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Socioeconomic Inequalities in Child Malnutrition in Urban India: A Systematic Slum Bias? Sumit Mazumdar (CSSSC, Kolkata) & Papiya G. Mazumdar (FHS, IIHMR, Kolkata) 8 th International Conference on Urban Health KICC, Nairobi, Kenya October 21 st -24 th , 2009 INSTITUTE OF HEALTH MANAGEMENT RESEARCH, JAIPUR

Socioeconomic Inequalities in Child Malnutrition in Urban India

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Paper presented at the 8th International Conference on UrbanHealth, International Society for Urban Health, Nairobi, Kenya, 18th-24thOctober, 2009

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Page 1: Socioeconomic Inequalities in Child Malnutrition in Urban India

Socioeconomic Inequalities in Child

Malnutrition in Urban India: A

Systematic Slum Bias?

Sumit Mazumdar (CSSSC, Kolkata) & Papiya G. Mazumdar (FHS, IIHMR, Kolkata)

8th International Conference on Urban Health

KICC, Nairobi, Kenya

October 21st-24th , 2009

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Page 2: Socioeconomic Inequalities in Child Malnutrition in Urban India

Background & Introduction

• India: The ‘Undernutrition’ Burden

• Not a rural phenomenon alone: Growing spread in Urban India

• Increased Urbanization

• Urban India --Livelihood challenges: Growing population pressure

(‘Metro Migration: The City Lights Syndrome’) leading to Slums &

Squatter Colonies with poor civic infrastructure

• Are the Slum population largely responsible for pushing up child

undernutrition levels in Urban India: Looking for a SLUM BIAS

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Page 3: Socioeconomic Inequalities in Child Malnutrition in Urban India

Research Questions

• Is the burden of chronic child undernutrition disproportionately on

the population living in the slums of major cities in urban India?

• What is the extent of socioeconomic inequality in chronic child

undernutrition in major cities in India, and how does it relates with

the slum/non-slum differentials in average child undernutrition?

• Is there a definite gradient of socioeconomic inequality in child

undernutrition in the major cities, and is such a gradient more

visible in slums?

• Are the children living in the slums of the major cities in India more

prone to suffer from undernutrition than their counterparts in non-

slum areas?

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Page 4: Socioeconomic Inequalities in Child Malnutrition in Urban India

Data & Methods

Cities Slum Non-Slum Total

Delhi City 270 (42.1%) 371 (57.9%) 641

Meerut 471 (52.9%) 420 (47.1%) 891

Kolkata 296 (61.5%) 185 (38.5%) 481

Indore 356 (53.3%) 312 (46.7%) 668

Mumbai 231 (60%) 154 (40%) 385

Nagpur 312 (50.4%) 307 (49.6%) 619

Hyderabad 374 (49.5%) 382 (50.5%) 756

Chennai 271 (54.1%) 230 (45.9%) 501

Total 2581 (52.2%) 2361 (47.8%) 4,942

•National Family Health Survey –III

(NFHS-3): Data for eight major cities

(Delhi City, Meerut, Kolkata, Indore,

Mumbai, Nagpur, Hyderabad &

Chennai) in India, with separate

samples of population living in

slums (as defined in Census 2001).

•Anthropometric data: standardized

z-scores for height-for-age (stunting)

primarily used as the major variable

of interest

•SE inequality measured by

Concentration Index. Logistic

regressions and Poisson regressions

used for addressing the research

questions

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Page 5: Socioeconomic Inequalities in Child Malnutrition in Urban India

Issue 1: Relative burden of Undernutrition in Major Indian

Cities & extent of SE Inequality

-0.300

-0.250

-0.200

-0.150

-0.100

-0.050

0.000

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Na

gp

ur

N. D

elh

i

Ko

lka

ta

All C

ities

Ind

ore

Mu

mb

ai

Me

eru

t

Ch

en

na

i

Hy

de

rab

ad

Slums Non-Slums Combined Concentration Index

�Chronic child undernutrition is

significantly higher in the slums

of all the cities

�Significant Slum/Non-slum

differentials in Nagpur, N.

Delhi, Kolkata & Indore; More

equal in southern cities

�Considerable variation in SE

inequality in chronic

undernutrition in the cities;

Average inequality in the cities

considered substantial (-0.167)

�Very high levels of SE

inequality in Meerut (-0.243) &

Chennai (-0.243), less

pronounced in Mumbai (-0.131)

& Nagpur (-0.142)

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Page 6: Socioeconomic Inequalities in Child Malnutrition in Urban India

Issue 2: How does SE inequality in chronic undernutrition

associate with intra-city spatial differentials

� No definite association

pattern between extent of

intra-city SE inequality and

slum/non-slum differentials in

chronic undernutrition

(Correlation p = 0.42)

�Apparently SE inequality is

greatest in cities with low

slum/non-slum differentials

, at both ends of the

distribution (Chennai &

Meerut): spatial inequality

overridden by SE inequality

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Page 7: Socioeconomic Inequalities in Child Malnutrition in Urban India

Issue 3: Examining the Gradient of SE Inequality in

Undernutrition– A Slum Bias?

Along expected lines, a higher

proportion of households in slums

belong to poor SES classes, averaged

over all the major cities.

However, there is no explicit evidence of a

higher burden of chronic undernutrition

among the poor SES from slums (except in

Meerut & Chennai), as seen from a

comparison of inter-SES class differentials

between slum & non-slum households

0

10

20

30

40

50

Slum/Non-slum comparison of chronic

undernutrition by interquintile range for SES

Slum Non-slum

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44.1

26.8

37.3

30.8

18.6

42.5

Slum

Non-

Slum

Poor Middle Rich

Page 8: Socioeconomic Inequalities in Child Malnutrition in Urban India

Issue 3: Examining the Gradient of SE Inequality in

Undernutrition– A Slum Bias?

�Significantly lower likelihood of

Suffering from chronic

undernutrition in higher SES

classes; Intensification of SES

gradient on controlling for other

model covariates

�No clear evidence of a pro-slum

bias: The poor SES in the slums do

not have (statistically significant)

higher risks of suffering

undernutrition

�No significant differences in the

predicted probabilities of suffering

from chronic undernutrition

between poor SES in slums or non-

slum areas

�The SES gradient in

undernutrition is evident, without

a discernible pro-slum bias

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47.4%

36.0%

25.7%

46.9%

31.6%22.6%

Poor Middle Rich

Predicted probabilities of likelihood of chronic

child undernutrition according to SES, Slum &

Non-Slum areas

Slum Non-slum

Cities Model 1 Model 2 Full Model

Middle SES -0.49** -0.47** -0.27**

Rich SES -0.98** -0.99** -0.37**

Middle SES*Non-Slum - -0.19 -0.14

Rich SES* Non-Slum - -0.18 -0.08

Non-Slum -0.005 -0.003

Odds ratios from Logistic Regression showing relative likelihood of

chronic undernutrition according to SES & place of residence

Page 9: Socioeconomic Inequalities in Child Malnutrition in Urban India

Issue 4: Do staying in slums per se increase the risks of

being chronically undernourished?

Relative Risk Ratios justify higher risks of being chronically undernourished for children residing in

slums, which, however withers away on gradual introduction of potential confounders with a visible reduction

in risks alongwith loss of statistical significance. Notably, the SES gradient persists even controlling for all

model covariates indicating its overarching influence in shaping risks towards chronic undernutrition in Indian

cities.

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Model Description

Slum-Non Slum

Differences

SES Differentials

(Poor-Middle)

SES Differentials

(Poor-Rich)

With only slum/non-slum parameter 0.733**

With SES confounder 0.898* 0.821** 0.545**

With confounders for SES, mother's

education, mothers BMI, safe water

availability in hh (community proxy) 0.935 0.870** 0.757**

With full model (confounders for

demographic, socioeconomic,

health care seeking behaviour and

community characteristics) 0.966 0.856** 0.834**

Incremental Relative Risk Ratios (IRR) from Poisson Regression showing relative likelihood of

chronic undernutrition according to SES & place of residence (Slum/Non-Slum)

Page 10: Socioeconomic Inequalities in Child Malnutrition in Urban India

Conclusion & Policy Implications

• A visible spatial (slum/non-slum) differential coupled with significant SE inequality

in child malnutrition marks the scenario for chronic child undernutrition in major

cities of India

• Absence of any clear-cut evidence suggesting higher burden of chronic

undernutrition in slums, or among the poorer SES households in slums compared to

the non-slum counterparts, suggesting SE inequality in child undernutrition to be a

pan-urban phenomenon in Indian cities, without an identifiable slum bias

• The apparent disproportionate burden of chronic undernutrition in slums, is not

singularly due to slum residence, or even due to non-linear impact of SES in slums

and non-slum localities, but most possibly due to other potential factors like access

to improved health & sanitation facilities, education among mothers, and mother’s

own nutritional status

• Future research needs to specifically focus on typical frameworks to further

understand the dynamics of SES and locality-effect on chronic undernutrition in

major cities across the developing world.

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Page 11: Socioeconomic Inequalities in Child Malnutrition in Urban India

Thanks for a patient hearing

Correspondence:

Sumit Mazumdar, Ph.D.

Research Consultant,

Centre for Studies in Social Sciences, Calcutta

R-1, Baishnabghata-Patuli Township, Kolkata

PIN-700094

WEB: www.cssscal.org

email: [email protected]

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