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Spatial Inequality in Child Nutrition in Nepal: Implications of Regional Context and Individual/Household Composition

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Spatial Inequality in Child Nutrition in Nepal: Implications of Regional Context and Individual/Household Composition ABSTRACT Title of Document: SPATIAL INEQUALITY IN CHILD NUTRITION IN NEPAL: IMPLICATIONS OF REGIONAL CONTEXT AND INDIVIDUAL/HOUSEHOLD COMPOSITION Ramu Bishwakarma, Doctor of Philosophy, 2011 Directed By: Professor Reeve D. Vanneman Department of Sociology With nearly 42% of children below age five nutritionally stunted, child malnutrition is a social, economic, and public health issue in Nepal. Even more disheartening is the wide variation of malnutrition across sub-regions within country, which seems to disproportionately disadvantage children in certain regions as opposed to others. This dissertation aims to understand the extent and causes of child stunting from a regional inequality perspective. Household data from the Nepal Demographic and Health Surveys (NDHS) 1996, 2001, and 2006 are used to analyze national and regional trends of stunting of children age 6-59 months. Various data sources including the Nepal Census and the Health Management and Information System are used for regional level data. Both household and regional data are then analyzed using two-level Hierarchical Linear Modeling (HLM). The results show that stunting is declining albeit very slowly in Nepal and across all thirteen regions. But there are significant and consistent disparities across regions that are not decreasing over time. HLM analyses show that the regional variance in child stunting is due to both household and regional (i.e. contextual) factors. Specifically, women’s literacy at the regional level is found to have a profound impact as it explains 60% of the regional variance in stunting. Among other factors, road accessibility and food production also appear to have important roles but not as large as women’s literacy. Together, these three contextual factors explain 75% of the regional variance. Adding household compositional factors- socioeconomics in particular- reduces the residual regional variance only by few additional points. One important finding from the household-level analysis is that the so- called lower caste children are disproportionately stunted compared to other caste groups. Regional women’s literacy remains a strong factor influencing child stunting above and beyond mother’s education at the household level. Hence, women’s literacy at the contextual level should comprise the most important policy agenda against malnutrition in Nepal which is not the case now. Moreover, a special emphasis on the disadvantaged castes is of utmost important so that potential inter-generational transfer of malnutrition could be reduced. SPATIAL INEQUALITY IN CHILD NUTRITION IN NEPAL: IMPLICATIONS OF REGIONAL CONTEXT AND INDIVIDUAL/HOUSEHOLD COMPOSITION By Ramu Bishwakarma Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2011 Advisory Committee: Professor Reeve Vanneman, Chair Professor Sonalde Desai Professor Kurt Finstersbusch Professor Roberto Patricio Korzeniewicz Dr. Kenneth Simler © Copyright by Ramu Bishwakarma 2011 ACKNOWLEDGEMENTS I would like to express my sincere gratitude to the Chair of my Dissertation Committee, Professor Dr. Reeve Vanneman, for supervising my research work, meticulously reviewing my drafts, providing valuable comments, and giving me continuous encouragement during the entire research process. I am also indebted to other committee members -- Dr. Sonalde Desai, Dr. Donna Howard, Dr. Kurt Finsterbusch, Dr. Kenneth Simler, and Dr. Roberto Patricio Korzeniewicz -- for their valuable feedback and suggestions during proposal defense. Their candid comments and feedback greatly helped enrich the quality of this research. I would like to take this opportunity to thank my beloved parents (Govinda and Tikamaya Bishwakarma), brothers, sisters and other family members for being there for me. Their confidence, trust, and love provided all the energy and motivation needed to conduct this study. Special thanks goes to my dear wife, Babita Shrestha, for being so understandable on my rather unpredictable and often solitaire mode of living during the course of this research. Without her continuous emotional, financial, and intellectual support, this study would probably have taken several more years to complete. Finally, I would like to extend my appreciation to Ms. Sharon Von Bergener of EEIGS (English Editing for International Graduate Students) of University of Maryland for providing English editorial help. ii Table of Contents List of Tables v List of Figures vii Chapter I: Introduction 1 Statement of Problem 1 Research Questions 6 Chapter II: Review of Literature 8 Nepal in general 8 Malnutrition Overview 9 Malnutrition and Development Agenda 10 Malnutrition in the Global Regional Context 12 Malnutrition within Country: Spatial Context 14 Spatial disparities in Malnutrition in Nepal 19 Spatial Disparity: Public policy 20 General Theories on Spatial Inequality 21 New Economic Geography Theory 25 Social Stratification Theory 28 Public Health Perspective 30 Individual Behavior Perspective 32 Chapter III: Conceptual Framework and Hypothesis 34 Conceptual Framework 34 Hypotheses 36 Chapter IV: Data and Method 38 Data Sources 38 Sample 39 Dependent Variable(s) 40 Independent Variable s 40 Method 67 Chapter V: Results 73 National Trend of Stunting 73 Regional Stunting in Nepal 75 A. Correlation of Stunting and Regional and Household variables, 2006 80 variables: a case for 2006 Stunting and Regional variables 80 Stunting and Household variables 81 Summary of Correlation Results 82 B. Correlation between Change in Stunting and Change in Regional and 83 Household variables iii Change of Stunting versus Change in Regional variables 83 Change in Stunting versus Change in Household variables 84 Summary of Change Correlation Results 86 Chapter VI: HLM Analysis 88 Effects of Regional and Household variables on Stunting regional variance 88 Impact of Regional (contextual) characteristics on Regional variance 89 Regional variance by contextual and compositional variables 102 Impact of Household level variables on child Height for Age 103 Fixed Effects Model 107 Results Summary 109 Chapter VII : Robustness Analysis 112 Replication on Stunting 112 Replication on WAZ 114 Replication on WHZ 116 Chapter VIII: Discussion 119 Research Findings Discussion 119 Women’s Literacy and Regional HAZ variance 122 Road Accessibility and Regional variance on HAZ 126 Food production and HAZ 127 Poverty and HAZ 130 Malnutrition and Sociocultural Specificity of Household Composition 132 Policy Implications 135 Limitations 138 Next step 140 Reference 204 iv List of Tables 1. Stunting Trend of under-age-five children in South Asian countries 144 2. Sources of regional data 145 3a. Region specific statistics of regional variables for 1996, 2001, 2006 146 3b. Region specific statistics for regional variables for 1996, 2001, 2006 147 3c. Region specific statistics for regional variables for 1996, 2001, 2006 148 4. Normality test and recommended mode of transformation 149 5. Factor analysis 150 6. Cronbach’s alpha 151 7. Region specific composite index variables for regional development 152 (rdindex) and social service institutions (ssindex) for 1996, 2001, 2006 8. Descriptive statistics for 1996, 2001, and 2006 153 9a. Region specific socioeconomic characteristics of the households, 155 NDHS 1996 and 2006 9b. Region specific Caste/ethnicity and Religion characteristics of 156 households, NDHS 1996 and 2006 9c. Region specific household Public health characteristics, NDHS 1996 157 and 2006 10. Regional stunting rate (<-2SD) ranking for 6 to 59 months 158 11. Stunting status and change pattern 159 12. Stunting coefficient of variation and standard deviation by year 160 13. Top and bottom five performing regions 161 14. Summarized regional data for 2006 with stunting ( sorted by Stunting ) 162 15. Correlation results on stunting with regional variables for 2006 163 16. Status of stunting versus other household variables for 2006 164 (sorted by stunting) 17. Correlation results of stunting with household variables for 2006 165 18. Percentage change of regional variables vis-à-vis nutritional 166 variables from 1996 to 2006 (sorted by absolute change of Stunting) 19. Correlation results of change in Stunting with change in other 168 regional contextual level variables 20. Change (both absolute as well as percentage) of household 169 variables vis-à-vis nutritional variables from 1996 to 2006 21. Correlation results of change in Stunting with change in 171 individual/household variables 22. Important variables for stunting (and change in Stunting) based 172 on correlation analysis 23. Baseline HLM model 173 24. HLM results of all individual macro variables on child 174 height for age (HAZ) 25. Two variable model results for Urbanization and Manufacturing 175 Establishments with Women’s Literacy 26. HLM results Regional Development Index 176 27. Two Variables Model Result for Health Facilities, Education 177 Facilities, and Female Child Health Care Volunteers v 28. Status of Stunting (6-59 m) and Social Sector Variables, 2006 178 29. HLM results on child HAZ by Social Service Index 179 30. Two Variables Model Result for Food Production and 180 Road Accessibility 31. HLM results for HAZ and selected regional level variables 181 32. HLM results for child HAZ with Years and selected regional 182 level variables 33. HLM results for child HAZ with Years and other selected regional 183 variables 34. Fixed effects HLM results for child
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