Analysing causes for under nutrition among urban poor women in Orissa and formulating a partnership model for

intervention

An independent research report submitted to Xavier Institute of Management By Vijay Rangarajan U308059, PGDM(Rural Management) 2008-10 Faculty Guide: Prof. Sandip Anand

1. Acknowledgement

I acknowledge with deep gratitude the help, encouragement and guidance rendered by my Guide Prof. Sandip Anand, Associate Professor, Marketing, Xavier Institute of Management in conducting my independent research project. I really appreciate his warm behaviour and friendliness. I thank him for spending time in clarifying all my doubts and providing insights of his research work which really quickened the learning process facilitating better understanding of the project. I would like to thank Hemalatha Jali, Sabita Dighalo, Krushna Nayak, Maguni Nayak and Saninlata Swain of Saliya Sahi slum for spending their time answering questions patiently without considering it as an intrusion to their private life. I also thank Prof. S.S Singh, Prof.S Peppin and Prof. Bipin Das for their guidance. Finally, I thank the institute for providing me an opportunity to conduct this research study helping me to understand about women malnutrition in Orissa.

Vijay Rangarajan Date: 23-Feb-2010

Contents

1. 2.

Acknowledgement ........................................................................................................................... 2 Abbreviations................................................................................................................................... 5

Definitions ............................................................................................................................................... 5 3. 4. Abstract ........................................................................................................................................... 8 Introduction ..................................................................................................................................... 9 Figure 1: Vicious Cycle of Poverty (National Nutritional Policy, Department of Human Resource Development, 1993) ............................................................................................................................ 9 5. 6. 7. Focus of the study .......................................................................................................................... 12 Objectives of the study .................................................................................................................. 13 Methodology ................................................................................................................................. 13 7.1 7.2 7.3 Ethnographic Study ................................................................................................................ 13 Data ....................................................................................................................................... 14 Outcome measures ................................................................................................................ 15

Table 1: Body Mass Index ................................................................................................................ 16 Table 2: Anemia Level ...................................................................................................................... 16 7.4 Covariates .............................................................................................................................. 16

Table 3: Covariates ............................................................................................................................ 17 7.5 7.6 Recoding of Variables ............................................................................................................. 21 Analysis .................................................................................................................................. 22

Table 4: Determinants of Anaemia (Dependent Variable Anaemic = 0, Not-Anaemic = 1) Odds Ratio from Logistic Regression .................................................................................................................... 22 3

8. 9. 10. 11.

Findings ......................................................................................................................................... 25 Limitations of the study ................................................................................................................. 27 References ................................................................................................................................. 28 Annexure ................................................................................................................................... 29

Annexure I Rural/Urban comparision of Anaemia Levels among women who belong to poorer and poorest wealth Index ................................................................................................................ 29 Annexure II: Unadjusted Logistic Regression Model ........................................................................... 30 Annexure III: Adjusted Logistic regression Model .............................................................................. 33

2. Abbreviations

AWC AWW BMI DHS ICDS NFHS

Anganwadi Worker Anganwadi Worker Body Mass Index Demographic and Health Survey Integrated Child Development Services National Family Health Survey

Definitions

Anemia

Low level of hemoglobin in the blood, as evidenced by a reduced quality or quantity of Red Blood cells; 50 per cent of anemia in world is caused by iron deficiency.

BMI

Body Mass Index (BMI) Body Weight in Kilograms divided by height in metres squared (Kg/m2). This is used as an index of fatness. Both high BMI(overweight, BMI greater than 25) and low BMI (thinness, BMI less than 18.5) are considered inadequate.
5

Malnutrition

Various forms of poor nutrition caused by a complex array of factors including dietary inadequacy, infections, and sociocultural factors. Underweight or stunting and overweight, as well as micro-nutrition deficiencies, are forms of malnutrition

Under nutrition

Low weight-for-age; that is two z-score below the international reference for weight-for age. It implies stunting or wasting and it is an indicator or under nutrition.

The portion of global burden of disease (mortality and morbidity, 1990 figures) in developing countries that would be removed by elimination of malnutrition is estimated as 32 percent. This includes the effects of malnutrition on the most vulnerable groups burden of mortality and morbidity from infectious disease only. This is therefore a conservative figure...
-John Mason, Philip Musgrove, and Jean-Pierre Habicht, 2003

3. Abstract

Purpose:

This study attempts to identify the determinants of nutritional status among the

urban poor women in Orissa and suggesting a partnership model for intervention Method: The study is mainly secondary and quantitative in nature. It included analysis of data collected for the National Family Health Survey (2005-06). Analysis was done using crosstabulation and logistic regression. Limitations: The major limitation is that the scope of the study is limited to the data collected as a part of the survey. Findings: Findings indicate that the womens autonomy with regard to visiting her family/relatives and frequency of watching television enhance the probability of her being nonanaemic. Practical Implications: The finding can be helpful in designing interventions to reduction levels of under nutrition among women.

4. Introduction
The past 20 years have shown that in many developing countries where the incomes have gone up substantially, malnutrition as not declined correspondingly [2]. This indicates that economic growth and markets alone are alone not enough to address malnutrition. Poor nutrition perpetuates the cycle of poverty and malnutrition through three main routes; direct loss in productivity from poor physical status, losses caused by diseases linked with malnutrition, indirect losses from poor cognitive development and losses in schooling. Several vitamin and mineral deficiencies in the womb leads to blindness, dwarfism, mental retardation, and neural tube defects.

Figure 1: Vicious Cycle of Poverty (National Nutritional Policy, Department of Human Resource Development, 1993)

Anemia has a direct and immediate effect on productivity of adults especially those physically demanding occupation. Eliminating anemia results in a 5% to 17% increase in productivity which is around 2% of GDP [2]. Malnutrition affects the immune system. About 60% of all deaths and 47% of burden of disease can be attributed to diet related chronic disease. It has been shown in Brazil and United States that height and weight of the adults (measured by BMI) affects wage rate even after controlling for education.[2] The mental development of a child happens during 0-2 Years of age. The right opportunity is to break the cycle is during pregnancy and first few years of the childhood. So the health and nutrition of pregnant women and preschool children assumes great importance [5]. In India, productivity losses (manual work only) from stunting, iodine deficiency and iron deficiency together are responsible for a loss of 2.95% of GDP [2]. Malnutrition in women causes a heightened risk of adverse pregnancy outcomes. A womans nutritional status has important implications for her health as well as the health of her children. A woman with poor nutritional status, as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiencies, has a greater risk of obstructed labour, having a baby with a low birth weight, having adverse pregnancy outcomes, producing lower quality breast milk, death due to postpartum haemorrhage, and illness for herself and her baby. Almost all modern societies going through a transition from Agrarian to an industrial one end up creating slums as a part of the urbanisation. The rural poor who moved to urban areas in hope of better life actually exacerbated their hunger, misery and health hazards. The government tries to address these issues through many programmes- the important one being the public distribution

10

system. Several economic, social and systemic factors prevent the effective implementation of these programmes. The malnutrition of women among urban areas is comparable to that of rural areas among the poor [1]. In fact, the percentage of women suffering from mild and severe anemia is more in urban areas. If the problems in rural areas are accentuated by inaccessibility and lack of infrastructure, the inadequate sanitation, hygiene and water results in more sickness, lower school enrollment and retention rates and lower work productivity in urban areas. Many

denotified slum dwellers, construction site workers and pavement dwellers in the cities are excluded from the benefits like ICDS, PDS etc. Issues like illegality, the fear of eviction and social exclusion are also reasons for lack of interest among the urban poor about their health and environment. The low socio-economic conditions and the rising food prices make their diet monotonous and lacking in nutrition. Their daily income cycle also forces them to buy groceries and vegetables either in small quantities or on credit leaving them on a poor bargaining condition on quality. The slums where the urban poor are concentrated have heterogeneous community due to migration and are low on social capital. Thus we see that urban poor lead a life which robs them of their dignity. It is under these circumstances that this study assumes importance. The reason for choosing particularly women for the study is that mothers can play a significant role in reducing the malnutrition levels of the children and it was found that the children of under nourished mothers are most likely to be under nourished. Understanding the social causes for under nutrition among women can also contribute towards reducing the under nutrition levels among the children. Though, everyone knows the facts given above, further studies are required
11

to analyse how these conditions are applicable to a particular region like the urban areas of Orissa. It was also felt that the traditional social sector approaches have made insufficient headway in addressing the problem of malnutrition. The problems have also increased in complexity and intensity over the years crying out for more entrepreneurial approaches that create more value with limited resources. The government of Orissa has also realised this and has come out with public private partnership policy in 2007. Government of Orissa successfully established partnerships in delivering health care services with civil societies to the marginalized population of the un-served and under-served areas.

5. Focus of the study

The study is focused on the urban poor women in Orissa since the incidence of malnutrition is more among the lower income groups than among the privileged groups [5]. The study is a kind of Positive Deviant Approach where it was attempted to identify the factors that determine whether a poor women is anaemic or non-anaemic. Though improvement in livelihood and literacy can reduce levels of malnutrition in the long run, there exists opportunities in the short run like targeted food aid, community based nutrition and health education and micro nutrient supplements. The study is done with the eye of a development professional. It explores the current problem of malnutrition and the limitations of the current approaches in solving the problem and provides an alternative entrepreneurial approach to solve the problem. It is intended to be helpful to civil
12

society organisations which are involved in the nutrition and health sectors. It explores the business opportunity in private and civil societies adding value to the provision of public services.

6. Objectives of the study

1. To study the under nutrition status in terms of BMI and Anemia level among the urban poor women in Orissa. 2. To examine the impact of various background variables on the nutritional status of women and identify the determinants of under nutrition. 3. Formulating a model of intervention involving public and private partners.

7. Methodology
7.1 Ethnographic Study
Ethnographic study and discussions were done with the people in the slums of Salia Shahi to understand the problem in the context of urban poor in Orissa. Many respondents did not cook in the morning. A few respondents ate breakfast bought from nearby shops. The reason for not cooking is the time it takes and also to save fuel. But some households using firewood ate rice all three times a day. For some respondents it has become a habit not to eat in the morning.

13

Very few families interviewed had Ration card. Others had applied through their counselor but of no use. Subsidized groceries through PDS helps them but since it is provided once in a month, they do not have ready cash with them and they borrow from others to buy them. They are aware that the retail grocery shops nearby charge higher and the quality is low. But since they buy groceries on credit, they want to maintain the relationship. So they buy from them even when they have money. With Rs 4500 wage per month, one household was able to buy rice and Atta for a month, send children to private school and save money in the bank and was not dependant on the PDS. Though none of them were starving due to lack of food, they expressed that they could not eat fruits, drink milk or meat often. The frequency of consumption of these items was once or twice in a month. They are able to afford fish and it is mostly part of their diet. Some of the families have left their children in the village. Accessibility to food is not a problem since there are sufficient shops selling groceries, firewood apart from the mobile vendors who sell snacks, vegetables and consumer durables. Most of the respondents were drinking water from an open well. They do not have toilets.

7.2 Data
For the purpose of the study, 2005-06 National family Health Survey (NHFS-3) dataset from the DHS website was used. NFHS-3, is a household survey which will provide estimates of indicators of population, health, and nutrition by background characteristics at the national and state levels. In NFHS-3, information is collected about households, and individual interviews are conducted with women age 15-49 and men age 15-54. NFHS-3 also includes height and weight
14

measurement and blood tests for HIV and anaemia. The dataset used for analysis consists of details of 278 women living in urban areas whose wealth index is either poorer or poorest quintiles as defined by the survey. The raw data in SPSS format was taken and the details of women living in urban areas in Orissa and belonging to the poorer and poorest quintiles of wealth index were filtered and a new dataset for further analysis was created. The women of Orissa were identified using the variable v001(PSU Number). The households belonging to Orissa were given the state code of 21 for the first two digits in the five digits of the PSU Number. The variable Type of Place of Residence (v025) was used to identify the women living in the urban areas. The variable wealth index (v190) was used to filter the poorer and poorest quintile.

7.3 Outcome measures

Two outcomes for women were analysed-Body Mass Index (v445) and Anaemia Level (v457). Since the objective was to identify the determinants of under nutrition and not in predicting the precise BMI value, the BMI was converted to a category variable with two categories - one for women whose BMI falls below 18.5 Kg/m2 - and other for BMI equal and above 18.5 Kg/m2 classifying women based on thinness or acute under nutrition. The women with BMI above 25 were also considered as normal due to very low prevalence of overweight in Orissa. The existing anaemia level had 4 categories, Severe, Moderate, Mild and No Anaemia. The levels of the anaemia were combined and the new outcome measure contained only two categories, anaemic and non-anaemic. As seen from the tables, we see that 42.8% of women are under nourished and 63.6% are anaemic.
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Table 1: Body Mass Index

Cumulative Frequency Valid BMI < 18.5 BMI >= 18.5 Total 119 159 278 Percent 42.8 57.2 100.0 Valid Percent 42.8 57.2 100.0 Percent 42.8 100.0

Table 2: Anemia Level

Cumulative Frequency Valid Anemic Not Anemic Total Missing Total 9 161 92 253 25 278 Percent 57.9 33.1 91.0 9.0 100.0 Valid Percent 63.6 36.4 100.0 Percent 63.6 100.0

7.4 Covariates
Based on earlier studies on malnutrition [3], several socioeconomic and demographic variables: age, religion, education, caste, wealth index, occupation, partners occupation, water and sanitation facilities, number of women, access to information, access to health care, consumption levels of food, occupation status, partners age, autonomy, children ever born, domestic violence
16

were considered. But due to lack of adequate cell frequency, the variables were recoded by merging two or more categories. The variables that did not have a category of frequency of 25 were excluded from the analysis. The final variables chosen and their frequencies are given in the table. These variables are chosen after the cross-tabulation between the outcome variables and the independent variable tested the relationship between them as statistically significant and not due to random sampling error. Table 3: Covariates Variable Description (Name in the dataset) BMI < BMI > Anaemic (%) Not Anaemic (%) I. Frequency Television(v159n) Not at all or less than once a Week At least Once a Week Daily II. Ever Emotional Violence (d104n) No Yes 65.2 49.1 34.8 50.9 72.8 57.1 55.4 27.2 42.9 44.6 of watching

18.5 (%)

18.5 (%)

17

III.

Spouse ever insulted or make feel bad (d103cn) No Yes 64 44.1 36 55.9

IV.

Highest Education Level (v106n) Primary Above Primary 69.9 52.9 30.1 47.1

V.

Type of caste or tribe of the household (sh46n) Scheduled Tribe Scheduled Caste Others 75.7 63.3 54.3 24.3 35.7 45.7

VI.

Number of Women per Household Member (WPHH) One Women for More than three Members One Women for three or less members 58 76.6 42 23.4

VII.

Daughters at home (v203n)

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No daughter or One Daughter More than one daughter VIII. Type of facility used(s368n) Public 41.1 Private 61.3 Did not Visit in the past three months 40.3 IX. Type of Earning(v741n) 70 58.9 38.7 59.7

67 51.8

33 48.2

Not Paid or Paid in Kind or Paid in Cash and 30 Kind In Cash 51 X. Final say in visiting relatives/family (v743dn) Respondent Involved Respondent Not Involved X1. Number of eligible women in the household (v138n) One

49

59.1 74.5

40.9 25.5

57.1

42.9

19

More than One

75.6

24.4

It was surprising that some of the important variables like Wealth Index, respondents Occupation, and Benefits received from ICDS, Type of heath facility visited, frequency of food consumption, water facilities, Age were found statistically insignificant. But since the analysis was conducted only among the poorer and poorest quintile, the assets owned would be almost the same. Most of the variables chosen did not share a statistically significant relationship with the outcome Variable BMI. From the cross-tabulation it can be seen that the anaemic status reduces as the frequency of watching television increases. This can be due to nutrition related programs and the expected affluence of those using the asset. The anaemia levels are also found to reduce when the women are treated well by their spouse. We also see that as womens education level increases, the percentage of anaemic women goes down. Most of the women in Scheduled Tribe and Caste are found to be more anaemic. The anaemic status is also dependent on the number of women in the household and the number of daughters at home. This can be due to sharing of the burden by other women in the household. Interestingly, anaemia is more prevalent among women who visit private health care facilities compared to public facilities. The women who are not free to visit their family and relatives are likely to be anaemic. This can be due to the lack of avenues to share their difficulties and support. In urban areas, because of the heterogeneity of the community, this assumes more importance. Women who are paid in cash are more less-likely to be under nourished.

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It is also noted that as the number of women in the household increase, anaemia status among the household also increases. Earlier studies have indicated the burden of work as one of the reasons for the high prevalence of anaemia among women. But, we find that even if the number of women per household member increases, it does not result in lower number of anaemic women. It can be because of the increase in the number of members of the household or because of impact of the additional women on the determinants of anemia. It is also found that as the number of daughters increase, the number of anaemic women decreases. And also, it is seen that there is a significant relationship between the number of eligible women and the autonomy in decision to visit family/relatives.

7.5 Recoding of Variables

Given below are the procedures followed in recoding of the variables. The variables for which the recoding is obvious from the name of the category are not explicitly described. Only recoding of those variables which are included in the final analysis is explained. For the variable, Ever Emotional Violence and Spouse ever insult or make feel bad, the categories often during the last 12 months, sometimes during last 12 months and not in the last 12 months are recoded as Yes. The variable, Number of women per household member is obtained by dividing the number of women per household by the number of members in the household. The Type of facility visited variable was recoded into either public or private based on the type of facility. In the variable, final say in visiting relatives/family the categories are recoded based on whether the respondent was involved in the decision making.

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7.6 Analysis
Logistic regression analysis for the variables which are found to have a significant relationship with the outcome variables was done to see the interaction of variables. The dependent variable was anaemic level. The variable had two categories, namely: Anaemic, not-anaemic. For the purpose of dichotomization of variable, the categories severe, moderate and mild levels of anaemia were merged under the category Anaemic and given the value 0. The Anaemic category was given 1. The relationship of two variables was found significant. The variables are frequency of watching television and autonomy in visiting relatives/family. They were later adjusted for demographic variables. Though the strength of the frequency of watching television was attenuated by these inclusions, it was found that the demographic variables strengthened the relationship of autonomy of women in deciding to visit her family/relatives. Table 4: Determinants of Anaemia (Dependent Variable Anaemic = 0, Not-Anaemic = 1) Odds Ratio from Logistic Regression Variable Category Un Adjusted Model Exp(B) Final Say in Visiting Respondent Family/ relatives (Reference) Respondent Not Involved Frequency of Not at all or less than once a Week (Reference) Involved 3.370 .015 4.593 .004 Sig. Adjusted Model Exp(B) Sig.

Watching Television

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At least Once a Week Daily Ever Violence Emotional Yes (Reference) No insulted or No (Reference) Yes Primary (Reference) Above Primary Type of caste or tribe Scheduled of the household (Reference) Scheduled Caste Others Tribe

1.656 2.887

.302 .037

1.774 2.866

.269 .052

.455

.221

.201

.159

Spouse

make her feel bad

1.071

.929

.782

.768

Literacy

1.175

.717

1.195

.705

1.942 2.389

.272 .131

2.154 2.405

.226 .145

Women

Per One Women for More than three Members (Reference) One Women for three or less members

Household Member

1.620

.418

.566

.367

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Number of eligible women household Daughters at home in the

One(Reference) More than One 1.985 .362 .505 .263

None or One(Reference) More than one 2.108 .104 1.194 .183

The model was adjusted for wealth index, Meeting with the anganwadi/Health worker in the past three months received any maternal benefits in the past three months, Body Mass Index and spouse ever humiliated her. It was found that the variables Final say in the decision to visit family/relatives was significant at 99% level of confidence and the frequency of watching television are found to be significant at 95% level of confidence. The other variables though they not not-significant contribute to the model. The variable Meeting anganwadi worker in the last three months, though was not significant earlier in bivariate analysis has become significant in the logistic regression. Maternal benefits received during the last three months and the wealth index also were significant at 90% level of confidence. The categorical variable codings of all the variables had a minimum frequency of 25. There were totally 140 cases included in the analysis and 138 missing cases. The variables were able to classify 75% of the cases as anaemic or non-anaemic based on prediction. The -2Log Likelihood value was 142.791. The pseudo R Square values are .253 and .346 respectively for Cox & Snell and Negelkerke methods respectively.

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A similar model for BMI could not be established because none of the variables either were found to be significant or contributing to the model. It is interesting that the determinants of anaemia and BMI are quite different

8. Findings
Based on the analysis, it was found that the womens autonomy in visiting her relatives/family emerges out as a significant factor in affecting the anaemia status. Also the women who watch television daily are also less likely to be anaemic. The women who met Anganwadi/Health Worker in the last 3 months were also less likely to be anaemic. The food they ate in the past three was not found to have any significant relationship with their anemia status. Since the analysis was restricted only to people with wealth index poorer and poorest, the usual determinants like Literacy and caste did not emerge significant. From the cross-tabulations, we find that the number of eligible women in the household affects the autonomy of the woman and the more the number of daughters at home, less the woman is likely to be anaemic. The existing measures taken are mostly by the government through provision of supplementary nutrition, food fortification and IEC through mass media and trainings. The existing infrastructure is mainly the anganwadi centers which are meant to be the focal point of delivery of services. They also serve as a meeting place for womens groups, mahila mandal, mothers club promoting awareness and women empowerment. The work of the NGOs related to nutrition include promoting production and consumption of vegetables, training for health worker, reviving traditional knowledge, creating awareness among the community and increasing food production.
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The AWC is an extremely important structure created exclusively for women and children. The only attraction to visit these centers is the supplementary nutrition [6]. The AWC is ineffective unless the women and children visit these centers and the AWW cannot leave the centre and call on mothers in their houses. 40% of AWWs time is spent on preparing and distributing food and 30% on Pre-school education [7]. So she is not able to spend sufficient time in the more important aspect of health and nutrition education. We need to incentivize women to visit the centers and also ensure that the above mentioned determinants are addressed. The above problems can be reduced through partnership with the community and NGOs. The partnership model should take into account the core competence of the partners in addressing the need of the clients. The government has the physical infrastructure at close proximity to the community along with dedicated staff. Participation of the women in the coverage area of the AWC will contribute to the success of the programme. It will help in spreading the awareness across the women. It can also facilitate women empowerment apart from giving a platform for women to come together and share their difficulties. In a heterogeneous community like urban poor, this can help women in building up their social capital. The women can be incentivized to visit the center by contracting out the supplement food preparation to the women groups. The NGOs can play a vital role in building the capacity of the women who are involved in managing the food preparation and related finances in AWC. The NGO can also make the woman aware of their rights so that they could fight for their rights collectively. The womens group can also check the mismanagement at the AWC. Provision of colour Televisions in the anganwadi centers can also incentivize people to visit the center. Awareness can be generated through messages in-between popular programmes.

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9. Limitations of the study

1. Some of the determinants could not be studied because they did not have adequate cell frequency. The model also did not take into account the interaction effect of those variables. 2. The variables chosen as determinants were limited by the data collected as a part of the NFHS-3 survey.

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10.

References

1. National Family Health Survey (2005-06) 2. The World Bank, Repositioning Nutrition as Central to Development, A strategy for Large-Scale Action 3. R. Radhakrishna and C. Ravi, (2004), Malnutrition in India: Trends and Determinants, Economic and Political Weekly, Vol. 39, No.7, pp. 671-676 4. Ministry of Human Resource Development, (1993), National Nutritional Policy, Department of Women and Child Development, New Delhi, 5. Pedro Belli. (1971), The Economic Implications of Malnutrition: The Dismal Science Revisited, Economic Development and Cultural Change, Vol. 20, No. 1, pp. 1-23 6. Economic and Political Weekly (1986), Management of Services for Mothers and Children, , Vol. 21, No. 12, pp. 510-512 7. NCAER Concurrent Evaluation, (2001)

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11.

Annexure

Annexure I Rural/Urban comparision of Anaemia Levels among women who belong to poorer and poorest wealth Index
Anemia level * Type of place of residence Crosstabulation

Type of place of residence

Urban Anemia level Severe Count % within Type of place of 2.4% residence Moderate Count % within Type of place of 18.2% residence Mild Count % within Type of place of 43.1% residence Not anemic Count % within Type of place of 36.4% residence Total Count % within Type of place of 100.0% residence 253 92 109 46 6

Rural 34

Total 40

1.7%

1.8%

334

380

17.1%

17.3%

930

1039

47.7%

47.2%

651

743

33.4%

33.7%

1949

2202

100.0%

100.0%

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Annexure II: Unadjusted Logistic Regression Model

Case Processing Summary Unweighted Casesa Selected Cases Included in Analysis Missing Cases Total Unselected Cases Total N 141 137 278 0 278 Percent 50.7 49.3 100.0 .0 100.0

a. If weight is in effect, see classification table for the total number of cases.

Dependent Variable Encoding Original Value Anemic Not Anemic Internal Value 0 1

Categorical Variables Codings Parameter coding Frequency Frequency of watching Television New Not at all or Less than once a week Atleast once a week Daily Type of caste or tribe of the household Scheduled Tribe Scheduled Caste Others Daughters at home No Daughter or One daughter More than one daughter Ever any emotional violence No 66 36 39 36 46 59 100 41 102 (1) .000 1.000 .000 .000 1.000 .000 .000 1.000 1.000 (2) .000 .000 1.000 .000 .000 1.000

30

Yes Spouse ever insult or make feel bad No Yes

39 117 24 92 49 124 17 115 26 101 40

.000 1.000 .000 .000 1.000 1.000 .000 1.000 .000 1.000 .000

Highest education level new Primary category Above Primary

Number of Eligible Women in One Women Household Number of women per houshold member More than One Women Less than or equal to Three Members More than Three Members Final say on visting relatives/family New Respondent involved Respndent Not Involved

Omnibus Tests of Model Coefficients Chi-square Step 1 Step Block Model 28.529 28.529 28.529 df 11 11 11 Sig. .003 .003 .003

Model Summary Cox & Snell R Step 1 -2 Log likelihood 156.009a Square .183 Nagelkerke R Square .251

a. Estimation terminated at iteration number 5 because parameter estimates changed by less than .001.

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Classification Tablea Predicted Anemia Level New Observed Step 1 Anemia Level New Anemic Not Anemic Overall Percentage a. The cut value is .500 Anemic 78 27 Not Anemic 12 24 Percentage Correct 86.7 47.1 72.3

Variables in the Equation B Step 1a v743dn(1) v159n v159n(1) v159n(2) d104(1) d103cn(1) v106nc(1) sh46n sh46n(1) sh46n(2) WPHH(1) v138n(1) v203n(1) Constant .664 .871 .482 .686 .746 -3.335 .604 .577 .595 .752 .459 1.058 .504 1.060 -.788 .068 .161 .489 .509 .644 .764 .444 1.215 S.E. .498 Wald 5.943 4.386 1.064 4.334 1.497 .008 .132 2.283 1.206 2.281 .656 .831 2.637 9.939 df 1 2 1 1 1 1 1 2 1 1 1 1 1 1 Sig. .015 .112 .302 .037 .221 .929 .717 .319 .272 .131 .418 .362 .104 .002 1.942 2.389 1.620 1.985 2.108 .036 1.656 2.887 .455 1.071 1.175 Exp(B) 3.370

a. Variable(s) entered on step 1: v743dn, v159n, d104, d103cn, v106nc, sh46n, WPHH, v138n, v203n.

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Annexure III: Adjusted Logistic regression Model

Case Processing Summary Unweighted Casesa Selected Cases Included in Analysis Missing Cases Total Unselected Cases Total N 140 138 278 0 278 Percent 50.4 49.6 100.0 .0 100.0

a. If weight is in effect, see classification table for the total number of cases.

Categorical Variables Codings Parameter coding Frequency Type of caste or tribe of the household Scheduled Tribe Scheduled Caste Others Frequency of watching Television New Not at all or Less than once a week Atleast once a week Daily Wealth index Poorest Poorer Final say on visting relatives/family New In past 3 mths met with Respondent involved Respndent Not Involved No 36 46 58 66 36 38 72 68 100 40 111 29 102 38 116 24 (1) .000 1.000 .000 .000 1.000 .000 .000 1.000 1.000 .000 .000 1.000 1.000 .000 1.000 .000 (2) .000 .000 1.000 .000 .000 1.000

anganwadi/comm health wkr Yes Ever any emotional violence No Yes Spouse ever insult or make feel bad No Yes

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Received Benefits during

No

115 25

.000 1.000

pregnancy or Breast Feeding Yes New Daughters at home No Daughter or One daughter More than one daughter Body Mass Index New BMI < 18.5 BMI >= 18.5 Number of women per houshold member Less than or equal to Three Members More than Three Members Highest education level new Primary category Spouse ever humiiated her New Above Primary No Yes

99 41 59 81 114 26 92 48 109 31

.000 1.000 .000 1.000 .000 1.000 .000 1.000 1.000 .000

Omnibus Tests of Model Coefficients Chi-square Step 1 Step Block Model 40.845 40.845 40.845 df 15 15 15 Sig. .000 .000 .000

Model Summary Cox & Snell R Step 1 a. -2 Log likelihood 142.791

a

Nagelkerke R Square

Square .253

.346

Estimation terminated at iteration number 5 because parameter estimates changed by less than .001.

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Classification Tablea Predicted Anemia Level New Observed Step 1 Anemia Level New Anemic Not Anemic Overall Percentage a. The cut value is .500 Anemic 78 24 Not Anemic 11 27 Percentage Correct 87.6 52.9 75.0

Variables in the Equation B Step 1a sh46n sh46n(1) sh46n(2) v190(1) v743dn(1) v159n v159n(1) v159n(2) s358(1) d104(1) d103an(1) Mat_Ben_New(1) v106nc(1) WPHH(1) v445n(1) v203n(1) d103cn(1) Constant .573 1.053 1.368 -1.604 .793 -1.209 .178 -.684 .615 .649 .246 -3.498 .519 .542 .636 1.140 1.083 .700 .469 .611 .432 .488 .833 1.009 .767 .877 .834 1.524 .634 .602 .451 .536 S.E. Wald 2.228 1.463 2.124 3.415 8.092 3.915 1.220 3.769 4.627 1.981 .536 2.985 .144 1.253 2.030 1.771 .087 12.032 df 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 Sig. .328 .226 .145 .065 .004 .141 .269 .052 .031 .159 .464 .084 .705 .263 .154 .183 .768 .001 1.774 2.866 3.927 .201 2.210 .298 1.195 .505 1.850 1.914 1.279 .030 2.154 2.405 2.303 4.593 Exp(B)

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Variables in the Equation B Step 1a sh46n sh46n(1) sh46n(2) v190(1) v743dn(1) v159n v159n(1) v159n(2) s358(1) d104(1) d103an(1) Mat_Ben_New(1) v106nc(1) WPHH(1) v445n(1) v203n(1) d103cn(1) Constant .573 1.053 1.368 -1.604 .793 -1.209 .178 -.684 .615 .649 .246 -3.498 .519 .542 .636 1.140 1.083 .700 .469 .611 .432 .488 .833 1.009 .767 .877 .834 1.524 .634 .602 .451 .536 S.E. Wald 2.228 1.463 2.124 3.415 8.092 3.915 1.220 3.769 4.627 1.981 .536 2.985 .144 1.253 2.030 1.771 .087 12.032 df 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 Sig. .328 .226 .145 .065 .004 .141 .269 .052 .031 .159 .464 .084 .705 .263 .154 .183 .768 .001 1.774 2.866 3.927 .201 2.210 .298 1.195 .505 1.850 1.914 1.279 .030 2.154 2.405 2.303 4.593 Exp(B)

a. Variable(s) entered on step 1: sh46n, v190, v743dn, v159n, s358, d104, d103an, Mat_Ben_New, v106nc, WPHH, v445n, v203n, d103cn.

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