Published: 2021-09-27

Childhood undernutrition inequalities in Empowered Action Group states of India: evidence from NFHS, 2006-2016

Anil Kumar, Bal Kishan Gulati, Jeetendra Kumar, Damodar Sahu, Rajaram Yadav, Anita Pal, M. Vishnu Vardhana Rao


Background: Child undernutrition is a major public health problem in many low and middle income countries and malnutrition alone accounted for 45% (3 million deaths annually) deaths among under-five children. Malnutrition is the concealed cause of one out of every two such deaths. A study was undertaken to examine the trends, determinants and socioeconomic-related inequalities in childhood undernutrition in empowered action group (EAG) states, India. The secondary data of the two rounds of National Family Health Survey, NFHS-3 (2005-06) and NFHS-4 (2015-16) comprising of 16,802 and 128,400 children aged 0-59 months respectively was analysed.

Methods: Non-linear Fairlie decomposition was used to identify and quantify the separate contribution of different socioeconomic characteristics in gap of childhood malnutrion between 2006 and 2016.

Results: Results show that the prevalence of undernutrition has decreased in EAG states during the last one decade, but the prevalence of wasting is remained almost same as 10 years back. The decomposition analysis shows that maternal education, household wealth and place of residence were contributing to socioeconomic inequality in childhood undernutrition from 2006 to 2016.

Conclusions: There is a need to adopt different strategies of health policy intervention. It is important to have policies towards improving female literacy in the EAG states because maternal education plays a vital role in child health and literacy rate is very low among women in EAG states. The existence of a functional health insurance system and increasing universal coverage are recommended to mitigate child undernutrition, so that the vulnerable and deprived populations who are not able to access health care facilities, can easily access health care services for early detection and treatment of undernutrition without any financial constraint.


Childhood undernutrition, EAG States, Decomposition analysis, Inequalities

Full Text:



Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet. 2005;365(9465):1147-52.

Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet. 1997;349(9063):1436-42.

Braveman P, Tarimo E. Social inequalities in health within countries: not only an issue for affluent nations. Soc Sci Med, 2002;54(11):1621-35.

Gwatkin DR. Poverty and inequalities in health within developing countries: filling the information gap. In: Leon DA, Walt G, eds. Poverty, inequality, and health: an international perspective. Oxford:Oxford University Press, 2000.

Wagstaff A, Watanabe N. Socioeconomic inequalities in child malnutrition in the developing world. World Bank Policy Research Working Paper. 2000;2434.

Smith LC, Ruel MT, Ndiaye A. Why is child malnutrition lower in urban than in rural areas? Evidence from 36 developing countries. World Develop. 2005;33(8):1285-305.

Van de Poel E, Hosseinpoor AR, Jehu-Appiah C, Vega J, Speybroeck N. Malnutrition and the disproportional burden on the poor: the case of Ghana. Int J Equity Health. 2007;6(1):21.

Uthman OA. Decomposing socio‐economic inequality in childhood malnutrition in Nigeria. Matern Child Nutr. 2009;5(4):358-67.

Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskär T. Boys are more stunted than girls in sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. BMC Pediatr. 2007;7(1):17.

Gayle HD, Dibley MJ, Marks JS, Trowbridge FL. Malnutrition in the first two years of life: the contribution of low birth weight to population estimates in the United States. Am J Dis Children. 1987;141(5):531-4.

Mushtaq MU, Gull S, Khurshid U, Shahid U, Shad MA, Siddiqui AM. Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children. BMC Public Health. 2011;11(1):790.

Ortiz J, Van Camp J, Wijaya S, Donoso S and Huybregts L. Determinants of child malnutrition in rural and urban Ecuadorian highlands. Public Health Nutr. 2014;17(9):2122-30.

Hong R, Banta JE, Betancourt JA. Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh. Int J Equity Health. 2006;5(1):15.

Fotso JC. Urban-rural differentials in child malnutrition: trends and socioeconomic correlates in sub-Saharan Africa. Health Place. 2007;13(1):205-23.

Burchi F. Child nutrition in Mozambique in 2003: the role of mother'’s schooling and nutrition knowledge. Econom Hum Biol. 2010;8(3):331-45.

Wamani H, Tylleskar T, Astrom AN, Tumwine JK, Peterson S. Mothers’ education but not fathers’ education, household assets or land ownership is the best predictor of child health inequalities in rural Uganda. Int J Equity Health. 2004;3(1):9.

Mazumdar S. Determinants of inequality in child malnutrition in India: the poverty-undernutrition linkage. Asian Popul Stud. 2010;6(3):307-33.

Agee MD. Reducing child malnutrition in Nigeria: combined effects of income growth and provision of information about mothers’ access to health care services. Soc Sci Med. 2010;71(11):1973-80.

International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-III) 2005-2006. Mumbai: IIPS, 2007. Available from: Accessed on 21 December 2020.

International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-IV) 2015-2016. Mumbai: IIPS, 2017. Available from: Accessed on 21 December 2020.

Fairlie RW. An Extension of the Blinder-Oaxaca Decomposition Technique to Logit and Probit Models. Economic Growth Center, Yale University Discussion Paper No. 873. 2003.

Akombi BJ, Agho KE, Renzaho AM, Hall JJ, Merom DR. Trends in socioeconomic inequalities in child undernutrition: Evidence from Nigeria Demographic and Health Survey (2003–2013). PloS One. 2019;14(2):e0211883.

Smith L, Haddad L. Explaining child malnutrition in developing countries - a cross country analysis. Research Report 111. Washington, D.C. International Food Policy Research Institute, 2000.

Zere E, McIntyre D. Inequities in under-five child malnutrition in South Africa. Int J Equity Health. 2003;2(1):7.

Sousa A, Hill K, Dal Poz MR. Sub-national assessment of inequality trends in neonatal and child mortality in Brazil. Int J Equity Health. 2010;9(1):21.

Van de Poel E, Hosseinpoor AR, Speybroeck N, Van Ourti T, Vega J. Socioeconomic inequality in malnutrition in developing countries. Bull World Health Organ. 2008;86:282-91.

Mussa R. Explaining urban rural malnutrition inequality in Malawi. In Conference on Measuring National Income, Wealth, Poverty, and Inequality in African Countries. Cape Town, South Africa, 2011.