Four Essays on Health and Nutrition of Indian Women and ChildrenKumulative Dissertation
Datum der mündl. Prüfung:2022-07-29
Betreuer:Prof. Dr. Sebastian Vollmer
Gutachter:Prof. Dr. Holger Strulik
Gutachter:Prof. Dr. S. V. Subramanian
EnglischThis cumulative doctoral thesis consists of four research manuscripts (hereafter essays). Essay 1: Using a nationally representative dataset for India, this study sets up a quasi-experimental study design – instrumental variable (IV) approach to assess the causal effect of age of marriage among young women (aged 15-24 years) on their nutritional status. Age of menarche was used as an IV. Findings suggest that one year increase in age of marriage could yield two percentage point increase in underweight and six percentage points reduction in overweight, including obesity. Each year increase in the age of marriage could result into three percentage points decrease in the waist-to-hip ratio (WHR) of ≥0.85 centimeter (cm), and four percentage points decrease in waist circumference (WC) of >80 cm. Delayed marriage could protect young women from increasing their body mass index, weight, WHR, WC, and hip circumference. We explored a potential mechanism through which the age of marriage could affect nutritional status. Our analytical approach and study findings were verified with various robustness checks. Essay 2: India has an unacceptably high burden of vitamin A deficiency (VAD) among children aged 6-59 months. To mitigate VAD and its adverse effects on child health, the Indian government runs a nationwide vitamin A supplementation (VAS) programme. However, the effect of VAS in reducing child morbidity and mortality remains inconclusive and has been debated globally. In this paper, we estimate the effect of VAS on two indicators of child nutrition - anaemia (categorized into any anaemia, and mild/moderate anaemia) and anthropometric failure (categorized into stunting, wasting, and underweight) among children aged 6-59 months. Using the nationally representative 2015-2016 National Family Health Survey dataset from India, we estimated household and mother fixed-effects of VAS on select types of child anaemia and anthropometric failure. Findings from both the household fixed-effects and mother fixed-effects analysis showed that VAS does not influence any types of childhood anaemia and anthropometric failure in India. We discussed the findings considering existing literature and possible limitations of the study. Infirm association of Vitamin A on anaemia and anthropometric failure is probably indicative of targeted VAS intervention, as opposed to universal VAS programme. Essay 3: This study used a wide range of information on parental sociodemographic, physical and behavioral characteristics as well as on the presence of non-communicable diseases among parents and examined the association of these attributes with anthropometric failure, anaemia and mortality of their children aged 0-59 months. Findings revealed that children of fathers aged 30-39 years were less likely to experience anthropometric failure and anaemia; however, survival of children of fathers below 18 years at marriage could be threatened. Parental education had protective association with children’s anthropometric failure, anaemia and under-five mortality. With increasing maternal height, children had lower odds of anthropometric failure and under-five mortality. Tobacco use by mothers was associated with increase in under-five mortality, and children with diabetic fathers had higher odds of under-five mortality. Essay 4: This study assessed intake of iron-and-folic-acid (IFA) tablet/syrup (grouped into none, <100 days of IFA consumption or <100 IFA, and ≥100 days of IFA consumption or ≥100 IFA) among prospective mothers and its association with various stages of low-birthweight (ELBW: extremely low-birthweight, VLBW: very low-birthweight, and LBW: low-birthweight) and neonatal mortality (death during day 0-1, 2-6, 7-27, and 0-27) in India. The cross-sectional, nationally representative, 2015-2016 National Family Health Survey (NFHS-4) data were used. Weighted descriptive analysis, and multiple binary logistic regression modelling were used. A total of 120,374 and 143,675 index children aged 0-59 months were included to analyze LBW and neonatal mortality, respectively. Overall, 30.7% mothers consumed ≥100 IFA in 2015-2016, and this estimate ranged from 0.0% in Zunheboto district of Nagaland state to 89.5% in Mahe district of Puducherry of India. Multiple regression analysis revealed that children of mothers who consumed ≥100 IFA had lower odds of ELBW, VLBW, LBW, and neonatal mortality during day 0-1, as compared to mothers who did not buy/receive any IFA. Consumption of IFA (<100 IFA and ≥100 IFA) had protective association with neonatal death during day 7-27, and 0-27. Consumption of IFA was not associated with neonatal death during day 2-6. While ≥100 IFA consumption during pregnancy was found to be associated with preventing select types of LBW and neonatal mortality, a large variation in coverage of ≥100 IFA consumption across 640 districts is concerning.
Keywords: anthropometry; nutrition; youth; quasi-experiment; instrumental variable; Vitamin A; anaemia; micronutrients; undernutrition; Epidemiology; Public Health; anthropometric failure; child anaemia; child mortality; social determinants of health; iron-deficiency anaemia; iron-and-folic-acid; India