministry of Health and Family Welfare (MoHFW),

Government of India, 2019), this study found that under-five children residing in rural areas

had a lower chance of undernutrition. One possibility might be improved awareness of dietary

diversity and access to seasonal, nutritious foods in rural areas (Murarkar et al., 2020). This

study also found a wide regional disparity in under-five children's undernutrition (Jain and

Agnihotri, 2020; Jose et al., 2018). The higher chances of undernutrition in the country's central

and western region that comprise a sizable proportion of the country's child population was a

cause of concern.

The study's strengths could be attributed to the findings based on a large representative sample

of children covered in the recently concluded NFHS-4 with a robust sampling design. Thus,

the results are contemporary. The study documents the determinants of nutritional status of

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under-five children and the insignificant effect of ICDS on nutritional status. However, the

survey's cross-sectional design limits child undernutrition's causal association with factors

drawn from this analysis. Moreover, this study does not identify a causal effect due to the

possible correlation between socioeconomic status, AWC utilization, and undernutrition.

Despite this, the study's findings would help strengthen the existing service delivery

mechanism to increase utilization/coverage and quality of services under ICDS, thus ensuring

a better nutritional status of under-five children. The study suggests the need to ensure all

available services to children enrolled in the AWC. Regular monitoring of service utilization

and supervision by the Child Development Project Officer (CDPO) may help in expanding the

coverage. More importantly, the program should also emphasize feeding practices and

educating parents about improving child health and nutrition.

Ethical statements

Informed consent was taken before interviewing the respondents in the NFHS-4. The NFHS-4

survey was approved by the Institutional Review Boards of the institutions involved. The

NFHS-4 datasets are available for broader use in social research at https://www.

dhsprogram.com. This study used secondary data of the NFHS-4.

Declaration of conflicting interest

The author(s) declare that there is no conflict of interest.

12

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15

Table 1: Socio–economic and demographic characteristics of children under-five who have

utilized ICDS services from anganwadi centre (AWC) in last 12 months, India, 2015-16

Characteristics % distribution

of children

Number of

children

Received food supplements from AWC*

Almost daily 36.0 38,880

At least once a week 21.8 30,410

At least once a month 26.9 36,045

Less often 4.7 8,927

Not at all 10.7 13,198

Received health check-ups in AWC*



Not at all 25.8 36,590

Received immunization in AWC*

Yes 74.4 90,117

No 25.6 37,040

Weight measured in AWC*


At least once in 3 months 21.8 26,889


Not at all 22.0 30,655

Age of child in months

<6 7.3 9,707

6-11 11.4 14,445

12-23 22.6 28,876

24-35 21.0 27,018

36-47 20.3 25,775

48-59 17.4 21,992

Gender of the child

Male 51.6 65,796

Female 48.5 62,017

Years of schooling of the mother

No schooling 28.6 37,468

Less than 10 years 43.2 56,179

10 and above years 28.3 34,166

Nutritional status of the mother*

Underweight 27.2 33,313

Normal 60.1 78,807

Overweight 12.7 15,274

Wealth quintile of the household

Poorest 25.7 34,146

Poorer 24.7 32,410

Middle 22.0 27,353

Richer 17.7 20,688

Richest 9.9 13,216

Social groups*

Scheduled caste (SC)/ Scheduled tribe (ST) 37.5 53,480

16

Other Backward Class (OBC) 45.0 50,017

Non-SC/ST/OBC 17.5 19,526

Religion

Hindu 80.8 97,299

Muslim 14.1 16,148

Others 5.1 14,366

Place of residence

Urban 20.7 23,546

Rural 79.3 1,04,267

Region#

North 10.6 20,708

Central 25.1 37,155

East 28.9 30,244

Northeast 3.4 15,778

West 12.0 9,600

South 20.0 14,328

Under-five children who received any ICDS

service

100.0 1,27,813

Note: * The sample size for respective predictor variables may not add to total sample size

due to missing values.

17

Table 2: Nutritional status of under-five children who have utilized ICDS services from

anganwadi centre (AWC) in last 12 months, by background characteristics, India, 2015-16

Background characteristics Stunting Wasting Underweight N

Received food supplements from

AWC*

Almost daily 38.2 22.1 36.5 38,880

At least once a week 39.6 22.7 37.8 30,410

At least once a month 40.2 22.3 37.4 36,045

Less often 40.3 19.8 35.2 8,927

Not at all 41.2 21.4 39.1 13,198

Chi-square X2 (p-value) 31.14

(0.000)

142.73

(0.000)

205.36 (0.000)

Received health check-ups in AWC*


Less often 39.5 22.1 37.2 27,275

Not at all 41.6 21.1 38.3 36,590


(0.004)

99.99

(0.000)

28.00 (0.000)

Received immunization in AWC*

Yes 40.0 22.9 38.2 90,117

No 38.0 19.7 34.5 37,040


(0.000)

435.53

(0.000)

500.34 (0.000)

Weight measured in AWC*


At least once in 3 months 39.4 21.8 37.2 26,889

Less often 40.3 21.1 37.4 14,470

Not at all 41.5 21.5 38.0 30,655


(0.006)

78.08

(0.000)

22.90 (0.000)


<6 20.9 31.3 26.7 9,707

6-11 23.6 27.8 29.6 14,445

12-23 43.5 23.4 37.0 28,876

24-35 43.9 20.1 38.8 27,018

36-47 44.5 18.6 40.5 25,775

48-59 41.1 19.2 41.4 21,992

Chi-square X2 (p-value) 3300

(0.000)

974.53

(0.000)

858.17 (0.000)

Gender of the child

Male 40.0 23.2 37.9 65,796

Female 38.9 20.8 36.6 62,017


(0.000)

105.95

(0.000)

35.03 (0.000)


No schooling 50.6 24.1 47.6 37,468

Less than 10 years 39.6 22.0 37.7 56,179

10 and above years 28.0 20.2 26.2 34,166


(0.000)

339.35

(0.000)

3700 (0.000)

Nutritional status of the mother

Underweight 45.8 28.1 48.6 33,313

18

Normal 38.8 20.8 35.1 78,807

Overweight 28.8 15.0 22.8 15,274


(0.000)

1400

(0.000)

3800 (0.000)


Poorest 50.9 25.8 49.5 34,146

Poorer 43.1 22.9 41.0 32,410

Middle 37.0 20.5 33.9 27,353

Richer 29.7 19.6 27.9 20,688

Richest 23.3 18.1 20.4 13,216


(0.000)

853.03

(0.000)

5300 (0.000)

Social groups*

Scheduled caste (SC)/ Scheduled

tribe (ST) 43.5 24.1 42.1 53,480

Other Backward Class (OBC) 39.2 21.6 36.5 50,017

Non-SC/ST/OBC 32.7 19.9 30.8 19,526


(0.000)

170.96

(0.000)

738.20 (0.000)

Religion

Hindu 39.6 22.4 37.7 97,299

Muslim 40.6 20.3 36.1 16,148

Others 34.6 21.2 33.3 14,366


(0.000)

467.30

(0.000)

971.94 (0.000)

Place of residence

Urban 34.0 20.7 31.6 23,546

Rural 40.9 22.4 38.7 1,04,267


(0.000)

41.16

(0.000)

365.97 (0.000)

Region

North 34.9 20.3 30.7 20,708

Central 44.6 22.4 41.5 37,155

East 42.5 22.6 40.7 30,244

Northeast 35.6 16.5 27.8 15,778

West 39.8 25.8 40.6 9,600

South 31.6 20.5 29.9 14,328


(0.000)

1100

(0.000)

3400 (0.000)

Total 39.5 22.1 37.3 1,27,813

Note- Bivariate association shown using Chi-square test for association and values in parentheses

are the p-values associated with the respective Chi-square;

* The sample size for respective predictor variables may not add to total sample due to missing

values.

19

Table 3. Odds ratios of binary logistic regression of factors affecting nutritional status of under-five children receiving ICDS services, India

(2015-16).

Background Characteristics

Model 1 (N=123976) Model 2 (N=119049)

Stunting Wasting Underweight Stunting Wasting Underweight

Adjusted OR

(95% CI)

Adjusted OR

(95% CI)

Adjusted OR

(95% CI)

Adjusted OR

(95% CI)

Adjusted OR

(95% CI)

Adjusted OR

(95% CI)

Received food supplements from AWC

Almost daily ® 1.00 1.00 1.00 1.00 1.00 1.00

At least once a week 1.04 (0.99, 1.09) 1.05*(1.00, 1.11) 1.05**(1.00, 1.10) 1.00 (0.95, 1.05) 1.00 (0.95, 1.06) 1.03 (0.98, 1.08)

At least once a month 1.04*(0.99, 1.09) 1.04 (0.98, 1.10) 1.02 (0.97, 1.07) 1.06**(1.01, 1.11) 0.99 (0.94, 1.05) 1.05*(1.00, 1.1)

Less often 1.02 (0.94, 1.1) 0.91**(0.83, 1.00) 0.92**(0.85, 0.99) 1.05 (0.96, 1.14) 0.93 (0.84, 1.02) 0.99 (0.91, 1.07)

Not at all 1.01 (0.95, 1.08) 0.98 (0.91, 1.05) 1.04 (0.97, 1.10) 1.05 (0.98, 1.12) 0.92**(0.85, 0.99) 1.06*(0.99, 1.13)

Received health check-ups in AWC

At least once a month® 1.00 1.00 1.00 1.00 1.00 1.00

Less often 1.03 (0.98, 1.08) 1.03 (0.97, 1.09) 1.04 (0.99, 1.09) 0.99 (0.94, 1.04) 1.03 (0.97, 1.1) 1.01 (0.96, 1.07)

Not at all 1.11***(1.06,

1.17) 0.96 (0.91, 1.02)

1.09***(1.04,

1.14) 1.04 (0.99, 1.09) 0.96 (0.91, 1.02) 1.03 (0.98, 1.09)

Received immunization in AWC

Yes® 1.00 1.00 1.00 1.00 1.00 1.00

No 0.89***(0.86,

0.93)

0.84***(0.8, 0.88) 0.84***(0.80,0.87

)

0.93***(0.89,

0.97)

0.93***(0.88,

0.98)

0.90***(0.86,

0.94)

Weight measured in AWC

At least once a month® 1.00 1.00 1.00 1.00 1.00 1.00

At least once in 3 months 1.04*(1.00, 1.09) 0.95**(0.9, 1.00) 1.01 (0.97, 1.06) 0.99 (0.94, 1.04) 0.96 (0.91, 1.02) 0.98 (0.94, 1.03)

Less often 1.07**(1.01, 1.14) 0.94*(0.87, 1.01) 1.04 (0.98, 1.10) 0.98 (0.92, 1.04) 0.96 (0.89, 1.03) 0.98 (0.92, 1.05)

Not at all 1.08***(1.03,

1.14) 0.99 (0.93, 1.05) 1.02 (0.97, 1.07) 1.03 (0.98, 1.09) 0.95*(0.89, 1.01) 0.97 (0.92, 1.03)


<6® 1.00 1.00 1.00

6-11 1.16***(1.06,

1.28)

0.80***(0.73,

0.87) 1.11**(1.02, 1.2)

12-23 3.07***(2.82,

3.34)

0.63***(0.58,

0.68)

1.58***(1.47,

1.71)

24-35 3.20***(2.93,

3.49)

0.53***(0.49,

0.58)

1.79***(1.66,

1.94)

20

36-47 3.21***(2.94, 3.5)

0.49***(0.45,

0.53)

1.93***(1.78,

2.09)

48-59 2.76***(2.53,

3.01)

0.50***(0.46,

0.55)

2.00***(1.85,

2.17)

Gender

Male® 1.00 1.00 1.00

Female 0.94*** (0.91,

0.97)

0.86***(0.83,

0.89) 0.93***(0.9, 0.96)


No schooling® 1.00 1.00 1.00

Less than 10 years 0.78*** (0.75,

0.81) 0.95**(0.91, 1)

0.83***(0.79,

0.86)

10 and above years 0.61*** (0.58,

0.65) 0.97 (0.91, 1.03) 0.66***(0.63, 0.7)

Nutritional status of the mother

Underweight® 1.00 1.00 1.00

Normal 0.83*** (0.80,

0.87)

0.71***(0.68,

0.74) 0.63***(0.6, 0.65)

Overweight 0.67*** (0.62,

0.71)

0.52***(0.48,

0.56) 0.43***(0.4, 0.46)


Poorest® 1.00 1.00 1.00

Poorer 0.83*** (0.79,

0.87)

0.86***(0.82,

0.91)

0.80***(0.77,

0.84)

Middle 0.69*** (0.66,

0.73)

0.76***(0.72,

0.81)

0.65***(0.61,

0.69)

Richer 0.54*** (0.50,

0.58) 0.74***(0.68, 0.8) 0.53***(0.5, 0.57)

Richest 0.42*** (0.38,

0.46)

0.67***(0.61,

0.74)

0.40***(0.36,

0.43)

Social groups

Scheduled caste (SC)/ Scheduled tribe (ST) ® 1.00 1.00 1.00

Other Backward Class (OBC) 0.95** (0.91,

0.99) 0.94**(0.9, 0.99)

0.93***(0.89,

0.96)

Non-SC/ST/OBC 0.78*** (0.74,

0.83)

0.90***(0.84,

0.96)

0.80***(0.75,

0.86)

Religion

21

Hindu® 1.00 1.00 1.00

Muslim 1.14*** (1.07,

1.22) 0.99 (0.92, 1.07)

1.09***(1.02,

1.16)

Others 0.99 (0.91, 1.09) 1.04 (0.93, 1.17) 1.07 (0.98, 1.17)

Place of residence

Urban® 1.00 1.00 1.00

Rural 0.91*** (0.86,

0.96)

0.92***(0.87,

0.98)

0.89***(0.84,

0.94)

Region

North® 1.00 1.00 1.00

Central 1.13*** (1.07,

1.20) 0.99 (0.93, 1.05)

1.18***(1.11,

1.25)

East 0.92*** (0.86,

0.98) 0.98 (0.91, 1.05) 1.02 (0.96, 1.09)

Northeast 0.72*** (0.66,

0.78)

0.70***(0.63,

0.79)

0.59***(0.54,

0.65)

West 1.13*** (1.04,

1.22)

1.30***(1.19,

1.42)

1.36***(1.25,

1.47)

South 0.86*** (0.80,

0.93) 1.00 (0.92, 1.08) 0.98 (0.91, 1.05)

Note: ®-reference category; OR-Odds ratio; CI- Confidence interval; ***p<0.01, **p<0.05, *p<0.10.

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Determinants of nutritional status of under-five children