National Family Health Survey Data Research Articles

Socio-economic inequalities in child health: Recent evidence from India

This paper analyses the Indian National Family Health Survey (2005–2006) data to present certain broad descriptive features of child health inequalities in India and their distribution across well-defined socio-economic groups classified by gender and sector-of-origin, and their dispersal across space. This study finds that poorer sections of the population are beleaguered with ill health whether in the quest for child survival or due to anxieties pertaining to child nutrition. The concentration index value for the indicators of under-five mortality, full immunisation and underweight outcomes at the national level is calculated to be −0.159, 0.204 and −0.158, respectively. The other disturbing finding here is that there are reigning regional and gender disadvantages irrespective of the developmental status of the State. This study would not only help policymakers to recognise these persistent inequalities but also would help understand health performance at the state and regional levels thus facilitating targeting intervention.

Socio-economic inequalities in child survival in India: A decomposition analysis

This paper provides a first time assessment of the decomposed contributions of socio-economic determinants of under2 child mortality in India and its states using the recent National Family Health Survey (NFHS-3, 2005-06) data. In the first stage analysis, concentration indices of under2 mortality were generated as measures of socio-economic inequalities. The concentration indices were then decomposed into their determining factors. Decomposition results reveal that poor household economic status (46%), mother's illiteracy (35%) and rural residence (15%) contribute to 96% of total socio-economic inequalities in child survival at the national level. The contribution of economic status is relatively smaller in 5 states that are advanced in health transition. The varying pattern of evidence across the states from decomposition analysis suggests the need for unique health intervention strategies for different states in accordance with the evidence of major contributions to total child health inequalities arising from poverty, illiteracy and rural residence.

Economic Stability Linkage with Adolescent Girls: Analytical Issues and Empirical Evidence from India

This study is an attempt to analyse the changes in adolescent girls in India which is effected by of some selected variables related to demographic and socioeconomic predictors. This is based on recent house hold surveys which include National Family Health Surveys (NFHS), Census Surveys, various Planning Commission reports and National Sample Survey Organization (NSSO) reports. The improvement achieved by India is fully accounted for by a wide range of variables, including sex ratio, literacy, mean age at marriages, usage of modern contraceptive methods. The plan outlays on family welfare programmes and its percentage share in total plan outlays has increased from 0.033 percent to 3.036 percent. This has led to a remarkable change in India’s growth performance as well as relatively status for women index in India. The study featured three NFHS and six census groups pertaining to adolescent girls and women and men on the issues of women’s progress in India. The study was also undertaken to see the awareness of adolescent girls regarding health aspects because awareness is one major factor for development of this group of population because of the fact that these adolescent girls would be the future housewives. Thus an informative and educated intervention seems to have a positive effect on awareness levels which would eventually encourage expansion of knowledge and positive health habits. The study applies Relative Status of Women Index to census survey, comparative analysis model to National Family Health Survey data and correlation model for planning commission data. The results show positively for women’s well being. Results revealed that the women empowerment is high and awareness level of different methods of family planning is significantly high. It may be concluded that the adolescent empowerment on socio-economic factor plays a vital role for awareness building on the family planning methods.

Prevalence of anaemia in women of reproductive age in Meghalaya: A logistic regression analysis

To examine the prevalence of anaemia in Meghalaya, India, by exploring the 2005-2006 National Family Health Survey (NFHS -3) data. Materials and methods: The study population consisted of 3934 ever-married women of reproductive age (15-49 years) from the state Meghalaya, India, which were taken from the NFHS-3 survey, to explore the predictors responsible for the prevalence of anaemia by using different background characteristics such as age, place of residence, nutritional status, number of children ever born, pregnancy status, educational achievement, and economic status. As a response variable, anaemia levels were categorised as a dichotomous variable, and the predicted probabilities were worked out through a binary logistic regression model, to assess the contribution of the predictors on anaemia. Results: A logistic regression analysis was performed for some selected predictors related to anaemia levels. All the predictors, except total children ever born, were found to be statistically significant. The mean haemoglobin concentration was evaluated as 117.43 g/L, and 49.6% of the women were found to be anaemic. Women of the age group 20-24 years, are at high risk of anaemia [P = 0.320, O.R. (95% C.I.) = 1.509 (0.671, 3.390)]. Conclusion: Pregnant, under nutritious, and poorest women are at high risk of anaemia. Urban women are also at high risk; however, higher educated women are at low risk of anaemia. The habit of cigarette smoking/pan/bidi/gutka etc. also increases the risk of anaemia.

Abstracts of Award‐Winning Theses

Abstracts of Award‐Winning Theses

Discrimination and Children's Nutritional Status in India

This article explores the differing health status of lower caste social groups in India, analyses the reasons for the differences and discusses some of the implications for policy. National Family Planning and Health Survey (NFH‐3) data shows that children belonging to lower castes have worse nutrition, health and mortality indicators and poorer access to health services and nutrition schemes than children from higher castes, even after other socioeconomic factors are considered. The article suggests that this points towards the possible role of discrimination and exclusion associated with caste and ‘untouchability’ and outlines some policy recommendations that are proactively inclusive, specifically in the nutrition domain.

Are Social Group Differentials in Fertility Narrowing with Rising Level of Living in Andhra Pradesh?

In spite of low fertility levels and higher contraceptive use in the state of Andhra Pradesh, differentials are still discernible between the caste groups. This paper examines whether the caste differentials in fertility and contraceptive use exist at each stage of socio-economic status, and whether these are of the same order and direction, using the Second National Family Health Survey data. Analyses of interaction effects of caste and other socioeconomic factors on fertility and contraceptive use show that the caste is not constant across the levels of socio-economic factors. Although the caste differentials are notable in rural areas, they are much narrower at the lower levels of socio-economic status. With the improvement of socio-economic status, not only will fertility decline with a corresponding increase in the use of contraception, but also the differences in fertility and contraceptive use between caste groups will disappear.

The Mortality Divide in India: The Differential Contributions of Gender, Caste, and Standard of Living Across the Life Course

We investigated the contributions of gender, caste, and standard of living to inequalities in mortality across the life course in India. We conducted a multilevel cross-sectional analysis of individual mortality, using the 1998-1999 Indian National Family Health Survey data for 529321 individuals from 26 states. Substantial mortality differentials were observed between the lowest and highest standard-of-living quintiles across all age groups, ranging from an odds ratio (OR) of 4.61 (95% confidence interval [CI]=2.98, 7.13) in the age group 2 to 5 years to an OR of 1.97 (95% CI=1.68, 2.32) in the age group 45 to 64 years. Excess mortality for girls was evident only for the age group 2 to 5 years (OR=1.33, 95% CI=1.13, 1.58). Substantial caste differentials were observed at the beginning and end stages of life. Area variation in mortality is partially a result of the compositional effects of household standard of living and caste. The mortality burden, across the life course in India, falls disproportionately on economically disadvantaged and lower-caste groups. Residual state-level variation in mortality suggests an underlying ecology to the mortality divide in India.

Child survival and safe motherhood program in Rajasthan

This study was planned to evaluate the MCH services, particularly immunization in rural areas of the poor-performing state of Rajasthan. A community-based, cross-sectional survey using the WHO 30 cluster technique was carried out as a field exercise by participants of 9th Field Epidemiology Training Programme (FETP) course by National Institute of Communicable Diseases (NICD) in rural areas of Alwar district of Rajasthan. Less than one third (28.9%) of children, aged 12-23 months, were fully immunized with BCG, 3 DPT, 3 OPV and Measles vaccines; around a quarter (26.5%) had not received even a single vaccine (non immunized), and little less than half (44.5%) were found partially immunized. Around half of the eligible children were vaccinated for BCG (55.9%) and Measles (43.6%). Though nearly two-third (66.8%) were covered with first dose of DPT and OPV, but about one third of these children dropped out of third dose of DPT and OPV for various reasons. National Family Health Survey (NFHS) data also had revealed that BCG coverage was 64.3%; measles was 36.2%; and coverage by DPT 1, 2, 3 and Polio 1,2 and 3 were 64.4%, 57.0%, 46.6% and 77.5%, 71.1% and 54.4% respectively in rural areas. The main reasons for drop-out or non-immunization was "lack of information about the immunization programme" (41.3%). Though nearly all (more than 96%) of the children were immunized through Government established centers, but immunization cards/documents were made available only to 27.6% of children. The problem of low coverage and high drop-out rate of immunization could be overcome by creating awareness of the program and relevance of 2nd and 3rd doses of DPT and polio vaccines. Increasing community participation through intensive and extensive health education campaign should also be undertaken. Since most of the deliveries were done at home under the supervision of untrained midwives, training programme as well as involving them in IEC activities should be contemplated.

Women’s Reproductive Health, Sociocultural Context and AIDS Knowledge in Northern India

This paper identifies sociocultural and reproductive health correlates of knowledge about HIV among ever-married women using 1998–99 National Family Health Survey data from two low HIV prevalence Indian states, Madhya Pradesh (MP) and Uttar Pradesh (UP). Logistic regressions were undertaken modelling women’s awareness of HIV, of whether the disease can be avoided and of effective means of protection. In MP 22.7 per cent women were aware of HIV; 56.4 per cent (of 22.7 per cent) knew that the disease can be avoided; and 47.5 per cent (of 56.4 per cent) possessed correct knowledge about effective means of protection. In UP 20.7 per cent women had awareness of HIV; 59.2 per cent (of 20.7 per cent) knew that the disease can be avoided; and 45.7 per cent (of 59.2 per cent) were informed about effective means of protection. In both states older, uneducated, rural, poor, those not exposed to television, and those who had never used a modern family planning method were less likely to possess HIV awareness. However, for women who were aware of HIV, acquisition of further knowledge about it had fewer socioeconomic barriers. These barriers were state specific so interventions to overcome them need to be highly focused.

Rural women's knowledge of AIDS in the higher prevalence states of India: reproductive health and sociocultural correlates

This study aimed to identify socio-cultural and reproductive health correlates of knowledge about AIDS among rural women using multivariate analysis of 1998-1999 National Family Health Survey (NFHS) data from two Indian states, Maharashtra and Tamil Nadu, where the urban HIV prevalence is relatively high. Analysis using multiple logistic regression was undertaken, modelling women's knowledge of AIDS, of whether the disease can be avoided, and of effective means of protection. Although 47% of all rural women in Maharashtra were aware of AIDS only about 28% knew that one can avoid it, and only about 16% possessed correct knowledge about its transmission. In Tamil Nadu, where overall 82% of rural women had awareness of AIDS, about 71% knew that one can avoid the disease but only about 31% possessed correct knowledge about its transmission. In both states, women from socially and economically backward groups had lower odds both of having awareness of AIDS and knowledge of ways to avoid getting the disease. Associations with socio-cultural and reproductive variables and the impact of contact with family planning services differed in the two states. The spread of the epidemic to rural areas presents a need actively to disseminate AIDS related knowledge for health protection rather than waiting for knowledge to follow the appearance of the disease in communities. Approaches to health promotion that do not consider differing contextual factors are unlikely to succeed. In particular, innovative strategies to disseminate knowledge among disadvantaged population groups are needed.

Fertility decline and gender bias in northern India

AbstractAlthough it is widely acknowledged that the preference for sons is a barrier to a decline in fertility, considerable disagreement exists as to what actually happens to this preference when fertility declines in a region of low female autonomy. By analyzing the data from the National Family Health Survey (NFHS), we present evidence from northern India to show that the preference for sons is reduced when the ideal family size becomes small, even though it does not completely disappear. This finding appears to contradict trends in the juvenile sex ratio and the incidence of female feti-cide that suggest the intensification of gender bias. We argue that the anomaly is the result of a diffusion of prenatal sex-diagnostic techniques in regions where there is a large unmet demand for such methods. Using the NFHS data, we estimate that in northern India, girls currently constitute about 60% of the unwanted births and that the elimination of unwanted fertility has the potential to raise the sex ratio at birth to 130 boys per 100 girls.

Current Contraceptive Use in India: Has the Role of Women's Education Been Overemphasised?

Using the recent Indian National Family Health Survey (NFHS) data, this article analyses the factors determining the current contraceptive use in rural and urban West Bengal in eastern India. A bivariate probit model with selection is used to determine the likelihood of not being sterilised and that of currently using some traditional or modern reversible method of contraception among non-sterilised women. Our results suggest that male and female sterilisation is a popular method among the poorer couples with little assets, poor education and more living children. More literate women are, however, more likely to use various reversible methods of contraception though the effect of husband's education remains insignificant. Relative to women's education or various household assets, the effect of belonging to an upper caste household is more pronounced on the current use of contraception, especially among rural women. Simulations of the effect of eliminating illiteracy suggest that the quantititive significance of education is small despite its robust statistical significance. Thus there is limited effect of household assets and women's education on current use of contraception in our sample.

Urban-rural differentials in maternal and child health in Andhra Pradesh, India

The unborn child is totally dependent on the mother; after birth, the child depends completely on the immediate social environment of the family and of the mother in particular. Recently the Indian Government changed its emphasis from family planning programs to family welfare programs. The intention was to promote the maternal and child health (MCH) programs to improve the health of mothers and young children. This study examined urban-rural differentials in MCH, and the factors influencing net change in MCH input, its utilisation and its output between the Indian National Family Health Survey (NFHS)-I and NFHS-II. The NFHS data collected from 4276 ever-married women in the age group 13-49 years in 1992 (NFHS-I) and 4032 ever-married women in the age group 15-49 years in 1998 (NFHS-II) were analysed. The analysis revealed a positive net change in maternal and child health input, its utilisation and its output in the years 1992-1998. Andhra Pradesh was one of the most successful Indian States in providing MCH services, even though urban-rural differentials still exist. The Indian Government must take the necessary steps to improve MCH programs, including the provision of information and education campaigns, and sending dedicated health personnel to remote and inaccessible rural areas in order to reduce child mortality.

Fertility Decline and Gender Bias in Northern India

Although it is widely acknowledged that the preference for sons is a barrier to a decline in fertility, considerable disagreement exists as to what actually happens to this preference when fertility declines in a region of low female autonomy. By analyzing the data from the National Family Health Survey (NFHS), we present evidence from northern India to show that the preference for sons is reduced when the ideal family size becomes small, even though it does not completely disappear. This finding appears to contradict trends in the juvenile sex ratio and the incidence of female feticide that suggest the intensification of gender bias. We argue that the anomaly is the result of a diffusion of prenatal sex-diagnostic techniques in regions where there is a large unmet demand for such methods. Using the NFHS data, we estimate that in northern India, girls currently constitute about 60% of the unwanted births and that the elimination of unwanted fertility has the potential to raise the sex ratio at birth to 130 boys per 100 girls.

An Exploratory Analysis of Fertility Differentials in India

The association between improving economic conditions and declining growth of population has led economists and demographers to hypothesise a direct relationship between indicators of economic development and fertility rates. Using recent National Family Health Survey data and the 1991 Census to explore factors contributing to fertility rates in India, we found that economic variables explain 70 per cent of the interstate variations in India's fertility rates. However, several non-economic variables explain an even greater proportion, for example, indicators of female autonomy explain 84 per cent of the variations. Our analysis demonstrates that to successfully explain Indian fertility rates, models must rely heavily on non-economic variables.

Family planning, gender differences and infant mortality: evidence from Uttar Pradesh, India

Abstract This paper modeled the proximate determinants of infant survival using the National Family Health Survey data on 11,500 women from the most populous Indian state Uttar Pradesh in the period 1982–1992. A methodological framework was developed for analyzing the inter-relationships between high fertility and infant mortality, gender differences in mortality, and for modeling the effects of health care and family planning variables. Probit models were estimated by maximum likelihood taking into account simultaneity of regressors and unobserved household differences. The proximate determinants of infant survival included maternal education and age at first birth, birth interval, the number of children before family planning was first used, maternal tetanus vaccination, and child's vaccinations. Indicator variables for a boy (girl) born at a birth order higher than the “ideal” number showed that unwanted births exacerbated female mortality.

Gender, family, and the nutritional status of children in three culturally contrasting states of India

This paper has three main aims: to measure the clustering of children with low weight for age z-scores within families, to establish whether significant differences exist by gender in weight for age z-scores, and to demonstrate whether the presence of a mother-in-law in the household has any significant impact on the nutritional status of young children. Regression modelling is used to examine the weight for age z-scores of children under the age of four years in Maharashtra, Tamil Nadu and Uttar Pradesh using the 1992–93 Indian National Family Health Survey data. Random effects models measure the clustering of children with low weight for age z-scores in families, controlling for a number of other family factors. Our findings do not reveal significant gender differences in weight for age z-scores. Although little variation was found between family structures in the nutritional status of children, there were significant differences between families after controlling for family type. This suggests that there are differences between families that cannot be explained by a cross-sectional demographic survey. The evidence from this work suggests that nutrition programs need to adopt community nutrition interventions that aim resources at young children from families where children with low weight for age z-scores are found to cluster. However, there is a need for further inter-disciplinary research to collect data from families on behavioural factors and resource allocation in order that we might better understand why some families are more prone to having children with low weight for age z-scores. The diversity in the significant covariates between the three states in the models has shown the need for Indian nutrition programs to adopt state-specific approaches to tackling malnutrition.

Estimating Wealth Effects without Expenditure Data-or Tears: An Application to Educational Enrollments in States of India

The relationship between household wealth and educational enrollment of children can be estimated without expenditure data. A method for doing so - which uses an index based on household asset ownership indicators - is proposed and defended in this paper. In India, children from the wealthiest households are over 30 percentage points more likely to be in school than those from the poorest households, although this gap varies considerably across states. To estimate the relationship between household wealth and the probability that a child (aged 6 to 14) is enrolled in school, Filmer and Pritchett use National Family Health Survey (NFHS) data collected in Indian states in 1992 and 1993. In developing their estimate Filmer and Pritchett had to overcome a methodological difficulty: The NFHS, modeled closely on the Demographic and Health Surveys, measures neither household income nor consumption expenditures. As a proxy for long-run household wealth, they constructed a linear asset index from a set of asset indicators, using principal components analysis to derive the weights. This asset index is robust, produces internally coherent results, and provides a close correspondence with data on state domestic product and on state level poverty rates. They validate the asset index using data on consumption spending and asset ownership from Indonesia, Nepal, and Pakistan. The asset index has reasonable coherence with current consumption expenditures and, more importantly, works as well as - or better than - traditional expenditure-based measures in predicting enrollment status. The authors find that on average a child from a wealthy household (in the top 20 percent on the asset index developed for this analysis) is 31 percent more likely to be enrolled in school than a child from a poor household (in the bottom 40 percent). This paper - a product of Poverty and Human Resources, Development Research Group - is part of a larger effort in the group to inform educational policy. The study was funded by the Bank`s Research Support Budget under the research project Educational Enrollment and Dropout (RPO 682-11).