child nutritional status, feeding practices and women's autonomy in rural andhra pradesh, india

161 Pages·2007·0.6 MB·English

CHILD NUTRITIONAL STATUS, FEEDING PRACTICES AND
WOMEN’S AUTONOMY IN RURAL ANDHRA PRADESH, INDIA

by

MONAL R. SHROFF

A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in
partial fulfillment of the requirements for the degree of Doctor of Philosophy in the
Department of Nutrition of School of Public Health

CHAPEL HILL

2007

Approved By:

Advisor: Margaret Bentley

Reader: Linda Adair

Reader: Jan Dodds

Reader: Chirayath Suchindran

Reader: Paula Griffiths
© 2007
Monal R. Shroff
ALL RIGHTS RESERVED
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ABSTRACT

Monal R. Shroff: Child nutritional status, feeding practices and Women’s Autonomy in Rural
Andhra Pradesh, India (Under the direction of Margaret Bentley)

Childhood under-nutrition is a prevalent public health issue through out the
developing world. In recent surveys, such as the one carried out by the National Nutrition
Monitoring Bureau, India, poor dietary intakes (energy, protein and micro-nutrients) and
nutrition status was evident among 0-3 year old children, even in families where the adults
meet their daily dietary requirements (NNMB, 2001). This indicates that availability of food
may not be the only necessarily cause of under-nutrition among the under three-year-olds in
such families. Further, recent research postulates the linkage between women’s autonomy
and child health, particularly in countries such as India where mothers play a vital role in
childcare. This dissertation investigates the influence of maternal autonomy on child feeding
and child nutritional status in a sequence of three essays. In the first essay, using logistic
regression, we examine the overall effect of mother’s autonomy on child stunting using a
secondary dataset from the state of Andhra Pradesh (AP) in India. In particular we examine
the influence of indicators of autonomy on child stunting. Our results show financial
independence and not needing permission to go to the local market have a positive impact in
reducing child stunting. In the second essay, we further investigate the role of woman’s
autonomy on feeding behavior through a set of qualitative interviews, conducted among a
sample of 43 mothers in 3 rural villages of Andhra Pradesh, India. In particular, we explored
the perception and beliefs regarding women’s autonomy and environmental factors such as
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income and family structure and their influence on infant feeding practices. We find that not
only does mother’s autonomy play a role in the woman seeking information through formal
health care system for a her to introduce foods and liquids to the infant, but the family
structure and the cultural norms surrounding the mother-child environment also plays an
important role in child feeding practices. In our third essay, using structural equation
modeling approach, we examine the impact of seven latent dimensions of maternal autonomy
on infant feeding practice. Our results indicate that mothers with higher autonomy [indicated
by financial autonomy and decrease experience of domestic violence] are more likely to
breastfeed 3-5 month old infants. Mothers in joint family households are more likely to have
infants with poor growth. Overall, these results suggest that improving certain dimensions of
maternal autonomy will have a positive impact on infant care and growth outcomes in rural
settings of India. Future research should consider autonomy as a multi-dimensional concept
to examine the influence of individual dimension of autonomy on health behaviors and health
outcomes.

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ACKNOWLEDGEMENTS

I am indebted to my family for providing me support to go through the program and
encouraging me through some of the important phases of the Ph.D. program. I feel lucky and
thankful to have been benefited from the knowledge of my advisor Dr Margaret Bentley and
her tremendous support through the dissertation process. My sincere thanks and gratitude go
to my other committee members Dr Linda Adair, Dr Jan Dodds, Dr. Chirayath Suchindran
and Dr Paula Griffiths for their time, commitment, support and feedback during the
dissertation process. I will be forever indebted to all of them for their insights and advice. I
also want to thank the research team at the National Institute of Nutrition, Hyderababd, India,
and especially Dr Shahnaz Vazir, for their exceptional patience and support in working with
me through the course of the data gathering process. I would also like to thank, Sharon
Christ, the consultant at the Odum Institute at the UNC for all her guidance and the time she
provided while I learnt some complicated methodology. And finally, to all my friends who
are scattered around the world, for their kind words, support and understanding through this
very enriching phase of my life.
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TABLE OF CONTENT

1. INTRODUCTION...............................................................................................................1
1.1. OVERVIEW......................................................................................................................1
1.2. SPECIFIC AIMS................................................................................................................2
1.3. BACKGROUND AND SIGNIFICANCE.................................................................................4
1.3.1. Problem and Causes of Child Malnutrition....................................................................4
1.3.2. Framework for Child growth, Development and Survival............................................5
1.3.3. Child Care – a proximate determinant of child growth.................................................6
1.3.4. The Asian Enigma..............................................................................................................9
1.3.5. Women’s Status and Women’s Autonomy......................................................................9
1.3.6. Measurement of Autonomy.............................................................................................11
1.3.7. Link between Women’s Autonomy and Child Growth and Child Care....................15
1.4. REFERENCES.................................................................................................................26
2. MATERNAL AUTONOMY IS INVERSELY RELATED TO CHILD STUNTING
IN ANDHRA PRADESH, INDIA (PAPER 1)....................................................................37
2.1. ABSTRACT.....................................................................................................................37
2.2. INTRODUCTION.............................................................................................................38
2.3. SUBJECT AND METHODS...............................................................................................41
2.4. RESULTS........................................................................................................................43
2.5. DISCUSSION...................................................................................................................52
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2.6. REFERENCES.................................................................................................................56
3. ROLE OF MATERNAL AUTONOMY AND HOUSEHOLD STATUS IN INFANT
FEEDING PRACTICES AMONG RURAL MOTHERS IN ANDHRA PRADESH,
INDIA: A QUALITATIVE ANALYSIS (PAPER 2).........................................................60
3.1. ABSTRACT.....................................................................................................................60
3.2. INTRODUCTION.............................................................................................................61
3. 3. METHODS.....................................................................................................................63
3.4. RESULTS........................................................................................................................68
3. 5. DISCUSSION..................................................................................................................84
3.6. REFERENCES.................................................................................................................89
4. MATERNAL AUTONOMY IS AN INDEPENDENT PREDICTOR OF FEEDING
PRACTICES AND GROWTH IN RURAL INDIAN INFANTS (PAPER 3).................96
4.1. ABSTRACT.....................................................................................................................96
4.2. INTRODUCTION.............................................................................................................97
4.3. DATA AND METHODS....................................................................................................99
4.3.1. Model Building: Construction of Latent Autonomy Factors (dimensions)..............101
4.3.2. Structural Equation Model...........................................................................................102
4.4. RESULTS......................................................................................................................103
4.5. DISCUSSION.................................................................................................................107
4.6. REFERENCES...............................................................................................................112
5. CONCLUSION...............................................................................................................129
5.1. SYNTHESIS..................................................................................................................133
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5.2. FUTURE DIRECTIONS..................................................................................................137
5.3. REFERENCES...............................................................................................................140
6. APPENDICES.................................................................................................................142

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LIST OF TABLES

TABLE 1: SAMPLE DESCRIPTIVE....................................................................................45
TABLE 2 : BIVARIATE ANALYSES -STUNTING AND AUTONOMY..........................47
TABLE 3 : BIVARIATE ANALYSES STUNTING AND COVARIATES.........................49
TABLE 4 : SURVEY LOGISTIC MODEL...........................................................................51
TABLE 5 : QUALITATIVE STUDY: SAMPLE CHARACTERISTICS.............................92
TABLE 6 : EXAMPLE OF QUOTES REPRESENTING MATERNAL AUTONOMY......93
TABLE 7 : MOTHERS SCORING HIGH AND LOW AUTONOMY
AMONG VARIOUS DIMENSIONS.....................................................................................95
TABLE 8 : QUANTITATIVE STUDY: SAMPLE DESCRIPTION...................................116
TABLE 9 : FREQUENCY DISTRIBUTION OF AUTONOMY VARIABLES.................123
TABLE 10 : FACTOR LOADINGS FROM CFA MODEL................................................125
TABLE 11 : CORRELATION BETWEEN AUTONOMY FACTORS..............................126
TABLE 12 : SEM RESULTS FOR INFANT FEEDING PRACTICE................................127
TABLE 13 : SEM RESULT FOR INFANT GROWTH......................................................128

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LIST OF FIGURES

FIGURE 1: UNICEF FRAMEWORK......................................................................................6
FIGURE 2 : CONCEPTUAL FRAMEWORK LINKING MATERNAL
AUTONOMY AND FEEDING PRACTICE.........................................................................21
FIGURE 3 : STRUCTURAL EQUATION MODEL(PICTORIAL)...................................117
FIGURE 4 : CFA MODEL: EXAMPLE OF ONE FACTOR..............................................118
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