District Level Household Survey Research Articles

The effect of a large-scale workfare program on child marriage in India

ABSTRACT This paper examines the impact of a large-scale workfare program, the National Rural Employment Guarantee Scheme (NREGS), on child marriage in India. We use two rounds of data from the District Level Household & Facility Surveys and estimate a difference-in-differences model by comparing changes in child marriage rates between a cohort of young women and a cohort of older women before and after program implementation. We find that NREGS is associated with an increase in the probability of marriage before 18 of 2.7 percentage points, or 10.6%. Our results are similar when using different definitions of child marriage and are also robust to using a hazard model and a model with program intensity at the district level.

Reduced health services at under-electrified primary healthcare facilities: Evidence from India.

Primary healthcare systems worldwide suffer from major gaps in infrastructure and human resources. One key infrastructure gap is access to reliable electricity, absence of which can significantly affect the quantity and quality of healthcare services being delivered at rural primary health facilities. However, absence of granular empirical evidence is a barrier for quantitatively understanding the significance of electricity access as one of the determinants of access to reliable primary healthcare. Using data from India's District Level Household and Facility Survey, we develop zero-inflated negative binomial models with co-variates and state-level fixed effects to estimate the relationship between levels of electricity access and the quantity of basic health services delivered at Primary Health Centers (PHCs). We find that lack of electricity access is associated with a significant and large decrease in the number of deliveries (64 percent), number of in-patients (39 percent), and number of out-patients (38 percent). We further find that lower level of electricity access at primary health centers is disproportionately associated with adverse effects on women's access to safe and quality healthcare.

Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveys

Half of the world's missing female births occur in India, due to sex-selective abortion. It is unknown whether selective abortion of female fetuses has changed in recent years across different birth orders. We sought to document the trends in missing female births, particularly among second and third children, at national and state levels. We examined birth histories from five nationally representative household surveys (National Family Health Surveys 1-4 and District Level Household Survey 2) to compute the conditional sex ratio (defined as the number of girls born per 1000 boys depending on previous birth sex) in India during 1981-2016. We estimated decadal variation in conditional sex ratio for 1987-96, 1997-2006, and 2007-16, and quantified trends in the numbers of missing female births for the states constituting >95% of India's population, as well as in 5-year intervals for each survey round. We used multivariate logistic regression to calculate the odds ratio of a second (or third) girl depending on the sex of the earlier child (or children), adjusting for education, wealth, religion, caste, and place of residence. We assessed 2·1 million birth histories across the five surveys. Applying the conditional sex ratios from the surveys to national births, we found that 13·5 million female births were missing during the three decades of observation (1987-2016), on the basis of a natural sex ratio of 950 girls per 1000 boys. Missing female births increased from 3·5 million in 1987-96 to 5·5 million in 2007-16. Contrasting the conditional sex ratio from the first decade of observation (1987-96) to the last (2007-16) showed worsening for the whole of India and almost all states, among both birth orders. Punjab, Haryana, Gujarat, and Rajasthan had the most skewed sex ratios, comprising nearly a third of the national totals of missing second-born and third-born females at birth. From about 1986, the conditional sex ratio for second-order or third-order births after an earlier daughter or daughters diverged notably from that after an earlier son or sons. From 1981 to 2016, the sex ratio for second-born children after an earlier daughter decreased from 930 (99% CI 869-990) to 885 (859-912), and that for third-born children after two earlier daughters decreased from 968 (866-1069) to 788 (746-830). The probability of missing girls was mostly determined by earlier daughters, even after considering wealth quintile and education levels. The conditional sex ratio among the richest and most educated mothers was most distorted compared with lower wealth and education groups, and generally decreased with time, until a modest improvement in 2007-16. In contrast to the substantial improvements in female child mortality in India, missing female births, driven by selective abortion of female fetuses, continues to increase across the states. Inclusion of a question on sex composition of births in the forthcoming census would provide local information on sex-selective abortion in each village and urban area of the country. None. For the Hindi translation of the abstract see Supplementary Materials section.

Analysis of Child Mortality for Muslim Women of Uttar Pradesh, India: An Application of Bayesian Frailty Model

In this paper an attempt has been made to analyze the child mortality by use of a hazard model in Bayesian environment, family effect through multiplicative random effect is also incorporated in the model. For fitting this model real data has taken from District Level Household and Facility Survey (DLHS)-3. The largest state (in population) of India i.e. Uttar Pradesh data is taken for analysis. Deviance information criteria are used for comparison of models. It found that the model with family frailty gives better fit. All the analysis is performed in winBUGS software, which is used Markov chain monte carlo simulation under gibbs sampling.

Mapping of Household Surveys to Measure Barriers to Access to Maternal and Child Health Services in India

Objective: To map the range of access barrier indicators for which data can be derived from the three most common health related household surveys in India. Methods: A mapping review study was conducted to identify access dimensions and indicators of access barriers for maternal and child health (MCH) services included in three household surveys in India: National Family Health Survey (NFHS), District Level Household and Facility Survey (DLHS) and Annual Health Survey (AHS). Results: The Tanahashi framework for effective coverage of health services was used in this study, and 12 types of access barriers were identified, from which 23 indicators could be generated. These indicators measure self-reported access barriers for unmet healthcare needs through delayed care, as well as forgone care, and unsatisfactory experiences during health service provision. Multiple barriers could be identified, although there was marked heterogeneity in variables included and how barriers were measured. Conclusions: This study identified tracer indicators that could be used in India to monitor the population that experiences healthcare needs but fails to seek and obtain appropriate healthcare, and determine what the main barriers are. The surveys identified are well validated and allow the disaggregation of these indicators by equity stratifiers. Given the variability of the frequency and methodologies used in these surveys, comparability could be limited.

Electricity access, sources, and reliability at primary health centers in India and effect on service provision: Evidence from two nation-wide surveys

Background:A large number of government primary health-care facilities (GPHCFs) in India do not have access to the regular electricity supply.Objectives:To assess the status and change in electricity access, sources, and reliability at primary health centers (PHCs) in India; and to understand the effect of regular electricity supply on health services provision and on workforce availability and retention.Materials and Methods:Secondary analysis of data from the lastest two rounds of district-level household survey (DLHS) in India, conducted in 2007–2008 and 2012–2013.Results:Data of 8619 PHCs from DLHS-3 and 8540 PHCs from DLHS-4 were analyzed. The proportion of PHCs with access to electricity increased from 87% to 91%. However, regular electricity supply was available at only 50% of PHCs in 2012–2013, which was an increase from 36% such PHCs in 2007–2008. PHCs with regular electricity supply provided services to 50% more beneficiaries (deliveries and vaccination) than PHCs without regular or no electricity (P ≤ 0.001). Increased access to regular electricity was associated with improved availability and retention of health staff (P = 0.001).Conclusion:Government policies should aim to ensure access to regular electricity-supply-beyond just connection from grid-at all GPHCFs, including health sub-centers, PHCs, and community health centers. Indicators on electricity access at GPHCFs could be standardized and integrated into regular health and facility-related surveys as well as in the existing dashboards for real-time data collection. Health policy interventions should be informed by regular data collection and analysis. Improving access to regular electricity supply at GPHCFs can contribute to achieve the goals of National Health Policy of India. This will also help to advance universal health coverage in the country. There are lessons from this study, for other low and middle income countries, on improving health service provision at government health care facilities.

A hybrid deep learning model for predicting and targeting the less immunized area to improve childrens vaccination rate

There has been a major and rising interest in India for increasing vaccination rate among peoples to make the nation healthier and safer. In this paper, a new hybrid deep learning model is proposed to predict and target vaccination rates in the less immunized regions. The Rank-Based Multi-Layer Perceptron (R-MLP) hybrid deep learning framework uses the data collected from the recently updated District Level Household Survey-4 (DLHS). R-MLP model predicts and categorizes the percentage of partly immunized vaccination rates as extreme, low and medium ranges. This predicted findings are cross-verified by Deep Soft Cosine Semantic and Ranking SVM based model (DSS-RSM). DSS-RSM model uses the data obtained from the medical practitioners through a location-based social network. The proposed model predicts and extracts patterns with high similarity frequency for identifying vulnerable low immunization regions. It classifies the predicted patterns into two classes such as Class 1 is denoted as high ranked regions and Class 2 is denoted as low ranked regions based on the percentage of pattern matches. Finally, the results from R-MLP and DSS-RSM models are cross-linked together using ensemble model. This model finds the loss values to identify the target regions were health care program need to be conducted for increasing the level of immunization among children’s. The proposed hybrid deep learning models trains and validates using python-based Keras and TensorFlow deep learning libraries. The performance of the proposed hybrid deep learning model is compared with other variant machine learning techniques such as Decision Tree C5.0, Naive Bayes and Linear Regression. This comparative results are evaluated using evaluation measures such as Precision, Recall, Accuracy and F1-Measure. Our results show that the hybrid deep learning system is clearly superior to any other alternative approach.

COVID-19 mortality effects of underlying health conditions in India: a modelling study

ObjectiveTo model how known COVID-19 comorbidities affect mortality rates and the age distribution of mortality in a large lower-middle-income country (India), and to identify which health conditions drive differences with...

Quality of care in sterilization services at the public health facilities in India: A multilevel analysis.

Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015-16 and District Level Household and Facility Survey (DLHS) 2012-13. The study is limited to only districts whose data are available in both DLHS 2012-13 and NFHS 2015-16. The methods of analysis include bivariate statistics, Pearson's chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client's confidence in the services, which is the key to success for any voluntary family planning program like in India.

Quality of Routine Immunization Services: Trends in some Districts of West Bengal

Routine Immunization remains the cornerstone in child survival initiative throughout the globe. Since launching of Expanded Programme on Immunization (EPI) in 1978 in India during last four decades immunization activities have been evolving, keeping pace with the relentless progress in the field of science of vaccinology. Routine Immunization has been embedded in the reproductive & child health program (RCH).West Bengal has been one of the better performing states of the country in terms of major RCH indicators like Infant mortality rate, maternal mortality rate, under five mortality rate, coverage of routine immunization etc. Independent assessments done in National Family Health Survey, District Level Household Survey or Coverage Evaluation Survey provide periodic assessment of reach & to some extent quality of services in the country.

Women Care and Practices in the Management of Childhood Diarrhea in Northeast India

ABSTRACT Northeast India is located away from mainland India and has a poor connectivity with the mainland India. Many inhabitants of the region have sociocultural beliefs and practices that are different from the mainstream Hindu and Islamic culture. It has the highest under-five child mortality rate in India and diarrhea is the third leading cause of death among under-five children, previous studies reported low treatment-seeking for diarrhea in the region. The region is also very common in the practice of traditional health remedies. Practicing of traditional remedies is common in the remote and inaccessibility region. The purpose of this paper is to understand the predictors of women’s practices in managing childhood diarrhea and the quality of diarrhea management practices by the source of care. The study is based on the unit level data from District Level Household Survey (DLHS-4) and 789 women age 15–49 years were analyze by applying logistic regression analysis to identify the potential predictors of diarrhea management. Continue normal breastfeeding during diarrhea decreases with increasing age of the mother. Seeking care from the government or private health care facilities increases the likelihood of the mother administering of Oral Rehydration Salt (ORS) or Zinc to a sick child. Appropriate diarrhea management practices were found to be associated with seeking care from government or private health facilities as compared to non-treatment seekers; inappropriate practices were observed among mothers who were agricultural workers. In order to improve the quality of diarrhea management practices among the non-treatment seekers, efforts should be made through the Intensified Diarrhea Control Fortnight (IDCF) program to create more awareness among mothers regarding prevention and effective and low-cost diarrhea treatments.

How Energy Access Impacts Primary Healthcare: Evidence from India

Background: Basic primary healthcare provides a critical safety net for the poor, but it is not always accessible. Unfortunately, primary health systems worldwide suffer from major gaps in infrastructure and human resources. One key infrastructure gap is access to reliable electricity, absence of which can significantly affect the quantity and quality of healthcare services being delivered at rural primary health facilities. However, absence of granular empirical evidence is a barrier for quantitatively understanding the significance of energy access as one of the determinants of access to reliable primary healthcare. Methods: We study the linkages between energy access and primary health services in extra-urban parts of India by focusing on the Primary Health Centers (PHCs), which are the main points of comprehensive primary care in the Indian public health system. Using data from District Level Household and Facility Survey, we develop zero-inflated negative binomial models with state-level fixed effects to estimate the relationship between levels of electricity access and the quantity of basic health services delivered at the PHCs. Findings: We find that lack of electricity access is associated with a significant and large decrease in the number of deliveries (64 percent), number of in-patients (43 percent), and number of out-patients (40 percent). We further find that lower level of energy access at primary health centers disproportionately affects women’s access to safe and quality healthcare. Interpretation: The evidence presented makes a strong case for rural health system policies to pay much more attention to understanding and integrating reliable energy access as an enabler of more equitable access to primary healthcare.

“Daughter-Only” Families in Selected High and Low Son Preference States in India: A Comparative Analysis

The deep-rooted patriarchal norms and the culture of son preference in India played a central role for avoiding the birth of a girl child. This study attempts to understand the extent of acceptance of daughters in selected high and low son preference states of India by using data from District Level Household and Facility Survey (DLHS) 3 and 4. Understanding the characteristics of the couples who have stopped childbearing only with daughters provide insights about the prevailing norms on acceptance of daughters. The results revealed that, from DLHS 3 to 4, there is an increasing trend in the daughter preference in both high and low son preference states. The results of the study indicate that the acceptance of daughters is initially emerging among younger, educated, urban and richer couples. The gradual increase in acceptance of daughters reveals weakening of rigid patriarchal norms and son preference in the study states.

Is Distribution a Problem in Iron-Folic Acid Consumption in India? An Exploration of District Level Household Survey

Aims: Anemia accounts for 40% of maternal deaths in India. In order to address this problem, the Government of India implemented the largest programme with the greatest potential to reduce maternal mortality by free distribution of Iron-Folic Acid (IFA) supplementations especially during Antenatal Care (ANC) visits. But the major concern among the policymakers and researchers has been poor adherence to the supplement among pregnant women. However, we tend to think that given the severity of the problem, there is no investigation on the adherence issue. Hence, the aim of the paper is to understand whether IFA consumption by pregnant women in India is largely a distribution problem of IFA supplements through ANC. Background: The distribution of Iron-Folic Acid (IFA) supplementation is not working especially through Antenatal Care (ANC) attendance. The program implementers believe that it is because of lack of adherence to IFA supplements by pregnant women. It is important to investigate the problem before any policy changes are made without proper evidence. Objectives: The purpose of this study is to examine whether the problem of IFA consumption by pregnant women is due to the problem of public distribution of IFA supplements through ANC attendance. Methods: This study had used the fourth round of District Level Household Survey data, which collects information on IFA supplements, their distribution and consumption. Bivariate and tri-variate analyses were used to understand the relationship between IFA distribution to pregnant women and their consumption patterns in 19 Indian states and two Union Territories (UTs) of pregnant women (88,487) and between the age of 15-49 years. Results: In almost all the states except Chhattisgarh, more than 75% of the pregnant women consumed 100 or more IFA supplements when they received 100 or more IFA supplements from providers. Similar is the case even among those women who received 100 or more IFA supplements through 1 or 2 ANC attendance except Arunachal Pradesh (60%), Meghalaya (67%), Pondicherry (57%) and Andaman and Nicobar (0%). The consumption of IFA supplements among pregnant women gets better than 75% if they receive 100 or more supplements only after attending three or more ANCs. Conclusion: It seems that distribution is a problem in the consumption of IFA supplements by pregnant women in India. Full antenatal attendance by the women could be part of the problem but not supplying at least 100 IFA supplementations to even those who attend ANC due to stock-outs and ineffective management is a serious concern. Hence, Governments should distribute at least the recommended 100 IFA supplements to the women in their 1st ANC attendance to address anaemia.

Is India’s public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4)

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012–13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states.Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in ‘infrastructure’ (0.55) and ‘infection prevention’ (0.44), while PHCs had low ‘potential staffing’ scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in ‘potential staffing’ except for PHCs, while the lowest scores were in ‘infection & prevention’ and ‘medicines and laboratory’. Goa and Maharashtra were consistently among the top 5 ranking states for readiness.Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Association of Poor Sanitation With Growth Measurements Among Children in India

Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized. To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years. This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India's District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019. Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water. Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects. The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, -0.22; 95% CI, -0.35 to -0.10; >7 to ≤12 years: β, -0.15; 95% CI, -0.24 to -0.06; >12 to ≤18 years: β, -0.10; 95% CI, -0.19 to -0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, -0.22; 95% CI, -0.33 to -0.12; >12 to ≤18 years: β, -0.16; 95% CI, -0.23 to -0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11). In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.

Regional convergence of social and economic development in the districts of West Bengal, India: Do clubs exist? Does space matter? An empirical analysis using DLHS I–IV and NFHS IV data

The present study attempts to explore the progress of social development [captured by Social Development Index (SDI)] across 17 districts of West Bengal over five time points (during 1998–1999 to 2015–2016) using District-Level Household Survey (DLHS I–IV) and National Family Health Survey (NFHS IV) data. The inequality of SDI and its components are found to be declining but the income [measured by per capita district domestic product (PCDDP)] inequality is found to be fluctuating over time. Thus, the inequality of social and economic development does not move in the same direction. The distribution dynamics of SDI is captured by kernel density function over five time points that clearly gives twin peaks distribution of SDI and ensures the possibility of ‘club convergence.’ Using the components of SDI, we employ K-means cluster; both kernel distribution and K-mean cluster confirm the existence of low-level trap found in four districts of West Bengal. We estimate Moran’s Index and results suggest that SDI is more spatially dependent than PCDDP. This analysis may be helpful to understand the dynamics of social changes observed among the districts of West Bengal over time.

Access to women physicians and uptake of reproductive, maternal and child health services in India

BackgroundLow availability of women physicians in rural areas can compromise women's health care seeking, where need can be greatest. We examined the associations between availability of women physicians and maternal and child health service utilization in India. MethodsWe analyzed cross-sectional district-level data from all 256 districts in 18 states, from India's District-Level Household and Facility Survey (2012–13) and the National Family Health Survey (2015–16). Assessed measures included lady medical officers (LMOs) availability at Primary Health Centers (PHCs, which are largely rural serving), modern contraceptive use, antenatal care (ANC), skilled birth attendance (SBA), maternal postnatal care (PNC), infant PNC, and child immunization. Multilevel regression models nesting districts in states examined associations between LMO availability and health service utilization, adjusting for district-level socioeconomic status (SES) indicators (e.g., women's education, household water access), urbanicity, health insurance coverage and sampled PHCs (15 on average) within districts. FindingsOnly 72 of 256 districts (28.1%) reported >50% of PHCs with LMOs. In multivariable models, LMO availability in PHCs was associated with higher district prevalence (%) of modern contraceptive use [β=0.04 (95% CI: 0.007, 0.08)], 4+ ANC [β =0.07 (95% CI: 0.008, 0.13)], skilled birth attendance [β=0.09 (0.03, 0.14) and maternal PNC [β=0.08 (95% CI: 0.03, 0.12)], but not infant PNC or child immunization. InterpretationHigher district availability of women physicians is associated with higher maternal health care utilization but not child health care utilization. Improving gender parity in the physician workforce and rural women physician access may improve maternal health care use in India.

Fertility behaviour in linguistic zones: revisiting the diffusion hypothesis in greater Bengal

ABSTRACT This study compares fertility-related behaviour in the adjacent regions of West Bengal (a state in eastern India) and Bangladesh. The starting premise of the paper is that common history and language has led to diffusion of fertility practices from West Bengal to Bangladesh. This is hypothesised to create a homogenous pattern of fertility behaviour in the bordering districts of both political regions. The study uses Demographic Health Survey (DHS) and District level Household Survey data for 1992, 2002, and 2012. Despite some reservations – as DHS is directed to produce state-level estimates, while DLHS is geared to yield district-level estimates – the similarity in sampling strategies and coverage of all districts (in West Bengal) and divisions (in Bangladesh) implies that the two data sets may be pooled, particularly in the absence of any alternatives. We tested whether fertility behaviour in (i) bordering districts differs from non-border districts in both countries, and (ii) bordering districts of both countries are similar using multi-level linear and logistic models. Outcome variables are contraceptive prevalence rate, and number of ever born children. The results reveal similarities in fertility behaviour between border divisions of Bangladesh and West Bengal, indicating possible cross-border diffusion of fertility practices.

Variation in Chronic Diseases Across Households, Communities, Districts, and States in India

Globally, chronic noncommunicable diseases are the leading cause of death and accounted for 6 million deaths in India in 2016. However, the extent to which variation in chronic disease can be attributed to different population levels in India is unknown, as is whether variation in individual-level factors explains outcome variation at different population levels. Cross-sectional data from the District Level Household and Facility Survey 2012-2013 conducted across 21 states, 275 districts, 14,235 villages, 378,487 households, and 1,098,940 individuals aged ≥18 years in India were analyzed in 2018‒2019. Multilevel logistic models were used to partition variation in outcomes and attribute it to individual, household, village, district and state population levels. Outcomes included experiencing respiratory, cardiovascular, musculoskeletal, or eye symptoms; reporting a positive diagnosis by a doctor for chronic heart disease, hypertension, diabetes, or vision problems; and objectively assessed real-time measures of hypertension and diabetes. For reported diagnosis of hypertension or diabetes, a much larger percentage of variation in these outcomes was attributed to differences among households as compared to differences among units within other population levels. However, for objectively measured hypertension and diabetes, variation in these outcomes was important at the village level, followed by variation at the household level. Wealth status was positively associated with respiratory and cardiovascular symptoms, as well as all reported diagnoses and real-time measurements except for vision problems. Inclusion of individual-level sociodemographic variables explained 0%-30% of variation attributed to the household level for most chronic disease symptoms and diagnoses, but almost none at the higher levels. These findings imply that household- and village-level factors explain substantial variation in the prevalence of chronic disease symptoms and reported diagnoses in India.