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Policy Research Working Paper 7794
Synergies in Child Nutrition
Interactions of Food Security, Health and Environment, and Child Care
Emmanuel Skoufias
Poverty and Equity Global Practice GroupAugust 2016
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Produced by the Research Support Team
Abstract
The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.
Policy Research Working Paper 7794
This paper is a product of the Poverty and Equity Global Practice Group. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The author may be contacted at [email protected].
This paper examines the extent to which the three key under-lying determinants of nutrition—food security; adequate caregiving resources at the maternal, household, and com-munity levels; and access to health services and a safe and hygienic environment—on their own and interactively are correlated with nutrition outcomes, such as height-for-age z-scores. Based on data from different years in eight coun-tries in four regions where malnutrition is high, an indicator
is constructed for each component of the three underlying drivers of nutrition. In spite of the limitations inherent in the available data, the analysis (i) reveals that progress toward improved access to adequate food security and adequate environment and health has been quite limited; and (ii) provides evidence of significant synergies among adequate food, child care, and environment and health.
SynergiesinChildNutrition:InteractionsofFoodSecurity,Healthand
Environment,andChildCare
EmmanuelSkoufias
Poverty&EquityGlobalPractice
TheWorldBankGroup
JELClassification:I14,I15,I18,I38,J13
Keywords:ChildNutrition,Stunting,FoodSecurity,HealthServices,Environment,ChildCare.
Contents
Acknowledgments...................................................................................................................................................................3
1.Introduction.........................................................................................................................................................................1
1.1 MethodologicalFramework.............................................................................................................................4
2 DataandMeasures........................................................................................................................................................7
2.1 MeasuresofFoodSecurity...............................................................................................................................8
2.1.1 “Ideal”IndicatorsofFoodSecurity.....................................................................................................8
2.1.2 AvailableIndicatorsforFood..............................................................................................................12
2.2 MeasurementofChildCare............................................................................................................................13
2.2.1 IdealIndicatorsforChildCare............................................................................................................13
2.2.2 AvailableIndicatorsforchildcare.....................................................................................................14
2.3 MeasurementofEnvironmentandHealth..............................................................................................15
2.3.1 IdealIndicatorsforenvironmentandhealth................................................................................15
2.4 Otherdataissuesandrelatedconsiderations........................................................................................16
3 Prevalenceofstuntingandaccesstoadequatefoodsecurity,childcare,andhealthandenvironment............................................................................................................................................................................19
3.1 Prevalenceofstunting......................................................................................................................................19
3.2 AdequaciesinFoodSecurity,Environment,Health,andCarePractices.....................................21
3.2.1 Adequatefoodsecurity..........................................................................................................................22
3.2.2 AdequateCarePractices........................................................................................................................25
3.2.3 AdequateEnvironmentandHealth...................................................................................................28
3.3 AdditionalConsiderations:WeakLinksinaChain..............................................................................33
4 Synergies.........................................................................................................................................................................38
4.1 Model.......................................................................................................................................................................38
4.2 Results.....................................................................................................................................................................40
5 ConcludingRemarksandPolicyConsiderations............................................................................................44
References................................................................................................................................................................................47
Annex1:Assetindex............................................................................................................................................................51
Annex2:Componentsofadequacymeasuresbywealth......................................................................................52
Annex3:Synergiesbywealthgroup.............................................................................................................................56
Acknowledgments
TheteamforthisstudywasledbyEmmanuelSkoufias(LeadEconomist,GPVDR)andwascomprisedofJoseAntonioCuesta,(SeniorEconomist,GPVDR),NkosinathiVusizihloboMbuya(SeniorNutritionSpecialist,GHNDR),SaileshTiwari(SeniorEconomist,GPVDR),EkoSetyoPambudiandIndiraMaulaniHapsarifromtheJakartaWorldBankOffice,KatjaVinha(Consultant),LauraMaratou‐Kolias(Consultant,GWASP),SushenjitBandyopadhyay(Consultant,GENDR),ChristineJ.Foreman(Consultant),andLeonardoTornarolli(Consultant).
ThepeerreviewerswereLeslieElder(SeniorNutritionSpecialist,GHNDR),PatrickHoang‐VuEozenou(Economist,GHNDR),CraigKullmann(SeniorWaterSupplyandSanitationSpecialist,GWASP),JohnNewman(LeadStatistician,GPVDR),andHaroldAlderman(SeniorResearchFellowatIFPRI).TheteamisespeciallythankfultotheNationalInstituteofHealthResearchandDevelopment(NIHRD)oftheMinistryofHealthofIndonesiaformakingavailabletherelevantdatafromthe2010RISKESDASsurvey.AdditionalcommentsandsuggestionswerereceivedfromMeeraShekar(LeadHealthSpecialist,GHNDR),ClaireChase(EconomistGWASP)andteam(DeanSpears,,andMariaQuattri),RajaB.Kattan(SectorLeader,AFTHD,onbehalfofVeraSongweandAFCF1HDteam),MartinRama(ChiefEconomist,SARCE),andGladysLopez‐Acevedo(LeadEconomist,SARCE).TheteamhasalsobenefittedfromcommentsreceivedfromparticipantsinseminarsattheWorldBank,IFPRI,andattheUNICEFHeadquartersinNewYork.
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1.Introduction
TherecentassessmentsoftheglobalprogresstowardstheachievementoftheMDGsshowthatprogressinnutritionhasbeenslowerthanexpected(WorldBank,2013).Malnutritionrateshaveremainedsurprisinglyhighinseveralcountrieswithrobusteconomicandagriculturalgrowth,whichsuggeststhatincreasesinrealGDPandincomeareinsufficientforreductionsinchildmalnutrition.
Whilethereiswidespreadagreementthatreducingchildhoodmalnutritioniscriticallyimportantfordevelopment,thereislessconsensusonhowtoachieveimprovementsinnutrition.Alargebodyofresearchinthefieldofpublichealthandnutritionhasconcentratedonevaluatingtheimpactsofspecificinterventionssuchasfood,mineral,andvitaminsupplementsortrainingprograms.Ontheotherhand,theCopenhagenConsensusrecommendationssuggestthatinterventionsoutsidethenutritionsectorcouldbemorecosteffective(Deolalikar,2008;Hoddinott,etal,2012).However,uptonow,thereislittleempiricalevidenceonthefactorsorcombinationofsector‐specificinterventionsthatareassociatedwithmeasurableimpactsinnutrition.
Recently,anumberofinitiativeshavesurfacedattheinternationalfrontaimingtoscaleupnutritioninterventions.OneprominentexampleistheScalingUpNutrition(SUN)movement,whoseframeworkisendorsedby30developingcountries(Horton,etal.2010).Leadersofthesecountriesareprioritizingnutritionasaninvestmentintheirpeople’sgrowth,andrecognizingnutritionasaninvestmentineconomicandsocialdevelopmenttostrengthentheirnations.Alongparallellines,initiativeswithintheWorldBankandotherdevelopmentagenciesandresearchinstitutions,aimtofosterknowledgeexchangeandcross‐sectoralcollaborationandcoordinationattheprojectlevelforimprovingnutrition.Alltheseinitiativesarebasedonthepremisethatthedeterminantsofmalnutritionaremulti‐sectoralandthatthesolutiontomalnutritionrequiresmulti‐sectoralapproaches.
TheUNICEFframework,firstproposedin1990(UNICEF,1990),wasoneofthefirstattemptsatemphasizingfoodsecurity,environmentandhealth,andchildcarepracticesasunderlyingdeterminantsofchildmalnutritionindevelopingcountries.Oneofthefundamentalideasunderpinningthisframeworkisthattherearesubstantialinteractionsandsynergiesamongfoodsecurity,environment,health,andcare.Thisconceptualframeworkhasbeenguidingoperationalandappliedanalyticalworkformorethan20yearsnow.1
Theempiricalevidencethatexiststodateprovidesaverypartialpictureregardingthedirectionandmagnitudeoftheinterdependenceamongadequate(orinadequate)accesstofoodsecurity,environment,health,andchildcareinchildnutrition.OnefundamentalpremiseoftheUNICEFconceptualframework,isthatincreasesinaccesstoadequateservicesinoneorallofthe
1Attheempiricallevel,the"guidance"providedbytheframeworkhasbeenprimarilyintermsofminimizingomittedvariablebiasor,putdifferently,intermsofsuggestingimportantvariablestobeusedasexplanatoryvariablesinreducedformregressionsattheindividual,householdand/orcommunitylevel(Alderman,HoogeveenandRossi,2005;BehrmanandDeolalikar,1998,ChristiaensenandAlderman,2004;Haddad,Alderman,Appleton,SongandYohannes,2003;ElfindriandGourangaLalDasvarma,1996;Rajaram,ZottarelliandSunil,2007;SahnandAlderman,1997;Skoufias,1999;StraussandThomas,1998).
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subcomponentsofanyoneoftheseclusters,sayforexample,foodsecurityalone,cannotsubstituteforinadequatelevelsofaccesstotheotherclustersorindividualcomponentsoftheseclusters.
Foranacceleratedprogresstowardsreducingchildmalnutritionwhatisrequiredisamorecompleteanddetailedknowledgeoftheextenttowhichtherearegapsinaccesstoadequatelevelsineachoftheclustersofunderlyingdeterminants.Incontextswherechildmalnutritionisprevalent,adetailedprofileofcommunitiesordistrictsorevencountriesintermsofwhetherthereisadequateorinadequateaccesstoeachofthesubcomponentsoffoodsecurity,environment,healthandchildcare,canprovideasolidbasisfortheidentificationofpotentialbindingconstraintsimpedingprogresstowardsreducingchildmalnutrition.Thisexercisemayalsofacilitatetheprioritizationamonginterventionsintheeventthatlimitedfinancialresourcesorcapacityontheground,donotpermitsimultaneousimprovementsinallofthecriticalfactorsofchildmalnutrition.
Inspiteofthefundamentalroleofinteractionsamongthethreepillarsof(i)foodsecurity,(ii)environmentandhealth,and(iii)childcare,thereisapaucityofevidenceontheextenttowhichthereisadequateorinadequateaccesstooneormoreofthesethreepillars.2Toalargeextentthelacunaofsuchevidence,maybeattributedtotherelativescarcityofnationallyrepresentativedatasetswithallthenecessarydetailedinformation(inthesamesurvey)onchildnutrition,andallthevariablesthatcouldcaptureinasatisfactorymannerthedifferentdimensionsoffoodsecurity,environmentandhealthandcarepractices.Untilnow,therehasbeennosystematiceffortatdocumentingthegapsinthenecessarydata.ThemostcommonlyusedsourcesofdatasuchastheDemographicandHealthSurveys(DHS)ortheMultipleIndicatorClusterSurvey(MICS),forhistoricorbudgetaryreasonscollectdataforsomekeyvariablessuchaschildcareandenvironmentandhealthwithoutmuchusefulinformationcollectedonfoodsecurity.Thesesurveysarecharacterizedbyastrongpathdependence,inthesensethattheoriginalsurveyscollectedinformationaboutspecificcomponentsofoneortwoofthethreepillarsmentionedabovewiththeadditionalquestionsaddedovertimeconstrainedbythe“straightjacket”ofmaintainingcompatibilitywiththeearliersurveys.Incontrast,otherspecializedsurveysendedupcollectinginformationondifferentdimensionsoffoodsecuritybutnoinformationatallchildnutritionandanthropometricmeasures,oronchildcareorhealthandenvironment.3
Withtheseconsiderationsinmind,thisreportcontributestotheexistingliteratureinthreeways.First,itprovidesoneofthefirstcomprehensiveinvestigationsofthedataavailabilityanddataconstraintsassociatedwithamoresystematicapplicationoftheUNICEFconceptualframeworkemphasizingtheinterrelationshipamongaccesstoadequatefoodsecurity,environmentandhealth,andchildcarepracticesintheprevalenceofmalnutritionratesamongchildrenindevelopingcountries.UsingdetaileddemographicandhealthsurveydataareusedfromBangladesh,Bolivia,
2NotableexceptionsareChongetal.(2003)andAldermanetal(2003).3Interestinglytheempiricalliteratureonthedeterminantsofchildhealthdoesnotappeartobeaffectedmuchbythescarcityofrelevantdataonthedeterminantsofchildmalnutrition.Thepracticeprevalentinthemajorityofstudiesistofocustheanalysisonthecontributionofafewkeyvariablesonchildnutritionaloutcomes.Examples,ofsuchvariablesincludetheeconomicstatusofthehousehold,measuredbyincome,consumptionexpenditures,orhouseholdassets(BehrmanandDeolalikar,1987),andthelevelofeducationofthemotherofthechild(Barrera,1990;BehrmanandWolfe,1984;Skoufias,1999;WebbandBlock,2004).Inmanystudiesvillage‐level(orsometimeshousehold‐level)fixedeffectsareusedtocontrolforthepotentialinfluenceofunobservedorunmeasuredfactorssuchastheenvironmentalhealthandthecarepractices.Unfortunately,fromtheperspectiveoflearningabouttheinteractionsamongthesefactorsthisistantamountto“throwingoutthebabywiththebathwater"(BellandJones,2012;BeckandKatz,1995,2001).
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Cambodia,Ethiopia,Indonesia,NepalandZimbabwe,acomparisoniscarriedoutoftheidealvariablessummarizingthevariousdimensionsorcomponentsoffoodsecurity,environmentandhealth,andchildcareagainstthemeasuresavailablefromcurrenthouseholdsurveys.Thesecomparisonsservetohighlightthelimitationsofmostdatasetsandthepotentialgainsassociatedwiththecollectionandavailabilityofadditionalinformation.
Second,bearinginmindthelimitationsimposedbythedataavailable,thereportalsoprovidesapracticaldiagnosticframeworkofthemaincorrelatesofchildmalnutritionthatcouldbeappliedtoidentifypotential“bindingconstraints”towardstheefforttoreducechildmalnutrition.Specifically,theUNICEFconceptualframeworkis“operationalized”byservingasaguideforinvestigatingtherelationshipbetweentheprevalenceofmalnutritioninthecountryandinadequatelevelsandaccesstothethreepillarssummarizingtheunderlyingcausesofmalnutrition.Next,foreachindicatoravailablefromthesurveyusedincountry,adefinitionof“adequacy”isconstructedusingthresholdsbasedonacceptedinternationalstandards.Thereportaimstoprovidea“helicopterview”oftheextenttowhichnutritionaloutcomes,asmeasuredbyachild’sheight‐for‐ageZscore(HAZ)atanygivenpointintime,aswellasovertime,areassociatedwithinadequatefoodsecurity,inadequateenvironmentandhealth,andinadequatechildcarepractices.Inconsiderationofthecomplexityofthelinkagesbetweentheunderlyingcausesofmalnutritionandtheeconomicsituationofthefamily,theanalysisisalsocarriedoutseparatelyforresource‐rich(top60%)andresource‐poor(bottom40%)householdsbasedonanassetindexconstructedforthatpurpose.
Third,thereportprovidessomeofthefirstempiricalevidenceonthesynergiesatworkincombatingmalnutritioninthesetofcountriesusedinthisstudywhenthereissimultaneousaccesstoadequatelevelsintwoormoreofthethreepillarsoftheunderlyingcausesofmalnutrition.Whileintuitivelyappealing,thesynergiesamongthethreeclustersofmalnutritionhavereceivedlittleempiricalvalidation.Therecentemphasisonsector‐specificnutritionsensitiveinterventions(WorldBank,2014)rightlyemphasizesthesynergiesthatcanbeexploitedwithinspecificsectorssuchagriculture,waterandsanitation,orsocialprotection.Theanalysisinthereportunderscoresthepointthatthesuccessofthesesector‐specificnutrition‐sensitiveinitiativesmaybeconstrainedbytheslowprogressintakingadvantageofthesynergiesamongthethreebroadclustersoftheunderlyingdeterminantsofmalnutrition:foodsecurity,childcare,environmentandhealth.Giventhatthesynergiesamongthesethreepillarsarebeyondthescopeofanyspecificsectorsuchasagricultureorsocialprotection,thesimultaneousprogresstowardsinallofthethreepillarsiseithertakenforgrantedorunderemphasized.Asaconsequence,nutritionsensitiveinterventionsinspecificsectorsendupbeingasectoralpriorityincontextswherethechancesofsuccessmaybelimitedbecauseofnoorverylowaccesstoimprovedinfrastructurewaterandsanitationfacilities.
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1.1 MethodologicalFramework
TheoriginalUNICEFconceptualframeworksummarizedinFigure1aviewsmalnutritionastheconsequenceofavarietyofinterlinkedandinterrelatedevents.Thecausesofmalnutritionareclassifiedintothreehierarchicalcategories:theimmediatecauses,theunderlyingcauses,andthebasiccausesofmalnutrition.Inanygivencontextidentificationoftheimmediatecausesofmalnutrition(diseaseorinadequatedietaryintake)isusefulforguidingpolicyactionsespeciallyinsituationsofcrises.However,diseaseorinadequatedietaryintakearetypicallyconsequencesofavarietyofunderlyingfactorsthatareinterrelated.Forconceptualsimplicitytheunderlyingcausesofmalnutritionarethemselvesgroupedintothethreeclusters:inadequatehouseholdfoodsecurity,inadequatecareandfeedingpractices,andunhealthyhouseholdenvironmentandinadequatehealthservices.Thebasiccausesofmalnutritionsummarizethesocial,cultural,economicandpoliticalcontextandtheprevailinginequalitiesinthedistributionofresourcesinthesociety.Incombinationthesecontextualorstructuralfactorsplayafundamentalroleintheextenttowhichthereareinequalitiesamonghouseholdsandtheirmembersinhavingadequatefoodsecurity,careandfeedingpractices,healthyenvironmentandadequatehealthservices(i.e.,theunderlyingcausesofmalnutrition).
Figure1a:DeterminantsofChildNutrition
Source:AnadaptationoftheUNICEF(1990)“StrategyforImprovedNutritionofChildrenandWomeninDevelopingCountries”
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Sinceitsconceptionthisconceptualframeworkhasbeenrevisedandextendedinvariousdimensions.Variousinternationalorganizationshaveadoptedaswellasadaptedthisframework.Forexample,FAO(2011)discussesadaptationofthisframeworkforFAO’snutritionanalysis.USAID‐FANTA(FoodandNutritionTechnicalAssistance)alsoadaptedthisframework(Rielyetal.,1999).WorldFoodProgram(WFP)referstoitastheFoodandNutritionSecurityConceptualFrameworkinitsEmergencyFoodSecurityAssessmentHandbook(WFP,2009,pg.25).However,whatevertheadaptationsandtheextensionstotheoriginalframework,thefundamentalideasregardingthecriticalinteractions,interrelationsandsynergiesamongfoodsecurity,environmentandhealth,andcarehaveremainedatthecore.Thisisalsoverytransparentintheframeworkforactionstoachieveoptimumfetalandchildnutritionanddevelopmentextractedfromthe2013LancetMaternalandChildNutritionSeries(seeFigure1bbelow).
Figure1b:FrameworkforActionstoAchieveOptimumFetalandChildNutritionandDevelopment
Source:theExecutiveSummaryof“TheLancetMaternalandChildNutritionSeries2013.”
Theanalysisinthisreportfocusesontheunderlyingcausesofmalnutrition.Thisisbecauseactionsaimedataffectingtheunderlyingcausesofmalnutritionarelikelytobemorefeasibleinthemediumtermandthusmorelikelytohavealongtermeffectonmalnutrition.4Foodsecurity
4Oneshouldnotunderestimatethepotentialofreductionsininequalitiesinthedistributionofresourcesinthesociety,orchangesinthesocial,cultural,economicandpoliticalcontextinhavinglargeandlastingpositiveeffectonchildnutrition.However,changesinthebasiccausesofmalnutritionarelikelytobeinhibitedbymanymoreconstraintsincludingvestedinterestsandpoliticaleconomyconsiderations.
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summarizestheavailability,access,andutilization(consumption)offood.5Environmentandhealthsummarizesthevarietyofcontextualfactorsthatcanimpactonchildren’ssusceptibilitytodiseasessuchaslackofimprovedsanitationandwaterfacilities,difficultyofaccesstohealthfacilities,orlowqualityofhealthcare.Finally,maternalandchildcaresummarizesthequalityofcareprovidedbythecaregiver,suchasfeedingandhygienepracticesadoptedandbytheavailabilityofthecaregiver.Furthermoreitmeasureshowwellthecaregiverissupportedinherchildrearingendeavors.
Althoughtheframeworkisaholisticwayofconceptualizingnutritionitisalsoimportanttoacknowledgethelimitationsoftheclassificationscheme.Prices,knowledge,education,andhouseholdincomeallinfluencecomponentsofthethreeclustersoftheframework,resultinginsomeoverlapinthemeasures.Themethodologyisinformativeinfindingtheoverallrelationships,fromwhichmorefocusedanddetailedanalysescanbecarriedouttodeterminemoreconcretelytheunderlyingcauses.Soforexample,moredetailedinformationwouldbeneededtodeterminewhetherfoodinadequacieswereduetothecostoffoodrelativetoincome,tolackofinformationontheimportanceofdiversifieddiet,orduetosomeotherfactor.Themodelsestimatedinthisreportarenotreducedformmodels(takingintoaccountbudgetconstraintsetc.)asdoneinBarrera(1990),butrathercorrelationsbetweennutritionaloutcomessuchaheightforagez‐scoresandhavingadequatelevelsofaccesstoeachofthevariablesgroupedintothethreeclusters.
5Itisimportanttobearinmindthatouruseoftheterm“utilization”representsanadaptationtoFAO’suseofthesametermintheirdefinitionoffoodsecurity.ForFAO,utilizationisthefollowing: “Utilizationoffoodthroughadequatediet,cleanwater,sanitationandhealthcaretoreachastateofnutritionalwell‐beingwhereallphysiologicalneedsaremet.”Thisbringsouttheimportanceofnon‐foodinputsinfoodsecurity.http://www.fao.org/forestry/13128‐0e6f36f27e0091055bec28ebe830f46b3.pdf
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2 DataandMeasures
Measurementisveryimportantforaproperdiagnosisofthelongerrunconstraintstoreducingchronicmalnutritioninanygivencontext.Eachofthethreeclustersofunderlyingcausesofmalnutritionisinherentlymultidimensionalmakingmeasurementdifficultandcostly.AsaconsequencethemainconceptsunderpinningtheoriginalUNICEFframeworkregardingtheinterrelationshipbetweenandsynergiesamongfoodsecurity,environmentandhealth,andchildcareareusuallytakenforgrantedormistakenlyassumedtohavebeeninvestigatedbyotherearlierstudies.
Table1liststhecountriesandsourcesofdatausedinthisstudy.Twocountrieswerepurposefullychosenfromeachofthefourregionswheremalnutritionisaproblem,(i.e.SouthAsia(SAR),LatinAmericaandtheCaribbean(LAC),EastAsiaPacific(EAP),andSub‐SaharanAfrica(SSA).Additionalcriteriaappliedincluded:(i)thesurveycontainedreliableinformationofchildren’sheight(andweight)whicharethewidelyacceptedmeasuresofchronicandshort‐termmalnutrition.ThiscriterionlimitedtheanalysistotheDemographicandHealthSurveys(DHS)asthesearetheonlysurveysismostcountrieswithchildheight(andweight)measures.(ii)Datawereavailableforatleasttwoyearsinthelastdecade;(iii)malnutritionrateswerestableorslowlydecliningovertime;(iv)therewasparallelanalyticworkintheBankondifferentdimensionsofpovertyandnutritiontakingplaceinsomeofthesecountries(e.g.Ethiopia);and(v)thereweremorethanonesurveyavailableinthesamecountry(e.g.,Bangladesh).ThesamplesinmostcountriesaremainlyruralexceptforBolivia,Peru,Indonesia,andtheHelenKellersurveyinBangladeshwhereurbanhouseholdsmakeupbetweenone‐thirdandone‐halfofthesamples.TheIFPRIsurveyforBangladeshincludesonlyruralhouseholds.
Table1:CountriesandDataSources
Region Country‐datasource
SARBangladesh(HelenKeller2010,2011andIFPRI2011)Nepal(DHS2001and2011)
LACBolivia(DHS2003and2008)Peru(DHS2005and2012)
EAPCambodia(DHS2005and2010)Indonesia(Riskesdas2010)
SSAEthiopia(DHS2000and2011)Zimbabwe(DHS2005and2010)
Giventhesecriteriathesampleofchildrenusedisbetween0and24monthsinBangladesh(HelenKellerdata),Cambodia,andZimbabwe,between0and25monthsinBangladesh(IFPRIdata)andIndonesia,andbetween0and36monthsinBolivia,Ethiopia,Nepal,andPeru.6
6Inspiteofrecentfindingsthatcatch‐upgrowthoccurswithoutinterventions(Prentice,etal.,2013),orasaresultofinterventions,muchofstuntingoccursbeforetheageof24months(Victora,etal.,2010).Inadditionrecentresearchhasfoundthatcatchupgrowthinschoolagedchildrenisnotassociatedwithimprovementsincognitiveability(Sokolovic,Selvam,Srinivasan,Thankachan,Kurpadand
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Thesetofcountriesusedintheanalysisisdiscussedandthenutritionliteratureissurveyedforthepurposeofidentifyingascompletelyaspossiblethesetoffactorsidentifiedinthenutritionliteratureastheidealvariablesormeasuresofunderlyingcausesofmalnutrition.
2.1 MeasuresofFoodSecurity
Thissectionservestohighlightthefactthatthenecessarydataformeasuringthedifferentdimensionsoftheconceptoffoodsecurityeitheratthehouseholdorattheindividuallevelarethedatamissingmostfrequentlyfromthestandardsurveysusedtoassessthelevelsanddeterminantsofmalnutrition.Incontrast,moredataseemtobeavailableforthemeasurementofsomeofthecomponentsofchildcareandenvironmentandhealthwiththelatterbeingmeasuredalmostasbestasonecouldhopefor.Thisisprobablyareflectionofthetradeoffsassociatedwithmeasurementandcost.Giventhelimitedsurveybudgetsallocatedtocollectinginformationonthedifferentdimensionsofnutrition,greateremphasismaybeplacedoncollectinginformationonenvironmentandhealthandchildcareasthesearecollectedatlowercostandperhapsevenmorereliablycomparedtothecostofadetailedsurveycollectinginformationonfoodavailability,accessandutilizationatthehouseholdorindividuallevel.
Asystematiceffortismadetoidentifytheextenttowhichanyorsomeoftheseidealvariables/measuresidentifiedintheliteratureasanimportantunderlyingcauseofmalnutritioncanbeapproximatedbyanyproxymeasurethatiscollectedintheexistingsurveysusedtoanalyzeormonitorchildmalnutritionatthenationalorevenattheregionallevelwithinanygivencountry.
2.1.1 “Ideal”IndicatorsofFoodSecurity
TheFoodandAgriculturalOrganization(FAO)definesfoodsecurityas“asituationthatexistswhenallpeople,atalltimes,havephysical,socialandeconomicaccesstosufficient,safeandnutritiousfoodthatmeetstheirdietaryneedsandfoodpreferencesforanactiveandhealthylife.”Thisdefinitionisasignificantdeparturefrompreviousconceptualizationsoffoodsecuritywhichfocusedinordinatelyontheavailabilityoffoodatthenationalorlocallevel.But,inbeingbroadandallencompassing,thisdefinitionisalsoadifficultonetooperationalize,asitemphasizestheimportanceofaccessandutilizationoffoodjustasmuchasavailability(Barrett,2009).
Whatconstitutesavailability,accessandutilization–thethreedimensionsofthecurrentthinkingonfoodsecurity?Availabilityisassociatedwiththesupplysideoffood,measuredmostoftenbytheextentofagriculturalproductionandfoodtradebalancerelativetothesizeofconsumptionforanygivencountry.Access,ontheotherhand,bringsinthedemandelementtotheequation:conditionalonwhatisavailableinthelocalmarketandthepriceatwhichitisavailable,whatistherangeoffoodchoicesthatareopentohouseholdsgiventheirincomes?Conceptually,itisthisdimensionoffoodsecuritythathasthestrongestresonancewithpovertyandvulnerabilitynotonlybecauseof
Thomas,2013)althoughcatch‐upgrowthinearlierchildhoodwasassociatedwithcognitiveabilitiessimilartothosewhohadneverbeenstunted(Crookston,Penny,Alder,Dickerson,Merrill,Stanford,PorucznikandDearden,2010).
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itsdirectrelationshipwithincome,butalsobecauseofitslinkstobroaderissuesofsocialandpoliticalenfranchisement.Foodsecurityofindividualhouseholdmembers,forexamplehingesontheirsocialstandingwithinthehouseholdalmostasmuchasitdoesonthehousehold’soverallabilitytoprocureenoughfood(vulnerablegroupswithinthehouseholdmayincludechildren,daughters,daughters‐in‐law,ortheelderly).Finally,theutilizationdimensionbringstobearthequalitydimensionoftheaccessedfood.Dohousehold’smakegooduseofthefoodtheyareabletoaccess?Aredietsdiverseenoughtoprovideallthemicroandmacronutrientsnecessaryforhealthyphysiologicalandcognitivegrowth?Arecookingmethodssanitaryandhealthyenoughtopreservethenutritionalattributesoftheeatenfood?
FollowingtheFAO’sacceptedandapplieddefinitionoffoodsecurityaneffortismadetomapthemostcommonlyusedmeasuresintoatleastoneofthethreedimensionsoffoodsecurity.Specifically,themeasuresconsideredare:percapitaexpenditure;shareoffoodintotalexpenditure;percapitacaloricavailability;foodconsumptionscore(FCS);householddietarydiversityscore(HDDS);childdietarydiversityscore(CDDS);mother’sdietarydiversityscore(MDDS);householdfoodinsecurityaccessscale(HFIAS);starchystapleratio(SSR);andshareoffoodexpenditureonstarchystaples(SSEXR).
Percapitaexpenditureisawidelyusedmeasureofahousehold’swealthstatusandoverallwell‐being.Itisindicativeofresourcesthatareavailabletoahouseholdthatthehouseholdcantapintotosatisfytheirfoodrequirements.Itisthususedasoneofthemeasuresofaccesscomponentoffoodsecurity.Foodshareoftotalexpenditureisanindicatorofthehousehold’seconomicvulnerabilityandcanbeaproxymeasureofhousehold’sabilitytoaccessfood.Householdsthatspendalargerproportionoftheirtotalexpenditureonfooddonothavesufficientsafetynetofnon‐foodexpendituretorelyonandthusaremoresusceptibletofooddeprivation.Inaneventofanegativeincomeshockorincreaseinfoodprices,householdswithahighershareoffoodexpenditurewillhavetoadjustbyeitherreducingfoodquantityorbyloweringthequalityoffoodtheyeat.Percapitacaloricavailabilityisanindicatorofdietquantityandrelatestotheaccesscomponentoffoodsecurity.Itisoneofthemostwidelyusedquantitativeindicatorsoffoodsecurity.Itmeasureswhetherahouseholdhasacquiredsufficientcaloriestomeetthedailyenergyrequirementsofitsmembers.Ifahousehold’sestimatedpercapitadailyenergyavailabilityislowerthanthepercapitadailyrequirement,thenthehouseholdisconsideredenergydeficientandcanbeclassifiedasfoodinsecure.
Anothermeasureoffoodsecurityusedistheshareofcaloriesderivedfromstarchystaples–orstarchystaplesratio(SSR).Itismeasuredasthepercentageofcaloriesderivedfromstarchystaples.Starchystaplesareenergy‐densebutarelowinproteinandmicronutrientswhichmeansthathouseholdswithhighervalueofSSRwillhavealowerqualitydietandwillbemorevulnerabletoproteinandmicronutrientdeficiencies.Moreover,starchystaplesarenotonlycheapersourcesofenergybutalsofigureprominentlyasapartofhousehold’sstaplediet.JensenandMiller(2010)suggestthismeasuretobeapotentiallypromisingwaytocapturefoodsecuritywithinthehousehold.Itreliesonconsumptionbehavior,torevealthehouseholdfoodsecuritysituation,as
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opposedtocaloricnorms.7Finally,thereisalsotheexpenditureanalogofthestarchystaplesratiowhichistheshareoffoodexpendituresthatisdevotedtothepurchaseofstarchystaples.Wecallthisthestarchystaplesexpenditureratio(SSEXR).
Dietarydiversityisameasureofdietqualityandreflectsthevariationinfoodtypicallyconsumedbyhouseholds.Ingeneral,itisdefinedasasumofthenumberoffooditemsorfoodgroupsconsumedoveragivenreferenceperiod.Althoughthereisnoageneralconsensusinconstructingameasureofdietarydiversity,studieshaveshownthatvariousmeasuresofdietarydiversityarepositivelycorrelatedwithothersmeasuresofhouseholdfoodsecuritysuchaspercapitaconsumption,calorieavailability,calorieintake,andintakeofessentialnutrients.8
Twoofthemostcommonlyusedindicatorsofdietarydiversityarehouseholddietarydiversityscore(HDDS)andindividualdietarydiversityscore(IDDS),developedbyUSAIDFoodandNutritionalTechnicalAssistance(FANTA).HDDSisdefinedasthenumberofdifferentfoodgroupsconsumedatthehouseholdlevelbyanaveragememberovera24‐hourrecallperiod.Whereas,IDDSisdefinedasthenumberofdifferentfoodgroupsconsumedbyanindividualovera24‐hourrecallperiod.FANTA/FAOusestwelve,eightandninefoodgroupclassificationtoconstructtheHDDS,CDDSandMDDS,respectively.ThevalueofHDDSrangesfrom0to12andthevaluesofCDDSandMDDSrangefrom0to8and0to9,respectively.
Foodconsumptionscore(FCS)isameasureofaccesscomponentoffoodsecuritydevelopedbytheWFP.WFPusesFCSasoneofthecoremeasuresoffoodconsumptionandfoodsecuritytomonitor,assess,andtrackchangesinfoodsecuritysituationandneedsofcountriesandregionsthatithasprogramsin.Itisacompositescorethatincorporatesdietarydiversity,foodfrequency,andrelativenutritionalimportanceofdifferentfoodgroupsconsumedbyahousehold.ForthecalculationoftheFCS,dataiscollectedonthe7‐dayrecalloffrequencyofconsumptionofdifferentfooditemsandfooditemsaregroupedinto8specificfoodgroupswitheachgroupgivenaweightrepresentingthenutrientdensityofthatfoodgroup.ThevalueofFCSrangesfrom0to112withahigherFCSrepresentingahigherdietarydiversityand/orfrequencyofconsumptionandhighernutritionalvalueofahousehold’sdietandviceversa.
Householdfoodinsecurityaccessscale(HFIAS)isameasuredevelopedbyFANTAtoassessfoodaccessproblemsfacedbyhouseholdduringarecallperiodof30days.Itaimstocapturethechangesinfoodconsumptionpatternsandreflecttheseverityoffoodinsecurityfacedbyhouseholdsduetolackoforlimitedresourcestoaccessfood.Itiscomposedofninequestionsandthesequestionsrelatetothreedifferentdomainsofaccesscomponentfoodinsecurity:anxietyanduncertaintyabouthouseholdfoodaccess,insufficientquality,andinsufficientfoodintake(Swindaleetal.2006).Eachquestionhasfourresponseoptions:never,rarely,sometimes,andoften,which
7Itisbasedontheideathatatlevelsbelowsubsistence,individualshavehighmarginalutilitiesforcaloriesandarelikelytochoosecheapsourcesofcaloriessuchasrice,wheat,cassavaetc.Astheypasssubsistence,theirmarginalutilityofcaloriesbeginstodeclineandtheybegintovalueothernon‐nutritionalattributesoffoodsuchastasteandstartdiversifyingtheirdiet.Whiletheactualsubsistencethresholdisunobserved,their“dietarytransition”isandthiscanbeusedtoidentifywhetherornottheyhavecrossedthefoodsecuritythreshold.Byrelyingdirectlyonconsumptionbehaviortoelicitinformationonhungerandfoodsecurity,thismethodobviatestheneedtoimposecaloricnormsandthresholds.8Ruel(2002),Weismannetal(2009)andHoddinottandYohannes(2002).
11
arecoded0,1,2and3inorderofincreasingfrequency.Responsestotheseninequestionsaresummedtoconstructafoodinsecurityscore,withamaximumscoreof27indicatingmostfoodinsecurehouseholds.
Table2belowpresentsasummarydescriptionofallthese“ideal”indicatorsofthedifferentdimensionsoffoodsecurity.
Table2:IdealFoodSecurityMeasures
DimensionsofFoodSecurity
FoodSecurityIndicator Description
Availability
Percapitadailycalorieavailability Indicateswhetherenoughfoodisavailabletomeetthedailyenergyrequirementsofanationalorlocalpopulation.Mostcommonlyusedmeasureoffoodsecurity.
Percapitahouseholdexpenditures Capturestheamountoffoodpurchasedoracquiredduringasurveyperiod.Associatedwithgeneralmeasuresofpoverty.
Shareoffoodintotalhouseholdexpenditures
Indicatorofthehousehold’seconomicvulnerability.Associatedwithgeneralmeasuresofpoverty.
Access&Utilization
FoodConsumptionScore(FCS) Compositescorethatincorporatesdietarydiversity,foodfrequency,andrelativenutritionalimportanceofdifferentfoodgroups.
Starchystaplesratio(SSR) Percentageofcaloriesthatahouseholdderivesfromstarchystaples.Alsoassociatedwithgeneralmeasuresofpoverty.
Starchystaplesexpenditureratio(SSEXR)
Shareoffoodexpendituresdevotedtothepurchaseofstarchystaples.Alsoassociatedwithgeneralmeasuresofpoverty.
DietaryDiversityScore(HDDS) Reflectsthevarietyoffoodsthatahouseholdtypicallyconsumes.Capturesinformationaboutdietaryquality.DDSdenotesthenumberofatotalofsevenfoodgroupsconsumedduringthepast24hours.Thesevenfoodgroupsconsideredare(1)grains,rootsandtubers;(2)legumesandnuts;(3)dairyproducts;(4)fleshfoodsincludingorganmeats;(5)eggs;(6)vitaminArichfruitsandvegetablesincludingorangeandyellowvegetables;(7)andotherfruits.Ideally,thisscoreshouldbedeterminedseparatelyforthechildandmother.InourstudyitwasonlyavailableforthechildandinthecaseofIndonesiaonlyavailableasanaveragedietarydiversityscoreforthehousehold.
MinimumAcceptableDiet– Forchildrenundertheageof6months,theonlyacceptabledietconsideredisbreastfeeding.Forchildren6‐36monthstheminimumacceptabledietconsistsofaDDSof4orgreater,currentlybreastfedorreceivingmilkfeedings(includingcowandothermilksinadditiontoformulafeeds)andageappropriateminimummealfrequency.Forbreastfedchildren6‐8monthsofage,thechildneedstohavebeenfedatleasttwiceinthepast24hours,forchildren9to36monthsatleastthreetimes.Fornon‐breastfedchildrenfrom6to23monthsofage,thechildneedstohavebeenfedfourtimesinthepast24hours
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DimensionsofFoodSecurity
FoodSecurityIndicator Description
HouseholdFoodInsecurityAccessScale(HFIAS)
Subjectiveindicatorbasedonperceptionsandexperience.Themeasureisbasedonstatementssuchas:(1)Youwereworriedyouwouldrunoutoffoodbecauseoflackofmoneyorotherresources;(2)Youwereunabletoeathealthyandnutritiousfoodbecauseoflackofmoneyorotherresources;(3)Youateonlyafewkindsoffoodbecauseoflackofmoneyorotherresources;(4)Youhadtoskipamealbecausetherewasnotenoughmoneyorotherresourcestogetfood;(5)Youatelessthatyouthoughtyoushouldbecauseoflackofmoneyorotherresources;(6)Yourhouseholdranoutoffoodbecauseoflackofmoneyorotherresources;(7)Youwerehungrybutdidnoteatbecauseoflackofmoneyorotherresources;(8)Youwentwithouteatingforawholedaybecauseoflackofmoneyorotherresources. LatermodifiedintotheHouseholdHungerScale(HHS)
ChildDietaryDiversityScore(CDDS)Reflectsthevarietyoffoodconsumedbythemotherandchildandis
basedonindividuallevelintakeinformationMother’sDietaryDiversityScore(MDDS)
2.1.2 AvailableIndicatorsforFood
Table3liststhevariousindicatorsoffoodsecurityeachcapturingdifferentdimensionsoftheidealfoodsecuritymeasureandtheindicatorsthatcanbeconstructedfromthesurveys(mainlyDHS)inthecountriesstudied.
Table3:ComponentsofFoodSecurityMeasured
IdealIndicators AVAILABLE
Children'sDietaryDiversityScore(CDDS) Yes
Mom’sDietaryDiversityScore(MDDS) No
MinimumAcceptableDiet(forchildren6‐24months) Yes
FoodInsecurityAccessScale(HFIAS) No(OnlyinHelenKeller)
FoodConsumptionScore(FCS) No
Relativepricesofdifferentfoodgroups No
PROXIESIFIDEALINDICATORSARENOTAVAILABLE
HouseholdDietaryDiversityScore(forchild/mom) HelenKeller
StarchyStapleRatioortheFractionofhouseholdCaloriesDerivedfromStarchyStaples
No(sincesurveysinthisstudydonotcontaindetailedhouseholdconsumptionmodule)
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Mostofthedatasetsusedinthisstudycontaininformationtoconstructadiversityscoreforthechildandtheminimumacceptabledietmeasure,butlackinformationrelevantfortheotherdimensionsoffoodsecurity.Thediversityscoresmeasurestheconsumptionfromdifferentfoodgroups.Ingeneraltherearesevengroups(grains,rootsandtubers;legumesandnuts;dairyproducts;fleshfoodsincludingorganmeats;eggs;vitaminArichfruitsandvegetablesincludingorangeandyellowvegetables;andotherfruits)ofwhichanindividualneedsdailyconsumefour.9Theminimumacceptabledietcombinesdietarydiversity,breastfeedingandmealfrequencies.10Thedietarydiversityscoredependsontheageofthechild.Forexample,thoseundersixmonthsofageshouldbeexclusivelybreastfedwhereasolderinfantsshouldreceivecomplementaryfeedingsaswellasmilk.11FortheHelenKellerdatafromBangladesh,weareabletoconstructahouseholdlevelfoodinsecuritymeasure,butnotameasureofminimumacceptablediet.Achildhastomeetboththedietarydiversityandtheminimumacceptablediet(orfoodsecurity)definitionsbeconsideredadequateinfood.
2.2 MeasurementofChildCare
2.2.1 IdealIndicatorsforChildCare
Adequatecaremeasuresthecapacityofthechild’scaregivertoprovideahealthyenvironmentforthechildtogrowupin.Ideally,themeasureisbasedoninformationon(1)thecaregiver’seducation,knowledge,andbeliefs;(2)thehealthandnutritionalstatusofthecaregiver;(3)thementalhealth,lackofstress,andself‐confidenceofthecaregiver;(4)thecaregiver'sautonomyandcontrolofresources;(5)theworkloadandtimeconstraintsofthecaregiver;and(6)thesocialsupportreceivedbythecaregiverfromfamilymembersandthecommunity.Belowweexpandonthespecificcomponentsofanidealadequatecaremeasure.
CaringBehavior:Breast‐feedingandComplementaryFeeding,HealthSeeking,Hygiene‐Relatedo Caregiverfeedingbehavior(observationofoneormoreeatingepisodeso Caregiverresponsivenessduringfeedingepisodeso Frequencyofbehaviorsuchasfeeding,numberofspoonfuls,numberoftoucheso Breastfeedingpractices(e.g.,exclusivebreastfeedingupto6months,earlyinitiationof
breastfeeding,breastfeedingat2years)o Introductionofsolid/semi‐solid/softfoods6‐8monthso Childfeedingindex(constructedfromDHSdatausingthefollowingyes/noquestions:
currentbreastfeeding;useofbottles;dietarydiversity;feeding/mealfrequency)o Takingachildtoahealthclinicfortreatmentofillnesso Maternalhand‐washingwithsoap
MaternalEducation,knowledgeandbeliefs
9ForIndonesiathedietarydiversitymeasuresisonlyavailableforthehousehold,notspecifictoeachchild.10MealfrequencyinformationisnotavailableintheHelenKellerBangladeshsurveyorintheIndonesiaRKDsurvey.11Formilkintakeweincludebreastmilk,formula,andcow’smilk.
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o YearsofSchoolingo Literate/illiterate(Selfreport,simpletestorexistingdata)o Beliefsandknowledgeaboutinitiationofbreastfeedingo Beliefsaboutcomplementaryfeeding–timing,types,controlofintake
WorkloadandTimeAvailabilityofCaregivero Observedtimeinchildcare(observedinsampleoftimeorcontinuously)o Recalledtimeinchildcare(24hourrecall)o Qualityofcareduringworktime(characteristicsofalternatecaregivers(e.g.age,gender)
SocialSupportforCaregivero Availabilityofalternatecaregiverso Communitysupport(assessmentofcommunityinstitutionsforchildcare‐feeding
programs,childcareprograms) PsychosocialCare
o Caregiver/childinteractions–naturalisticobservationofcaregiverandchildforashortperiod(codevariablessuchasdelaytorespond,typeofresponse,levelofvocalizationbycaregiverandchild)
o Childappearance(ratingofappearanceeitherinapublicplaceoroveraperiodofvisits)o Caregiver’sunderstandingofmotormilestones
2.2.2 AvailableIndicatorsforchildcare
Oftheidealcomponentswehaveinformationonlyonafewofthecaringbehaviors,namely,someinformationonbreast‐feedingandcomplementaryfeeding.Table4liststheidealandtheavailablemeasures.Inourmeasureofadequatecare,initialbreastfeedingforimmediateskin‐to‐skincontacthastohaveoccurredwithinthefirsthourafterbirth.12Forchildrenundertheageof6months,adequatecareconsistsofexclusivebreastfeeding.Forchildren6to8monthsofagewerequirecomplementaryfeedings.Allchildrenunder24monthsarerequiredtobebreast‐fed.Althoughthesurveyshaveinformationontheeducationallevelofthemother,thepresumedcaregiver,thereisnoconsensusonhowtotranslatethatinformationtoameasureofthemother’scaregivingabilitiesandthuswedonotincludeitinourmeasure.
Table4:ComponentsofCare
IDEAL AVAILABLE
Workloadandtimeavailabilityofcaregiver No
Socialsupportforcaregiver No
Psychosocialcare No
CaringBehaviors:Breast‐feeding Yes
12ForBoliviaandPeruinitialbreastfeedingcanonlybeidentifiedinthefirst100minutes(insteadof60minutes)andthemeasureisnotavailableintheIFPRIBangladeshdata.
15
CaringBehaviors:Healthseeking No
CaringBehaviors:Complementaryfeeding Yes
CaringBehaviors:Hygiene No
CaringBehaviors:Childfeedingindex No
Notes:Anotherimportantindicatorofcareismaternaleducationthoughthereisnoconsensusonthethreshold(orlevelofeducation)foradequatenutritioncarebehaviors
2.3 MeasurementofEnvironmentandHealth
2.3.1 IdealIndicatorsforenvironmentandhealth
Theidealindicatorforadequateenvironmentandhealthcapturesaccesstoenvironmentalinfrastructureandhealthserviceutilization.TheconstructionoftheidealmeasureofadequateenvironmentandhealthisbasedonthedefinitionsadoptedbyWHOandUNICEF.Namely,
Accesstosafewater–AccordingtoWHOandUNICEF(2006),thewatersourceisconsideredimprovedifthedrinkingwaterispipedintothedwelling/yard/plot,comesfromapublictap/standpipe,comesfromatubewelloraborewell,comesfromaprotectedwellorspringorrainwaterisused.Furthermore,thedrinkingwaterisconsideredimprovedifitcomesfromanunimprovedsource(suchassurfacewater,unprotectedwellorspring)butitisdisinfectedbyeitherboiling,addingbleach/chlorineorbysolardisinfection.Unprotectedspringsordugwells,cartwithsmalltank/drum,tanker‐trucks,surfacewaterorbottledwaterareallconsideredunimproved.
Accesstoadequatesanitation–FollowingWHOandUNICEF(2006)householdsaredefinedashavingaccesstoimprovedsanitationifthehouseholdusesaflushorpourflushlatrinewithalatrinepit,septictankorpipedsewersystem,aventilatedimprovedpitlatrine,apitlatrinewithslaboracomposingtoilet.Unimprovedsanitationfacilitiesincludeflush/pourflushtounknownornon‐closedsystem,pitlatrinewithoutslab,bucket,hangingtoiletorlatrineornofacilities.Thesanitationisconsideredimprovedonlyifitisnotshared.Duetolackofinformationonsharedfacilities,theconditionisdroppedinallothercountries,butCambodia.
Communitylevelsanitation–Measuresthepercentageofhouseholdsinthechild’slocality(i.e.village)withaccesstoadequatesanitation.Athresholdof75%isused,exceptforPeruwheresanitationinformationwasnotcollected.
Useofprenatalservices–Numberofprenatalvisitsbymotherwhilepregnant.TheWHO(2007)recommendsatleast4prenatalvisitsandtheadequacymeasureuses4visitsasthethreshold.
Immunizationstatus–BasedonnationalorWHO(2013)recommendedimmunizationschedules.Dependingontheageofthechild,therequiredvaccinesdiffer.Ingeneral,forexample,thefirstDTP3(diphtheria‐tetanuspertussis)isrecommendedat6weeksofage.Givingaleewayofthreemonths,achildwhois4monthsoldisincomplianceonlyiftheyhavereceivedthefirstDTP3vaccine.
16
VitaminASupplementationstatus–BasedontheWHOguidelinesthatrecommendationchildren6through59monthsshouldreceiveavitaminAsupplementinareaswherevitaminAdeficiencyisaknownpublichealthproblem.
Presenceofunpennedanimals–Measuresthelikelihoodthatachildmaybeincontactwithnon‐humansourcedfecalmatter.
ORSusefortreatmentofdiarrhea–Measureofuseoforalrehydrationsolutionsintreatingdiarrheainyoungchildren.
Antibiotictreatmentforpneumonia–Anationalmeasurecapturingthepercentageofchildrenaged0–59monthswithsuspectedpneumoniareceivingantibiotics.
Thesurveystypicallycontainmoreinformationtoconstructacomprehensivemeasureofenvironmentandhealththancomprehensivemeasuresoffoodorcare.Inourmeasure,weconsideraccesstosafewater,improvedsanitation,andrequirethatmorethan75%ofchild’scommunityhaveaccesstoimprovedsanitation.Intermsofprenatalhealthservices,amothermusthavehadatleastfourprenatalvisits.Forpost‐natalhealthserviceswerequirethechildtohavetheirimmunizationsuptodateandthatthechildhasreceivedavitaminAsupplementation(asdropsortablets)sincebirth.AlthoughsomeofthesurveyscollectedinformationonORSuseorantibiotics,theinformationwasonlyavailableforthosechildrenwhohadrecentlyexperienceddiarrheaorabacterialinfectionandnotforallchildren.Table5liststheidealandtheavailablecomponentstobeconsideredforadequateenvironmentandhealth.
Table5:ComponentsofEnvironmentandHealth
IDEAL AVAILABLE
Accesstosafewater Yes
Accesstoimprovedsanitation Yes(exceptBolivia)
Communitylevelsanitation Yes(exceptBolivia,Ethiopia,Indonesia,andHK)*
Useofprenatalservices Yes(exceptIndonesia)
Ageappropriateimmunizationstatus Yes(exceptHK)VitaminAsupplementationstatus(typicallyforchildren6monthsandolder)
Yes(exceptIndonesia,Bolivia)
ORSusefortreatmentofdiarrhea No*CommunitylevelsanitationwasnotincludedforBoliviaasnosanitationinformationwascollected.CommunitylevelsanitationwasnotincludedintheadequacymeasuresforIndonesiaaswedidnothaveaccesstothevillageidentifiers.CommunitysanitationwasdroppedfromtheanalysesinEthiopiaandBangladeshHKastheresultingnumberofchildrenwithaccesstoadequateenvironmentbecomenegligible.
2.4 Otherdataissuesandrelatedconsiderations
17
Sinceeachsurveyisdesignedslightlydifferently,caremustbetakenwhencomparingacrossdifferentcountries.Table6summarizesthecomparabilityofthedifferentindicatorsacrossthecountriesandthesurveyyearforeachcountry.Inmostcases,thetwosurveyyearshavecomparabledataanditispossibletocomparetheevolutionoftheindicatorswithinacountry.ThenotableexceptionisBoliviawhereslightlydifferentdatawerecollectedinthetwosurveyyearsandthecomparisonofadequatefoodoradequatecaremeasuresthroughtimeisnotpossible.Comparisonsacrosscountriesaremoredifficult.Therearetwosetsofcountrieswhichhavesimilarinformation.ThefirstiscomprisedofCambodiaandZimbabweandthesecondofEthiopiaandNepal.Ifthefactthatthefirstsetcollectsinformationforunder24‐montholdsandthesecondforunder36‐montholdsisnotaconcern,thenallthefourcountriescanbecompared.
Currentlymanyhouseholdlevelsurveyshaveinformationonaspectsofenvironmentandhealthbuttheinformationregardingfoodandcareaspectsofnutritionislessrobust.Understandingthesynergiesfromtheadequaciesandnutritionwouldbenefitfrommoredetaileddatacollectionespeciallyoffoodandcarecomponents.Informationonfoodsecurityiscrucialincomplementingfooddiversityandminimumacceptabledietcomponentstoconstructaholisticadequatefoodmeasure.Informationontheknowledgeofthecaregiverregardingbestchildcarepracticesismissinginallthesurveysthatwereviewed.
Anotherimportantconsiderationisthatcurrentlymoststudiesarecross‐sectionalandwithfewquestionsregardingthetimingofvariousactionsorinformationonpastconditions.Theimplicationisthatwecanonlyassessthechild’scurrentsituationandnotthechild’scumulativeexperience.Thefactthatachildmeetstherecommendationsforhisorherageatthetimeofthesurvey,doesnotimplythatheorshehasalwaysmettheageappropriateadequacydefinitions.Soforexampleinthemajorityofourstudies,forachildthatisayearold,itisnotpossibletoknowwhetherthechildwasexclusivelybreastfeduntil6monthsandreceivedatleastonecomplementaryfoodat6to8months.SimilarlyitisnotusuallypossibletoknowifvaccinationsorvitaminAsupplementswerereceivedattherecommendedages,sincemanyfamiliesonlyreportwhetherthechildhasreceivedthevaccinationorsupplementbutnottheactualdate.Somecomponents,suchasaccesstoimprovedsanitation,mostlikelyhavenotchangedforthemajorityofchildrensincetheirbirth,butotherbehaviors,suchashandwashingmaybecomponentsthatmayhavechanged.Thelackofpastinformationpotentiallyleadstoinflatednumbersofchildrenidentifiedasadequateinaparticularcomponentwheninfacttheyhavebeeninadequateforsomespanoftimesincebirth.
Manyoftheunderlyingmeasuresaredichotomousleadingtobinaryadequacymeasures.Thechallengeandlimitationwithbinarymeasuresistheunderlyingassumptionsthatneedtobemaderegardingcut‐offvaluesorconditions.Continuousadequacymeasureswouldallowtomeasurethecorrelationsbetweenchangesintheadequacylevelsandnutritionaloutcomesandthusprovidingmoredetailedinformationontherelationshipsandsynergies.However,itisnoteasytoenvisiontheconstructionofmeaningfulcontinuousadequacymeasures.
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Table 6: Comparability of indicators across years and countries
Country and data year
Food Environment & Health Care
Maxim
um age (months)
Dietary diversity
Food security
Meal frequen
cy
Accep
table diet
Second round comparable to
first round
Improved sanitation
Community sanitation
Access to safe water
Vaccinations
Prenatal checkups
Vitam
in A supplemen
tation
Second round comparable to
first round
Exclusive breastfeeding
Immed
iate skin‐to‐skin contact
Complemen
tary feeding (6‐8
months)
Breastfeeding for 24 m
onths
Second round comparable to
first round
Cambodia (2005) 24 Y N Y Y Y Y Y Y Y Y Y Y Y Y
Cambodia (2010) 24 Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Ethiopia (2000) 36 Y N Y Y Y Y2 Y Y Y Y Y Y Y Y
Ethiopia (2011) 36 Y N Y Y Y Y Y2 Y Y Y Y Y Y Y Y Y Y
Nepal (2000) 36 Y N Y Y Y Y2 Y Y Y Y Y Y Y Y
Nepal (2012) 36 Y N Y Y Y Y Y2 Y Y Y Y Y Y Y Y Y Y
Bolivia (2003) 36 Y N N N N N Y Y Y N Y Y4 Y Y
Bolivia (2008) 36 Y N Y Y N N N Y Y Y Y N Y Y4 Y Y Y
Peru (2005) 36 Y N Y Y Y Y Y Y Y Y Y Y4 Y Y
Peru (2012) 36 Y N Y Y Y Y Y Y Y Y Y Y Y Y4 Y Y Y
Zimbabwe (2005) 24 Y N Y Y Y Y Y Y Y Y Y Y Y Y
Zimbabwe (2010) 24 Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Bangladesh (HK, 2010) 24 Y Y N N Y Y2 Y Y Y Y3 Y Y Y Y
Bangladesh (HK, 2011) 24 Y Y N N Y Y Y2 Y N Y Y3 N Y Y Y Y Y
Bangladesh (IFPRI, 2011) 24 Y N Y Y n/a Y Y Y Y Y Y n/a Y N Y Y n/a
Indonesia (RKD, 2010) 24 Y1 N N N n/a Y N Y Y N N n/a Y Y Y Y n/a
NOTES: Y = yes, N = no; 1At the household level instead of child‐specific; 2Community sanitation not included in the environment adequacy measure used in the regressions (only in summary statistics). 3Vitamin A supplementation information asked for only 6 to 24 month olds. 4Within first 100 minutes (not 60 minutes) as is used in the other countries.
19
3 Prevalenceofstuntingandaccesstoadequatefoodsecurity,childcare,andhealthandenvironment
Inlinewiththecommonpracticeintheliterature,thereportadoptsheight‐for‐ageasthemeasureofchronicmalnutrition.Giventhatstunting,height‐for‐agemorethantwostandarddeviationsbelowthemedianheight‐for‐agefortheparticularageandgender,captureschronicmalnutrition,itischosenoverwasting,weight‐for‐heightmorethantwostandarddeviationsbelowmedianweight‐for‐height,sincethelattermostfrequentlyindicatesarecentepisodeofsevereweightlossassociatedwithstarvationand/orseverediseaseresultinginacutemalnutrition.
3.1 Prevalenceofstunting
Althoughstuntingremainshighinmostofthestudycountries,ithasdecreasedsignificantlyovertimeforbothundertwo‐yearoldsaswellasforunderfive‐yearolds.Figure2depictsstuntingintheundertwo‐yeargroupintheeightcountriesandFigure3depictsstuntingintheunderfive‐yeargroup.ItisimportanttobearinmindthatforBolivia,Cambodia,Ethiopia,Nepal,Peru,andZimbabwethestuntingratesarebasedonstuntingratesreportedbytheStatCompilerofDHSfortheindicatedyearsusingallthechildrenwithheightinformation.ForBangladeshtheinformationisderivedfromtheHKandIFPRIdatasetsandforIndonesiafromtheRKDdataset.Inbothagegroupsthesevencountriesforwhichtherearemultipleyearsofdatashownoincreasesinstunting.InEthiopiaandNepalthereductionshavebeenthegreatest.From2001to2011,Nepalexperienceda17percentagepointreductionintheprevalenceofstuntinginNepalintheunder5‐yearcohortand15pointreductionintheunder2‐yearcohort.InEthiopiafrom2000to2011,stuntingreducedby13percentagepointsinbothagecohorts.EthiopiaandNepalwerealsothetwocountrieswiththehighestbaselinestuntingrates.Inaddition,Peruachievedlargereductionsinstunting,bynearlyhalvingthestuntingprevalenceintheunder5‐yearoldcohortsothatin2012theprevalenceofstuntingwas18%.Intheothercountriesthereductionshavebeenintherightdirectionbutmodestreductionsoffivepercentagepointsorless.
20
Figure2:Stuntingunder2‐yearolds
Figure3:Stuntingunder5‐yearolds
3230
37
25
20
2927
44
3130
42
26
22
17
30
26
010
2030
40P
erce
nta
ge
of c
hild
ren
with
HA
Z <
-2
SD
Bangladesh (HK)Bangladesh (IFPRI)
BoliviaCambodia
EthiopiaIndonesia (RKD)
NepalPeru
Zimbabwe
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010; Ethiopia 2000, 2011; Indonesia 2010 (RKD); Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010
Based on official DHS estimates when available
Stunting in children 0 to 23 months
Stunting year 1 Stunting year 2
36
33
43
32
27
43
40
58
44
34
57
41
29
18
35
32
020
4060
Per
cen
tag
e o
f ch
ildre
n w
ith H
AZ
< -
2 S
D
Bangladesh (HK)Bangladesh (IFPRI)
BoliviaCambodia
EthiopiaIndonesia (RKD)
NepalPeru
Zimbabwe
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010; Ethiopia 2000, 2011; Indonesia 2010 (RKD); Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010
Based on official DHS estimates when available
Stunting in children 0 to 59 months
Stunting year 1 Stunting year 2
21
Inalleightcountries,childrenlivinginresource‐poorhouseholdsaremorelikelytobestuntedthanchildrenlivinginresource‐richhouseholds.Ahouseholdisclassifiedasresourcerichifitisinthetop60%ofanassetindexandasresourcepoorthebottom40%oftheindexvalue.Annex1describestheconstructionoftheassetindex.ThedifferenceinstuntingratesbyaccesstoresourcesisespeciallymarkedinPeruwhereonly6%ofthechildreninresource‐richhouseholdsarestunted,but20%ofchildreninresource‐poorhouseholdsarestunted—aquadruplingoftheprevalence(Figure4).Similarly,theotherLACcountryofthestudy—Bolivia—showedlargedifferencesinstuntingratesbywealth.Childreninresource‐poorBolivianhouseholdsweremorethantwiceaslikelytobestuntedaschildreninresource‐richhouseholds.TheothercountrieswithalargeprevalencegapbyresourceaccesswereBangladeshbasedontheHelenKellerdataandNepal.InCambodia,Ethiopia,Indonesia,andZimbabwe,thestuntingratesforresource‐poorandresource‐richchildrenwerewithin4percentagepoints.
Figure4:Stuntingresource‐poorvsresource‐richhouseholds
3.2 AdequaciesinFoodSecurity,Environment,Health,andCarePractices
Giventheindicatorsavailableinthesurveys,thedeterminationofwhetherchildrenhaveaccesstoanadequateorinadequatelevelofeachspecificunderlyingdeterminantofnutritioniscarriedoutusingacceptedinternationalstandardsregardinginfantandchildfeedingpractices,foodsecurity,improvedwaterandsanitation,andpre‐aswellaspost‐natalcarepractices.Specifically,theWHO(2008)standardsareusedforassessinginfantandyoungchildfeedingpractices,theUSAID(2012)
42
26
44
32
35
16
3735
32
28 28
25
47
30
20
6
25
22
010
2030
4050
Per
cen
tag
e o
f ch
ildre
n w
ith H
AZ
< -
2 S
D
BGD, HKBGD, IFPRI
BOL*ETH*
IDNKHM
NPL*PER*
ZWE
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (IFPRI); Bolivia 2008; Cambodia 2010; Ethiopia 2011; Indonesia 2010 (RKD); Nepal 2011; Peru 2012; Zimbabwe 2010. *Stunting for under 36 month olds. The rest under 24 month olds.
Stunting in children 0 to 23 or 35 months
Resource poor Resource rich
22
standardsonmaternaldietarydiversity,theWHO(2013)recommendationsonchildimmunizationsschedules,theWHOandUNICEF(2006)guidelinesondrinkingwaterandsanitation,aswellasthe1990UNICEFstrategyonimprovednutritionofchildrenandwomen.InBoliviaandPerucountryspecificimmunizationpracticesareused.TheseimmunizationschedulesfollowcloselytheWHOguidelines.
Theprevalenceofadequaciesvariesacrosscountriesandresourceaccess,butinmostcontextschildrenweremostlikelytobeadequateincareandleastlikelytobeadequateinenvironmentandhealth.AdequatecarewasthefacetwhichwasmostlikelytobemetinallcountrieswiththeexceptionofIndonesia,wheretheprevalenceofadequatefoodwasgreaterthantheprevalenceofadequatecare(Figure5a,6aand7a).Inallcountriesitisadequateenvironmentandhealththatismostlacking.WiththeexceptionofBolivia,inthemostrecentsurveyforeachcountryonly10%orlessofthechildrenlivedinahouseholdwherethehousinginfrastructureandhealthopportunitieswereadequate(Figure7a).However,forBolivianoinformationonsanitationwascollectedandthusthemeasureisnotcomparabletotheothercountrieswheresanitationmeasureswereincluded.
3.2.1 Adequatefoodsecurity
Inmostcountrieseitheradequatedietarydiversityoradequatemealfrequencyisthecomponentoffoodsecuritywhichisleastprevalentamongchildren.Infourofthesevendatasetwithcomparableinformationwefindmealfrequencytobetheleastprevalentcomponentandinthreeitisdietarydiversity(Figure5a).ThetwoSouthAmericancountrieshaveabove80%ofthechildrenconsumingfoodsfromatleastfourofthesevengroups.Indonesiaalsohasmorethan80%ofchildrenwithdiversediets,however,themeasureisnotcomparabletotheotherssinceitisbasedonhouseholdfoodconsumptionandnotchild‐specificfoodconsumption.ExceptforEthiopiaandZimbabwe,morethanhalfofthechildrenunder6monthsareexclusivelybreastfed.ThehighestprevalenceofexclusivelybreastfedchildrenareinCambodia(78%)andPeru(81%).
23
Figure5a:ComponentsofAdequateFoodSecurity
Applyingstricterstandardsbyrequiringsimultaneousaccesstoadequatelevelsofeachcomponentoffoodsecurity,lessthanone‐halfoftheyoungchildreninthestudycountriesappeartohaveaccesstoadequatefoodsecurity.Infactinsixoutofthe9surveyslessthanone‐thirdofthechildrenhadaccesstoadequatefood(Figure5b).InEthiopia,withthelowestaccesstoadequatefoodsecurity,only12percentofthechildrenmetthecriteriaforadequatefoodsecurity.Asfigure5aaboveclearlyindicates,thisisprimarilyduetotheverylowprevalenceofadequatedietarydiversity(13percent).BoliviaandIndonesiaweretheonlycountrieswheremorethanhalfofthechildrenhadaccesstoadequatefoodsecurity,at51and68percent,respectively.However,inIndonesiathedietarydiversitywasnotmeasuredforeachchild,andthemeasureisbasedexclusivelyonthedietarydiversityatthehouseholdlevelsoitisnotcomparablewiththeotherstudies.Dependingonhowdifferentthechild’sdietisfromthegeneraldietofthefamily,thetrueprevalenceofadequatefoodsecuritymaybemuchsmaller.
Inmostcountries,theimprovementsinaccesstoadequatefoodsecurity(asdefinedabove)havebeenmodest(Cambodia,PeruandZimbabwe)tonone(Ethiopia,Nepal)inthe5to10yearsbetweensurveys.ThedecreaseinBoliviainaccesstoadequatefoodsecurityisduetothechangeinthedefinition.In2003noinformationwascollectedonmealfrequenciesandthustheminimumacceptabledietvariablecouldnotbeconstructed.In2008theinformationwasavailableanditwasincludedaspartofthefoodadequacymeasure,thusmakingthe2008definitionamorecomprehensiveonethanthe2003measure.Furthermore,basedontheHelenKellerdata,inBangladeshtheaccesstoadequatefoodhalvedbetween2010and2011.Comparingthesecond
45
55
72
50 51
31
80
67
54
13
49
22
86
69
33
78
66
30
67
37
8681
66
40
3026
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD (HK, '11)BGD (IFPRI, '11)
BOL ('08)ETH ('11)
IDN (RKD, '10)KHM ('10)
NPL ('11)PER ('12)
ZWE ('10)
Source: Author estimates.Note: (1) Dietary diversity: 4 out of 7 food groups. In Indonesia based on household (not child specific) dietary diversity;(2) Meal frequency depends on age
Components of Adequate Food
Dietary diversity > 5 months Exclusively breastfed < 6 months
Meal frequency Food security
24
yearoftheHelenKellersurveyandtheIFPRIsurveywhichwerebothcollectedin2011,weobservelargedifferencesinthenumberofchildrenclassifiedasadequateinfood.BasedontheIFPRIsurvey33%oftheruralchildreninBangladeshhadaccesstoadequatefoodbutonly14%ofbothruralandurbanchildrenwerefoundtobeadequateinfoodintheHelenKellersurvey.Besidessamplingadifferentpopulation,thetwosurveyslendthemselvestodifferentdefinitionsofadequatefood.InHelenKelleritisnotpossibletodeterminewhetherachildhasmettheminimumacceptabledietbasedonthecompositionandfrequencyofmeals,butitpossibletodeterminewhetherthehouseholdhasexperiencedfoodinsecurity.IntheIFPRIsampleitispossibletodeterminetheminimumacceptablediet,butnotwhetherthehouseholdexperiencedfoodinsecurity.
Figure5b:TheEvolutionofAccesstoAdequateFoodSecurity
Childreninresource‐poorhouseholdsarelesslikelytohaveaccesstoadequatefoodsecuritythanchildreninresource‐richhouseholds,butingeneralthedifferencesaresmall.Althoughinallthecountriesanalyzedchildreninresource‐poorhouseholdswerelesslikelytohaveaccesstoadequatefood,thereweredifferencesinthedegreeofdisparity(Figure5c).13Thelargestdisparity
13Weusethemostrecentyearofdataforthecomparisonsbetweenresource‐poorandresource‐richhouseholds.TheonlyexceptionistheHelenKellerdataforBangladeshwhereweuse2010andnot2011,thereasonbeingthatnovaccinationinformationwasavailablefor2011.
29
14
34
57
51
12 12
68
3134
29 28
4346
15
22
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bangladesh (HK) includes food security but no information on meal frequencies.(2) Bolivia (2003) does not include information on dietary diversity.(3) Indonesia (RKD) only has information on household level dietery diversity, and no information on meal frequencies.
Prevalence of Adequacy in Food
Year 1 Year 2
25
wasobservedinBangladeshfortheHelenKellersample,whichincludebothurbanandruralchildren,wherethedisparitywas25percentagepoints.IntheIFPRIsamplewhichonlyincludesruralchildren,therewasnodifferencebetweenthetwogroups.InBolivia,Cambodia,NepalandZimbabwe,thedifferencebetweenthetwogroupswasbetweensevenandfourpercentagepoints.Thesefindingsareconsistentwiththefundamentalroleofnutrition‐relatedbehaviorsandcaringpracticesandthecriticalneedfornutritionknowledgeacrossallincomegroups.InEthiopia,IndonesiaandPerubothresource‐richandresource‐poorchildrenhadsimilaraccesstoadequatefoodasthedifferenceswereonlyonepercentagepoint.
Figure5c:AdequateFoodSecuritybyHouseholdWealth
3.2.2 AdequateCarePractices
Morethan80%ofthechildrenunderageof24monthswerebreastfedinthecountriesstudied,butaccesstotheotherthreecomponentsofadequatecarewasmixed.14InZimbabweonly30%ofthechildrenundertheageofsixmonthswereexclusivelybreast‐fedandonlyinCambodiaandPeruweremorethanthree‐fourthsofthechildrenundersixmonthsexclusivelybreast‐fed(Figure6a).Earlyinitiationofbreastfeedingrangedfrom45%ofchildreninNepalto78%ofchildreninBolivia.
14Sinceweusedchildrenunder24or36monthsofage,thisdoesnotimplythatmorethanfour‐fifthsofthechildrenreceivedmilkuntiltheywere24monthsold.
13
3834 34
47
53
12 13
67 68
32
37
2529
46 47
18
25
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD (HK, '10)BGD (IFPRI, 11)
BOL ('08)ETH ('11)
IDN ('10)KHM ('10)
NPL ('11)PER ('12)
ZWE ('10)
Source: Author estimates.Note: (1) Bangladesh (HK) include food security but not information on minimum acceptable diet.(2) Indonesia (RKD) only has information on household level diatery diversity, nothing else.
By wealth
Prevalence of Adequacy of Food
Resource Poor Resource Rich
26
Complementaryfeedingsforsix‐toeight‐montholdswashighinBangladesh(intheIFPRIsample),Nepal,ZimbabweandBolivia,wheremorethan80%ofthechildrenoftheagerangereceivedcomplementaryfoods.InNepal,only44%ofthesix‐toeight‐montholdsreceivedcomplementaryfeedingsfromoneofthedietarydiversityfoodgroups.
Figure6a:ComponentsofAdequateCare
Applyingstricterstandardsbyrequiringsimultaneousaccesstoadequatelevelsofeachcomponentofchildcare,accesstoadequatecarehasincreasedsignificantlyovertimeinmostcountries.Adequatecareincreasedby24percentagepointsinCambodia,14percentagepointsinNepal,9percentagepointsinEthiopia,6percentagepointsinPeru,5percentagepointsinBangladesh,and3percentagepointsinZimbabwe(Figure6b).15Forthemostrecentyearofdata,mostcountrieshadaboutone‐thirdtotwo‐thirdsofthechildrenlivinginsituationswithadequatecare.However,adequatecarewasalsothemeasureforwhichmanyoftheidealcomponentsweremissing.Nonetheless,theresultssuggestanincreasedawarenessoftheimportanceofearlyinitiationofbreastfeedingandcontinuedbreastfeedinguntiltwoyearsofage,aswellasfollowingtherecommendationsonage‐appropriatecomplementaryfeedings.
15InBoliviatheprevalenceofadequatecarewasthesameforthetwosurveys.However,the2003definitiondoesnotincludevitaminAsupplementation(astheinformationwasnotcollected)andthe2008definitiondoes.
55
68 69
91
51
10096
67
7880 80
49 51 50
83
69
48
100
78
69
59
82
67
45 44
98
81
74
86
80
30
63
8482
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD (HK, '11)BGD (IFPRI, '11)
BOL ('08)ETH ('11)
IDN (RKD, '10)KHM ('10)
NPL ('11)PER ('12)
ZWE ('10)
Source: Author estimates.Note: (1) Exclusive breastfeeding for first 6 months; (2) Complementary feedings for 6- to 8-month olds;(3) Breastfeeding within 1 hour of birth (100 minutes for Bolivia and Peru);(4) Breast-fed for 24 months or currently breastfeeding if less than 24 months.
Components of Adequate Care
Exclusive breastfeeding Early breastfeeding initiation
Complementary feedings Breast-fed up to 24 months
27
Figure6b:TheEvolutionofAccesstoAdequateCare
Childreninresource‐poorhouseholdsaremorelikelytohaveaccesstoadequatecarethanchildreninresource‐richhouseholds.Possiblycontrarytoexpectation,inallcountriesexceptforNepal,childreninresource‐poorhouseholdsweremorelikelytohaveaccesstoadequatecarethanchildreninresource‐richhouseholds(Figure6c).Thatis,childrenfromresource‐poorhouseholdsdidnothaveworseaccesstothecomponentsofadequatecarethatweremeasured.Althoughthedifferencesinmostcasesweremodest,inPeru72%ofthechildreninresource‐poorhouseholdswereadequateincarewhereasonly52%ofchildreninresource‐richhouseholdswereadequate,adifferenceoftwentypercentagepoints.InBangladesh(IFPRI)andBoliviathedifferenceinadequatecarewaseightpercentagepointsandfortherestthedifferencesweresixpercentagepointsorless.Acrosstheeightcountries,childreninresourcepoorhouseholdstendedtobebreastfedlonger,butwerelesslikelytoreceivecomplementaryfeedsduringtheagesofsixtoeightmonths(Annex2).Overall,thesefindingsfurtherunderscoretheimportantroleofnutritionknowledgeregardlessofsocioeconomicstatus.
5055
84
59 59
28
37 36
28
52
24
38
55
61
3639
020
4060
8010
0
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) In Peru and Bolivia early initiation of breastfeeding is within 100 minutes, not within 60 minutes as in others.(2) Bolivia 2003 does not include information on Vitamin A supplemenation.(3) Bangladesh (HK, 2011) does not include information on vaccinations.(4) Bangladesh (IFPRI) does not include information on early initiation of breastfeeding
Prevalence of Adequacy in Care
Year 1 Year 2
28
Figure6c:AccesstoAdequateCarebyHouseholdWealth
3.2.3 AdequateEnvironmentandHealth
Ingeneralchildrenlackaccesstoimprovedwaterandsanitationinfrastructure.Figure7ahighlightsthelackofaccesstoimprovedsanitationatthehouseholdandcommunitylevel.Evenifachildhasaccesstoimprovedsanitationintheirhome,thegreatmajorityofthechildrenliveincommunitieswherelessthan75%ofthehouseholdsofthecommunityhaveaccesstoimprovedsanitation(Figure7a).OnlyintheIFPRIsampleofBangladeshichildrendomorethan50%ofthechildrenlivecommunitieswhere75%ofthehouseholdshaveaccesstoimprovedsanitation.InEthiopiaonly3%ofthechildrenliveinsuchcommunitiesandinCambodiaonly11%.However,exceptforEthiopia,morethanthree‐fourthsofchildreninthesurveyshaveaccesstoimproveddrinkingwater.Thatis,themajorityofthechildrendrinkwaterthathasbeentreatedtoreducedisease‐producingcontaminants.
52 50
89
81
64
56
3937
40
34
5451
3639
72
52
4038
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HK '10BGD, IFPRI '11
BOL '08ETH '11
IDN '10KHM '10
NPL '11PER '12
ZWE '10
Source: Author estimates.Note: (1) In Peru and Bolivia early initiation of breastfeeding is within 100 minutes, not within 60 minutes as in others.(2) Bangladesh (IFPRI) does not include information on early initiation of breastfeeding(3) Indonesia does not include information on complementary feeds for 6 to 8 month olds.
By wealth
Prevalence of Adequacy of Care
Resource Poor Resource Rich
29
Figure7a:ComponentsofAdequateEnvironment
Incontrasttothecaseofbasicinfrastructure,childrenappeartodobetterinhavingaccesstoadequatepreventivehealthservicesandfacilities.Intermsofvaccinations,therearetwogroupsofcountries.ThefirstgroupconsistingofBangladesh,Bolivia,Cambodia,PeruandZimbabwe,wheremorethantwo‐thirdsofchildrenhavehadreceivedageappropriatevaccinations.ThesecondgroupconsistingofEthiopia(15%),Indonesia(17%)andNepal(30%)wherelessthanone‐thirdhavereceivedthem(Table7b).MorethanhalfofthechildreninBolivia,Cambodia,NepalandZimbabwehavehadfourormoreprenatalvisits,andlessthanathirddidsoinBangladeshandEthiopia.Morethan50%ofthechildreninthestudieshavereceivedvitaminAsupplementation,exceptforinEthiopia(47%)andPeru(10%).InEthiopianoneofthecomponentsreach50%prevalence.
47
18
93
75
65
7981
15
3
29
64
81
28
11
84
39
20
76
53
46
75
56
33
76
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD (HK, '11)BGD (IFPRI, '11)
BOL ('08)ETH ('11)
IDN (RKD, '10)KHM ('10)
NPL ('11)PER ('12)
ZWE ('10)
Source: Author estimates.
Components of Adequate Environment
Improved sanitation Improved community sanitation
Improved drinking water
30
Figure7b:ComponentsofAdequateHealthServices
Applyingstricterstandardsbyrequiringsimultaneousaccesstoadequatelevelsofeachcomponentofenvironment/infrastructureandhealthservices,accesstoadequateinfrastructureappearstohaveincreasedovertimeinmostcountries.Forexample,accesstoadequateinfrastructurehasincreasedinBolivia,Nepal,Cambodia,andPeru(Figure7c).Ethiopiashowsverylittleprogressprimarilybecauseofthelowprevalenceofimprovedsanitationatthecommunitylevel(seealsoFigure7a).Alongsimilarlines,accesstoadequatehealthserviceshaveincreasedinBolivia,Cambodia,andZimbabwe,withlittleorveryminorprogressinEthiopia(Figure7d).16
16InPeruthedeclinewascausedbythedeclineinvitaminAsupplementaldosecoveragewhichfellfrom22%to10%.Alltheothercomponentsofthemeasureimprovedovertime.
23
53
80
26
72
80
72
67
15
28
47
17
80
64
58
30
55
7276
95
10
66
61 60
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD (HK, '11)BGD (IFPRI, '11)
BOL ('08)ETH ('11)
IDN (RKD, '10)KHM ('10)
NPL ('11)PER ('12)
ZWE ('10)
Source: Author estimates.Note: For Bangladesh (HK) Vitamin A supplementation is only for children over 6 months.
Components of Adequate Health
Adequate vaccinations 4+ prenatal visits
Vitamin A supplementation
31
Figure7c:TheEvolutionofAccesstoAdequateEnvironment
Figure7d:TheEvolutionofAccesstoAdequateHealthServices
Childreninresource‐poorhouseholdsarelesslikelytohaveaccesstoadequateenvironmentandhealthservicesthanchildreninresource‐richhouseholds.Thus,incontrasttothesituationwith
1714
45
71
81
0 1
49
5
10
2
16
32
38 36
31
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bolivia (2003 and 2008) do not include improved sanitation.(2) Ethiopia, Nepal, Bolivia, and Indonesia do not include community sanitation.
Prevalence of Adequacy in Environment
Year 1 Year 2
21
1618
42
78
4 5
18
4
35
0
13 13
8
22
27
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bangladesh (IFPRI) has Vitamin A supplementation for 6 to 24 month olds only.(2) Indonesia does not have information on prenatal checkups or Vitamin A supplementation.
Prevalence of Adequacy in Health
Year 1 Year 2
32
childcarewheretheresourcepoorhouseholdsappearedtohavehigheraccesstoadequatecarethanchildreninresourcerichhouseholds(seefigure6c),childreninresource‐poorhouseholdshaveloweraccesstoadequateinfrastructureandadequatehealthservices(Figures7eand7f).).Thesedifferencesaresubstantial.ExceptforEthiopia,thedifferencesinaccesstoadequateenvironmentalinfrastructurearemorethantenpercentagepointsinthecountriesstudiedandmorethan25percentagepointsinBolivia,Peru,andZimbabwe.ExcludingPeru,thedifferencesinaccesstoadequatehealthservicesrangesfrom4percentagepointsto12percentagepointsinoursetofcountries,favoringchildreninresource‐richhouseholds.InPeruchildreninresourcepoorhouseholdsaremorelikelytohaveaccesstoadequatehealthservices.Theresultisdrivenbythehigherlikelihoodofachildfromaresource‐poorhouseholdinhavinghadavitaminAsupplement.
Figure7e:AccesstoAdequateEnvironmentbyHouseholdWealth
8
22
38
50
63
94
0 1
41
54
0
17
7
20
11
57
4
50
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HK '10BGD, IFPRI '11
BOL '08ETH '11
IDN '10KHM '10
NPL '11PER '12
ZWE '10
Source: Author estimates.Note: (1) Bolivia does not include improved sanitation.(2) Ethiopia, Nepal, Bolivia, and Indonesia do not include community sanitation.
By wealth
Prevalence of Adequacy of Environment
Resource Poor Resource Rich
33
Figure7f:AccesstoAdequateHealthServicesbyHouseholdWealth
3.3 AdditionalConsiderations:WeakLinksinaChain
Theprecedingdiscussionsuggestsacorrelationbetweentheobservedreductionsinstuntingandtheincreasesinaccesstoadequatefoodsecurity,adequatecareandadequateenvironmentandhealthservicesoverthesameperiodinthecountriesstudied.Forthecountrieswithtwoyearsofsimilarsurveydata,theprevalenceofstuntingfell(Figures2and3).Inthesametimespanthereweremarkedimprovementsintheadequacyofcare(Figure6b),someimprovementinadequateenvironmentandhealth(Figures7cand7d)andamixedstoryinadequatefoodwithsomecountriesexperiencingadecreaseintheaccesstoadequatefood(Figure5b).Whetherthereisindeeda“causal”relationshipasopposedtoasimplecorrelationbetweenimprovedaccesstoadequatefood,careandenvironmentandhealthandtheobservedreducedstuntingandincreasedaverageheight‐for‐ageofchildren,isaquestionthatneedstobeaddressedwithmorecomplexmodelsusingdetailedpaneldataonchildrenthroughtime.
Asthefirststeptowardsexploringpotentialsynergiesinrelationtochildnutrition,theanalysisbelowinvestigatesinmoredetailtheextenttowhichchildrenhavesimultaneousaccesstoadequatelevelsinanyone,ortwo,orallthreeoftheclustersofunderlyingdeterminantsofnutrition.Sofartheaccesstoadequateenvironmentwastreatedseparatelyfromtheaccesstoadequatehealthservices.Intheremainderofthisreportenvironmentandhealtharecombinedintooneclustermainlyforthepurposeofsimplifyingthepresentation.Oneshouldbearinmind,thatcombininghealthandenvironmentintooneaggregateclustercreatesaverystrictsetofstandards
13
25
11
22
38
47
26
1719
31
38
9
14 14
4
22
30
020
4060
8010
0P
erce
nta
ge
of c
hild
ren
wh
o m
eet
crit
eria
BGD, HK '10BGD, IFPRI '11
BOL '08ETH '11
IDN '10KHM '10
NPL '11PER '12
ZWE '10
Source: Author estimates.Note: (1) Bangladesh (IFPRI) has Vitamin A supplementation for 6 to 24 month olds only.(2) Indonesia does not have information on prenatal checkups or Vitamin A supplementation.
By wealth
Prevalence of Adequacy of Health
Resource Poor Resource Rich
34
foradequacyinhealthandenvironmentrequiringsimultaneousaccesstoimprovedlevelsforeachcomponentofinfrastructureaswellasaccesstoadequatelevelforeachcomponentofhealthservices.Inthiscasethe“chainisonlyasstrongasitsweakestlink”inthesensethataslongasthereisverylowaccesstoanadequatelevelinanyoneofthecomponentsofthecluster(e.g.sanitationatthecommunitylevel)thenoverallaccesstoadequatehealthandenvironmentisforcedtobeverylow,inspiteofconsiderablyhigheraccesstoadequatelevelsintheothercomponentsofhealthandenvironment.Theprecedingargumentisalsovalidforthedeterminationofwhetherachildhasaccesstoadequatecareoradequatefoodsecurity.Aslongaseachoneoftheclustersconsistsofnumerousindicatorsmeasuringthedifferentdimensionsofchildcareorfoodsecurity,adequatecareoradequatefoodsecurityoverallwillbedeterminedbythelevelofadequacyinoneofthesub‐componentsorthe“weakestlink.”Inotherwords,theanalysisfollowingtakesitasagiventhatthethreeclusters—food,care,environmentandhealth—andthevarioussub‐componentsofeachoftheseclustersworkintandemtoproducenutritionaloutcomes.
UsingZimbabweasanexample,althoughthereare22%ofchildrenadequateinfood,39%adequateincare,and10%adequateinenvironmentandhealthcombined(Figures5a,6aand7a),manychildren(47%)arenotadequateinanycomponentandonlyafew(17%)areadequateinmorethanonecomponent(Figure8a).Asexpected,fromtheearlieranalysis,childreninresource‐richhouseholdsaremorelikelytobeadequateintwoofthethreefacets(17%vis‐à‐vis11%)andinallthreecomponents(4%vis‐à‐vis0%)thanchildreninresource‐poorhouseholds(Figure8b).ThesamegeneralpatternsappeartoholdforNepal(seeFigures8cand8d).
Figure8a Figure8b
47
8
23
6
15
2
020
4060
8010
0P
erc
ent
age
of
child
ren
who
me
et c
rite
ria
Source: Author estimates.
Adequacy status in Zimbabwe (2010)
None Food only
Care only Environmental health only
Two of three adequacies All three adequacies
53
7
29
0
11
0
44
8
18
9
17
4
020
4060
8010
0P
erc
ent
age
of
child
ren
who
me
et c
rite
ria
Resource-poor Resource-rich
Source: Author estimates.
By wealthAdequacy status in Zimbabwe (2010)
None Food only
Care only Environmental health only
Two of three adequacies All three adequacies
35
Figure8c Figure8d
Overall,thisdescriptiveanalysisrevealsthat(i)thereareonlyafewchildrenadequateinallthreeclustersand(ii)manychildrenareadequateinnoneorinonlyoneoftheunderlyingclusters.WiththeexceptionofBoliviaandBangladesh(IFPRI),morethanonequarterofthechildrendonothaveadequateaccesstoanyofthethreepillars(Figure9).Bolivia,withthecaveatthattheadequateenvironmentdoesnotmeasuresanitation,hasthehighestpercentage(13percent)ofyoungchildrenwithaccesstoadequatelevelsinallthreeclusters.TheothercountriesincludedinthestudyhavelessthanfivepercentofthechildrenmeetingthethreeadequacieswithCambodiaandEthiopiahavingthefewest,withlessthanhalfapercentofyoungchildrenhavingaccesstoallthreeadequacies.Between6%(Ethiopia)and39%(Bolivia)ofchildrenareadequateintwoofthethreeadequacies.Whenonlyoneadequacyismet,inmostofourstudycountriesitiscare.TheonlyexceptionisIndonesiawhereachildwhoonlymeetsoneoftheadequacycategoriesismorelikelytobeadequateinfoodthanincareorinenvironmentandhealth.However,inIndonesiathefoodadequacymeasureisbasedonhouseholdlevelinformationonfoodconsumptionandnotchildspecificinformationonwhatkindsoffoodsthechildconsumed.
44
14
23
2
14
2
020
4060
8010
0P
erc
ent
age
of
child
ren
who
me
et c
rite
ria
Source: Author estimates.
Adequacy status in Nepal (2011)
None Food only
Care only Environmental health only
Two of three adequacies All three adequacies
49
14
24
1
12
1
42
14
23
3
15
3
020
4060
8010
0P
erc
ent
age
of c
hild
ren
who
me
et c
rite
ria
Resource-poor Resource-rich
Source: Author estimates.
By wealthAdequacy status in Nepal (2011)
None Food only
Care only Environmental health only
Two of three adequacies All three adequacies
36
Figure9:PrevalenceofAdequacies,recentyear
Althoughchildreninresource‐richhouseholdsareingeneralmorelikelytohavemetallthreeadequacies,insomecountriestheyareaslikelyaschildrenfromresource‐poorhouseholdstomeetnoneoftheadequacies.Between6%(Ethiopia)and48%(Bolivia)ofthechildrenfromthepoorest40%ofhouseholdsareadequateinatleasttwoofthethreemeasures(Figure10a).However,childrenfromthewealthiest60%ofthehouseholds,donotfaremuchbetter,sinceonlybetween7%(Ethiopia)and55%(Bolivia)ofthechildrenareadequateinatleasttwoofthethreemeasures(Figure10b).17Thatis,inthestudycountries,childreninthewealthiesthouseholdsarestillmorelikelytobewithoutaccesstoadequatelevelsinanyofthethreeclustersthantohaveaccesstotwoormoreadequacies.
17TheprevalenceofadequaciesinBolivia,Ethiopia,NepalandIndonesiaareinflatedincomparisontotheothersasthereisnocommunitysanitationinformation.
19%3%
36%
3%
39%
13%24%
6%
33%
3% 14%2%
34%
1%
15%2%
Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)
Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)
Zimbabwe (2010)
None
Food only
Care only
Environmental health only
Two of three adequacies
All three adequacies
Source: Author estimates. See Table 5 for the specific components used in each country for the adequacy measures.
Recent year
Adequacy status
37
Figure10a:PrevalenceofAdequacies,Resource‐poorhouseholds
Figure10b:PrevalenceofAdequacies,Resource‐richhouseholds
42%
3%41%
3%11% 11%
52%
34%
3%19%
9%
20%5%
38%
9%
36%
10%32%
22%
55%
6%
33%
6%25%
31%6%1%
33%
3%
49%
14%
24%
1%12%1%
21%
7%
32%
40%
53%
7%
29%
11%
Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)
Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)
Zimbabwe (2010)
None
Food only
Care only
Environmental health only
Two of three adequacies
All three adequacies
Source: Author estimates. See Table 5 for the specific components used in each country for the adequacy measures.
Recent year
Adequacy status - Resource-poor
28%
12%
25%
6%
24%
5% 16%
41%2%
37%
3% 15%
9%
10%
11%39%
15%32%
12%25%
4%
26%
56%
6%
30%
1%7%28%
32%1%3%
33%
4%
42%
14%
23%
3%
15%3%
30%
17%22%
1%
30%
1%
44%
8%18%
9%
17%4%
Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)
Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)
Zimbabwe (2010)
None
Food only
Care only
Environmental health only
Two of three adequacies
All three adequacies
Source: Author estimates. See Table 5 for the specific components used in each country for the adequacy measures.
Recent year
Adequacy status - Resource-rich
38
4 Synergies
Inthissection,aneffortismadetoderivesomequantitativeestimatesoftheroleofsynergiesassociatedwithhavingsimultaneousaccesstoadequatelevelsinoneormoreoftheclustersoffoodsecurity,childcare,andhealthandenvironment,onchildnutrition.Theanalysisispurelydescriptive,inthatitisaimedatquantifyingthecorrelationbetweenimprovedorhigherheightforageZ‐scoresandsimultaneousaccesstoadequatelevelsinmorethanoneoftheclusters.Toexplorethepotentialsynergiesamongthethreeclustersofunderlyingdeterminantsandnutritionaloutcomes,asimpleregressionmodelisusedtosummarizeinaparsimoniouswaythedifferencesinthemeanheight‐for‐ageamongchildrenwithaccesstoonlyormoreofthethreeofthethreeclustersoftheunderlyingdeterminantsofnutrition.Purposefully,noadditionalcontrolsareusedintheseregressionssinceincludingsuchcontrolsislikelytocreatetheimpressionthataneffortismadetominimizetheinfluenceofconfoundingfactorsintherelationshipbetweenthedependentandindependentvariablesintheregression,apracticecommontoallstudiesaimedatestimatingcausalregressionswithinaneconometricframework
4.1 Model
Thefollowingeconometricspecificationisestimated
+
∗ ∗ ∗ +
∗ ∗ (A1)
whereHAZiistheHeight‐for‐AgeZ‐scoresforthechildi,andAidenotesaccesstothethreeadequacies,foreachchildi.Namely,A1is1whenthehouseholdisadequateinfood(F)andis0otherwise;A2is1whenthehouseholdisadequateinenvironmentandhealth(H)andis0otherwise;and,A3is1whenthehouseholdisadequateincare(C)andis0otherwise.Thesebinaryvariablesareconstructedwithoutanyconsiderationofwhetherthechildhasaccesstoadequatelevelsintheothertwoclusters.ItisalsoimportanttokeepinmindthattherearenoadditionalcontrolvariablesusedintheregressionbecausetheobjectivehereissimplytocomparemeanvaluesinHAZamongchildreninthesedifferentsub‐groupsofchildrendefinedbytheextenttowhichtheyhaveaccesstooneormoreofthepillars.
Inthisspecificationtheconstantterm providesanestimateofthemeanvalueofHAZscoresforchildrenwithoutaccesstoadequatefoodsecurity( =0),adequateenvironmentandhealth( =0),andadequatecare( =0).Thatis,with | 1 0 denotingtheexpected(ormean)valueofheight‐for‐age(outcome),conditionalonhavingadequateaccess(A=1)orinadequateaccess(A=0)toclusterA,theexpectedheight‐for‐ageforwhenthechilddoesnothaveadequateaccesstoanyofthethreeclustersis:18
18Itisalsoassumedthat | , , 0.
39
| 0, 0, 0
Thecoefficients yieldestimatesoftheincreaseinthemeanHAZscoreofchildrenwhenachildhasaccesstoadequatelevelsinoneoftheclustersonly(andnottheothers).Thatis:
| 1, 0, 0
| 0, 1, 0
| 0, 0, 1 ,respectively.
Specifically,thecoefficient yieldsanestimateoftheincreaseinthemeanHAZscoreofchildren(comparedtothemeanHAZscoreofreferencegroupsummarizedbytheconstantterm, )thathaveaccesstoadequatefoodsecurityonly( =1)butdonothaveaccesstoadequateenvironmentandhealth( =0),andnoaccesstoadequatecare( =0).Thecoefficients and haveananalogousinterpretationsforenvironmentandhealthandcare,respectively.
Moreover,thecoefficients yieldestimatesofthesynergiesorcomplementaritiesassociatedwith
havingaccesstoadequatelevelsinmorethanoneoftheclusterofunderlyingdeterminantsofnutrition.Specifically,themeanHAZscoreofchildrenhavingaccesstoadequatefoodsecurity( =1)andadequateenvironmentandhealth( =1)issummarizedbytheexpression
| 1, 1, 0 .
TheexpressionforthemeanvalueofHAZscoresofchildreninhouseholdswithaccesstoadequatefoodsecurityandadequateenvironmentandhealthcanbeconsideredasconsistingofthesumofthreecomponents:thefirstcomponentistheincreaseinHAZscoresassociatedwithchildreninhouseholdswithadequatefoodsecurityonly(i.e., );thesecondcomponent(i.e., )istheincreaseinHAZscoresassociatedwithchildreninhouseholdswithadequateenvironmentandhealthonly,andthethirdcomponent(i.e., )istheincreaseinHAZscoresassociatedwithchildreninhouseholdsthathaveaccesstobothadequatefoodsecurityandadequateenvironmentandhealth.Thusthecoefficient yieldsinformationonwhetherthereareadditional(extra)gains(orlosses)inHAZscoresderivedfromaccesstoadequatefoodonlyoraccesstoadequateenvironmentandhealthonly.Asignificantandpositivevalueofthecoefficient impliessynergiesfromthesimultaneousaccesstoadequatefoodsecurityandadequateenvironmentandhealthintheproductionofchildnutrition.
Alongsimilarlines,themeanHAZofchildrenfromhavingaccesstoadequatefoodsecurity( =1)andadequatecare( =1)oradequateenvironmentandhealth( =1)andcare( =1)aresummarizedbytheexpressions
| 1, 0, 1 .
| 0, 1, 1
40
withthecoefficient summarizingpotentialsynergiesfromsimultaneousaccesstoadequatefoodsecurityandadequatecareandthecoefficient summarizingpotentialsynergiesfromsimultaneousaccesstoadequateenvironmentandhealthandadequatecare.
ThemeanHAZofchildrenfromhavingaccesstoallthreecomponents(i.e.adequatefoodsecurity( =1)andadequateenvironmentandhealth( =1)andadequatecare( =1))isgivenbytheexpression
| 1, 1, 1
withthecoefficient summarizingthepotentialsynergiesfromsimultaneousaccesstoallthreecomponents.
ThemodelemployedabovedoesnotallowforcausalinferencesontheeffectsofhavingaccesstoadequatelevelsinthevariousclustersadequacycomponentsonnutritionnorprovideaformaltestoftheUNICEFframework.Amorerigorouscausalanalysiswouldrequiretheuseofmethodsaimedataddressingtheendogeneitybiasassociatedwiththefactthatmanyoftheclustersthemselvesaretoalargeextentchoicevariables(e.g.suchaschildcarevariables,vaccinations,andvisitsforprenatalcare)aswellastheinclusionofadditionalcontrolvariablesaimedatreducingoreliminatingtheimpactofothercontextualvariableomittedfromtheregression(omittedvariablebias).
Nevertheless,theestimatesfromsuchamodelserveasausefulbenchmarkforpolicyintermsofhighlightingthepotentialgainsthatcouldbeaccomplishedwithhavingsimultaneousaccesstoadequatelevelsoftheotherclusters.Thisspecificationallowsfortheexplorationofthepatternsofcorrelationbetweenthevariousadequacymeasuresandnutritionaloutcomesasmeasuredbyheight‐for‐age.Thatis,themodelestimatesthecorrelationbetweenadequaciesandheight‐for‐ageforeachchildbasedoninformationinonetimeperiod.
Animportantcaveattothemodelisthatinmanyofthecountriesanalyzedonlyasmallfractionofchildrenareadequateinenvironmentandhealth.Inmostcases,thesamplesizesaretoosmalltoyieldreliableestimatesofthesynergieswithenvironmentandhealth.Infact,inEthiopiaandNepalthecommunitylevelsanitationconditionwasdroppedgiventherestrictionitplacedonthenumberofchildrenadequateinenvironmentandhealth.
4.2 Results
Therearesignificantandsizablesynergiesassociatedwithsimultaneousaccesstoadequatelevelsin2ormoreclusters.Table7andFigure11presentasummaryoftheresultsfromestimatingEquationA1.Mostofthesynergycoefficients, , ,and ,associatedwithsimultaneousaccesstoadequatefoodsecurityandadequatecare,oradequateenvironmentandhealthandadequatecare,oradequatefoodssecurityandenvironmentandhealtharepositive.Therefore,thereare
41
additional(extra)gainsinHAZscoresoverandabovethegainsderivedfromhavingaccesstoadequatefoodonlyoraccesstoadequateenvironmentandhealthonlyoraccesstoadequatecareonly.Focusingonthefivecountriesforwhichwehavethemostcompleteinformation—Cambodia,Ethiopia,Nepal,Peru,andZimbabwe—wefindthatthesynergycoefficientsbetweentwoclustersareingeneralpositiveandthatsixoutofthefifteencoefficientsarestatisticallysignificantlygreaterthanzero.Thatis,therearepositivesynergiesfromhavingaccesstoadequatelevelsinmorethanonecluster.Giventhesmallnumberofchildrenwhoareadequateinmorethanonecomponentinmostofthecountries,itmaybethatwithadditionalobservationsthecurrentlystatisticallynon‐significantcoefficientestimateswouldbecomestatisticallysignificantandsuggestpositivesynergiesinadditionalcountries.
Accesstoadequatecareonlyisinmanycasesnegativelyassociatedwithheight‐for‐age.Allthecoefficientestimatesforcarearenon‐positivewithsixoftheeightcoefficientestimatesbeingstatisticallysignificantlynegative(Table7).Thisnegativeassociationisthelikelyconsequenceoftargetinghealthychildcarecampaignstopopulationsatrisk.Evenafteradoptingthepromotedbehaviors(suchasexclusivebreastfeedingandbreastfeedinguntilthechild’ssecondbirthday)thepopulationatriskmaystillnotbeabletoovercometheotherobstaclesinprovidingadequatenutritiontothechildren.Ofthethreemeasures,thecomponentsofadequatecarearemoreeasilymodifiedbythemotherandthefamilyastheyarebehavioral.Ultimatelyadequatefooddependsontheavailabilityofdifferentfoodtypesinthehousehold’scommunityandthefinancialabilityofthehouseholdtopurchasenutritiousfood.Adequateenvironmentandhealthpartlydependsonlargerinvestmentsininfrastructurethatahouseholdmaynothavethefinancialabilitytodo(eveniftheyhavetheknowledgeandwillingness).
Ingeneral,thesynergycoefficientfromhavingaccesstoadequatelevelsinallthreeclustersisnegative.Havinganegativesynergycoefficientinallthreedoesnotimplythatchildrenwhoareadequateinallthreeareshorter,butthatthesynergiesfromtheadequacypairsoverestimatethedifference.Table8andFigure12presentthetotalcoefficientestimateforchildrenineachspecificadequacycategory.ExceptforPeruandBangladesh(IFPRI)thechildrenwhoareadequateinallthreearealsotaller.Infourofthesevencasestheyarestatisticallysignificantlytaller.19Again,giventhesmallnumberofchildrenwhoareadequateinallthreethesecoefficientestimatesarebasedononlyafewobservations.
Synergycoefficientsdonotappeartobesystematicallydifferentforchildreninresource‐poorhouseholdsthanforchildreninresource‐richhouseholds.Thereissomepreliminaryevidencethatinsomecountries(namelyPeru,Bolivia,Nepal,BangladeshandZimbabwe)beingadequateinmorethanoneoftheadequacymeasuresisassociatedwithlargersynergiesinresource‐poorhouseholdsvis‐à‐visresource‐richhouseholds(Annex3).However,inothercases(Ethiopia,Indonesia,andCambodia)thesynergiesarelargerinresource‐richhouseholdsthaninresource‐poorhouseholds.
19InPeru,ifvitaminAsupplementsareremovedfromtheadequateenvironmentalhealthconditionthenthetotalcoefficientestimateforbeingadequateinallthreebecomes0.270anditisstatisticallysignificantatthe99%levelofconfidence.
42
Table 7: Marginal increases (Synergies) in mean HAZ of children under 37 or 24 months
Adequacy Coefficien
t
Cam
bodia (2010)
Ethiopia (2011)
Nep
al (2011)
Bolivia (2008)
Peru (2012)
Zimbabwe (2010)
Bangladesh (HK,
2010)
Bangladesh
(IFPRI, 2011)
Indonesia (RKD,
2010)
Food only 0.220 1.000*** 0.498*** 0.140 0.004 ‐0.031 0.055 ‐1.094* ‐0.187**
Environment and health only 0.214 0.863*** ‐0.212 0.059 ‐0.210 ‐0.085 0.570*** ‐0.824* 0.720***
Care only 0.092 ‐0.255*** ‐0.074 ‐0.570*** ‐0.133** ‐0.158* ‐0.121* ‐0.602*** -0.219
Environment x Food 0.208 ‐0.479 0.671* 0.166 ‐0.478 ‐0.028 ‐0.261 2.107*** ‐0.563**
Environment x Care 0.525 0.685* 0.951*** 0.329** 0.476* 0.418 ‐0.371 1.104** ‐0.136
Care x Food 0.172 0.708*** 0.331 0.473*** ‐0.090 0.332* 0.241 1.478** 0.240
Food x Care x Environment ‐0.557 ‐1.175** ‐1.701*** ‐0.573** 0.012 ‐0.387 0.415 ‐2.559*** 0.511
Observations 1,354 5,605 1,397 4,311 5,248 2,022 4,994 1,056 6,671 Source: Author calculations. Notes: *** p<0.01, ** p<0.05, * p<0.1
Table 8: Simultaneous Adequacy in 2 or more clusters and the total effect on mean HAZ of children under 37 or 24 months
Adeq
uacy
Coefficient
Cam
bodia (2010)
Ethiopia (2011)
Nep
al (2011)
Bolivia (2008)
Peru (2012)
Zimbabwe (2010)
Bangladesh (HK,
2010)
Bangladesh (IFPRI,
2011)
Indonesia (RKD,
2010)
E x F 0.643 1.384*** 0.957*** 0.365** ‐0.684** ‐0.144 0.364* 0.188 ‐0.030
E x C 0.832 1.293*** 0.665** ‐0.183* 0.133 0.175 0.078 ‐0.323 0.365
C x F 0.484*** 1.453*** 0.756*** 0.043 ‐0.219*** 0.143 0.175* ‐0.218 ‐0.166**
F x C x E
0.875*** 1.346*** 0.465 0.023 ‐0.419*** 0.062 0.528*** ‐0.391 0.365**
Source: Author calculations. Note: *** p<0.01, ** p<0.05, * p<0.1
43
Figure11:Synergyeffects
Figure12:Totaleffects
-.5
0.5
11.
52
Coe
ffici
ent
est
ima
te fr
om
Mo
del A
1
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh (HK) 2010; Bangladesh (IPRI) 2011; Bolivia 2008; Cambodia 2010; Ethiopia 2011; Nepal 2011; Peru 2012; Zimbabwe 2010
Synergies among adequacies
Environment & Food Environment & Care
Food & Care
-.5
0.5
11.
5C
oeffi
cie
nt e
stim
ate
fro
m M
ode
l A1
BGD, HKBGD, IFPRI
BOLETH
IDNKHM
NPLPER
ZWE
Source: Author estimates. Data for Bangladesh (HK) 2010; Bangladesh (IPRI) 2011; Bolivia 2008; Cambodia 2010; Ethiopia 2011; Nepal 2011; Peru 2012; Zimbabwe 2010
Total effects among adequacies
Environment & Food Environment & Care
Food & Care
44
5 ConcludingRemarksandPolicyConsiderations
ThisstudyprovidedoneofthefirstcomprehensiveinvestigationsofthedataavailabilityanddataconstraintsassociatedwithamoresystematicapplicationoftheUNICEFconceptualframeworkemphasizingtheinterrelationshipamongaccesstoadequatefoodsecurity,environmentandhealth,andchildcarepracticesintheprevalenceofmalnutritionratesamongchildrenindevelopingcountries.UsingdetaileddemographicandhealthsurveydatafromBangladesh,Bolivia,Cambodia,Ethiopia,Indonesia,NepalandZimbabwe,acomparisoniscarriedoutoftheidealvariablessummarizingthevariousdimensionsorcomponentsoffoodsecurity,environmentandhealth,andchildcareagainstthemeasuresavailablefromcurrenthouseholdsurveys.Thesecomparisonsservetohighlightthelimitationsofmostdatasetsandthepotentialgainsassociatedwiththecollectionandavailabilityofadditionalinformation.
Bearinginmindthelimitationsimposedbythedataavailable,thereportalsoprovidedapracticaldiagnosticframeworkofthemaincorrelatesofchildmalnutritionthatcouldbeappliedtoidentifypotential“bindingconstraints”towardstheefforttoreducechildmalnutrition.Specifically,theUNICEFconceptualframeworkis“operationalized”byservingasaguideforinvestigatingtherelationshipbetweentheprevalenceofmalnutritioninthecountryandinadequatelevelsandaccesstothethreepillarssummarizingtheunderlyingcausesofmalnutrition.Next,foreachindicatoravailablefromthesurveyusedincountry,adefinitionof“adequacy”isconstructedusingthresholdsbasedonacceptedinternationalstandards.Thereportaimstoprovidea“helicopterview”oftheextenttowhichnutritionaloutcomes,asmeasuredbyachild’sheight‐for‐ageZscore(HAZ)atanygivenpointintime,aswellasovertime,areassociatedwithinadequatefoodsecurity,inadequateenvironmentandhealth,andinadequatechildcarepractices.Inconsiderationofthecomplexityofthelinkagesbetweentheunderlyingcausesofmalnutritionandtheeconomicsituationofthefamily,theanalysisisalsocarriedoutseparatelyforresource‐rich(top60%)andresource‐poor(bottom40%)householdsbasedonanassetindexconstructedforthatpurpose.
Thereportalsoprovidedsomeofthefirstempiricalevidenceonthesynergiesatworkincombatingmalnutritioninthesetofcountriesusedinthisstudywhenthereissimultaneousaccesstoadequatelevelsintwoormoreofthethreepillarsoftheunderlyingcausesofmalnutrition.Whileintuitivelyappealing,thesynergiesamongthethreeclustersofmalnutritionhavereceivedlittleempiricalvalidation.Therecentemphasisonsector‐specificnutritionsensitiveinterventions(WorldBank,2013)rightlyemphasizesthesynergiesthatcanbeexploitedwithinspecificsectorssuchagriculture,waterandsanitation,orsocialprotection.Theanalysisinthereportunderscoresthepointthatthesuccessofthesesector‐specificnutrition‐sensitiveinitiativesmaybeconstrainedbytheslowprogressintakingadvantageofthesynergiesamongthethreebroadclustersoftheunderlyingdeterminantsofmalnutrition:foodsecurity,childcare,environmentandhealth.Giventhatthesynergiesamongthesethreepillarsarebeyondthescopeofanyspecificsectorsuchasagricultureorsocialprotection,thesimultaneousprogresstowardsinallofthethreepillarsiseithertakenforgrantedorunderemphasized.Asaconsequence,nutritionsensitiveinterventionsinspecificsectorsruntheriskofbeingasectoralpriorityincontextswherethechancesofsignificantsuccessmaybelimitedbecauseofnoorverylowaccesstoimprovedinfrastructurewaterandsanitationfacilities.
45
Overall,theanalysishighlightedthecriticalneedforadditionalinformationonnationalhealthsurveys.Asystematicreviewofthedataavailableinthecurrentnationalhealthsurveysinrelationtothespecificcomponentsofthethreeclustersofunderlyingcausesofmalnutritionconsideredasimportantbythenutritionalscientificcommunityrevealsthatthesesurveyscontaininformationononlyasmallfractionoftheidealmeasuresoffoodsecurity,childcareandenvironmentandhealth.Thecollectionofinformationontheseadditionalvariablescurrentlymissingfromthesesurveyswillenableamorerobustunderstandingoftheextenttowhichchildrenhaveaccesstoadequatecareoradequatefoodsecurityorenvironmentandhealth.Paneldataofyoungchildrenbetweentheagesof6and18monthswouldalsofurtherourunderstandingoftherelativecontributionofthevariouscomponentsofthethreepillars,andhowaccesstodifferentcomponentsofthethreepillarsatdifferentagesofachildaffectsnutritionaloutcomes.Inthesampleofcountriescoveredinthisreportitisfoundthatthemostcompleteinformationiscollectedonthecomponentsofenvironmentandhealth,whilethereismuchlessrobustinformationcollectedonthecomponentsofchildcareandfoodsecurity.AspointedoutbyBarrett(2010)inhisarticleonmeasuringfoodsecurity,recognitionthat“measurementdrivesdiagnosisandresponse”iscriticalforsettingarenewedandhigherstandardintheefforttoreducechildmalnutritionworldwide.
Usingalltheinformationavailable,albeitincomplete,theanalysisrevealedthatprogresstowardsimprovedaccesstoadequatefoodsecurityandtoadequateenvironmentandhealthhasbeenquitelimited.Itappearsthataccesstoadequateenvironmentandhealthremainsthegreatestchallengerelativetotheothertwopillarsoffoodsecurityandcare.Accesstoimprovedsanitationbothinthehouseholdandinthecommunityasawholewerethelowestofalltheothercomponentsofenvironmentandhealth.Inthecountriescoveredinthisreportaccesstoadequateenvironmentandhealthingeneralisnotsurpassing10%ofthepopulationofchildren.Accesstoadequatecarehasimprovedinsomecountriesbymorethan10percentagepointssuggestingthesuccessofcampaignsontheimportanceofbreastfeedingandcomplementaryfeedingwhichcomprisethemeasure.However,thishastobeviewedinperspectiveasthisimprovementisbasedonlyontheoneortwochildcarevariablesthatmaybefoundinthesurveyscollected.
Inspiteofthelimitationsinherentintheavailabledata,thereportpresentedevidenceofimportantsynergiesamongadequatefood,childcareandenvironmentandhealth.Theeconometricanalysiscarriedoutisaimedatsummarizingsimplecorrelationsratherthancausalrelations,nordoesitprovideaformaltestofthevalidityoftheUNICEFconceptualframework.However,itdoesserveasusefulevidencethataccesstoadequatelevelofserviceinmorethanonepillaratthesametimeisassociatedwithbetternutritionaloutcomescomparedtothe“sumofitsparts”.Inotherwords,intheaggregate,thereductionsinchildmalnutritionthatcanbeaccomplishedaregreaterwhensomechildrenareprovidedsimultaneouslywithaccesstoadequatefoodsecurity,care,andenvironmentandhealthcomparedtothereductioninmalnutritionthatcanbeaccomplishedbyprovidingsomeofthechildrenwithadequatehealthenvironmentandanothergroupofchildrenwithadequatefoodsecurityandanothergroupofchildrenwithadequatecare.ThedegreeandtheimportanceofthesynergiesvariesfromcountrytocountrybutingeneralsimultaneousaccesstothethreeclustersisassociatedwithhigherHAZscores.
46
Thereportalsohighlightedtheneedforincreasedawarenessattheoperationalandprojectlevelofthelimitsofexclusivelyfocusingontacklingoneparticulardimensionofinadequacywithoutconsideringthegreatercontext.Forexample,thebestdesignedprogramforimprovedaccesstonutritiousfood,mayyieldminimalreturnsiftheprogrambeneficiariesdonothaveaccesstosanitationorcleanwater.Similarly,healthcampaignstoencouragebreastfeedingorvaccinationsmaychangethesebehaviorstobeinlinewithbestpractices,butwithoutaddressingtheneedsforaccesstoadequatefoodsecurityoradequateenvironmentandhealth,mayresultinverylimitedreductionsinmalnutrition.Moreover,suchcoordinationacrosssectorsmaybenecessarynotonlyatthebroadlevelbutalsowithinsector‐specificprojects.Forexample,emphasisonimprovednutrition‐sensitiveagriculturalinterventions,suchashomegrownvegetablegardensmaybemootifmostdwellingsaresurroundedbyunpennedanimalsroamingfreelyandincreasingthepotentialexposureofachildtoanimalfecalmatter.
47
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Annex1
51
Annex1:Assetindex
Table A3: Components of asset index used to determine resource‐rich and ‐poor households
Asset Cam
bodia
Ethiopia
Nep
al
Bolivia
Peru
Zimbabwe*
Bangladesh
(HK)**
Bangladesh
(IFPRI)***
Indonesia****
Electricity yes yes yes yes yes yes
Radio yes yes yes yes yes1 yes
TV yes yes yes yes yes1 yes
Computer yes yes
Refrigerator yes yes yes
Garbage disposal yes yes
Mobile/telephone yes yes yes yes yes yes yes
Telephone yes yes yes yes
Floor type yes yes yes yes yes
Cooking fuel type yes yes yes yes yes yes yes
Roof type yes yes yes yes
Wall type yes yes yes yes
Kitchen yes yes
Bicycle yes yes yes yes yes yes
Motorcycle yes yes yes yes yes yes yes yes
Car/truck yes yes yes yes yes yes yes
Boat with motor yes yes yes yes
Oxcart/horse yes yes yes yes Notes: 1 TV and radio are combined
* Also included source of water supply, sanitation facility, ownership of a watch, land, livestock, cattle, goats, sheep, pig, poultry, having a bank account, domestic servant
** Also includes solar panel, khat/chawki, almirah, table/chair, watch/clock, rickshaw/van, power tiller, shallow machine, and fishing net. *** Also includes ownership of suitcase, buckets, stove, metal cooking pots, bed/khat/chowki, armoire/cabinet/alna, table/chair, hukka, electric fan, electric iron, audio cassette/cd player, wall clock/watch, jewelry, sewing machine, rickshaw, van, boat, dheki, jata, randa, saw, hammer, patkoa, fishing net, spade, axe, shovel, shabol, daa, khacchar, ass, solar energy panel, electricity generator, IPS, other assets, kaste, nirani, ladder, rake, plough, reaper/sickle, manual sprayer, wheelbarrow, bullock cart, push cart, light machinery, tractor, power tiller, trolley, thresher, fodder cutting machine, swing basket, don, hand tube well, treadle pump, rower pump, low lift pump, shallow tube well, deep tubewell, electric motor pump, diesel pump, spraying machines, harvester, other heavy machinery, mason equipment, potters chaka, blacksmith's hapor, charka, a servant in household, more rooms than median; the household has access to health center/hospital, bus stop, main road, railway station, local shop/shops, bazaar, nearest town, college, agricultural extension office, post office, bank, brac, Grameen bank, asa. **** Used per capita expenditures to divide the sample to resource rich (top 60%) and resource poor (bottom 40%).
Annex2
52
Annex2:Componentsofadequacymeasuresbywealth
2625
3227
4434
6764
7687
8981
3735
6964
3128
6665
7679
3629
6965
7591
802223
5245
1412
5453
6373
8375
2935
4857
5346
3175
5952
5745
0 20 40 60 80 100Percentage of children who meet criteria
ZWE ('10)
PER ('12)
NPL ('11)
KHM ('10)
IDN ('10)
ETH ('11)
BOL ('08)
BGD (IFPRI, 11)
BGD (HK, '10)
Source: Author estimates.Note: In Indonesia dietary diversity based on household (not child specific) information
By wealth
Components of Adequate Food
Resource-poor DD Exclusive Meal frequency Food security
Resource-rich DD Exclusive Meal frequency Food security
53
808586
816363
322776
869177
668576
8797
994540
4741 69
6480
866650
706776
7910010047
4965 75
838549
5151525245
7685
847576
806373
9697
10010048
579496
777959
6459
52
0 20 40 60 80 100Percentage of children who meet criteria
ZWE ('10)
PER ('12)
NPL ('11)
KHM ('10)
IDN ('10)
ETH ('11)
BOL ('08)
BGD (IFPRI, 11)
BGD (HK, '10)
Source: Author estimates.Note: Exlusive breastfeeding for first 6 months; Complementary feedings from 6 months;Early initiation of breastfeeding within 60 mins (100 mins BOL and PER) of birth; Continued breastfeeding until 24 months
By wealth
Components of Adequate Care
Resource-poor Exclusive Early initiation Complementary Breastfeeding
Resource-rich Exclusive Early initiation Complementary Breastfeeding
54
8661
526
7728
8566
6415
7521
7967
259
4524
9077
201
4212
7491
7646
3517
42
1711
9364
8079
6663
7871
9897
2411
5525
0 20 40 60 80 100Percentage of children who meet criteria
ZWE ('10)
PER ('12)
NPL ('11)
KHM ('10)
IDN ('10)
ETH ('11)
BOL ('08)
BGD (IFPRI, 11)
BGD (HK, '10)
Source: Author estimates.
By wealth
Components of Adequate Environment
Resource-poor Sanitation Community Water
Resource-rich Sanitation Community Water
55
6159
6456
7160
518
9792
7776
7076
6141
3225
5958
7057
8376
1815
4941
3024
189
6669
8258
8079
7172
3218
8278
7070
3418
9283
0 20 40 60 80 100Percentage of children who meet criteria
ZWE ('10)
PER ('12)
NPL ('11)
KHM ('10)
IDN ('10)
ETH ('11)
BOL ('08)
BGD (IFPRI, 11)
BGD (HK, '10)
Source: Author estimates.Note: In Helen Keller (HK) Vitamin A supplementation only for 6 months and older
By wealth
Components of Adequate Health
Resource-poor Vaccinations Prenatal Vitamin A
Resource-rich Vaccinations Prenatal Vitamin A
Annex3
56
Annex3:Synergiesbywealthgroup
-4 -2 0 2 4Coefficient estimate from Model A1
ZWE
PER
NPL
KHM
IDN
ETH
BOL
BGD, IFPRI
BGD, HK
Source: Author estimates. Data for Bangladesh (HK) 2010; Bangladesh (IPRI) 2011; Bolivia 2008;Cambodia 2010; Ethiopia 2011; Nepal 2011; Peru 2012; Zimbabwe 2010
By wealth
Synergies among adequacies
Resource-poor Environment & Food Environment & Care Food & Care
Resource-rich Environment & Food Environment & Care Food & Care