Why are Hindu Scheduled Caste/Tribe Children Still Prone to Higher Risk of Undernutrition than Upper Caste in India? A Chronological Study (2005-06 to 2019-21)

doi:10.21203/rs.3.rs-5033356/v1

Background & Objectives: Socioeconomic deprivation among marginalized communities in India before independence necessitates further investigation into the inequality in undernutrition prevalence between upper caste and marginalized children within the framework of SDGs 2, 3, and 10. This study aims to estimate the gap in overall undernutrition prevalence, between upper caste (UC) and Scheduled Caste/Scheduled Tribe (SC/ST) children in traditional Hindu society during the periods 2005–06, 2015–16, and 2019–21. Additionally, it seeks to quantify the contributions of various factors—including child, maternal, household, and regional backgrounds—in explaining the CIAF gap between UC and marginalized children over the past 15 years.

Design: The study employed 3 rounds of the National Family Health Survey Data (NFHS-3, 4, and 5). The Fairlie decomposition method was utilized to estimate persisting inequality and quantified contributions of different background variables in explaining the inequality between UC and SC/ST children in the prevalence of CIAF.

Results: The findings reveal a notable gap in the prevalence of CIAF between Hindu UC and SC/ST children from 2005–06 to 2019–21. Moreover, there has been a gradual reduction in these inequalities over the same period. The influence of background variables in explaining the CIAF gap between Hindu UC and SC/ST children has declined from 2005–06 to 2019–21, indicating an increasing impact of unmeasured determinants over time. This study also highlights the substantial roles of household socioeconomic status, maternal education, household WASH conditions, child anaemia levels, and birth order in explaining the CIAF gap between Hindu UC and SC/ST children over the past decade.

Conclusions: The outcome of the study suggests innervations to reduce socioeconomic inequality between UC and SC/ST sections and adequate measures to improve mothers’ education level, household WASH condition and childhood anaemia among marginalized sections for reducing inter-group difference in the prevalence of childhood undernutrition in India.

Child Health

Undernutrition

CIAF

Caste/Tribe

Social Inequality

SDG2. SDG3

SDG10

India

1.4 Background of the study

Undernutrition continues to be a pervasive public health challenge globally, and its burden is disproportionately high among children in South Asian countries, particularly India. In 2019, more than half of all stunted and two third of all wasted children under five years lived in Asia [1]. India is the largest contributor stunted and wasted children in the South Asian region. Despite implementation of various nutritional programmes by the Government of India (GOI), for eliminating undernutrition, the nation’s progress regarding this matter remains unsatisfactory. The most recent National Family Health Survey Report (NFHS-5) indicates that the prevalence of stunting, wasting, and underweight in children are 36%, 19%, and 32%, respectively, significantly exceeding the global averages [2]. Moreover, existing reports and literature underscored the disproportionate burden of stunting, wasting and being underweight across various caste, ethnic and religious groups in India over the past few decades [2-4]. In the 21st century, children from socioeconomically marginalized sections continue to bear an enormous burden of undernutrition compared to other groups. This issue demands deeper interventions to address the disproportional burden of childhood undernutrition between socioeconomically marginalized and other social groups in India.

Addressing this caste/ethnic disparity in the prevalence of childhood undernutrition is crucial for meeting several Sustainable Development Goals (SDGs), including ending hunger (SDG 2.1), eliminating malnutrition (SDG 2.2), reducing child mortality (SDG 3.2), and promoting social inclusion (SDG 10.2). In addition, “United Nations Decade of Action on Nutrition” (2016-2025) seeks to expedite coordinated efforts to eliminate hunger and eradicate all forms of malnutrition globally [5]. The World Health Organization's "Global Nutrition Targets 2025" similarly prioritize reducing stunting and wasting for children [6]. To step forward with these SDGs and global initiatives, Government of India recently (2018) launched POSHAN Abhiyan aimed to reduce stunting and underweight 2%-point per year among children [7]. However, last two rounds of NFHS survey reported 2.0% and 3.7%-point reduction of stunting and underweight respectively between 4-5 years, from 2015-16 to 2019-21 in India [2-3]. Despite substantial economic progress, India's score in Global Hunger Index (GHI) has worsened gradually over the last decade [8]. Besides, India’s current under-five child mortality (41.9 deaths per 1000 live birth) [2] is still higher than the global average (38 deaths per 1000 live birth) [9]. While this undernutrition is the major contributor of child mortality [10] and prevalence of childhood undernutrition, mortality has varied across religion, caste, and ethnic groups in India during the last 30 years [2-4], identifying the factors contributing to persistent social inequality in childhood undernutrition is therefore imperative for effective intervention and policy formulation.

The majority of the Indian population belongs to traditional Hindu society. Historically, the caste system fragmented and segregated Indian Hindu society before independence. Among these social groups, Scheduled Castes (SC) and Scheduled Tribes (ST) are the most socioeconomically disadvantaged. According to the traditional caste system, lower strata of the Hindu society recognized as SC after independence. Besides, Scheduled Tribe (ST) or Adivasis that indicates ‘original inhabitants’ or ‘indigenous’ social group in India, have mentioned geographical and social isolation, preserving own traditions, religious beliefs, cultures, and dialects, with socio-cultural values distinct from mainstream progressive Hindu society [11]. Historical deprivation of SC/ST communities in accessing health, education, and even basic amenities such as water, sanitation, and hygiene facilities is well documented previously [12-17]. Within these two marginalized communities, ST sections had greater deprivation, and slower progress compared to SC [18-19]. These socioeconomic deprivations and limited access to better health and healthcare, adequate nutritional supplements have created huge burden of childhood mortality, morbidity, undernutrition among marginalized SC, ST communities as compared to the other sections in India over past few decades [20-30]. Despite of substantial progress between 2016 to 2021 in different dimensions of health and nutrition of Indian STs remained backward than the others [31]. In this context, two critical questions arise: (i) After 76 years of independence, does inequality still exist in the prevalence of undernutrition between upper-caste and marginalized children (SC/ST) in traditional Hindu society? (ii) If so, which factors are responsible for maintaining this gap in the prevalence of undernutrition among children over the last two decades, and to what extent? The current study was conducted to answer these questions.

1.2 Evidence before this study and research gaps

Existing literature provides a comprehensive overview of child undernutrition, measured through anthropometric indicators such as stunting, wasting, and being underweight, at various time points in India. This body of work highlights the evolving understanding of the specific determinants of these three indicators of undernutrition [25, 32-37]. Additionally, numerous studies have consistently demonstrated the socioeconomic inequalities and the impact of socioeconomic factors on childhood undernutrition [38-44]. Some studies examined the social inequality and the role of caste, ethnicity, religion in child growth and the prevalence of stunting, wasting, underweight in India [25, 41, 45-50]. Maity in 2017, [51] outlined persisting inequality between SC and ST communities with greater deprivation of STs in various child health outcomes over the past few decades. However, the identification of the underlying factors driving this inequality remains unclear. Van de Poel & Speybroeck, in 2010 [52] using the NFHS-2 database (1998-99) decomposed the nutritional inequality among children between two marginalized sections, specifically SC and ST in India. No attention yet been paid in quantifying the underlying factors contributing to the inequality in childhood undernutrition between marginalized sections and non-marginalized or upper castes in India.

Besides, three popular anthropometric measures of undernutrition—stunting, wasting, and underweight—fail to capture the comprehensive picture of child undernutrition [53-56]. In this context, the Composite Index of Anthropometric Failure (CIAF) presents a more comprehensive and holistic overview of overall child's undernutrition. There is a growing interest in estimating the prevalence of undernutrition using the CIAF and identifying its determinants at both regional and national levels in India [28, 57-60] as well as in other countries [61-65]. This trend has garnered the attention of social scientists, health geographers, public health analysts, and policymakers, driving them to investigate further. However, a critical research gap exists in understanding the persistent disparities in the prevalence of overall undernutrition or CIAF, particularly between upper-caste Hindu children and those belonging to SC and ST in India.

1.3 Research objectives

The study aims to understand the prevalence of undernutrition employing the CIAF measures among children under five years of age belonging to Hindu upper castes (UC) and Scheduled SC/ST communities for the periods 2005-06, 2015-16, and 2019-21. It also seeks to identify the CIAF gap between upper-castes and socially marginalized (SC/ST) children within Indian Hindu society from 2005-06 to 2019-21. Furthermore, the investigation tries to outline the contributions of various determinants—such as the backgrounds of children, mothers, households, and geographic regions—that explain the difference in overall undernutrition prevalence between Hindu UC and SC/ST children in 2005-06, 2015-16, and 2019-21. In alignment with SDGs 2, 3, and 10, the current study endeavors to unravel the multifaceted influences of child, maternal, household, and geographic factors on the undernutrition gap and to propose evidence-based strategies to address this critical public health challenge.

1.4 Significance of the study

Firstly, the uniqueness of this study is identifying the significant factors behind this social gap in the prevalence of undernutrition. This can help frame certain policies and interventions for reducing health inequality among children from various social groups. This is linked with promoting equity and social justice for every child’s good health and well-being. Secondly, this identification can reveal systemic weaknesses within the health infrastructure. Finally, by pinpointing the specific challenges faced by SC/ST children, policymakers and public health practitioners can formulate evidence-based strategies that directly address the root causes of undernutrition in these communities.

2.1 Database and sample selection

This investigation utilizes data from the third, fourth, and fifth rounds of the National Family Health Survey (NFHS), conducted jointly by the Ministry of Health and Family Welfare (MoHFW) and the International Institute for Population Sciences (IIPS) in 2005-06, 2015-16, and 2019-21 across various states and Union Territories of India. These surveys employed a two-stage stratified sampling technique, with the probability proportional to size (PPS) method to select primary sampling units (PSUs) in both rural and urban areas [2-3].

Demographic and health information for 56,438, 238,945, and 222,233 live children under five years of age were reported in the NFHS-3, 4, and 5 survey databases, respectively. For this study, only the most recent births were considered, as information on mothers' healthcare service utilization is available for the last-born children. Among those latest-born children under five years, whose biometric measurement were taken during the time of the survey, were included in the analysis. The inclusion and exclusion criteria, as well as the number of child samples considered, are detailed in Figure 1.

The NFHS divided the entire sample into four broad categories based on caste: ST, SC, OBC (Other Backward Class), and Others. Individuals who did not identify their caste were excluded from this study. Consequently, the analysis focused on children and mothers from the SC, ST, and Other or General categories within Hindu society. In this context, children and mothers belonging to the Other or General categories in Hindu society are termed Hindu Upper Caste (Hindu UC) in this study. Therefore, the analysis includes children from three primary social groups: Hindu UC, Hindu SC, and Hindu ST.

2.2 Outcome variable

Nandy et al. [54-56] introduced the CIAF, which aggregates three popular anthropometric measures of undernutrition—stunting, wasting, and underweight—to provide a comprehensive representation of overall undernutrition. Following their methodology, this study determines the CIAF to assess the level of undernutrition. Children were marked as stunted, wasted, and underweight if their height-for-age, weight-for-height, and weight-for-age, respectively, were below -2 standard deviations according to WHO growth standards. According to Nandy et al., [54-56] combining stunted, wasted, and underweight children results in the formation of seven distinct anthropometric groups (Table 1). Children falling into any of these anthropometric failure groups are considered undernourished (CIAF) and are coded as “1,” while those belonging to no failure group are coded as “0.”

Table 1 Different subgroups of anthropometric failure
Groups	Description	Undernutrition
Groups	Description	Wasted	Stunted	Underweight
A	No failure	No	No	No
B	Wasted only	Yes	No	No
C	Wasted and Underweight	Yes	No	Yes
D	Wasted, Stunted and Underweight	Yes	Yes	Yes
E	Stunted and Underweight	No	Yes	Yes
F	Stunted only	No	Yes	No
Y	Underweight only	No	No	Yes
Source: Adopted from Nandi and others 2005, 2012

2.3 Explanatory variables

UNICEF (1998), in its conceptual framework on the causes of child malnutrition, outlined some immediate causes related to child health, such as dietary intake and disease, along with causes at the household, family, and societal levels¹. Building on this framework and various studies on the determinants of undernutrition in India [25, 28, 32-34, 36, 57, 60, 66] this study selects 19 explanatory variables across four major dimensions: children's backgrounds, mothers, households, and geographic space (see Appendix A). Households' socioeconomic condition is represented by the wealth index. The NFHS calculates the wealth index by using principal component analysis to combine various indicators of a household's characteristics, basic amenities, assets, and services. Furthermore, the physical, sociocultural, economic, and political ecology varies across different geopolitical regions and places of residence, significantly impacting health and nutritional conditions in India. Therefore, geopolitical regions and places of residence have been considered geographic determinants in this study.

2.4 Analytical strategies

Firstly, a binary assessment was administered to understand the prevalence of different categories of anthropometric failure across Hindu UC, SC, and ST groups in 2005-06, 2015-16, and 2019-21. Subsequently, the prevalence of overall undernutrition, or CIAF, across Hindu UC, SC, and ST groups was determined to obtain a comprehensive proportion of undernutrition. Additionally, the gaps in various categories of anthropometric failure and CIAF between Hindu UC and Hindu SC and ST groups were estimated for the years 2005-06, 2015-16, and 2019-21, using absolute percentage point differences. In this case, as the place was higher order among Hindu hierarchical society, Hindu UC has been considered as the base category.

Fairlie decomposition model [67] was employed to understand the explained and unexplained proportion along with the role of different background variables for creating the difference between Hindu UC, and SC, ST (Hindu UC vs Hindu SC, and Hindu UC vs Hindu ST) in the prevalence of CIAF for the year of 2005-06, 2015-16 and 2019-21. In this context, the Fairlie decomposition model (Fairlie, 1999) can be explained as follows:

Here, the first segment of the formula represents the explained portion, while the subsequent segment accounts for the unexplained part of the socio-religious gap in the probability of CIAF. s stands for Hindu SC and ST categories and u indicates Hindu are the average probability of CIAF for Hindu SC/ST and Hindu UC; is the total gap attributed to group differences; F denotes cumulative function of the logistic distribution. Multiple random sub-samples of Hindu SC and ST children (each matching the size of the Hindu UC children sample) are drawn to pair with the Hindu UC child sample individually for conducting separate decompositions. Subsequently, an approximate decomposition for the overall Hindu SC and ST sample is obtained using the mean value of all these separate decomposition estimates. In this context, as the number of replications enhances the stability of the outcome, the replication number is fixed at 500 to get the mean value of the decomposition in this study. Therefore, the average result of 500 replications of such decomposition was presented in calculation tables.

3.1 Background characteristics of the sample population

Appendix B elucidates the intricate interplay between ethnic/caste identities in Hindu society and various demographic, health, socioeconomic parameters, and geographic backgrounds of children in India. The proportion of boys exceeds that of girls across all categories, with Hindu UC consistently having the highest percentage of boys. The share of children decreases with increasing age across the three social groups. The proportion of average-sized births increased from 2005-06 to 2019-21 across all three sections of Hindu society. The proportion of children in higher birth order, those suffering from moderate or severe anemia, and those still being breastfed is comparatively higher among Hindu ST, followed by SC and UC, since 2005-06. While fever is more prevalent among Hindu UC, followed by SC and ST, there is no significant variation in the prevalence of diarrhea across these three sections of Hindu society from 2005-06 to 2019-21.

Moving to the background characteristics of mothers, the share of teenaged, thin, moderate, or severely anaemic, non-educated mothers are comparatively greater among Hindu ST, followed by SC and UC in India since 2005-06. The proportion of mothers who have not taken 4 or more ANC checkups and do not watch TV is comparatively more among Hindu ST, followed by SC and UC.

Turning to household backgrounds, UC households consistently show higher access to improved sanitation facilities with water, compared to SC and ST households. Although this type of household has increased significantly in 2019-21 across all three sections of the Hindu society. In contrast, the share of poor households is also higher among Hindu ST, followed by SC and UC since 2005-06. However, this proportion has declined across all three socioreligious groups in India between 2005-6 to 2019-21.

In examining the geographic space, notable variations emerge between Hindu UC, SC, and ST populations. Firstly, in terms of the place of residence, Hindu UC populations show higher proportions residing in urban areas compared to Hindu SC and ST populations, which may reflect differences in economic opportunities and urbanization patterns. Secondly, disparities are observed across geopolitical regions, with Hindu UC populations having higher representation in the Northern and Western part, while the share of Hindu SC and ST populations are more in socioeconomically disadvantaged regions like the Central, Eastern and Northeast, suggesting spatial inequalities that may influence access to healthcare services and socio-economic opportunities.

3.2 Prevalence and Inequality of anthropometric failures between Hindu UC, and SC/ST

Figure 2 shows all categories of anthropometric failures were comparatively higher among Hindu SC/ST children as compared to the UC in India since 2005-06. The gap between Hindu UC and SC/ST children was largest in the prevalence of the combination of stunting and underweight from 2005-06 to 2019-21. The inequality in the prevalence of triple burden of undernutrition (stunting, wasting and underweight) between UC and SC/ST children significantly declined from 2005-06 to 2019-21.

3.3 Prevalence and Inequality of CIAF between Hindu UC and Hindu SC/ST

Figure 3(a) illustrates that while all caste groups have shown improvements over time, substantial disparities persist. Hindu UC children consistently exhibit the lowest prevalence of anthropometric failures across all three surveys. In NFHS-3, 47.80% of Hindu UC children experienced anthropometric failures, which decreased to 45.05% in NFHS-4 and further to 41.25% in NFHS-5. Hindu SC children consistently have higher rates of anthropometric failures compared to Hindu UC children with a prevalence of 67.08% in NFHS-3, reducing to 59.10% in NFHS-4 and further to 55.92% in NFHS-5. Hindu ST children bear the highest burden of anthropometric failures among the three groups. In NFHS-3, the prevalence was 70.26%, which decreased to 65.34% in NFHS-4 and further to 59.68% in NFHS-5.

The gap between Hindu UC and Hindu SC children consistently indicates higher prevalence of CIAF among Hindu SC children (Figure 3(b)). In NFHS-3, the prevalence of anthropometric failures was 19.28% point higher among Hindu SC children compared to Hindu UC children. This gap reduced to -14.05% in NFHS-4 and further to -14.67% in NFHS-5, indicating a narrowing but persistent inequality. Similarly, in NFHS-3, about 22.46%-point more CIAF prevalence among Hindu ST children compared to Hindu UC children indicates a substantial gap between these two groups. This gap reduced to -20.28%-point in NFHS-4 and further to -18.42%-point in NFHS-5, suggesting a gradual improvement but persistent disparity. A comparison in the prevalence of stunting, wasting, underweight and CIAF among three social sections represented in Appendix C.

3.4 Decomposition of CIAF prevalence between Hindu UC and Hindu SC children

The Fairlie decomposition analysis (Table 2) presents consistently higher probabilities of CIAF among Hindu SC children compared to Hindu UC children across all three surveys. The gap in the probability of CIAF between Hindu UC and Hindu SC children declined from NFHS-3 to NFHS-5, but inequality existed between the two groups over time (Appendix D).

It also reveals that a substantial proportion of the gap in CIAF between Hindu UC and Hindu SC children can be explained by various background variables. In NFHS-3, 77.67% of the gap was explained by these selected variables, which decreased to 73.31% in NFHS-4 and further to 56.44% in NFHS-5. This indicates that the contribution of background variables in explaining the observed disparities has declined over time, leaving a larger proportion of the gap unexplained.

Among the background variables, socioeconomic status, maternal education level, household WASH conditions, and age group of the child consistently made significant contributions to the observed gaps in CIAF between UC and SC children. Other variables, such as birth order, nutritional level (BMI), and place of residence, also demonstrated notable contributions but varied across survey periods. Sex of the child exhibits negligible influence on the gap, with coefficients close to zero across survey waves. Conversely, age group, birth size, birth order, and child's anaemia level consistently contribute significantly to the gap, albeit with varying magnitudes.

Table 2 Fairlie Decomposition of CIAF between children belonging to Upper Castes (UC) and Scheduled Castes (SC) in Indian Hindu society
Terms of decomposition	NFHS-3 (2005-06)			NFHS-4 (2015-16)			NFHS-5 (2019-21)
Probability of CIAF among Hindu UC	0.457			0.436			0.399
Probability of CIAF among Hindu SC	0.651			0.606			0.560
Difference in the probability of CIAF	0.1939			0.1701			0.1614
Explained	0.1506			0.1247			0.0911
Unexplained	0.0433			0.0454			0.0703
Explained part (%)	77.67			73.31			56.44
Unexplained part (%)	22.33			26.69			43.56
Coefficient and contributions of the background variables for the gap of CIAF between Hindu UC and SC
Background variables	Coefficient	p-value	Contribution (%)	Coefficient	p-value	Contribution (%)	Coefficient	p-value	Contribution (%)
*Backgrounds of the children*
Sex of the child	0.000037	0.812	0.024	-0.000251	0.005	-0.201	-0.000176	0.000	-0.194
Age group of the child	-0.002462	0.000	-1.635	-0.002469	0.000	-1.980	-0.001549	0.000	-1.700
Birth size	0.001587	0.000	1.054	0.000399	0.000	0.320	0.000399	0.000	0.438
Birth order	0.012182	0.000	8.089	0.006817	0.000	5.466	0.007260	0.000	7.970
Child's anaemia level	0.018032	0.000	11.974	0.008011	0.000	6.424	0.005721	0.000	6.280
Diarrhoea	0.000274	0.206	-0.074	-0.000105	0.940	-0.084	0.000088	0.134	0.096
Fever	-0.000112	0.000	0.182	-0.000007	0.125	-0.006	0.000082	0.005	0.090
Breastfeeding	0.003710	0.001	2.464	0.004063	0.000	3.258	0.002738	0.000	3.006
*Backgrounds of the mothers*
Mother's age	-0.000212	0.640	-0.141	0.001312	0.000	1.052	0.002049	0.000	2.249
Birth in last three years	0.004157	0.000	2.761	-0.000331	0.177	-0.265	-0.000346	0.001	-0.379
Nutritional level (BMI)	0.005927	0.000	3.936	0.002051	0.000	1.645	0.000882	0.000	0.968
Anaemia level	0.000435	0.687	0.289	0.000801	0.069	0.642	0.000423	0.004	0.464
ANC 4	0.008103	0.003	5.381	0.005308	0.000	4.256	0.000506	0.109	0.556
Education level	0.027339	0.000	18.154	0.028262	0.000	22.664	0.018008	0.000	19.768
Mass media exposure	0.006519	0.035	4.329	0.007539	0.000	6.046	0.003056	0.000	3.355
*Household's backgrounds*
WASH condition	0.018828	0.001	12.503	0.016286	0.000	13.060	0.007791	0.000	8.552
Socio-economic status	0.048621	0.000	32.287	0.052391	0.000	42.013	0.048403	0.000	53.132
*Geographic Space*
Place of residence	-0.005492	0.005	-3.647	-0.004041	0.000	-3.240	-0.003198	0.000	-3.510
Geopolitical regions	0.003118	0.000	2.071	-0.001245	0.000	-0.998	-0.000936	0.000	-1.027
Samples included for the analysis; Hindu UC (N): 4821, Hindu SC (N): 3498 in NFHS-3 (2005-06); Hindu UC (N): 17149, Hindu SC (N): 22239 in NFHS-4 (2015-16); Hindu UC (N): 14024, Hindu SC (N): 21258 in NFHS-5 (2019-21).

3.5 Decomposition of CIAF prevalence between Hindu UC and Hindu ST children

Table 3 depicts a substantial gap in the risk of CIAF between Hindu UC and Hindu ST children, albeit with a declining trend over time. In NFHS-3, the probability of CIAF among Hindu ST children exceeded that among Hindu UC children by 0.2261, which decreased to 0.1972 in NFHS-5. This decline may indicate some progress in addressing the disparity, though it remains significant (Appendix D).

The analysis reveals that both explained and unexplained factors contribute to the CIAF gap between Hindu UC and Hindu ST children. In NFHS-3, 92.22% of the gap was explained by these selected variables, which decreased to 78.83% in NFHS-4 and further to 68.41% in NFHS-5. Explained factors consistently account for major portion gap, indicating the influence of socio-economic, demographic, and health-related variables in shaping CIAF differentials. However, the proportion of the gap attributed to unexplained factors increases over time, suggesting the emergence of complex and possibly unmeasured determinants.

Household-level factors, such as socio-economic status and WASH conditions, also play a pivotal role in shaping the CIAF gap. Maternal factors, including age, nutritional status (BMI), education level, and access to antenatal care (ANC), emerge as influential determinants of the CIAF gap. Sex of the child exhibits minimal influence on the gap, with coefficients close to zero in all surveys. Conversely, variables such as age group, birth order, birth size, and child's anaemia level consistently contribute significantly to the gap, highlighting their importance in driving CIAF disparities.

Table 3 Fairlie Decomposition of CIAF between children belonging to Upper Castes (UC) and Scheduled Tribes (ST) in Indian Hindu society
Terms of decomposition	NFHS-3 (2005-06)			NFHS-4 (2015-16)			NFHS-5 (2019-21)
Probability of CIAF among Hindu UC	0.457			0.436			0.399
Probability of CIAF among Hindu ST	0.684			0.657			0.596
Difference in probability of CIAF	0.2261			0.2206			0.1972
Explained	0.2085			0.1739			0.1349
Unexplained	0.0176			0.0467			0.0623
Explained part (%)	92.22			78.83			68.41
Unexplained part (%)	7.78			21.17			31.59
Coefficient and contributions of the background variables for the gap of CIAF between Hindu UC and ST
Background variables	Coefficient	p-value	Contribution (%)	Coefficient	p-value	Contribution (%)	Coefficient	p-value	Contribution (%)
*Backgrounds of the children*
Sex of the child	-0.000104	0.806	-0.050	-0.000418	0.001	-0.240	-0.000396	0.000	-0.293
Age group of the child	-0.002304	0.000	-1.105	-0.001726	0.000	-0.992	-0.001251	0.000	-0.928
Birth size	0.001054	0.000	0.506	0.000674	0.001	0.387	0.000400	0.000	0.296
Birth order	0.021848	0.000	10.479	0.003307	0.000	1.901	0.006388	0.000	4.735
Child's anaemia level	0.022502	0.000	10.793	0.008850	0.000	5.089	0.009556	0.000	7.084
Diarrhoea	0.000016	0.907	0.008	-0.000077	0.421	-0.044	0.000070	0.133	0.052
Fever	-0.000158	0.500	-0.076	0.000510	0.043	0.293	-0.000252	0.004	-0.187
Breastfeeding	0.003769	0.081	1.808	0.006434	0.000	3.700	0.003864	0.000	2.864
*Backgrounds of the mothers*
Mother's age	0.003629	0.000	1.741	0.001535	0.000	0.882	0.002187	0.000	1.621
Birth in last three years	0.000015	0.901	0.007	0.000071	0.533	0.041	-0.000103	0.001	-0.076
Nutritional level (BMI)	0.008365	0.000	4.012	0.004142	0.000	2.382	0.001751	0.004	1.298
Anaemia level	0.003022	0.239	1.449	0.001761	0.020	1.012	0.001089	0.109	0.807
ANC 4	0.003141	0.515	1.506	0.001522	0.066	0.875	0.000293	0.000	0.217
Education level	0.033188	0.000	15.917	0.033382	0.000	19.196	0.025198	0.000	18.679
Mass media exposure	0.009626	0.217	4.617	0.007307	0.003	4.202	0.005432	0.000	4.027
*Household's backgrounds*
WASH condition	0.022565	0.049	10.822	0.037621	0.000	21.634	0.012964	0.000	9.610
Socio-economic status	0.090213	0.000	43.268	0.090000	0.000	51.754	0.076889	0.000	56.997
*Geographic Space*
Place of residence	-0.007242	0.183	-3.473	-0.008345	0.000	-4.799	-0.006438	0.000	-4.772
Geopolitical regions	-0.004695	0.000	-2.252	-0.012564	0.000	-7.225	-0.002641	0.000	-1.958
Samples included for the analysis; Hindu UC (N): 4821, Hindu ST (N):1505 in NFHS-3 (2005-06); Hindu UC (N): 17149, Hindu ST (N): 13469 in NFHS-4 (2015-16); Hindu UC (N): 14024, Hindu ST (N): 13345 in NFHS-5 (2019-21).

4.1 Key findings of the study

The current study has outlined a greater prevalence of CIAF consistently since 2005-06 among Hindu ST children followed by SC and UC children in India. Although all caste groups have shown improvements in reducing undernutrition over time. These gains are largely attributed to the effective execution of various health policies aimed at combating childhood undernutrition. Key initiatives include the National Health Mission (NHM, 2005), the Integrated Child Development Scheme (ICDS, 2008–2009), Janani Suraksha Yojana (JSY, 2006–2007), Indira Gandhi Matritva Sahyog Yojana (2010), and Pradhan Mantri Matru Vandana Yojana (PMMVY, 2017), all of which focus on improving the nutrition and health status of children and mothers. In addition, strengthening household food security through schemes like the Public Distribution System (PDS, 1960), with a specific focus on disadvantaged social groups, and the National Food Security Act (NFSA, 2013), which prioritizes pregnant or lactating mothers and children (6 months-14 years of age), has likely contributed positively to reducing undernutrition over the past 2 decades across all three social sections. India’s recently launched “POSHAN Abhiyaan” (2018) aiming to make ‘Malnutrition Free India’ by 2022 may be accounted for addressing the reduction of undernutrition across all social groups during recent years.

This study also revealed a significant gap in the prevalence and risk of CIAF between Hindu UC and SC/ST children from 2005-06 to 2019-21. Although there has been a gradual reduction in these inequalities from 2005-06 to 2019-21, the differentials remain substantial. However, the findings reveal consistent and significant gaps between Hindu UC and SC/ST children across all three surveys in the prevalence of undernutrition, highlighting the persistence of social inequalities in child health outcomes in India. This finding supports the hypothesis on caste/ethnic or social inequality with the deprivation of marginalized sections (SC/ST group) in child health outcomes in India during the last 15 years [20-21, 27-29, 36, 51, 68]. These findings underscore the urgent need for targeted interventions to reduce inequality within Hindu society and address the specific needs of marginalized sections. Furthermore, in agreement with previous statements [25, 28-29, 68] it can be argued that Indian policies aimed at eliminating undernutrition and hunger may be failed to reduce the inequality in the prevalence of undernutrition significantly between marginalized sections and upper castes children in Hindu society over the past two decades.

While the contributions of background variables explaining the CIAF gap between Hindu UC and SC/SC children have declined over time (from 2005–06 to 2019–21), a significant proportion of this gap remains unexplained, suggesting the influence of complex and unmeasured multifaceted factors. It also indicates the gradual increase in the effect of unmeasured determinants over time. Further research at the regional level or qualitative studies may identify the unexplained part of the CIAF gap between Hindu UC and SC/ST in India. In this context, the selected backgrounds explained more of the CIAF gap between Hindu UC and ST as compared to the CIAF gap between Hindu UC and SC since 2005–06. Previous studies highlighted the substantial role of household’s socioeconomic status, maternal education, household WASH condition, child’s level of anaemia, and birth order in the prevalence of anthropometric failures among Indian children since past two decades [25, 29, 32-33, 52, 57, 66]. Current study updates show that the aforesaid factors significantly contributed to explaining the CIAF gap between marginalized and upper caste children in Hindu society since 2005–06 in India.

The critical role of household socioeconomic status in the prevalence of various dimensions of undernutrition—namely stunting, wasting, and underweight [31-33, 40-43]—as well as overall undernutrition (CIAF) [60-61, 66] among Indian children has been well established in earlier research. Building on these findings, the current study demonstrates that since 2005–06, household socioeconomic status has been the most significant factor driving the CIAF prevalence divide between UC and SC/ST children in Indian Hindu society. Historically a large portion of households from Hindu SC/ST communities belongs to poor socioeconomic status whereas this proportion is comparatively lower among UCs (See Appendix B). This socioeconomic marginalization, and ‘chronic poverty’ among Hindu SC/ST communities are deeply rooted in historical caste discrimination, ‘social exclusion’, discrimination, and deprivation which limits their access to employment opportunities, social capital, cultural capital and even basic household amenities [12-16]. Since independence, these circumstances have restricted access to nutritional supplements for pregnant mothers and newborns, adequate healthcare facilities, and medical care practices among Hindu SC/ST communities. This inequality in access to nutritious food and healthcare is linked to the persistent gap in overall undernutrition prevalence between Hindu UC and SC/ST children in India. The study also highlights that the contribution of socioeconomic status to explaining the inequality between upper-caste and marginalized children has increased over time. This finding is consistent with previous research indicating an increasing socioeconomic disparity in the prevalence of anthropometric failures in India over time (1990 to 2006) [38-39, 42].

Previous investigations have highlighted maternal education as a major predictor of several forms of childhood undernutrition in India [28-29, 33, 52, 57, 69]. Consistent with these findings, the present study updates the substantial contribution of maternal education levels to the persistent gap CIAF gap between UC and SC/ST children in Indian Hindu society. Historically, Hindu UC families have been privileged with higher level of maternal education which is linked to women empowerment, and enhancement of human, social and cultural capital. This advantage enables upper-caste Hindu mothers to maintain good health during pregnancy and possess accurate knowledge of healthcare management and disease control for their children. Blunch & Gupta (2020) [70] outlined existing disparities in healthcare knowledge among mothers from different castes and religions in India. In this context, the lack of health consciousness and knowledge of healthcare management among Hindu SC/ST mothers is connected to the higher prevalence of undernutrition among their children since 2005-06 in India.

Considering the substantial impact of household WASH infrastructure on the prevalence of childhood disease and undernutrition [71-74], the current study identified its significant contribution in explaining the gap between UC and SC/ST children in the prevalence of overall anthropometric failure during last 15 years. This finding supports the previous previous research demonstrating the crucial influence of a household’s WASH environment on the prevalence of various childhood diseases and undernutrition in India [75-76]. Historically, Hindu UCs have been privileged in accessing water, sanitation and hygiene facilities compared to SC/ST communities in India [28, 77]. In contrast, deprivation of the SC/ST communities in accessing WASH facilities may raise the risk of different communicable diseases as well as undernutrition among their children. However, the improvement in households' WASH infrastructure among SC/ST community over past 15 years may have reduced the contribution of the WASH environment in explaining the CIAF gap between UC and SC/ST children over time.

In line with previous research [28, 57], the current study updates the significant contribution of child birth order in explaining the inequality in the prevalence of CIAF between UC and SC/ST in Indian Hindu society. In households with more than one child, the intra-household allocation of resources tends to favour earlier-born children. The proportion of higher birth order children has been comparatively higher in SC/ST communities in India over the past 15 years (See Appendix B). Therefore, the varying proportions of higher birth order children might have played a role in the disparity in overall undernutrition rates between the UC and SC/ST children.

Building on earlier research highlighting the positive link between child anaemia and undernutrition prevalence [28], as well as the persistent inequality in childhood anaemia rates across social groups in India [29-30], the current study elucidates the substantial impact of child anaemia on the ongoing CIAF gap between UC and SC/ST children in India over the past 15 years. On the other hand, inequality in exclusive breastfeeding and continuation of breastfeeding across social groups [78] during this period may also explain the inequality in the prevalence of CIAF between UC and SC/ST children.

Corroborating previous findings on the significant impact of mothers’ mass media exposure on the prevalence of undernutrition [28, 66, 79], the current study updates the substantial contribution of mothers’ TV watching behaviour to the persistent CIAF gap between Hindu UC and SC/ST sections over past 15 years. Mothers from upper castes, benefitting from socioeconomic and educational advantages, are likely to have greater mass media access, which provides better knowledge of maintaining good health, child care practices, and locating quality medical care [35]. This situation is likely made a difference in child undernutrition prevalence between UC and SC/ST communities.

Previous studies underscored the significant impact of maternal nutritional level (BMI) on the prevalence of various anthropometric failures among Indian children [25, 28, 33]. In contrast, the current study outlines a declining effect of maternal nutritional status from 2005-06 to 2019-21, in the existing CIAF gap between UC and marginalized children in India. Additionally, the contribution of ANC (antenatal care) checkups in explaining the inequality of CIAF between UC and SC/ST children has been found to decline over time. Improvements in maternal nutritional status and the coverage of more than four ANC checkups among SC/ST mothers over the past 15 years (Appendix B) have contributed to reducing intra-group inequality. This improvement explains the declining contribution of maternal nutritional status and ANC checkups in the CIAF inequality between upper-caste and SC/ST children.

The findings of the study emphasize the persistent social disparities in child undernutrition and the need for targeted interventions to address these inequalities. Outcome of the study suggests the following interventions along with ongoing policies to eliminate social inequality (between Hindu UC and SC/ST section) in the prevalence of childhood undernutrition in India: Firstly, prioritize the interventions that are targeted to reduce socioeconomic inequalities between UC and SC/ST section. Secondly, adequate measures to improve maternal education, household WASH conditions, reduce childhood anaemia among marginalized sections through various government scheme. Additionally, interventions should focus on addressing the unexplained factors contributing to the observed disparities to ensure comprehensive and effective strategies for improving child health outcomes in India.

4.2 Limitations and strength

The current study is limited in mainly two aspects. Firstly, father’s occupational structure, education status, maternal behavioural aspects, autonomy, dietary intake and healthcare practice, all of which may have a significant impact on the result of this study.

This study significantly enhances global understanding in this field through three key advancements. Firstly, the study outlined a comprehensive scenario of the prevalence and trend of undernutrition using CIAF measures among the children from three contrasting social groups within Hindu society. It also underscores the enduring gap in CIAF prevalence between Hindu UC and Hindu SC/ST groups. Secondly, it highlighted the magnitude of the contribution of the significant factors from children, mothers, households’ backgrounds, and geographic spaces in creating this social gap in the prevalence of CIAF in India from 2005-6 to 2015-16. Thirdly, it sheds light on the explained and unexplained proportion of these social gaps in the prevalence of CIAF in India since 2005-06. As far as the author is aware, this is the first endeavour outlining the magnitude and significant factors of the inequality in the prevalence of CIAF between Hindu UC and SC/ST in India during the last two decades.

Using the nationally representative database at three time points (2005-06, 2015-16 and 2019-21) of the 21^st century the study significantly identified the enduring gap in overall undernutrition prevalence between upper castes and marginalized children of traditional Hindu society. In addition, the study outlined the major, and continuous influence of household’s socioeconomic status, WASH condition, maternal education, child’s birth order and level of anaemia in explaining the inequality of overall undernutrition between upper caste and SC/ST children in India. However, the declining contribution of all selected backgrounds from 2005-06 to 2019-21 explaining the CIAF gap between Hindu UC and SC/SC children indicates the influence of complex and unmeasured multifaceted factors. By identifying and quantifying the magnitude of the influence of the factors contributing to the overall undernutrition gap between two contrasting social sections, the present study aspires to inform targeted interventions that contribute to the global agenda of achieving zero hunger (SDG 02) and reduce child mortality (SDG 03) and promote child health equity, foster inclusivity of social groups (SDG 10) in India.

ANC: Antenatal Care

CIAF: Composite Index of Anthropometric Failure

NFHS: National Family Health Survey

SDG: Sustainable Development Goal

SC: Scheduled Caste

ST: Scheduled Tribe

UC: Upper Caste

Ethics approval and consent to participate

This study utilized publicly accessible secondary data. No personally identifiable information about survey respondents is included in the dataset. Therefore, no ethical approval is required for this study.

Consent for publication

Not Applicable

Availability of data and materials

All National Family Health Survey datasets used in the study are available at the official website of Demographic and Health Surveys (DHS): https://dhsprogram.com/data/availabledatasets.cfm. In addition, this data can be obtained by registering as a DHS data user and requesting access for legitimate research purposes: https://dhsprogram.com/data/Access-Instructions.cfm.

Competing interests

The authors declare that they have no competing interests.

Funding

This research did not receive any specific grant from any funding agency, commercial entity or non-for-profit organization.

Author’s contributions

Pritam Ghosh: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft, Writing - review & editing.

Conflict of Interest

No conflict declared

Ethical Approval

International Institute of Population Science conducted the National Family Health Survey-3, 4 & 5 and the ethical review board of this institution has given the ethical clearance of these two surveys. We have operated the analysis in this research based on these two-survey data.

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Acknowledgment

The analysis has been made based on secondary data available on the DHS website. The database has been received with a request for use only research purposes. The DHS had no role in the study design and data analysis.

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No competing interests reported.

Appendix.docx

Why are Hindu Scheduled Caste/Tribe Children Still Prone to Higher Risk of Undernutrition than Upper Caste in India? A Chronological Study (2005-06 to 2019-21)

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Version 1

Abstract

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1. Introduction

2. Database and Methodology

3. Results

4. Discussion

5. Conclusion

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References

Additional Declarations

Supplementary Files

Status:

Version 1