Household and Environmental Conditions Influencing Health and Survival of Children in Northern and Southern Regions of India
Ankit Anand* and Duryodhan Sahoo** International Institute for Population Sciences, Mumbai, India *E-mail:
[email protected] **E-mail:
[email protected]
Paper to be presented at XXVII IUSSP International Population Conference 26 August to 31 August 2013 Busan, South Korea 1
Household and Environmental Conditions Influencing Health and Survival of Children in Northern and Southern Regions of India
Ankit Anand and Duryodhan Sahoo International Institute for Population Sciences, Mumbai, India
ABSTRACT: The child health situation in India has been improving slowly over the past few years and remains a major development challenge for India. Highest number of child deaths in world takes place in India. Nutrition level has not much improved form NFHS-2 to NFHS-3. The main purpose of the study to assess and compare the overall health of children in northern and southern states of India and to examine the relationship between several household and development related environmental factors to the health and survival of children in rural parts of two different northern and southern regions of India. Data from NFHS-3 has used for these purposes. Several indicators of nutrition and morbidity are used. Poor sanitation and electricity facilities significantly reduce the chances of children to secure better health in the both the regions. Poor water condition is also founds to be significant impact on wasting among children. Use of non-solid cooking fuel is also associated with survival and health situation of children. Education status of mother was very important determinants of child health and survival. Non nuclear families are also founds to be better than nuclear families in northern region but opposite is true for southern region.
2
INTRODUCTION "Significant action is required to achieve healthier, safer and cleaner environments in the places where children live, learn, work and play – this is imperative for child health. It requires using strategies that are available, building on existing programmes and partnerships, translating research and knowledge into protective policies and fulfilling political commitments to action."- WHO Globally 98.6 percent of under five child deaths take place in developing countries, 33.3 percent of under five deaths take place in South Asia and 22.3 percent under five deaths take place only in India. India has the highest number of under five deaths followed by Nigeria, Dem. Republic of Congo, Pakistan and China. The contribution of India in under five deaths in world and especially in South Asia is very significant (UNICEF, 2011). Although under five Mortality rate in India have been declined to 109.3 in 1992-93 to 74.3 in 2005-06 (NFHS-3). Child health situation is not very rosy in developing world, there are number of infectious diseases which are common among children and are the cause of high mortality in them. These include diarrhoea, acute respiratory infections (ARI), Measles, pertussis (whooping cough), diphtheria and tetanus. Acute respiratory-tract infections remain the major cause of deaths among children followed by diarrhoea. Even in neonatal causes, deaths from infectious disease are also very high (WHO, 2005). Infectious diseases are widespread among children under 5 years in developing countries and can affect development through direct and indirect pathways. Unhygienic practices and unsafe drinking water is some of its main causes. Wealth of studies exits showing impact of household’s environmental condition on child health and survival. The quality of care a child receives clearly affects its survival chances. This includes the kind of home-based preventive and curative care given to children and the mother's level of care in ensuring good hygiene and sanitation and significantly influenced by women's autonomy, social class and mothers' education (Das Gupta, 1990). Mother’s literacy, access to a flush or pit toilet, household head’s religion and caste/tribe membership and economic level of the household (usually indicated by wealth index which is based on ownership of consumer goods) have substantial and often statistically significant effects on infant and child health. Better economic condition of household may increase the opportunity to acquire better health care. Household wealth inequality is strongly associated with 3
childhood adverse growth rate stunting. Reducing poverty and making services more available and accessible to the poor are essential to improving overall childhood health and nutritional status (Rathavuth Hong, James E Banta and Jose A Betancourt, 2006). Malnutrition has been highly linked with poverty and economic condition however female education also plays very important role in improving nutrition status of children. Environmental surrounding of children also has major effect on the survival and health of children. Children are especially more at risk because they have no control over their prenatal and postnatal environment including, the air they breathe, water they drink, food they eat and their place of residence. Increasing access to safe potable water and sanitation improve the surrounding environment, therefore improve child health and mortality situation (WHO, 2009). Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use (Mathew et al, 2011). Environmental conditions have a very important role in growth and development of children. The effect of disadvantageous environmental conditions—such as limited electricity and water supply derives both from a lack of community infrastructure and from the inability of some households to exploit it when available. Policy needs to operate at both the community and household levels to correct such deficiencies (Ellen Van De Poel, Owen O’donnell & Doorslaer, 2009). In resource-poor settings, environmental risks stem from a variety of sources, including unclean water, poor sanitation, crowded living situations, dangerous working conditions and smoke from biomass cooking. There can be possible environmental causes of children’s illnesses and disorders, as well as the prevention and treatment of environmentally mediated diseases in children and infants. Children are highly vulnerable to the negative health consequences associated with many environmental exposures. Rapidly developing children are more at risk and more vulnerable to the conditions than adults. These threats from the foundation of poor health and often cause and exacerbate other causes. For example, while tremendous progress has been made to create vaccines that prevent diarrhea, increased attention is needed to address the underlying social and environmental determinants such as clean water. Traditional environmental risks in rural areas are very prominent. These risks can affect the growth of children and can increase the risk of several diseases among children. 4
This environmental condition also represents the low infrastructure in those areas and can reflect their abilities to utilize the health care facilities, which may be present there. Hence the main purpose of the study to asses and compare the overall health of children and to examine the relationship between several developments related environmental, household and demographic factors to the health and survival of children in two different northern and southern regions of India. Figure 1 gives the conceptual framework for the study. Nutritional intake of child, socioeconomic and environmental factors as well as mother and child’s characteristics may influence the growth and chances of infections among children. Growth faltering and disease causation will have an influence on health and survival of children. Although growth factor may influence the disease pattern and infection in children may affect the growth of children. Figure 1: Conceptual Framework
Nutrition intake
Child growth Health & Survival
Socio economic and environmental conditions
Infections
Child’s and mother’s characteristics
OBJECTIVES I.
To assess and compare the overall child health and mortality situation in northern and southern regions.
II.
To examine the impact of household environmental factors on child health in rural parts of northern and southern region.
First objective is to analyze the mortality, nutrition and morbidity situation of children in the northern and southern states of India. There are several factors which influence the health of 5
children. Especially rural areas have been substantial way behind in achieving better health of children. Hence the second objective is to determine the impact of environmental and household factors on the child health in rural areas in two different regions of India. SOURCES OF DATA The third round of National Family Health Survey (NFHS-3), conducted in 2005-06 has been used for the study. It has collected information about 51,555 under five children from a nationally representative sample of 124,385 women age 15-49 in all 29 states. Children from ever married women included in the study. NFHS-3 adopted a two-stage sample design in most rural areas and a three-stage sample design in most urban areas. In each state, the rural sample was typically selected in two stages: the first stage involved selection of Primary Sampling Units (PSUs) with probability proportional to population size (PPS); the second stage involved the systematic selection of households within each PSU. Women’s average characteristics has been taken as proxy for PSU characteristics and treated as environmental condition around children’s surroundings.
METHODOLOGY Data has been divided into two parts one consist of northern states (Haryana , Himachal Pradesh , Jammu & Kashmir, Punjab, Rajasthan , Uttaranchal, Chhattisgarh , Madhya Pradesh , Uttar Pradesh, Bihar, Jharkhand and Assam) and other consist of southern states (Orissa, West Bengal, Goa, Gujarat, Maharashtra, Andhra Pradesh, Karnataka, Kerala and Tamil Nadu). Other north eastern states have not been used in the study. Survival status of all the children who were born to the women who was interviewed has been collected. Children born 0 to 59 months before the survey have been included in the study. Other child health care information was collected only for living children and hence for further analysis only living children are considered. Some children are left out of this analysis because of missing information on the dependent variable in focus. Bi-variate analysis is the simultaneous analysis of two variables (attributes). It explores the concept of relationship between two variables. It has been used to analyze the mortality and child health indicators in different northern and southern states and hence to fulfil the first objective. Cox regression (proportional hazards regression) is method for investigating the effect of several variables upon the time a specified event takes to happen. In the context of 6
an outcome such as death this is known as Cox regression for survival analysis. An assumption of the proportional hazard model is that the hazard function for an individual (observation in the analysis) depends on the values of the covariates and the value of the baseline hazard. Given two individuals with particular values for the covariates, the ratio of the estimated hazards over time will be constant. Logistic regression is a type of regression analysis used for predicting the outcome of a binary dependent variable (a variable which can take only two possible outcomes, such as yes vs. no or success vs. failure) based on one or more predictor variables. For assessment of child health logistic regression model have been used. RESULTS Child mortality in India has been consistently declining. Figure 2 shows the trend in Infant Mortality Rate (IMR) India (1980-2009). The infant mortality has declined in both in urban and rural areas but in still in rural areas the IMR is quite high compare to urban areas. Although mortality among infants and children has significantly declined, India is still behind with some of its neighbouring countries like Sri Lanka, Bangladesh and Nepal. Figure 2: Levels and trend of IMR in India 130 110 90 70 50 30
Rural
Urban
Total
Source: SRS, registrar general, India
Figure 3 shows the trend in IMR in India and states (SRS report 2009). There is a huge regional disparity in terms of infant mortality situation. At one side there are southern states Like Kerala, Tamil Nadu, Goa and Maharashtra where the IMR is very low and on the other side northern states like Uttar Pradesh, Madhya Pradesh, Rajasthan and Bihar where the IMR is very high but within these states the mortality in rural areas is quite high compare with urban areas. Infant mortality in urban India is 34 and in rural India is 55. High mortality in rural areas highly contributes to the overall Infant mortality. States which have high mortality 7
also have high mortality in rural areas compare to urban areas such as Assam, Uttar Pradesh, Madhya Pradesh and Rajasthan and low mortality states had small urban-rural differences. Figure 3: IMR in India and states, 2009 80 70 60 50 40 30 20 10 0
Rural
Urban
Total
Source: SRS, registrar general, India
Table 1 provides the percentage of children into various combinations of stunted wasted and underweight in northern and southern states. The percentage of children who are neither stunted nor wasted nor underweight is highest in Kerala and Goa followed by Punjab, Himachal Pradesh, Jammu & Kashmir, Andhra Pradesh and Tamil Nadu. Madhya Pradesh, Jharkhand, Chhattisgarh, Uttar Pradesh and Bihar have one of the lowest percentages in that category. The percentage of children who are all stunted, wasted and under weight is high in Bihar, Jharkhand, Chhattisgarh, Madhya Pradesh, Gujarat and it is on low side in Goa, Kerala, Andhra Pradesh, Punjab and Tamil Nadu. The percentage of children, who are all stunted, wasted and under weight is almost double in northern region compare to southern region and the percentage of children who are not stunted wasted and underweight is quite better in southern region. Table 2 provides the percentage of children who are suffering from diarrhoea, fever and cough in northern and southern states. The percentage of children who are not suffering from any diarrhoea, fever and cough is high in Tamil Nadu, Andhra Pradesh, Himachal Pradesh, Haryana, Maharashtra and Karnataka, lowest in Gujarat, Jharkhand, Orissa, West Bengal and Madhya Pradesh. The percentage of children who are suffering from all diarrhoea, fever and cough is high in Jharkhand, Bihar, Uttaranchal, Gujarat, Orissa and Jammu & Kashmir, lowest in Andhra Pradesh, Tamil Nadu, Haryana, Chhattisgarh and Goa. Overall in northern 8
region the percentage of children who are not suffering from any diarrhoea, fever and cough is very similar to southern region but percentage of children who are suffering from diarrhoea, fever and cough is quite high in northern region. The percentage of children suffering from diarrhoea is very high in northern states and percentage suffering from cough is relatively high in southern states. Child mortality and health situation is worse in northern states. Some states like Uttar Pradesh, Rajasthan, Bihar, Madhya Pradesh and Assam are way behind in achieving better health for children. Kerala, Goa and Tamil Nadu are some of the few which has remarkably better health and mortality situation in comparison with other states. As shown by various studies the rural areas way behind to the urban areas and for further analysis rural areas has been focused. Table 3 provides the results of proportion hazard regression. Children from poor sanitation facility were less likely to survive compare with children from good sanitation facility in southern region. Children belonging to poor electricity condition were less likely to survive compare with children from good electricity conditions. Poor use of non-solid fuel also had high chances of not surviving among children in both the regions. High education of mother also has significantly improved the survival chances of children especially in northern region. Table 4 provides the results of logistic regression results of stunting among children. It gives the odds ratio of not being stunted. Children from good sanitation facility are significantly less likely to be stunted compare with children from poor sanitation facility especially in southern region. Education of mother has been significantly associated with stunting. Better education and economic status reduces the chances of being stunted. Nuclear families have founds to be better than non-nuclear families in southern region but reverse is true for northern region Table 5 provides results of logistic odds ratio of wasting. In the northern region poor water and sanitation situation is significantly, increase the chances of wasting among children but not much in southern region. Education of mother and household structure were not found to be related with wasting among children Table 6 provides results of logistic regression of underweight among children. Poor sanitation conditions reduce the chance of being underweight among children. In Northern region increasing education among mother increases the chances of being underweight among 9
children. Similarly in northern region Children belong to non-nuclear families have less chances of being underweight. Table 7 provides the results of logistic regression odds of having diarrhoea. Children in poor sanitation facilities are significantly more likely to have diarrhoea compare with children in good sanitation facilities. Children in non-nuclear families have low odds of having diarrhoea compare to nuclear families in northern region but not in southern region. Education of mother showed a reverse pattern increasing education among mother leads to increased chances of diarrhoea among children especially in northern region. Table 8 provides the results of logistic regression in odds of having fever. Poor use of improved sanitation situation has high odds of having fever compare to good use of improved sanitation facilities in northern region. Children belonging to poor electricity condition have high odds of having fever compare to children belonging to good electricity situation. Children in non-nuclear families were less likely to have fever than nuclear families Table 9 provides the results of logistic regression in odds of having cough. Children living in poor electricity situation are more likely to suffer from cough. In southern region sanitation situation is also associated with having cough among children. Children in non-nuclear families have low odds of having cough compare to nuclear families in both regions but it was significant in southern region. Improvement in education however shows the increasing chances of having diarrhoea, fever and cough in northern region. One explanation would be that better educated women are more aware of the disease symptoms and report better than low educated women. CONCLUSION There exists a great regional variation in survival and health of children in India. States like Uttar Pradesh Bihar, Assam, Madhya Pradesh and Rajasthan are characterized by high mortality and poor health among children. Kerala, Goa and Tamil Nadu are the states, which have achieved better health of children, compare to all other states in India. Several studies have shown that water and sanitation conditions have considerable influenced on the survival and health of children. Sanitation has been one of the most neglected areas in rural parts of India and situation is even worse in northern parts. Poor sanitation and electricity facilities have significantly reduce the chances of children to secure better health in the both the regions. Improving sanitation facility is also very important to secure the better health of children. Stunting among does not vary by water source. This may be related to the 10
fact that stunting is an indicator of the long-term effects of malnutrition and it does not vary according to recent dietary intake. Poor water condition is also founds to be significant impact on morbidity situation of children. Education of the mother was very important determinants of child health and survival. Improving education status of mother found to be having significant impact on child health.
LIMITATIONS OF THE STUDY v
NFHS-3 is a cross sectional survey, information is collected at a particular period of time and the analysis has the assumption that it has remain the same since the birth of child.
v
Study focused on selected environmental factors in rural areas. There can be other important environmental factors in both urban and rural areas which may affect the health of children. Hence conclusion is only based on the selected environmental factors.
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Table 1: Percentage of children age between 0 to 35 months who are stunted, wasted and underweight by northern and southern states, National Family Health Survey, 2005-06 Only stunted
Only under weight
Only wasted
Stunted and under weight
Under weight and wasted
Stunted, under weight and wasted
Not stunted, wasted and under weight
15.4
0.9
7.8
12.6
5.4
5.1
52.9
11.3
2.0
6.4
15.5
6.0
7.5
51.3
Punjab
16.0
1.8
2.6
14.1
3.1
4.5
57.9
Uttaranchal
16.4
2.7
5.0
15.7
6.0
7.2
46.9
Haryana
15.0
1.8
4.5
18.4
8.3
9.8
42.3
Rajasthan
13.1
1.5
5.5
18.3
8.3
8.7
44.6
Uttar Pradesh
19.2
2.0
4.6
24.7
6.4
8.5
34.6
Bihar
8.3
2.8
5.4
24.9
10.2
17.0
31.4
Assam
14.6
2.6
4.2
20.7
6.5
6.1
45.3
Jharkhand
7.6
2.9
6.7
22.6
12.1
17.0
31.1
Chhattisgarh
14.9
1.7
4.8
26.7
8.4
10.9
32.5
Madhya Pradesh
7.8
3.3
6.8
21.9
15.8
16.9
27.6
North
13.6
2.3
5.2
22.5
8.8
11.5
36.1
West Bengal
13.4
2.4
5.1
21.1
6.8
7.3
43.9
Orissa
14.3
2.3
6.4
20.0
7.6
9.6
39.8
Gujarat
16.2
3.3
4.8
22.9
5.0
10.0
37.8
Maharashtra
19.9
2.5
4.0
16.9
6.0
7.1
43.6
Andhra Pradesh
17.1
1.8
4.3
17.4
6.9
3.7
48.8
Karnataka
17.7
2.2
5.5
17.7
6.4
7.0
43.6
Goa
11.1
1.3
4.1
11.1
5.3
3.5
63.6
Kerala
13.3
2.4
6.7
9.8
5.6
3.4
58.8
Tamil Nadu
13.6
1.6
11.2
12.6
6.8
4.9
49.2
South
16.0
2.3
5.6
18.1
6.4
6.9
44.7
States Jammu & Kashmir Himachal Pradesh
14
Table 2: Percentage of children age between 0 to 35 months who are suffering from diarrhoea, fever and cough by northern and southern states, National Family Health Survey, 2005-06 Only diarrhoea and fever
Only cough and fever
All diarrhoea fever and cough
No diarrhoea fever and cough
Only diarrhoea
Only cough
Only fever
Only diarrhoea and cough
6.5
3.7
4.7
1.3
2.8
10.8
3.9
66.3
7.2
2.9
4.8
0.9
1.1
3.9
2.3
77.0
Punjab
5.5
7.6
2.5
2.1
0.4
9.2
3.2
69.5
Uttaranchal
7.9
3.3
4.2
1.4
2.9
6.9
4.0
69.4
Haryana
9.8
3.5
2.7
1.5
1.3
4.7
1.1
75.3
Rajasthan
7.5
7.5
1.9
2.2
0.7
7.5
3.2
69.4
Uttar Pradesh
5.5
6.4
3.3
1.2
1.1
10.5
3.0
68.8
Bihar
6.6
3.2
4.7
1.0
1.5
11.3
4.9
66.8
Assam
5.3
7.2
4.2
1.3
0.5
8.5
3.1
70.1
Jharkhand
7.9
5.0
4.4
2.4
2.5
11.7
5.9
60.2
Chhattisgarh
3.8
12.7
3.6
1.4
0.8
7.0
1.4
69.3
Madhya Pradesh
9.4
6.4
4.8
1.9
2.3
6.0
3.5
65.6
North
6.6
5.9
3.7
1.5
1.3
9.4
3.5
68.0
West Bengal
2.7
13.8
2.7
1.5
0.7
18.1
2.8
57.7
Orissa
8.3
9.1
4.0
1.3
2.5
8.9
3.8
62.0
Gujarat
9.8
11.2
3.3
3.2
1.9
7.3
4.0
59.4
Maharashtra
6.1
4.6
3.0
1.6
1.3
6.2
2.7
74.6
Andhra Pradesh
4.8
6.4
2.1
1.4
0.6
6.6
0.9
77.4
Karnataka
7.4
3.6
4.5
1.1
1.5
7.0
2.4
72.5
Goa
3.4
5.0
6.9
2.7
0.3
12.9
2.0
66.7
Kerala
4.1
4.2
7.0
0.8
1.0
14.0
2.7
66.3
Tamil Nadu
5.3
5.0
2.9
0.6
0.7
5.1
0.8
79.5
South
5.9
7.6
3.3
1.5
1.2
9.2
2.5
68.8
States Jammu & Kashmir Himachal Pradesh
15
Table 3: Results of Cox’s proportional hazard regression analysis (risk of dying) of children age between 0 to 59 months, National Family Health Survey, 2005-06 North# Use of improved source of drinking water
Use of improved sanitation Electricity Use of non solid cooking fuel
South#
Good® Poor Good® Medium Poor Good® Poor Good® Poor
0.885
1.024
0.781* 0.769*
1.040 1.195
1.088
1.253
1.063
1.257
No education® 0.877 0.754 Primary Mother's education 0.741** 0.542** Secondary 0.325** 0.506 Higher Nuclear® Household Structure 0.922 Non nuclear 0.790 # control for other variables such as Caste, Religion, Sex of the child, Birth order, Birth interval, Age of mother at birth ® = reference category, * p
