Progress in child nutrition outcomes: Insights from India’s recent experience

Progress in child nutrition outcomes: Insights from India’s recent experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Progress in child nutrition outcomes: Insights from India’s recent experience Ivica Petrikova, Narender Kumar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6195701/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Improvements in child nutrition outcomes have lagged behind India’s recent rapid economic growth, a phenomenon known as the ‘Indian enigma.’ Between 2015-16 and 2019-21, stunting and wasting rates declined only slightly, with some Indian states even experiencing worsening malnutrition. This study investigates the factors driving these trends, focusing on the impact of the COVID-19 pandemic, children’s dietary quality, access to water, sanitation, and hygiene (WASH), and the role of government nutrition programmes. Methods: The study employs a mixed-methods approach, combining a quantitative analysis of data from India’s National Family Health Surveys (NFHS) IV (2015-16) and V (2019-21) with a qualitative comparative case study of Rajasthan and Himachal Pradesh—two states with contrasting malnutrition trends. Individual- and district-level regression models were used to assess the effects of dietary diversity, WASH access, and government programs, whilst interviews with policy makers in Rajasthan and Himachal have provided insights into programme implementation and local responses during the pandemic. Results: Our findings confirm that dietary diversity, particularly consumption of animal-sourced foods, and improved WASH access are key drivers of better nutrition outcomes in India. However, contrary to expectations, our study does not find a consistently negative relationship between the COVID-19 pandemic and child malnutrition. Instead, flexible expansion of some of the welfare programmes during the pandemic along with reductions in children’s disease rates and improvement in some sanitation practices may have mitigated the expected deterioration. Findings from the comparative study of Rajasthan and Himachal further highlighted the importance of tailoring the welfare programmes to specific local conditions, such as the large proportion of migrant labourers in Himachal. Conclusions: Our study challenges assumptions about the pandemic’s uniformly negative effects on child nutrition and highlights the importance of resilient, locally tailored safety nets. The findings underscore the need for policy interventions that enhance dietary diversity, sustain WASH improvements, and strengthen the adaptability of food and nutrition programmes to crises. Clinical trial number: not applicable child nutrition India NFHS pandemic WASH animal-sourced food Rajasthan Himachal Pradesh Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The Indian economy has grown rapidly for the past three decades, with the highest growth in the world in 2023. However, India’s improvement in children’s nutrition outcomes, widely used as an indicator of countries’ food and nutrition security, has not been commensurate with the fast economic growth, a paradox referred to as the ‘Indian enigma’ [ 1 ]. Between 2015-16 and 2019-21, key malnutrition indicators including child stunting (too short for age) and wasting (too thin for height) declined but only marginally – from 38 to 36 percent and from 21 to 19 percent [ 2 , 3 ]. This slight overall reduction additionally hides a lot of variation, with child stunting and wasting actually increasing in one third of Indian states in the time period. Given the negative health, educational, and economic implications of child malnutrition for the individuals affected, their families, communities, and countries’ development [ 4 ], further investigation of India’s persistently high rates of child malnutrition is important. Using quantitative analysis of NFHS 4 (2015-16) [ 2 ] and 5 (2019-21) [ 3 ] data and a comparative case study of two Indian states, Rajasthan and Himachal Pradesh, in this article we investigate the factors that have contributed to the (lack of) improvement in Indian children’s malnutrition rates. The key issue that we examine is the effect of the pandemic and its interplay with children’s dietary patterns, access to sanitation, and the performance of relevant government programmes. Alongside expected findings, such as that consumption of more diverse diets and animal-sourced food and better access to sanitation are correlated with better nutrition outcomes, our findings challenge conventional assumptions about the pandemic's impact. Contrary to expectations, we do not find a clearly negative link between the Covid-19 pandemic and children’s nutrition outcomes. Deeper analysis of the quantitative data and the comparative qualitative case study suggest that the flexibility of safety nets when responding to crises combined with lower incidence of disease and better sanitation during the pandemic might largely account for the finding. The article proceeds in the following manner. The next section reviews existing literature on the drivers of children’s nutrition outcomes generally and specifically in India. The following sections describe our data and the methods utilised to analyse them and present our results. The last section discusses the relevance and implications of our findings within the context of other existing literature and offers some policy recommendations and concluding remarks. Drivers of child nutrition outcomes In the Indian context, two issues have been highlighted as particularly crucial for children’s nutrition outcomes: the quality of 1. children’s diets and of 2. water, sanitation, and hygiene (WASH) access. The Indian government has attempted to address these issues through a range of government programmes for decades, with varying effectiveness records. However, both the issues and the programmes in place to address them were affected by the Covid-19 pandemic, with significant consequences for children’s nutrition outcomes. This section of the article first discusses existing literature on the links between children’s diets, WASH, and nutrition outcomes. Second, it reviews the programmes that the Indian government has put in place to address nutrition issues. Finally, it summarises existing studies on the effects of the pandemic on India’s food and nutrition security. The World Health Organisation (WHO) has specified a series of recommended dietary practices for young children: they should be breastfed exclusively for the first 6 months of their life and from then breastfed alongside an appropriately frequent and diverse diet of (semi)solid complementary feeds, so-called ‘minimum acceptable diet’ [ 5 ]. Existing literature is generally unified that there are positive links between timely weaning (at six months) and growth [ 6 – 9 ] as well as between higher dietary diversity/minimum acceptable diet and growth [ 10 – 13 ]. In the Indian context specifically, the low proportion of iron-rich and animal-sourced foods in children’s diets has been identified as one of the key drivers of high children’s malnutrition rates [ 7 ]. Livestock ownership could facilitate the consumption of animal-sourced foods, given the generally high market prices of these items but empirical findings on this issue suggest the existence of a heterogeneous relationship, as livestock ownership might in addition to greater consumption of animal-sourced foods also lead to a greater occurrence of enteric diseases in animal-keeping households [ 13 – 15 ]. Poor water, sanitation, and hygiene services are another key factor driving children’s malnourishment across low- and middle-income countries generally and in India specifically. Poor WASH increases the likelihood of diarrhoeal diseases and diarrhoea has been identified as one of the leading causes of malnutrition in children under five years old [ 5 , 16 – 18 ]. India has historically had very high levels of open defecation and the inter-district differences in open-defecation rates were found to explain up to 55 percent of variation in their child stunting rates [ 19 ]. Gastro-intestinal infections caused by poor-quality drinking water and higher rates of malaria brought about by greater water pooling in areas with deficient sanitation have been described as additional pathways between poor WASH and high child malnutrition rates [ 20 ]. India’s nutrition-related government programmes The Indian government has been addressing the country’s food and nutrition security since 2013 through the framework of the National Food Security Act (NFSA), which has legally enshrined Indian people’s right to food [ 21 ]. The NFSA is based primarily on three social programmes: the Public Distribution System (PDS), the Integrated Child Development Scheme (ICDS), and the Mid-Day Meal Scheme (MDMS). Water, sanitation, and hygiene programmes are also of interest here. The PDS was established after World War Two with the two-pronged aim of bolstering national food production and improving people’s access to food and to date it has remained India’s largest national food-access programme [ 22 ]. It has always involved the sale of highly subsidised rice and wheat to beneficiaries but has varied in coverage, oscillating between universal and more narrowly targeted. Since the implementation of the NFSA, the PDS covers 75 percent of rural and 50 percent of urban population (the less wealthy sections), whom it grants the right to purchase 5 kg subsidised grains, mostly wheat flour and rice, per month [ 23 ][1] . The ICDS and MDMS are aimed at addressing food and nutrition insecurity amongst particularly vulnerable populations. The ICDS was established in 1975 with a focus on encouraging correct nutritional, feeding, hygiene, and health practices in pregnant and lactating women and in children under six years of age [ 24 ]. Specific interventions within the scheme have included the provision of supplementary nutrition to young children and their mothers, of nutritional and health education to mothers, and of growth-monitoring, de-worming, and pre-school education to children [ 22 ]. The services are provided through an extensive national network of anganwadi centres (AWCs). Meanwhile, the MDMS has been implemented nationally since 2001, to improve nutrition along with school attendance amongst primary-school pupils [ 25 ][2] . Finally, given that deficient water and sanitation access have been seen as key drivers of India’s high malnutrition rates [ 19 ], successive Indian governments implemented drives to build toilets and eradicate open defecation. The most recent and arguably most successful such programme to date has been the Swachh Bharat, implemented from 2014 to 2019 [ 26 , 27 ]. The programme has claimed to have eradicated open defecation; whilst survey data do not support that conclusion, they do indicate that a significant reduction in open defecation has taken place [ 3 ]. The effects of these government programmes on food and nutrition security have been mixed. Some studies found the PDS to have increased caloric consumption [ 28 – 30 ], whilst others did not [ 31 , 32 ]. The programme’s positive effect on people’s access to food arguably increased after the reform under the NFSA [ 30 , 33 ], but its impact on nutrition outcomes is more questionable, with beneficiaries found to consume more wheat and rice at the expense of nutritious grains, fruit, and dairy [ 31 , 34 , 35 ]. The ICDS has been more successful in improving nutrition outcomes. Whilst earlier studies of the ICDS showed minimal impact [ 24 , 36 ], later studies indicated a positive effect for some groups of children [ 37 – 39 ]. The Swachh Bharat programme reduced open defecation rates, the occurrence of diarrhoeal diseases, and infant and child mortality [ 40 , 41 ], although infrastructure issues for waste disposal and other barriers remain [ 42 , 43 ]. Covid-19- pandemic and child nutrition in India Food and nutrition security in India and beyond has been significantly affected by the Covid-19 pandemic and its related impact. The long-term effects of the pandemic in India have not been explored in detail yet; existing literature proposes that the effects have been largely negative due to harmful economic consequences but partially offset by the emergency expansion of the welfare programmes discussed. As many other countries, India implemented a national lockdown in March 2020, which started to be relaxed two months later. During the second wave of the pandemic in India, in the spring 2021, some states re-instated a lockdown for several months. Indian schools were, however, closed for longer, for 82 weeks between March 2020 and October 2021 [ 44 ] – the longest closure in the world after Uganda. The economic lockdowns intended to reduce the spread of Covid-19 led to complete or partial losses of income in many households, with low-income urban households particularly negatively affected. Food programmes, especially the PDS, were expanded in an attempt to make up for the loss of income. Between March 2020 and November 2022, the Government of India implemented the Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY), which granted all PDS-eligible households extra 5 kgs of rice or wheat per person and 1 kg of dal per household per month. New beneficiaries were also added to the lists of PDS eligible recipients at the beginning of the pandemic [ 45 ]. The ICDS and MDMS were significantly disrupted by the pandemic, however. The MDMS could no longer serve hot cooked meals to pupils when schools were closed and the need for social distancing also led to temporary closures of some ICDS Anganwadi centres. The programmes attempted to swiftly shift to the provision of dry-food rations and cash transfers but with mixed results. Two studies, one from Hyderabad [ 46 ] and one from Bihar [ 47 ] described how the pandemic significantly increased household food insecurity, measured through household food insecurity indices. Another study [ 48 ] explored the effects of the pandemic on children’s weight-for-age scores in selected districts in Bihar, Uttar Pradesh, and Odisha and found the effect to be also significantly negative, although not for all children. One of the pathways through which the deterioration is believed to have occurred was via deterioration in dietary quality in response to greater economic deprivation [ 48 , 49 ]. The effects of the pandemic on the other main pathway, sanitation, have been more mixed, with some increase in open defecation but improvement in hygiene practices [ 43 , 50 ]. Other relevant studies [ 51 – 54 ] noted the disruption of welfare programmes during the pandemic but also some positive trends – for example, that the lower social contact between households during the pandemic led to fewer diseases amongst children [ 55 ] and public-service delivery innovations such as combining Vitamin-A supplementation with immunisations and using WhatsApp groups to share information about child feeding [ 51 ]. Hypotheses With a view to existing findings, this article investigates the factors underlying the slow progress that India has achieved in reducing child malnutrition, with specific attention paid to the following: H1. The effect of the Covid-19 pandemic – we expect the pandemic to have undermined gains made in reducing child malnutrition rates but less so in households and areas where welfare programmes proved to be resilient and/or were expanded. We further investigate H2. The role of children’s dietary quality – we expect that primarily households and areas with greater improvement in children’s diets (MAD, ASF consumption) experienced greater reduction in child malnutrition rates. However, we expect the pandemic to have worsened dietary trends. H3. The role of WASH – we expect households and areas with greater WASH access to have experienced more reduction in child malnutrition rates. We expect the pandemic to have influenced WASH as well, but the direction of the influence is a matter of investigation. Methods This study uses mixed research methods. The first part is a quantitative analysis of data from NFHS IV [ 2 ] and NFHS V [ 3 ]. First, individual-level data from the two waves are combined and analysed followed by a panel-data analysis of matched district-level data. The second part of the study involved a qualitative comparative analysis of two Indian states – Himachal Pradesh, which experienced significant deterioration in child malnutrition rates between 2015-16 and 2019-21, and Rajasthan, which experienced significant improvement. Quantitative national analysis First, the study analyses data on more than 75,000 Indian children between 6 and 23 months of age gathered by NFHS IV (~ 40,000) and NFHS V (~ 36,000), nationally representative Indian household surveys. The lower cut-off age of 6 months was selected due to the WHO recommendation for children from that age onwards to be ‘weaned’; i.e. to receive semisolid food as a supplement to breast milk [ 5 ]. The upper cut-off point was chosen because the first two years of children’s lives are considered the most crucial to ensuring good nutrition and health outcomes in later life [ 56 ] and because data on children’s diets were collected only up to that age. The data are first analysed jointly when pooled[3] and second when averaged and matched by district. Most district boundaries remained unchanged between 2015-16 and 2019, but some changed, mostly by being divided into smaller sections. We therefore work with the 640 2015-16 districts, to which we matched the 2019-21 districts. In estimating the effects of the Covid-19 pandemic, we exploit the fact that one-third of NFHS V survey data collection occurred after the first wave of Covid-19 in India. Our individual-level empirical models examine children’s nutrition outcomes as a function of children’s diets and other characteristics as well as their mothers’, households’, and communal characteristics. The district-level models analogously examine the district-level prevalence of children’s nutrition outcomes as a function of district-averaged children’s, their mothers’, and households’ characteristics, under the assumption that the surveyed households are collectively representative of the districts in which they reside. We estimate the individual-level models using Probit and Tobit regressions that control for region of residence and whose robust standard errors are clustered by districts [following e.g., 7, 57, 58]. The district-level data are analysed using panel Tobit regressions that control for region. Qualitative analysis The second part of the analysis comprises a qualitative comparative case study of Rajasthan and Himachal Pradesh. Data relevant to the two states were collected from policy documents, online sources, and semi-structured online and in-person interviews with a range of state officials between December 2023 and April 2024 (7 individual and group interviews in Jaipur, 7 individual and group interviews in Shimla). These data were analysed using thematic analysis. Variables Dependent variables The study examines four malnutrition outcome measures in children – stunting (too short for age), underweight (too light for age), wasting (too light for height), and anaemia (lower than normal red-blood-cell count). All four types of malnutrition can be brought about by deficient feeding, but stunting is generally reflective of longer-term whilst wasting of shorter-term nutrition deprivation. Underweight can be a result of either stunting or wasting whereas anaemia may be caused by iron-deficient diets, alongside frequent diarrhoea and/or intestinal parasites [ 58 , 59 ]. The study further investigates three additional nutrition outcomes – height-for-age (Z scores), weight-for-age (Z scores), and weight-for-height (Z scores). Key independent variables The main variables of interest in this study involve the pandemic, government’s welfare programmes, children’s diets, WASH, and their interaction. The pandemic variable relates only to NFHS 5 data and takes on a value of 1 when the household was surveyed after the first Covid-19 wave in India – i.e., between November 2020 and May 2021. The only relevant programme on which data in the NFHS are collected is the ICDS – we use several relevant variables here, looking at weekly receipts of food, receiving support in pregnancy, and when breastfeeding. We also look at the PDS, MDMS, and Swachh Bharat in the qualitative case study. In terms of child feeding, the variables of interest include whether a child received the WHO-defined Minimum Acceptable Diet (MAD), of satisfactory frequency and diversity of food groups, in the 24 hours prior to the administration of the survey and whether s/he has received any animal-sourced food (ASF) other than milk. At the individual level, all these are binary variables. We further look at the household ownership of cattle, poultry, and agricultural land (also all binary variables), which might be linked with the children’s diet composition. For WASH, we utilise several variables - whether a household has a private improved sanitation facility (flushing toilet or an improved latrine), whether a household has access to an improved water source (both binary variables), and the prevalence of private improved toilets at the district level. We also look at the availability of water and of soap/ash at handwashing sites (binary variables as well). Other independent variables Factors other than poor dietary trends and lack of access to WASH linked with a higher likelihood of childhood malnutrition include, at the child level, being born male, preterm, with a low birthweight, later birth order, and a shorter birth interval with a preceding sibling [ 6 , 7 , 26 , 60 , 61 ]. At the household level, poorer, younger, worse nourished, less educated mothers with more children have also generally been found to be more likely to have malnourished children [ 6 , 20 , 27 , 62 – 64 ]. Other factors identified as consequential in India have included household caste [ 7 , 12 ], religion [ 65 ], and urban versus rural residence [ 66 ]. Accordingly, at the child level, we consider whether a child was born prematurely, his/her gender, age, birth order, birth interval with preceding sibling, whether s/he has had diarrhoea and fever in the last two weeks, and whether s/he has been breastfed for six months. At the mother’s level, we control for her age at giving birth, her education level, and whether she is underweight and/or anaemic. From household variables, we include their size, whether they are female headed, how many children under five they have, their caste (scheduled caste, scheduled tribe, other backward caste, or upper caste), and their religion (Hindu, Muslim or other). Finally, we consider if their residence is in a rural or an urban area, whether it is in a coastal district, and its geographical region in India[4] . Results Summary statistics of NFHS data used Table 1 displays the summary statistics of all the variables used in the analysis, separately for the two NFHS rounds examined. The individual-level data used are limited to children between 6 and 23 months old, as dietary data are available only for that age group. The dependent variables section demonstrates that within the sample investigated, as is true of the broader sample of children under five years old, stunting, underweight, and wasting rates all declined whilst the rate of anaemia increased between NFHS 4 and 5. Children’s average height-for-age, weight-for-age, and weight-for-height correspondingly increased as well albeit still remaining firmly below the WHO average of zero. Turning to information on the operation of ICDS, the proportion of households receiving food assistance from the programme at least once a week remained largely flat. The support women received in pregnancy and when breastfeeding rose, however, from 81 and 74 percent in 2015-16 to 87 and 83 percent in 2019-21. Looking at the dietary variables, the percentage of children eating the minimum acceptable diet increased from 8 to 10 percent; similarly, 39 percent of 6-23-month-olds in 2019-21 were reported to have eaten some animal-sourced food other than milk in the preceding 24 hours as opposed to 35 percent in 2015-16. The ownership of cattle remained approximately the same throughout (45 percent households), with poultry ownership slightly decreasing (from 19 percent households in 2015-16 to 18 percent in 2019-21) and agricultural land ownership slightly increasing (from 48 to 50 percent households). Regarding WASH, there was a significant improvement in access to improved sanitation facilities, reflecting successes of the Swachh Bharat, with the proportion of households with private improved toilet rising from 38 percent in 2015-16 to 65 percent in 2019-21. The result is, however, still quite far off the 100 percent target touted by the programme as having been achieved. Household access to an improved water source remained broadly unchanged but the proportion of households with running water and soap/ash at handwashing place grew significantly (81 to 92 percent for water, 71 to 81 percent for soap/ash). Many of the control variables utilised, displayed in the last section of Table 1, also remained broadly similar between NFHS 4 and 5. Mothers’ average age at birth, the children’s gender and age, birth order and interval with preceding sibling, whether the child was breastfed for six months, households’ average size, caste and religious breakdown, and the proportion of households living in urban and coastal areas changed only marginally. Other socio-demographic characteristics changed more notably. In the five years between the two surveys, mothers became more educated and less undernourished and households wealthier. The proportion of preterm births increased from 6 to 12 percent whilst the proportion of children who had suffered from diarrhoea or fever in the last two weeks declined from 15 and 18 percent to 10 and 16 percent. Female-headed households also increased in prevalence, from 12 to 15 percent. Quantitative results Tables 2.1 and 3.1 below show regression results on key independent variables (Tables 2.2 and 3.2 in the Appendix contain results on control variables). Table 2 contains results from the analysis of individual-level data whilst Table 3 from the analysis of district-level data. Both sets of results highlight the importance of dietary behaviour and WASH in improving children’s nutrition outcomes. They also suggest that the pandemic’s first wave has not had a singularly negative effect on India’s child malnutrition rates. To expand on the last point, in contradiction of our first hypothesis, the pandemic – or at least its first wave observed here – does not appear to have unequivocally worsened malnutrition rates amongst young Indian children. In some aspects it actually appears to have had a positive effect. In the individual-level results (Table 2.1), the pandemic is linked with lower height-for-age scores but also with lower likelihood of children being wasted or anaemic, measures of more acute nutrition deprivation. In the district-level results (Table 3.2), the pandemic is linked with lower prevalence of stunting, underweight, wasting, and anaemia. However, it is not significantly associated with overall higher height-for-age, weight-for-age or weight-for-height, indicating that the effect has been one of malnutrition amelioration rather than an overall increase in the weight or height of Indian children. Looking at the role of the ICDS, which we hypothesised could have helped cushion the negative economic impact of the Covid-19 lockdown alongside other government welfare programmes, it is not positively connected with better nutrition outcomes. The results are largely insignificant with the exception of wasting and weight-for-height in the individual data, where receiving weekly food from the ICDS is associated with worse nutrition outcomes. The nature of the relationship in that case, however, is more likely in the opposite direction, with wasted children more likely to be recipients of the ICDS food aid than others. We investigate how the ICDS and other welfare programmes in India were affected by the pandemic further in the article but before doing so, let us turn to the other key independent variables. From the dietary variables, consuming animal-sourced food - unlike the minimum acceptable diet – is evidently and consistently associated with lower malnutrition prevalence as well as greater height and weight. This is in line with our second hypothesis. From the agricultural variables examined, having access to agricultural land is linked with lower likelihood of stunting and underweight. In contrast, cattle and poultry ownership are associated with worse nutrition outcomes. This might seem counterintuitive since households with cattle or poultry have more direct access to animal-sourced food. Nevertheless, it could be a function of the high correlation between agricultural land and livestock ownership, which might be biasing the results, as well as of the higher exposure to animal-vector gastro-intestinal diseases in livestock-owning households that might undermine nutrition outcomes [e.g., 11, 13]. WASH is also clearly linked with better nutrition outcomes, consistent with our third hypothesis. Households with private improved toilets are less likely to have stunted, underweight, wasted, and anaemic children and more likely to have children with greater height-for-age, weight-for-age, and weight-for-height scores. The same is true of the prevalence of private improved toilets on the district level – districts with better sanitation have better nutrition outcomes on most of the nutrition dimensions analysed. Access to an improved water source and water at handwashing place are also associated with some better nutrition outcomes – lower likelihood of wasting in the case of an improved water source and reduced prevalence of underweight and wasting in the case of water accessibility at handwashing place. Before delving in more detail into the relationship between the pandemic and the other key variables, Tables 2.2 and 3.2 in the Appendix show the relationships between control variables and nutrition outcomes. These are largely in line with expectations. At the child level, boys are more likely to be malnourished than girls, as are higher-order children, children with shorter birth intervals with preceding siblings, children who were born prematurely, and children who have had diarrhoea or fever within two weeks of the survey. Wealthier households and more educated mother are more likely to have well-nourished children; the opposite is true of children born to underweight and anaemic mothers. Upper-caste children are significantly less malnourished than children from other castes. Further area characteristics that reduce malnutrition likelihood are rural and coastal areas of residence. The results from the individual-level data are largely replicated in the district-level data. The pandemic puzzle Our finding that the pandemic has not had a significantly negative effect on children’s nutrition outcomes – and in some cases even appears to have actually helped ameliorate malnutrition – is not in line with our expectations or existing literature. The fact that the pandemic is positively associated with reduced risk of malnutrition, particularly wasting and anaemia, but not with general increase in height or weight in all children, suggests the possibility of this effect being driven by the expansion of welfare safety nets during the pandemic. The NFHS data contain information only on one relevant welfare programme, the ICDS. Table 4 below looks at the proportion of Indian households using the programme’s different services and shows that the weekly provision of food by the service declined after the first wave of Covid-19, although not drastically – from 51 percent in 2019 to 46 percent in 2021. Figure 1 further shows that after the first wave of Covid-19, the food receipts became more progressive – with the poorest 20 percent of households seeing a significant increase in food benefits whilst the wealthiest 60 percent a significant reduction. Compared to food receipts, the provision of support during pregnancy and breastfeeding from the ICDS increased, from 88 and 80 percent before the pandemic to 91 percent and 88 percent after the first wave. This could be related to the increased use of WhatsApp by ICDS workers following the onset of the pandemic, as described in previous research [51]. Results in Table 5 and Figs. 2 and 3, which look at the links between the ICDS pregnancy and breastfeeding support services, the pandemic, and children’s nutrition outcomes, interestingly demonstrate that after the first Covid-19 wave, the provision of regular pregnancy and breastfeeding support to mothers is linked with significantly lower rates of underweight, wasting, and anaemia. Whilst, as we explained earlier, the direction of the relationship between ICDS services and nutrition outcomes is difficult to ascertain through these regressions, it could be a sign that the increased provision of these ICDS services helped parents improve their children’s nutrition outcomes, through better feeding or sanitation practices. Other possible factors underlying the observation of a positive link between the pandemic and children’s nutrition outcomes are listed in Table 6, which shows the prevalence of children’s diseases and WASH variables in the districts that were not surveyed during the pandemic, in 2015/16 and 2019/20, as compared to the districts that were surveyed after the onset of the pandemic, again in 2015/16 and then in 2020/21. The occurrence of disease – both diarrhoea and fever within two weeks of the survey – appears negatively correlated with children’s nutrition outcomes, particularly their weight (Tables 2.2 and 3.2). Table 6 shows that following the first wave of Covid-19, Indian children were suffering significantly less from diarrhoea and fever, likely due to reduced social contact [55]. This is a very plausible pathway through which the pandemic may have contributed to reduced malnutrition rates. Another might be the greater importance placed on good-quality WASH in the pandemic messaging. Table 6 shows that whilst there was a general increase in the presence of water and soap/ash at handwashing places between NFHS 4 and 5, the increase was significantly greater in districts surveyed after the first wave of Covid-19. Since these variables are also linked with lower malnutrition rates (Table 2.2 and 3.2), this is another feasible pathway through which the Covid-19 pandemic might have contributed to better children’s nutrition outcomes. The following comparative study of Rajasthan and Himachal Pradesh explores this issue in greater depth. Comparative case study – Rajasthan and Himachal Pradesh In order to gain a deeper understanding of the factors underlying the trajectory of change in Indian children’s nutrition outcomes, this second part of our analysis compares the recent experience of two states – Rajasthan and Himachal Pradesh. We chose these two states because, as Fig. 4 shows, whilst Rajasthan experienced a significant reduction in child malnutrition rates between NFHS4 and 5, the opposite happened in Himachal. The proportion of under-five stunted, underweight, and wasted children in Rajasthan declined from 39, 37, and 24 percent in 2015/16 to 33, 30, and 19 percent in 2019/21; conversely, in Himachal the corresponding rates increased from 26, 21, and 14 percent to 33, 26, and 17 percent. The overall malnutrition rates in Rajasthan have remained slightly higher than in Himachal but the two state’s trajectories have been very different, making them good case studies for a more detailed study of the relevant factors. Before delving into that analysis, let us look at some basic characteristics of the two states in Table 7. In some respects, the states are quite different. Himachal Pradesh is only one sixth of Rajasthan in size and has one tenth of Rajasthan’s population [67]. At the same time, Himachal is more than 50 percent richer on per-capita basis than Rajasthan and has a significantly larger proportion of migrant labourers (35.2 percent compared to 7.6 percent of the population). However, there are also many similarities between the states. They are both situated in northern India, not far from the country’s capital, New Delhi. They are both predominantly Hindu, with relatively small Muslim minorities, and most people in both states speak Hindi. They are predominantly rural, with only 7 percent of Himachal and 17 percent of Rajasthan inhabitants residing in urban areas. Pandemic and welfare programmes In turn, we now consider in more detail the factors identified in the previous section as influential for child malnutrition rates – the pandemic, social welfare programmes, dietary factors, WASH, and their interaction. An important point to note here is that NFHS 5 data for Himachal Pradesh were all gathered prior to the onset of the pandemic whereas 15 out of 33 districts in Rajasthan were partly or wholly surveyed after the first wave of Covid-19. Hence, whilst the NFHS5 data for Rajasthan partially reflect the effects of the pandemic, the data for Himachal Pradesh do not. The first factor that we investigated in the quantitative section as a pathway through which the pandemic may have influenced malnutrition rates were welfare programmes, specifically the ICDS, on which the NFHS gathers data. Our data analysis does not obviously show a link between programme participation and better outcomes, but we did not employ more sophisticated measures of trying to control for reverse causality to establish impact (e.g., propensity score matching, instrumental variable equations). Other research has suggested that the ICDS does tend to have positive impacts on nutrition outcomes, at least for some groups of children [37–39]. In both Rajasthan and Himachal, the ICDS coverage increased between NFHS4 and NFHS5, particularly when it comes to pregnancy and breastfeeding assistance – from 78 and 65 percent to 84 and 80 percent in Himachal and from 49 and 38 percent to 68 and 57 percent in Rajasthan. But in Rajasthan, the increase in the coverage by these services was particularly notable during the pandemic, with a 39 percent increase for coverage of pregnancy assistance and 61 percent for coverage of breastfeeding assistance (the proportion of households receiving weekly food rations declined, on the other hand, from 55 to 47 percent, but as on the national level, this affected households in the poorest quintile proportionally the least). A similar enlargement of ICDS pregnancy and breastfeeding services occurred according to our interviewees during the pandemic in Himachal - had survey data there been collected also after the first wave of Covid-19, perhaps the results for malnutrition rates in Himachal would have looked different. Further innovations were recently made in the Rajasthan ICDS, which might have also helped with the state’s significant strides forward in nutrition outcomes. One has been the rollout of the community-based management of malnutrition in 20 Rajasthani districts in 2018 [68]. The programme surveyed all children between 6 and 59 months old in the districts where it was implemented and referred children affected by severe acute malnutrition to medical centres or community care, with good results. Sixty-seven percent of the treated children recovered within 12 weeks – without the programme, they would have likely continued to be malnourished. The other improvement within the Rajasthani ICDS has been the establishment of specific coordination between the Ministry of Women and Children, traditionally tasked with overseeing the ICDS, and the Ministry of Education, to ensure that the activities of both ministries aligned in their support for the ICDS. One result of this coordination has been greater awareness of early child development issues throughout the state’s government, another has been the increasing trend of opening Anganwadi centres in primary schools, a move that boosted Anganwadi attendance by younger siblings of primary school pupils. We are not aware of equivalent initiatives in Himachali ICDS. The other national programme with a large potential to affect children’s nutrition is the PDS. Its coverage, estimated at 61 percent, is greater in Rajasthan than in Himachal (38 percent) [69] and according to our interviewees, Rajasthan has made good progress in reducing the programme’s leakage by eliminating intermediary godowns for grains. Now the PDS grains are transferred directly from national godowns to fair-price shops in Rajasthan, with digital tracking of the deliveries and immediate online reporting of all transactions, until the delivery to the household [70]. The PDS offering in Himachal Pradesh is much more comprehensive than in Rajasthan, on the other hand. In addition to wheat and rice, Himachal government provides NFSA beneficiaries also with subsidised (not free) edible and refined oil, salt, sugar, and pulses – black gram, chana dal, masoor dal, and green gram (interviews) and the food is available at subsidised, albeit less so, prices also to Himachali residents without NFSA ration cards [71]. According to interviewees, the issue of the quality of food available through the PDS is still problematic in both states, which more localised quality controls could help address [70, 71]. However, the biggest apparent problem with the PDS in Himachal has been the issue of migrant labourers. As Table 7 shows, 35 percent of Himachali population is constituted by labour migrants. Whilst these are predominantly men, some are women and children – and unless they have family in Himachal Pradesh, they are not entitled to obtain a Himachali ration card (either an NFSA one or general). The Indian government has tried to address this problem recently with the One Nation One Ration Card programme, but thus far this has been largely not functional in Himachal and hence Himachali migrant labourers have not been able to obtain their PDS rations whilst living in Himachal [71]. The operation of the One Nation One Card Scheme in Rajasthan was in contrast described as relatively successful [70] – but even if it were not, Rajasthan is home to a significantly smaller proportion of migrant labour than Himachal, which makes the issue of a lack of access to the PDS due to changed area of residence less problematic on the state level. In response to the Covid-19 pandemic, the Indian government temporarily expanded the PDS with the PMGKAY, which provided NFSA beneficiaries with 5 kilograms extra grains per person and 1 kilogram of pulses per household per month between March 2020 and December 2023. Unlike the ICDS, the operation of which was disrupted due to the closure of Anganwadi centres during the first lockdown, the PDS along with the PMGKAY operated relatively smoothly throughout most of the pandemic. The granular data on Rajasthani PDS deliveries demonstrates that there was some leakage of the rations, but most households received the majority of their grain and pulse entitlements. Dietary trends, WASH, and disease However, even though the safety-net programmes, PDS and ICDS, were relatively resilient throughout the pandemic, it has long been agreed that their positive influence on children’s nutrition outcomes is limited by the low diversity of the food they provide. They are particularly low on protein-rich and animal-sourced food, which the quantitative analysis confirmed as one of the key factors in Indian children’s nutrition outcomes. The consumption of animal-sourced food by Indian children is in general very low by international standards. It increased between NFHS4 and 5 but only slightly, from 35 percent of 6–23 month-old-children having eaten any animal-sourced food in the last 24 hrs before the survey in 2015/16 to 39 percent in 2019/21. The rate of increase was dampened during the pandemic, which was undoubtedly also connected with the low or non-existent provision of animal-sourced food by the PDS and ICDS, for cultural and religious reasons. In recognition of the situation, in recent years some Indian states have started to include eggs in the ICDS, but neither HP nor Rajasthan has done so [70–72]. HP has trialled including eggs in ICDS meals but due to some parental protest terminated the pilot [71]. Rajasthan has not even attempted to include eggs but did start to include greater amounts of dairy in the ICDS meals, which unlike meat or eggs does not face religious objections. Himachali ICDS meals also include a small amount of milk powder, but the protein content of that amount is negligible and other options, such as providing paneer, have been rejected on hygiene grounds, as most Anganwadi centres lack refrigerated storage facilities [71]. Looking to WASH, another key driver of child nutrition outcomes, both Rajasthan and Himachal Pradesh experienced improvements in WASH access between NFHS 4 and NFHS 5. Particularly the access to private improved toilets grew significantly and more so in Rajasthan than in Himachal. Whilst the proportion of households with a private improved toilet in Himachal rose from 68 to 78 percent (a 15-percent increase), in Rajasthan the proportion expanded from 38 to 64 percent (a 68-percent increase) (NFHS 4, 5). The other WASH and disease variables highlighted as potential pathways through which the pandemic may have reduced some malnutrition rates changed in the desirable direction during the pandemic also in Rajasthan – the rates of households with water and soap/ash at handwashing points increased and the rate of diarrhoea and fever in young children decreased. Our interviewees in both Himachal and Rajasthan also noted the lower disease occurrence in young children during the pandemic, which may have contributed to better nutrition outcomes even during a time of relative economic crisis [70, 71]. Discussion and conclusions Child nutrition outcomes specifically and food and nutrition security more broadly remain a challenge in India. These issues have experienced improvement in recent decades, but the rate of progress has been slow. Our study has contributed to the understanding of the multiple drivers of this complex issue and highlighted the importance of child feeding practices, including animal-sourced food consumption, of improved water, sanitation, and hygiene practices, and of the resilience of relevant welfare programmes, which had been tested during the pandemic. The study also highlighted that the effects of the pandemic on India’s nutrition security have not been uniformly as negative as suggested in other existing research and, through the comparative qualitative case study of Rajasthan and Himachal Pradesh, underscored the importance of locally tailored state-level policies. The importance of timely weaning of children with sufficiently diverse and frequent diets for Indian children’s nutrition outcomes has been previously established [7]. This study further emphasises the importance of introducing proteins and micronutrients found in ASFs into children’s diets to encourage growth and reduce malnutrition rates. Our interviews with civil servants in Rajasthan and Himachal revealed that there is awareness of this issue on the ground but there are barriers still in place against increasing access to such foods in welfare programmes, cultural, religious, as well as logistic, including a lack of refrigerated storage spaces. Greater emphasis on parental awareness-raising in this regard could make a big difference, too, as even many non-vegetarian parents do not feed ASFs to young children due to erroneous beliefs about potential harm [73]. Neither Rajasthan nor Himachal Pradesh have thus far included eggs in their ICDS offering, unlike many North-Eastern and Southern Indian states, but our interviewees in Himachal suggested that since the Covid-19 pandemic, there has been a greater general acceptance of egg consumption even by vegetarians [71]. The state and local governments could thus make a stronger case for the inclusion of ASFs in feeding programmes, which could contribute to healthier children. Unlike Himachal, Rajasthan has included more dairy in its ICDS food, which could be one of the reasons why Rajasthan has managed to reduce child malnutrition rates quite notably between 2015-16 and 2019-21. Our study further re-affirmed the importance of access to improved WASH in attaining positive nutrition outcomes. At all levels of the data analysis, ownership of private improved toilets was significantly positively associated with lower levels of child malnutrition. This was true not only at the individual level. Districts with greater prevalence of private improved toilets were found to have further positive association with lower levels of malnutrition, highlighting the importance of communal or ecological sanitation and hygiene as well. The Swachh Bharat programme undoubtedly increased both people’s access to and usage of improved sanitation; however, at the communal level the question of sewage needs further addressing [42]. Both Rajasthan and Himachal Pradesh experienced an increase in people’s access to improved sanitation as well, but the rate of increase in Rajasthan has been much steeper, which could be another reason underlying the divergence in the two states’ child-nutrition trajectories. Finally, the study shed some new light on the effects of the pandemic on nutrition security in India and its interaction with the welfare services in place to shore up food and nutrition security. Unlike other existing studies, the quantitative data analysis, which took advantage of the fact that part of the NFHS 5 data were gathered after the first wave of the Covid-19 pandemic, did not reveal a consistently negative picture of the pandemic’s effects. The results did not suggest that the pandemic had an overall positive effect on children’s growth but showed a positive association between the pandemic and reduced malnutrition rates, particularly when measured through wasting and anaemia. One potential explanation for this might lie in the welfare programmes in place and their expansion during the pandemic. The PDS was during the pandemic supplemented with the PMGKAY, which gave NFSA-eligible households extra grains and pulses. The ICDS operations were disrupted more but home food deliveries were introduced after initial disruption and the provision of some services, such as the ICDS pregnancy and breastfeeding advice, actually increased, likely because of the greater use of mobile technologies by the programmes [see also 74]. However, as our quantitative and qualitative analyses indicated, there are other, as or more likely pathways through which the pandemic might have had a positive effect on children’s nutrition status than through changes to welfare programmes. Hygiene observation (handwashing with soap) during the pandemic improved, which, together with lower levels of social contact, led to a lower prevalence of disease (diarrhoea, fever) in young children [in line with 55]. Both of these were shown to be linked with lower malnutrition rates in our study. That is not to contend, however, that the performance of welfare programmes and their local tailoring have had no bearing on the trajectory of child malnutrition rates across India, as was underscored by our comparative case study of Rajasthan and Himachal. Some of the reasons why the nutrition situation in Rajasthan improved between 2015-16 and 2019-21 and worsened in Himachal in the same time period were undoubtedly linked with the performance of the PDS and ICDS. In Rajasthan, the improvements may have been at least partially driven by better integration and coordination of the Education and Women and Child ministries in the delivery of ICDS services as well as innovative programmes like the community-based management of malnutrition. Conversely, in Himachal Pradesh the deterioration was likely related to a rapid influx of migrant labourers, which have had a hard time gaining access to PDS rations if migrating from other states. The One Nation One Ration Card initiative is aimed at addressing this specific issue but so far, its implementation has been patchy and largely inadequate, particularly given India’s growing rate of inter-state labour movement [70, 71]. The slow progress in improving child nutrition outcomes in India, despite rapid economic growth, underscores the complexity of malnutrition and the need for multifaceted solutions. This study’s findings highlight the critical role of ASF consumption, improved WASH services, and resilient welfare programmes. The comparative analysis of Rajasthan and Himachal Pradesh provided further insight into issues of effective policy implementation and highlighted the importance of state-specific strategies. Concerted efforts at both the Indian national and state levels, informed by robust data[5] and innovative practices, are essential to accelerating progress in improving India’s child nutrition outcomes. Abbreviations ASF – animal-sourced food HP – Himachal Pradesh ICDS – Integrated Child Development Services LMICs – low- and middle-income countries MAD – minimum acceptable diet MDMS – mid-day meal scheme NFHS – National Family Health Survey NFSA – National Food Security Act PDS – Public Distribution System PMGKAY - Pradhan Mantri Garib Kalyan Anna Yojana WASH – water, sanitation, and hygiene WHO – World Health Organisation Declarations Ethics approval and consent to participate The field research part of this study, in Rajasthan and Himachal Pradesh, received an ethics approval from research ethics committees at both Royal Holloway, University of London and Jawaharlal Nehru University. Consent for publication Not applicable. Data availability Datasets analysed are publicly available at https://microdata.worldbank.org/index.php/catalog/3110 and at https://microdata.worldbank.org/index.php/catalog/4482. Competing interests The authors declare that they have no competing interests. Funding This research received support from internal research funding at Royal Holloway, University of London. Authors’ contributions IP analysed quantitative and qualitative data and co-wrote the manuscript. NK collected and analysed qualitative data and co-wrote the manuscript. Acknowledgements We want to express our deepest gratitude to all our interview participants in Rajasthan and Himachal Pradesh as well as to participants at ECPR 2024 conference in Dublin for their comments on an earlier draft of the article. We further want to thank the article’s peer reviewers and editors at BMC Public Health. References Ramalingaswami V, Jonsson U, Rohde J. Malnutrition: a South Asian enigma. In: Malnutrition in South Asia. Kathmandu: UNICEF; 1997. NFHS 4. 2015-16 [cited 2025 Mar 3]. Available from: https://microdata.worldbank.org/index.php/catalog/3110 NFHS 5. 2019-21. [cited 2025 Mar 3]. Available from: https://microdata.worldbank.org/index.php/catalog/4482 Dewey K, Begum K. 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A panel could not be constructed since each round of NFHS surveys different households. As a robustness test, data are also analysed separately for each wave. Southern states (Andaman and Nicobar Islands, Andhra Pradesh, Karnataka, Kerala, Lakshadweep, Puducherry, Tamil Nadu, Telangana), North-Eastern states (Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura), Eastern states (Bihar, Jharkhand, Odisha, West Bengal), Northern states (Chandigarh, Haryana, Himachal Pradesh, Jammu and Kashmir, Ladakh, Delhi, Punjab, Rajasthan), Central states (Chhattisgarh, Madhya Pradesh, Uttar Pradesh, Uttarakhand), and Western states (Dardra, Nagar Haveli, Daman, and Diu, Goa, Gujarat, Maharashtra). At the time of writing, the US has just cancelled funding for all Demographic and Health Surveys (DHS), on which the NFHS is also based. The authors hope that India, which is now self-funding the 6th round of NFHS, will follow previous practice of releasing the final datasets to academic researchers for analysis. The cancellation of the DHS is to grave detriment to global health research, particularly in low- and middle-income countries, and should be resurrected through other financial means. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 17 Mar, 2025 Editor assigned by journal 13 Mar, 2025 Submission checks completed at journal 13 Mar, 2025 First submitted to journal 10 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6195701","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":428174630,"identity":"46e8b541-df79-4740-b1a6-18d3263a33ac","order_by":0,"name":"Ivica Petrikova","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie2RMUvEMBTHXyhcl9A5x0n7FVJur1+lIeAtHjgWFK4l0Ck4V/RLOLlGArpE/AIdFOEmh94iDiLmQnGQ9ro65Dckjxd+yf8RAI/nHzIDVPYlEvs1BgJIuQaeUHCvLK0CB5Vf7Hmw31k5pUSEV90ntPHxQgu6q7PV3bWkCi4yoEYNByNMzCVslzhigl3VfH3TGqs8cKBP5bCC72ubQDOJkdDYBOuGnFplpoA+j4xvFfQFetMrmxVxyvcBJazqwL6SY6twXOjcKahW48HCSiyO6DaVBom0KR7ThpycKXbJ8Xxk/ESEr7v3ok1CGb6Rjp4nhPDbl+4jiyOTDydz0L/35dMfORzB4/F4PI4ff/VZIgBq6+sAAAAASUVORK5CYII=","orcid":"","institution":"Royal Holloway University of London","correspondingAuthor":true,"prefix":"","firstName":"Ivica","middleName":"","lastName":"Petrikova","suffix":""},{"id":428174632,"identity":"dc15f749-8a92-45f8-b79d-415910bcf4b4","order_by":1,"name":"Narender Kumar","email":"","orcid":"","institution":"Jawaharlal Nehru University","correspondingAuthor":false,"prefix":"","firstName":"Narender","middleName":"","lastName":"Kumar","suffix":""}],"badges":[],"createdAt":"2025-03-10 12:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6195701/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6195701/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24436-y","type":"published","date":"2025-09-30T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78732893,"identity":"a1578f12-236b-4527-9c40-89f84fc34a2c","added_by":"auto","created_at":"2025-03-18 07:53:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29113,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe pandemic’s effect on ICDS food receipts by household wealth quintile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource\u003c/em\u003e: authors’ own analysis. Figure depicts the marginal effects of regressing the pandemic variable on ICDS weekly food receipts by household wealth quintile.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/3e9392ddbdc953ad2b105779.png"},{"id":78732894,"identity":"ea1549a2-05f6-43eb-ac89-85bac8d97436","added_by":"auto","created_at":"2025-03-18 07:53:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eICDS pregnancy and breastfeeding support and wasting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource\u003c/em\u003e: authors’ own analysis. Figures depict the marginal effects of regressing ICDS assistance on wasting by the proportion of district surveyed during the pandemic (November 2020 to May 2021).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/2c4d8fa85942484eb555c596.png"},{"id":78732897,"identity":"802fa572-a466-4b5a-97b5-d4c37d40e04b","added_by":"auto","created_at":"2025-03-18 07:53:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28827,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eICDS pregnancy and breastfeeding support and wasting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource\u003c/em\u003e: authors’ own analysis. Figures depict the marginal effects of regressing ICDS assistance on wasting by the proportion of district surveyed during the pandemic (November 2020 to May 2021).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/bfd51d0c96f08430db932e71.png"},{"id":78732909,"identity":"f4055469-c84a-4b2a-9799-e44261a8a546","added_by":"auto","created_at":"2025-03-18 07:53:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":61059,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMalnutrition rates in Rajasthan and Himachal Pradesh\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource\u003c/em\u003e: authors’ own analysis of NFHS data\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/7ea96a820c49ec97babd6899.png"},{"id":92883980,"identity":"9026ab87-115c-4a66-8c6d-20643bbdaa0e","added_by":"auto","created_at":"2025-10-06 16:11:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1010074,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/feb99401-8234-4bae-85fc-b21f22f72ce7.pdf"},{"id":78732892,"identity":"a0332b01-cb25-48ab-8a8a-656aafe6cd57","added_by":"auto","created_at":"2025-03-18 07:53:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":58504,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/d2c0c546e5dba5b74e789328.docx"},{"id":78734510,"identity":"2924f451-c607-487d-8d16-b95fd345cd06","added_by":"auto","created_at":"2025-03-18 08:01:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":50081,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6195701/v1/386f42ec92d2ac283debe94a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Progress in child nutrition outcomes: Insights from India’s recent experience","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Indian economy has grown rapidly for the past three decades, with the highest growth in the world in 2023. However, India\u0026rsquo;s improvement in children\u0026rsquo;s nutrition outcomes, widely used as an indicator of countries\u0026rsquo; food and nutrition security, has not been commensurate with the fast economic growth, a paradox referred to as the \u0026lsquo;Indian enigma\u0026rsquo; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Between 2015-16 and 2019-21, key malnutrition indicators including child stunting (too short for age) and wasting (too thin for height) declined but only marginally \u0026ndash; from 38 to 36 percent and from 21 to 19 percent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This slight overall reduction additionally hides a lot of variation, with child stunting and wasting actually increasing in one third of Indian states in the time period. Given the negative health, educational, and economic implications of child malnutrition for the individuals affected, their families, communities, and countries\u0026rsquo; development [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], further investigation of India\u0026rsquo;s persistently high rates of child malnutrition is important.\u003c/p\u003e \u003cp\u003eUsing quantitative analysis of NFHS 4 (2015-16) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and 5 (2019-21) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] data and a comparative case study of two Indian states, Rajasthan and Himachal Pradesh, in this article we investigate the factors that have contributed to the (lack of) improvement in Indian children\u0026rsquo;s malnutrition rates. The key issue that we examine is the effect of the pandemic and its interplay with children\u0026rsquo;s dietary patterns, access to sanitation, and the performance of relevant government programmes. Alongside expected findings, such as that consumption of more diverse diets and animal-sourced food and better access to sanitation are correlated with better nutrition outcomes, our findings challenge conventional assumptions about the pandemic's impact. Contrary to expectations, we do not find a clearly negative link between the Covid-19 pandemic and children\u0026rsquo;s nutrition outcomes. Deeper analysis of the quantitative data and the comparative qualitative case study suggest that the flexibility of safety nets when responding to crises combined with lower incidence of disease and better sanitation during the pandemic might largely account for the finding.\u003c/p\u003e \u003cp\u003eThe article proceeds in the following manner. The next section reviews existing literature on the drivers of children\u0026rsquo;s nutrition outcomes generally and specifically in India. The following sections describe our data and the methods utilised to analyse them and present our results. The last section discusses the relevance and implications of our findings within the context of other existing literature and offers some policy recommendations and concluding remarks.\u003c/p\u003e\n\u003ch3\u003eDrivers of child nutrition outcomes\u003c/h3\u003e\n\u003cp\u003eIn the Indian context, two issues have been highlighted as particularly crucial for children\u0026rsquo;s nutrition outcomes: the quality of 1. children\u0026rsquo;s diets and of 2. water, sanitation, and hygiene (WASH) access. The Indian government has attempted to address these issues through a range of government programmes for decades, with varying effectiveness records. However, both the issues and the programmes in place to address them were affected by the Covid-19 pandemic, with significant consequences for children\u0026rsquo;s nutrition outcomes. This section of the article first discusses existing literature on the links between children\u0026rsquo;s diets, WASH, and nutrition outcomes. Second, it reviews the programmes that the Indian government has put in place to address nutrition issues. Finally, it summarises existing studies on the effects of the pandemic on India\u0026rsquo;s food and nutrition security.\u003c/p\u003e \u003cp\u003eThe World Health Organisation (WHO) has specified a series of recommended dietary practices for young children: they should be breastfed exclusively for the first 6 months of their life and from then breastfed alongside an appropriately frequent and diverse diet of (semi)solid complementary feeds, so-called \u0026lsquo;minimum acceptable diet\u0026rsquo; [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Existing literature is generally unified that there are positive links between timely weaning (at six months) and growth [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] as well as between higher dietary diversity/minimum acceptable diet and growth [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the Indian context specifically, the low proportion of iron-rich and animal-sourced foods in children\u0026rsquo;s diets has been identified as one of the key drivers of high children\u0026rsquo;s malnutrition rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Livestock ownership could facilitate the consumption of animal-sourced foods, given the generally high market prices of these items but empirical findings on this issue suggest the existence of a heterogeneous relationship, as livestock ownership might in addition to greater consumption of animal-sourced foods also lead to a greater occurrence of enteric diseases in animal-keeping households [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePoor water, sanitation, and hygiene services are another key factor driving children\u0026rsquo;s malnourishment across low- and middle-income countries generally and in India specifically. Poor WASH increases the likelihood of diarrhoeal diseases and diarrhoea has been identified as one of the leading causes of malnutrition in children under five years old [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. India has historically had very high levels of open defecation and the inter-district differences in open-defecation rates were found to explain up to 55 percent of variation in their child stunting rates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Gastro-intestinal infections caused by poor-quality drinking water and higher rates of malaria brought about by greater water pooling in areas with deficient sanitation have been described as additional pathways between poor WASH and high child malnutrition rates [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIndia\u0026rsquo;s nutrition-related government programmes\u003c/h2\u003e \u003cp\u003eThe Indian government has been addressing the country\u0026rsquo;s food and nutrition security since 2013 through the framework of the National Food Security Act (NFSA), which has legally enshrined Indian people\u0026rsquo;s right to food [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The NFSA is based primarily on three social programmes: the Public Distribution System (PDS), the Integrated Child Development Scheme (ICDS), and the Mid-Day Meal Scheme (MDMS). Water, sanitation, and hygiene programmes are also of interest here.\u003c/p\u003e \u003cp\u003eThe PDS was established after World War Two with the two-pronged aim of bolstering national food production and improving people\u0026rsquo;s access to food and to date it has remained India\u0026rsquo;s largest national food-access programme [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It has always involved the sale of highly subsidised rice and wheat to beneficiaries but has varied in coverage, oscillating between universal and more narrowly targeted. Since the implementation of the NFSA, the PDS covers 75 percent of rural and 50 percent of urban population (the less wealthy sections), whom it grants the right to purchase 5 kg subsidised grains, mostly wheat flour and rice, per month [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e][1]\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eThe ICDS and MDMS are aimed at addressing food and nutrition insecurity amongst particularly vulnerable populations. The ICDS was established in 1975 with a focus on encouraging correct nutritional, feeding, hygiene, and health practices in pregnant and lactating women and in children under six years of age [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Specific interventions within the scheme have included the provision of supplementary nutrition to young children and their mothers, of nutritional and health education to mothers, and of growth-monitoring, de-worming, and pre-school education to children [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The services are provided through an extensive national network of \u003cem\u003eanganwadi\u003c/em\u003e centres (AWCs). Meanwhile, the MDMS has been implemented nationally since 2001, to improve nutrition along with school attendance amongst primary-school pupils [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e][2]\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eFinally, given that deficient water and sanitation access have been seen as key drivers of India\u0026rsquo;s high malnutrition rates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], successive Indian governments implemented drives to build toilets and eradicate open defecation. The most recent and arguably most successful such programme to date has been the Swachh Bharat, implemented from 2014 to 2019 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The programme has claimed to have eradicated open defecation; whilst survey data do not support that conclusion, they do indicate that a significant reduction in open defecation has taken place [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe effects of these government programmes on food and nutrition security have been mixed. Some studies found the PDS to have increased caloric consumption [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], whilst others did not [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The programme\u0026rsquo;s positive effect on people\u0026rsquo;s access to food arguably increased after the reform under the NFSA [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], but its impact on nutrition outcomes is more questionable, with beneficiaries found to consume more wheat and rice at the expense of nutritious grains, fruit, and dairy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The ICDS has been more successful in improving nutrition outcomes. Whilst earlier studies of the ICDS showed minimal impact [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], later studies indicated a positive effect for some groups of children [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The Swachh Bharat programme reduced open defecation rates, the occurrence of diarrhoeal diseases, and infant and child mortality [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], although infrastructure issues for waste disposal and other barriers remain [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCovid-19- pandemic and child nutrition in India\u003c/h3\u003e\n\u003cp\u003eFood and nutrition security in India and beyond has been significantly affected by the Covid-19 pandemic and its related impact. The long-term effects of the pandemic in India have not been explored in detail yet; existing literature proposes that the effects have been largely negative due to harmful economic consequences but partially offset by the emergency expansion of the welfare programmes discussed. As many other countries, India implemented a national lockdown in March 2020, which started to be relaxed two months later. During the second wave of the pandemic in India, in the spring 2021, some states re-instated a lockdown for several months. Indian schools were, however, closed for longer, for 82 weeks between March 2020 and October 2021 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] \u0026ndash; the longest closure in the world after Uganda.\u003c/p\u003e \u003cp\u003eThe economic lockdowns intended to reduce the spread of Covid-19 led to complete or partial losses of income in many households, with low-income urban households particularly negatively affected. Food programmes, especially the PDS, were expanded in an attempt to make up for the loss of income. Between March 2020 and November 2022, the Government of India implemented the Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY), which granted all PDS-eligible households extra 5 kgs of rice or wheat per person and 1 kg of dal per household per month. New beneficiaries were also added to the lists of PDS eligible recipients at the beginning of the pandemic [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The ICDS and MDMS were significantly disrupted by the pandemic, however. The MDMS could no longer serve hot cooked meals to pupils when schools were closed and the need for social distancing also led to temporary closures of some ICDS Anganwadi centres. The programmes attempted to swiftly shift to the provision of dry-food rations and cash transfers but with mixed results.\u003c/p\u003e \u003cp\u003eTwo studies, one from Hyderabad [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] and one from Bihar [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] described how the pandemic significantly increased household food insecurity, measured through household food insecurity indices. Another study [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] explored the effects of the pandemic on children\u0026rsquo;s weight-for-age scores in selected districts in Bihar, Uttar Pradesh, and Odisha and found the effect to be also significantly negative, although not for all children. One of the pathways through which the deterioration is believed to have occurred was via deterioration in dietary quality in response to greater economic deprivation [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The effects of the pandemic on the other main pathway, sanitation, have been more mixed, with some increase in open defecation but improvement in hygiene practices [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Other relevant studies [\u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] noted the disruption of welfare programmes during the pandemic but also some positive trends \u0026ndash; for example, that the lower social contact between households during the pandemic led to fewer diseases amongst children [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] and public-service delivery innovations such as combining Vitamin-A supplementation with immunisations and using WhatsApp groups to share information about child feeding [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eHypotheses\u003c/h3\u003e\n\u003cp\u003eWith a view to existing findings, this article investigates the factors underlying the slow progress that India has achieved in reducing child malnutrition, with specific attention paid to the following:\u003c/p\u003e \u003cp\u003eH1. The effect of the Covid-19 pandemic \u0026ndash; we expect the pandemic to have undermined gains made in reducing child malnutrition rates but less so in households and areas where welfare programmes proved to be resilient and/or were expanded.\u003c/p\u003e \u003cp\u003eWe further investigate\u003c/p\u003e \u003cp\u003eH2. The role of children\u0026rsquo;s dietary quality \u0026ndash; we expect that primarily households and areas with greater improvement in children\u0026rsquo;s diets (MAD, ASF consumption) experienced greater reduction in child malnutrition rates. However, we expect the pandemic to have worsened dietary trends.\u003c/p\u003e \u003cp\u003eH3. The role of WASH \u0026ndash; we expect households and areas with greater WASH access to have experienced more reduction in child malnutrition rates. We expect the pandemic to have influenced WASH as well, but the direction of the influence is a matter of investigation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study uses mixed research methods. The first part is a quantitative analysis of data from NFHS IV [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and NFHS V [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. First, individual-level data from the two waves are combined and analysed followed by a panel-data analysis of matched district-level data. The second part of the study involved a qualitative comparative analysis of two Indian states \u0026ndash; Himachal Pradesh, which experienced significant deterioration in child malnutrition rates between 2015-16 and 2019-21, and Rajasthan, which experienced significant improvement.\u003c/p\u003e\n\u003ch3\u003eQuantitative national analysis\u003c/h3\u003e\n\u003cp\u003eFirst, the study analyses data on more than 75,000 Indian children between 6 and 23 months of age gathered by NFHS IV (~\u0026thinsp;40,000) and NFHS V (~\u0026thinsp;36,000), nationally representative Indian household surveys. The lower cut-off age of 6 months was selected due to the WHO recommendation for children from that age onwards to be \u0026lsquo;weaned\u0026rsquo;; i.e. to receive semisolid food as a supplement to breast milk [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The upper cut-off point was chosen because the first two years of children\u0026rsquo;s lives are considered the most crucial to ensuring good nutrition and health outcomes in later life [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] and because data on children\u0026rsquo;s diets were collected only up to that age. The data are first analysed jointly when pooled[3]\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e and second when averaged and matched by district. Most district boundaries remained unchanged between 2015-16 and 2019, but some changed, mostly by being divided into smaller sections. We therefore work with the 640 2015-16 districts, to which we matched the 2019-21 districts. In estimating the effects of the Covid-19 pandemic, we exploit the fact that one-third of NFHS V survey data collection occurred after the first wave of Covid-19 in India.\u003c/p\u003e \u003cp\u003eOur individual-level empirical models examine children\u0026rsquo;s nutrition outcomes as a function of children\u0026rsquo;s diets and other characteristics as well as their mothers\u0026rsquo;, households\u0026rsquo;, and communal characteristics. The district-level models analogously examine the district-level prevalence of children\u0026rsquo;s nutrition outcomes as a function of district-averaged children\u0026rsquo;s, their mothers\u0026rsquo;, and households\u0026rsquo; characteristics, under the assumption that the surveyed households are collectively representative of the districts in which they reside. We estimate the individual-level models using Probit and Tobit regressions that control for region of residence and whose robust standard errors are clustered by districts [following e.g., 7, 57, 58]. The district-level data are analysed using panel Tobit regressions that control for region.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative analysis\u003c/h2\u003e \u003cp\u003eThe second part of the analysis comprises a qualitative comparative case study of Rajasthan and Himachal Pradesh. Data relevant to the two states were collected from policy documents, online sources, and semi-structured online and in-person interviews with a range of state officials between December 2023 and April 2024 (7 individual and group interviews in Jaipur, 7 individual and group interviews in Shimla). These data were analysed using thematic analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDependent variables\u003c/h2\u003e \u003cp\u003eThe study examines four malnutrition outcome measures in children \u0026ndash; stunting (too short for age), underweight (too light for age), wasting (too light for height), and anaemia (lower than normal red-blood-cell count). All four types of malnutrition can be brought about by deficient feeding, but stunting is generally reflective of longer-term whilst wasting of shorter-term nutrition deprivation. Underweight can be a result of either stunting or wasting whereas anaemia may be caused by iron-deficient diets, alongside frequent diarrhoea and/or intestinal parasites [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. The study further investigates three additional nutrition outcomes \u0026ndash; height-for-age (Z scores), weight-for-age (Z scores), and weight-for-height (Z scores).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKey independent variables\u003c/h2\u003e \u003cp\u003eThe main variables of interest in this study involve the pandemic, government\u0026rsquo;s welfare programmes, children\u0026rsquo;s diets, WASH, and their interaction. The pandemic variable relates only to NFHS 5 data and takes on a value of 1 when the household was surveyed after the first Covid-19 wave in India \u0026ndash; i.e., between November 2020 and May 2021. The only relevant programme on which data in the NFHS are collected is the ICDS \u0026ndash; we use several relevant variables here, looking at weekly receipts of food, receiving support in pregnancy, and when breastfeeding. We also look at the PDS, MDMS, and Swachh Bharat in the qualitative case study. In terms of child feeding, the variables of interest include whether a child received the WHO-defined Minimum Acceptable Diet (MAD), of satisfactory frequency and diversity of food groups, in the 24 hours prior to the administration of the survey and whether s/he has received any animal-sourced food (ASF) other than milk. At the individual level, all these are binary variables. We further look at the household ownership of cattle, poultry, and agricultural land (also all binary variables), which might be linked with the children\u0026rsquo;s diet composition. For WASH, we utilise several variables - whether a household has a private improved sanitation facility (flushing toilet or an improved latrine), whether a household has access to an improved water source (both binary variables), and the prevalence of private improved toilets at the district level. We also look at the availability of water and of soap/ash at handwashing sites (binary variables as well).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOther independent variables\u003c/h2\u003e \u003cp\u003eFactors other than poor dietary trends and lack of access to WASH linked with a higher likelihood of childhood malnutrition include, at the child level, being born male, preterm, with a low birthweight, later birth order, and a shorter birth interval with a preceding sibling [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. At the household level, poorer, younger, worse nourished, less educated mothers with more children have also generally been found to be more likely to have malnourished children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Other factors identified as consequential in India have included household caste [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], religion [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], and urban versus rural residence [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccordingly, at the child level, we consider whether a child was born prematurely, his/her gender, age, birth order, birth interval with preceding sibling, whether s/he has had diarrhoea and fever in the last two weeks, and whether s/he has been breastfed for six months. At the mother\u0026rsquo;s level, we control for her age at giving birth, her education level, and whether she is underweight and/or anaemic. From household variables, we include their size, whether they are female headed, how many children under five they have, their caste (scheduled caste, scheduled tribe, other backward caste, or upper caste), and their religion (Hindu, Muslim or other). Finally, we consider if their residence is in a rural or an urban area, whether it is in a coastal district, and its geographical region in India[4]\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eSummary statistics of NFHS data used\u003c/h2\u003e\n \u003cp\u003eTable 1 displays the summary statistics of all the variables used in the analysis, separately for the two NFHS rounds examined. The individual-level data used are limited to children between 6 and 23 months old, as dietary data are available only for that age group. The dependent variables section demonstrates that within the sample investigated, as is true of the broader sample of children under five years old, stunting, underweight, and wasting rates all declined whilst the rate of anaemia increased between NFHS 4 and 5. Children’s average height-for-age, weight-for-age, and weight-for-height correspondingly increased as well albeit still remaining firmly below the WHO average of zero.\u003c/p\u003e\n \u003cp\u003eTurning to information on the operation of ICDS, the proportion of households receiving food assistance from the programme at least once a week remained largely flat. The support women received in pregnancy and when breastfeeding rose, however, from 81 and 74 percent in 2015-16 to 87 and 83 percent in 2019-21. Looking at the dietary variables, the percentage of children eating the minimum acceptable diet increased from 8 to 10 percent; similarly, 39 percent of 6-23-month-olds in 2019-21 were reported to have eaten some animal-sourced food other than milk in the preceding 24 hours as opposed to 35 percent in 2015-16. The ownership of cattle remained approximately the same throughout (45 percent households), with poultry ownership slightly decreasing (from 19 percent households in 2015-16 to 18 percent in 2019-21) and agricultural land ownership slightly increasing (from 48 to 50 percent households).\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003eRegarding WASH, there was a significant improvement in access to improved sanitation facilities, reflecting successes of the Swachh Bharat, with the proportion of households with private improved toilet rising from 38 percent in 2015-16 to 65 percent in 2019-21. The result is, however, still quite far off the 100 percent target touted by the programme as having been achieved. Household access to an improved water source remained broadly unchanged but the proportion of households with running water and soap/ash at handwashing place grew significantly (81 to 92 percent for water, 71 to 81 percent for soap/ash).\u003c/p\u003e\n \u003cp\u003eMany of the control variables utilised, displayed in the last section of Table 1, also remained broadly similar between NFHS 4 and 5. Mothers’ average age at birth, the children’s gender and age, birth order and interval with preceding sibling, whether the child was breastfed for six months, households’ average size, caste and religious breakdown, and the proportion of households living in urban and coastal areas changed only marginally. Other socio-demographic characteristics changed more notably. In the five years between the two surveys, mothers became more educated and less undernourished and households wealthier. The proportion of preterm births increased from 6 to 12 percent whilst the proportion of children who had suffered from diarrhoea or fever in the last two weeks declined from 15 and 18 percent to 10 and 16 percent. Female-headed households also increased in prevalence, from 12 to 15 percent.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eQuantitative results\u003c/h2\u003e\n \u003cp\u003eTables 2.1 and 3.1 below show regression results on key independent variables (Tables 2.2 and 3.2 in the Appendix contain results on control variables). Table 2 contains results from the analysis of individual-level data whilst Table 3 from the analysis of district-level data. Both sets of results highlight the importance of dietary behaviour and WASH in improving children’s nutrition outcomes. They also suggest that the pandemic’s first wave has not had a singularly negative effect on India’s child malnutrition rates.\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003eTo expand on the last point, in contradiction of our first hypothesis, the pandemic – or at least its first wave observed here – does not appear to have unequivocally worsened malnutrition rates amongst young Indian children. In some aspects it actually appears to have had a positive effect. In the individual-level results (Table 2.1), the pandemic is linked with lower height-for-age scores but also with lower likelihood of children being wasted or anaemic, measures of more acute nutrition deprivation. In the district-level results (Table 3.2), the pandemic is linked with lower prevalence of stunting, underweight, wasting, and anaemia. However, it is not significantly associated with overall higher height-for-age, weight-for-age or weight-for-height, indicating that the effect has been one of malnutrition amelioration rather than an overall increase in the weight or height of Indian children.\u003c/p\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eLooking at the role of the ICDS, which we hypothesised could have helped cushion the negative economic impact of the Covid-19 lockdown alongside other government welfare programmes, it is not positively connected with better nutrition outcomes. The results are largely insignificant with the exception of wasting and weight-for-height in the individual data, where receiving weekly food from the ICDS is associated with worse nutrition outcomes. The nature of the relationship in that case, however, is more likely in the opposite direction, with wasted children more likely to be recipients of the ICDS food aid than others. We investigate how the ICDS and other welfare programmes in India were affected by the pandemic further in the article but before doing so, let us turn to the other key independent variables.\u003c/p\u003e\n \u003cp\u003eFrom the dietary variables, consuming animal-sourced food - unlike the minimum acceptable diet – is evidently and consistently associated with lower malnutrition prevalence as well as greater height and weight. This is in line with our second hypothesis. From the agricultural variables examined, having access to agricultural land is linked with lower likelihood of stunting and underweight. In contrast, cattle and poultry ownership are associated with worse nutrition outcomes. This might seem counterintuitive since households with cattle or poultry have more direct access to animal-sourced food. Nevertheless, it could be a function of the high correlation between agricultural land and livestock ownership, which might be biasing the results, as well as of the higher exposure to animal-vector gastro-intestinal diseases in livestock-owning households that might undermine nutrition outcomes [e.g., 11, 13].\u003c/p\u003e\n \u003cp\u003eWASH is also clearly linked with better nutrition outcomes, consistent with our third hypothesis. Households with private improved toilets are less likely to have stunted, underweight, wasted, and anaemic children and more likely to have children with greater height-for-age, weight-for-age, and weight-for-height scores. The same is true of the prevalence of private improved toilets on the district level – districts with better sanitation have better nutrition outcomes on most of the nutrition dimensions analysed. Access to an improved water source and water at handwashing place are also associated with some better nutrition outcomes – lower likelihood of wasting in the case of an improved water source and reduced prevalence of underweight and wasting in the case of water accessibility at handwashing place.\u003c/p\u003e\n \u003cp\u003eBefore delving in more detail into the relationship between the pandemic and the other key variables, Tables 2.2 and 3.2 in the Appendix show the relationships between control variables and nutrition outcomes. These are largely in line with expectations. At the child level, boys are more likely to be malnourished than girls, as are higher-order children, children with shorter birth intervals with preceding siblings, children who were born prematurely, and children who have had diarrhoea or fever within two weeks of the survey. Wealthier households and more educated mother are more likely to have well-nourished children; the opposite is true of children born to underweight and anaemic mothers. Upper-caste children are significantly less malnourished than children from other castes. Further area characteristics that reduce malnutrition likelihood are rural and coastal areas of residence. The results from the individual-level data are largely replicated in the district-level data.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eThe pandemic puzzle\u003c/h2\u003e\n \u003cp\u003eOur finding that the pandemic has not had a significantly negative effect on children’s nutrition outcomes – and in some cases even appears to have actually helped ameliorate malnutrition – is not in line with our expectations or existing literature. The fact that the pandemic is positively associated with reduced risk of malnutrition, particularly wasting and anaemia, but not with general increase in height or weight in all children, suggests the possibility of this effect being driven by the expansion of welfare safety nets during the pandemic. The NFHS data contain information only on one relevant welfare programme, the ICDS. Table 4 below looks at the proportion of Indian households using the programme’s different services and shows that the weekly provision of food by the service declined after the first wave of Covid-19, although not drastically – from 51 percent in 2019 to 46 percent in 2021. Figure 1 further shows that after the first wave of Covid-19, the food receipts became more progressive – with the poorest 20 percent of households seeing a significant increase in food benefits whilst the wealthiest 60 percent a significant reduction. Compared to food receipts, the provision of support during pregnancy and breastfeeding from the ICDS increased, from 88 and 80 percent before the pandemic to 91 percent and 88 percent after the first wave. This could be related to the increased use of WhatsApp by ICDS workers following the onset of the pandemic, as described in previous research [51].\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eResults in Table 5 and Figs. 2 and 3, which look at the links between the ICDS pregnancy and breastfeeding support services, the pandemic, and children’s nutrition outcomes, interestingly demonstrate that after the first Covid-19 wave, the provision of regular pregnancy and breastfeeding support to mothers is linked with significantly lower rates of underweight, wasting, and anaemia. Whilst, as we explained earlier, the direction of the relationship between ICDS services and nutrition outcomes is difficult to ascertain through these regressions, it could be a sign that the increased provision of these ICDS services helped parents improve their children’s nutrition outcomes, through better feeding or sanitation practices.\u003c/p\u003e\n \u003ctable id=\"Tab7\" border=\"1\"\u003e\u003c/table\u003e\n \u003cp\u003eOther possible factors underlying the observation of a positive link between the pandemic and children’s nutrition outcomes are listed in Table 6, which shows the prevalence of children’s diseases and WASH variables in the districts that were not surveyed during the pandemic, in 2015/16 and 2019/20, as compared to the districts that were surveyed after the onset of the pandemic, again in 2015/16 and then in 2020/21. The occurrence of disease – both diarrhoea and fever within two weeks of the survey – appears negatively correlated with children’s nutrition outcomes, particularly their weight (Tables 2.2 and 3.2). Table 6 shows that following the first wave of Covid-19, Indian children were suffering significantly less from diarrhoea and fever, likely due to reduced social contact [55]. This is a very plausible pathway through which the pandemic may have contributed to reduced malnutrition rates. Another might be the greater importance placed on good-quality WASH in the pandemic messaging. Table 6 shows that whilst there was a general increase in the presence of water and soap/ash at handwashing places between NFHS 4 and 5, the increase was significantly greater in districts surveyed after the first wave of Covid-19. Since these variables are also linked with lower malnutrition rates (Table 2.2 and 3.2), this is another feasible pathway through which the Covid-19 pandemic might have contributed to better children’s nutrition outcomes. The following comparative study of Rajasthan and Himachal Pradesh explores this issue in greater depth.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003eComparative case study – Rajasthan and Himachal Pradesh\u003c/h2\u003e\n \u003cp\u003eIn order to gain a deeper understanding of the factors underlying the trajectory of change in Indian children’s nutrition outcomes, this second part of our analysis compares the recent experience of two states – Rajasthan and Himachal Pradesh. We chose these two states because, as Fig. 4 shows, whilst Rajasthan experienced a significant reduction in child malnutrition rates between NFHS4 and 5, the opposite happened in Himachal. The proportion of under-five stunted, underweight, and wasted children in Rajasthan declined from 39, 37, and 24 percent in 2015/16 to 33, 30, and 19 percent in 2019/21; conversely, in Himachal the corresponding rates increased from 26, 21, and 14 percent to 33, 26, and 17 percent. The overall malnutrition rates in Rajasthan have remained slightly higher than in Himachal but the two state’s trajectories have been very different, making them good case studies for a more detailed study of the relevant factors.\u003c/p\u003e\n \u003cp\u003eBefore delving into that analysis, let us look at some basic characteristics of the two states in Table 7. In some respects, the states are quite different. Himachal Pradesh is only one sixth of Rajasthan in size and has one tenth of Rajasthan’s population [67]. At the same time, Himachal is more than 50 percent richer on per-capita basis than Rajasthan and has a significantly larger proportion of migrant labourers (35.2 percent compared to 7.6 percent of the population). However, there are also many similarities between the states. They are both situated in northern India, not far from the country’s capital, New Delhi. They are both predominantly Hindu, with relatively small Muslim minorities, and most people in both states speak Hindi. They are predominantly rural, with only 7 percent of Himachal and 17 percent of Rajasthan inhabitants residing in urban areas.\u003c/p\u003e\n \u003ctable id=\"Tab9\" border=\"1\"\u003e\u003c/table\u003ePandemic and welfare programmes\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\"\u003e\n \u003cp\u003eIn turn, we now consider in more detail the factors identified in the previous section as influential for child malnutrition rates – the pandemic, social welfare programmes, dietary factors, WASH, and their interaction. An important point to note here is that NFHS 5 data for Himachal Pradesh were all gathered prior to the onset of the pandemic whereas 15 out of 33 districts in Rajasthan were partly or wholly surveyed after the first wave of Covid-19. Hence, whilst the NFHS5 data for Rajasthan partially reflect the effects of the pandemic, the data for Himachal Pradesh do not.\u003c/p\u003e\n \u003cp\u003eThe first factor that we investigated in the quantitative section as a pathway through which the pandemic may have influenced malnutrition rates were welfare programmes, specifically the ICDS, on which the NFHS gathers data. Our data analysis does not obviously show a link between programme participation and better outcomes, but we did not employ more sophisticated measures of trying to control for reverse causality to establish impact (e.g., propensity score matching, instrumental variable equations). Other research has suggested that the ICDS does tend to have positive impacts on nutrition outcomes, at least for some groups of children [37–39]. In both Rajasthan and Himachal, the ICDS coverage increased between NFHS4 and NFHS5, particularly when it comes to pregnancy and breastfeeding assistance – from 78 and 65 percent to 84 and 80 percent in Himachal and from 49 and 38 percent to 68 and 57 percent in Rajasthan. But in Rajasthan, the increase in the coverage by these services was particularly notable during the pandemic, with a 39 percent increase for coverage of pregnancy assistance and 61 percent for coverage of breastfeeding assistance (the proportion of households receiving weekly food rations declined, on the other hand, from 55 to 47 percent, but as on the national level, this affected households in the poorest quintile proportionally the least). A similar enlargement of ICDS pregnancy and breastfeeding services occurred according to our interviewees during the pandemic in Himachal - had survey data there been collected also after the first wave of Covid-19, perhaps the results for malnutrition rates in Himachal would have looked different.\u003c/p\u003e\n \u003cp\u003eFurther innovations were recently made in the Rajasthan ICDS, which might have also helped with the state’s significant strides forward in nutrition outcomes. One has been the rollout of the community-based management of malnutrition in 20 Rajasthani districts in 2018 [68]. The programme surveyed all children between 6 and 59 months old in the districts where it was implemented and referred children affected by severe acute malnutrition to medical centres or community care, with good results. Sixty-seven percent of the treated children recovered within 12 weeks – without the programme, they would have likely continued to be malnourished. The other improvement within the Rajasthani ICDS has been the establishment of specific coordination between the Ministry of Women and Children, traditionally tasked with overseeing the ICDS, and the Ministry of Education, to ensure that the activities of both ministries aligned in their support for the ICDS. One result of this coordination has been greater awareness of early child development issues throughout the state’s government, another has been the increasing trend of opening Anganwadi centres in primary schools, a move that boosted Anganwadi attendance by younger siblings of primary school pupils. We are not aware of equivalent initiatives in Himachali ICDS.\u003c/p\u003e\n \u003cp\u003eThe other national programme with a large potential to affect children’s nutrition is the PDS. Its coverage, estimated at 61 percent, is greater in Rajasthan than in Himachal (38 percent) [69] and according to our interviewees, Rajasthan has made good progress in reducing the programme’s leakage by eliminating intermediary godowns for grains. Now the PDS grains are transferred directly from national godowns to fair-price shops in Rajasthan, with digital tracking of the deliveries and immediate online reporting of all transactions, until the delivery to the household [70]. The PDS offering in Himachal Pradesh is much more comprehensive than in Rajasthan, on the other hand. In addition to wheat and rice, Himachal government provides NFSA beneficiaries also with subsidised (not free) edible and refined oil, salt, sugar, and pulses – black gram, chana dal, masoor dal, and green gram (interviews) and the food is available at subsidised, albeit less so, prices also to Himachali residents without NFSA ration cards [71]. According to interviewees, the issue of the quality of food available through the PDS is still problematic in both states, which more localised quality controls could help address [70, 71].\u003c/p\u003e\n \u003cp\u003eHowever, the biggest apparent problem with the PDS in Himachal has been the issue of migrant labourers. As Table 7 shows, 35 percent of Himachali population is constituted by labour migrants. Whilst these are predominantly men, some are women and children – and unless they have family in Himachal Pradesh, they are not entitled to obtain a Himachali ration card (either an NFSA one or general). The Indian government has tried to address this problem recently with the One Nation One Ration Card programme, but thus far this has been largely not functional in Himachal and hence Himachali migrant labourers have not been able to obtain their PDS rations whilst living in Himachal [71]. The operation of the One Nation One Card Scheme in Rajasthan was in contrast described as relatively successful [70] – but even if it were not, Rajasthan is home to a significantly smaller proportion of migrant labour than Himachal, which makes the issue of a lack of access to the PDS due to changed area of residence less problematic on the state level.\u003c/p\u003e\n \u003cp\u003eIn response to the Covid-19 pandemic, the Indian government temporarily expanded the PDS with the PMGKAY, which provided NFSA beneficiaries with 5 kilograms extra grains per person and 1 kilogram of pulses per household per month between March 2020 and December 2023. Unlike the ICDS, the operation of which was disrupted due to the closure of Anganwadi centres during the first lockdown, the PDS along with the PMGKAY operated relatively smoothly throughout most of the pandemic. The granular data on Rajasthani PDS deliveries demonstrates that there was some leakage of the rations, but most households received the majority of their grain and pulse entitlements.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003eDietary trends, WASH, and disease\u003c/h2\u003e\n \u003cp\u003eHowever, even though the safety-net programmes, PDS and ICDS, were relatively resilient throughout the pandemic, it has long been agreed that their positive influence on children’s nutrition outcomes is limited by the low diversity of the food they provide. They are particularly low on protein-rich and animal-sourced food, which the quantitative analysis confirmed as one of the key factors in Indian children’s nutrition outcomes. The consumption of animal-sourced food by Indian children is in general very low by international standards. It increased between NFHS4 and 5 but only slightly, from 35 percent of 6–23 month-old-children having eaten any animal-sourced food in the last 24 hrs before the survey in 2015/16 to 39 percent in 2019/21. The rate of increase was dampened during the pandemic, which was undoubtedly also connected with the low or non-existent provision of animal-sourced food by the PDS and ICDS, for cultural and religious reasons. In recognition of the situation, in recent years some Indian states have started to include eggs in the ICDS, but neither HP nor Rajasthan has done so [70–72]. HP has trialled including eggs in ICDS meals but due to some parental protest terminated the pilot [71]. Rajasthan has not even attempted to include eggs but did start to include greater amounts of dairy in the ICDS meals, which unlike meat or eggs does not face religious objections. Himachali ICDS meals also include a small amount of milk powder, but the protein content of that amount is negligible and other options, such as providing paneer, have been rejected on hygiene grounds, as most Anganwadi centres lack refrigerated storage facilities [71].\u003c/p\u003e\n \u003cp\u003eLooking to WASH, another key driver of child nutrition outcomes, both Rajasthan and Himachal Pradesh experienced improvements in WASH access between NFHS 4 and NFHS 5. Particularly the access to private improved toilets grew significantly and more so in Rajasthan than in Himachal. Whilst the proportion of households with a private improved toilet in Himachal rose from 68 to 78 percent (a 15-percent increase), in Rajasthan the proportion expanded from 38 to 64 percent (a 68-percent increase) (NFHS 4, 5). The other WASH and disease variables highlighted as potential pathways through which the pandemic may have reduced some malnutrition rates changed in the desirable direction during the pandemic also in Rajasthan – the rates of households with water and soap/ash at handwashing points increased and the rate of diarrhoea and fever in young children decreased. Our interviewees in both Himachal and Rajasthan also noted the lower disease occurrence in young children during the pandemic, which may have contributed to better nutrition outcomes even during a time of relative economic crisis [70, 71].\u003c/p\u003e\n\u003c/div\u003e\n"},{"header":"Discussion and conclusions","content":"\u003cp\u003eChild nutrition outcomes specifically and food and nutrition security more broadly remain a challenge in India. These issues have experienced improvement in recent decades, but the rate of progress has been slow. Our study has contributed to the understanding of the multiple drivers of this complex issue and highlighted the importance of child feeding practices, including animal-sourced food consumption, of improved water, sanitation, and hygiene practices, and of the resilience of relevant welfare programmes, which had been tested during the pandemic. The study also highlighted that the effects of the pandemic on India’s nutrition security have not been uniformly as negative as suggested in other existing research and, through the comparative qualitative case study of Rajasthan and Himachal Pradesh, underscored the importance of locally tailored state-level policies.\u003c/p\u003e\u003cp\u003eThe importance of timely weaning of children with sufficiently diverse and frequent diets for Indian children’s nutrition outcomes has been previously established [7]. This study further emphasises the importance of introducing proteins and micronutrients found in ASFs into children’s diets to encourage growth and reduce malnutrition rates. Our interviews with civil servants in Rajasthan and Himachal revealed that there is awareness of this issue on the ground but there are barriers still in place against increasing access to such foods in welfare programmes, cultural, religious, as well as logistic, including a lack of refrigerated storage spaces. Greater emphasis on parental awareness-raising in this regard could make a big difference, too, as even many non-vegetarian parents do not feed ASFs to young children due to erroneous beliefs about potential harm [73]. Neither Rajasthan nor Himachal Pradesh have thus far included eggs in their ICDS offering, unlike many North-Eastern and Southern Indian states, but our interviewees in Himachal suggested that since the Covid-19 pandemic, there has been a greater general acceptance of egg consumption even by vegetarians [71]. The state and local governments could thus make a stronger case for the inclusion of ASFs in feeding programmes, which could contribute to healthier children. Unlike Himachal, Rajasthan has included more dairy in its ICDS food, which could be one of the reasons why Rajasthan has managed to reduce child malnutrition rates quite notably between 2015-16 and 2019-21.\u003c/p\u003e\u003cp\u003eOur study further re-affirmed the importance of access to improved WASH in attaining positive nutrition outcomes. At all levels of the data analysis, ownership of private improved toilets was significantly positively associated with lower levels of child malnutrition. This was true not only at the individual level. Districts with greater prevalence of private improved toilets were found to have further positive association with lower levels of malnutrition, highlighting the importance of communal or ecological sanitation and hygiene as well. The Swachh Bharat programme undoubtedly increased both people’s access to and usage of improved sanitation; however, at the communal level the question of sewage needs further addressing [42]. Both Rajasthan and Himachal Pradesh experienced an increase in people’s access to improved sanitation as well, but the rate of increase in Rajasthan has been much steeper, which could be another reason underlying the divergence in the two states’ child-nutrition trajectories.\u003c/p\u003e\u003cp\u003eFinally, the study shed some new light on the effects of the pandemic on nutrition security in India and its interaction with the welfare services in place to shore up food and nutrition security. Unlike other existing studies, the quantitative data analysis, which took advantage of the fact that part of the NFHS 5 data were gathered after the first wave of the Covid-19 pandemic, did not reveal a consistently negative picture of the pandemic’s effects. The results did not suggest that the pandemic had an overall positive effect on children’s growth but showed a positive association between the pandemic and reduced malnutrition rates, particularly when measured through wasting and anaemia. One potential explanation for this might lie in the welfare programmes in place and their expansion during the pandemic. The PDS was during the pandemic supplemented with the PMGKAY, which gave NFSA-eligible households extra grains and pulses. The ICDS operations were disrupted more but home food deliveries were introduced after initial disruption and the provision of some services, such as the ICDS pregnancy and breastfeeding advice, actually increased, likely because of the greater use of mobile technologies by the programmes [see also 74]. However, as our quantitative and qualitative analyses indicated, there are other, as or more likely pathways through which the pandemic might have had a positive effect on children’s nutrition status than through changes to welfare programmes. Hygiene observation (handwashing with soap) during the pandemic improved, which, together with lower levels of social contact, led to a lower prevalence of disease (diarrhoea, fever) in young children [in line with 55]. Both of these were shown to be linked with lower malnutrition rates in our study.\u003c/p\u003e\u003cp\u003eThat is not to contend, however, that the performance of welfare programmes and their local tailoring have had no bearing on the trajectory of child malnutrition rates across India, as was underscored by our comparative case study of Rajasthan and Himachal. Some of the reasons why the nutrition situation in Rajasthan improved between 2015-16 and 2019-21 and worsened in Himachal in the same time period were undoubtedly linked with the performance of the PDS and ICDS. In Rajasthan, the improvements may have been at least partially driven by better integration and coordination of the Education and Women and Child ministries in the delivery of ICDS services as well as innovative programmes like the community-based management of malnutrition. Conversely, in Himachal Pradesh the deterioration was likely related to a rapid influx of migrant labourers, which have had a hard time gaining access to PDS rations if migrating from other states. The One Nation One Ration Card initiative is aimed at addressing this specific issue but so far, its implementation has been patchy and largely inadequate, particularly given India’s growing rate of inter-state labour movement [70, 71].\u003c/p\u003e\u003cp\u003eThe slow progress in improving child nutrition outcomes in India, despite rapid economic growth, underscores the complexity of malnutrition and the need for multifaceted solutions. This study’s findings highlight the critical role of ASF consumption, improved WASH services, and resilient welfare programmes. The comparative analysis of Rajasthan and Himachal Pradesh provided further insight into issues of effective policy implementation and highlighted the importance of state-specific strategies. Concerted efforts at both the Indian national and state levels, informed by robust data[5]\u003ca href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e and innovative practices, are essential to accelerating progress in improving India’s child nutrition outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASF \u0026ndash; animal-sourced food\u003c/p\u003e\n\u003cp\u003eHP \u0026ndash; Himachal Pradesh\u003c/p\u003e\n\u003cp\u003eICDS \u0026ndash; Integrated Child Development Services\u003c/p\u003e\n\u003cp\u003eLMICs \u0026ndash; low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eMAD \u0026ndash; minimum acceptable diet\u003c/p\u003e\n\u003cp\u003eMDMS \u0026ndash; mid-day meal scheme\u003c/p\u003e\n\u003cp\u003eNFHS \u0026ndash; National Family Health Survey\u003c/p\u003e\n\u003cp\u003eNFSA \u0026ndash; National Food Security Act\u003c/p\u003e\n\u003cp\u003ePDS \u0026ndash; Public Distribution System\u003c/p\u003e\n\u003cp\u003ePMGKAY - Pradhan Mantri Garib Kalyan Anna Yojana\u003c/p\u003e\n\u003cp\u003eWASH \u0026ndash; water, sanitation, and hygiene\u003c/p\u003e\n\u003cp\u003eWHO \u0026ndash; World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe field research part of this study, in Rajasthan and Himachal Pradesh, received an ethics approval from research ethics committees at both Royal Holloway, University of London and Jawaharlal Nehru University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets analysed are publicly available at https://microdata.worldbank.org/index.php/catalog/3110 and at https://microdata.worldbank.org/index.php/catalog/4482.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received support from internal research funding at Royal Holloway, University of London.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIP analysed quantitative and qualitative data and co-wrote the manuscript. NK collected and analysed qualitative data and co-wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to express our deepest gratitude to all our interview participants in Rajasthan and Himachal Pradesh as well as to participants at ECPR 2024 conference in Dublin for their comments on an earlier draft of the article. We further want to thank the article\u0026rsquo;s peer reviewers and editors at BMC Public Health.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRamalingaswami V, Jonsson U, Rohde J. Malnutrition: a South Asian enigma. In: \u003cem\u003eMalnutrition in South Asia.\u003c/em\u003e Kathmandu: UNICEF; 1997.\u003c/li\u003e\n\u003cli\u003eNFHS 4. 2015-16 [cited 2025 Mar 3]. Available from: https://microdata.worldbank.org/index.php/catalog/3110\u003c/li\u003e\n\u003cli\u003eNFHS 5. 2019-21. [cited 2025 Mar 3]. 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First 1,000 days [Internet]. 2017 [cited 2024 Mar 3]. Available from: https://www.unicef.org/southafrica/SAF_brief_1000days.pdf\u003c/li\u003e\n\u003cli\u003eHaile D, Azage M, Mola T, Rainey R. Exploring spatial variations and factors associated with childhood stunting in Ethiopia: Spatial and multilevel analysis. \u003cem\u003eBMC Pediatr.\u003c/em\u003e 2016;16:1-14.\u003c/li\u003e\n\u003cli\u003eTassew AA, Tekle DY, Belachew AB, Adhena BM. Factors affecting feeding 6\u0026ndash;23 months age children according to minimum acceptable diet in Ethiopia: a multilevel analysis of the Ethiopian Demographic Health Survey. \u003cem\u003ePLoS One.\u003c/em\u003e 2019;14(2):e0203098.\u003c/li\u003e\n\u003cli\u003eWHO. 2024 [cited 2025 Mar 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition\u003c/li\u003e\n\u003cli\u003eJeyakumar A, Supriya N, Nayak S. Prevalence and risk factors of undernutrition among children less than 2 years in urban slums of Pune, Maharashtra, India. \u003cem\u003eEcol Food Nutr.\u003c/em\u003e 2019; doi:10.1080/03670244.2019.1613985.\u003c/li\u003e\n\u003cli\u003eRao N, Bala M, Ranganathan N, Anand U, Dhingra S, Costa JC, et al. Trends in the prevalence and social determinants of stunting in India, 2005\u0026ndash;2021: findings from three rounds of the National Family Health Survey. \u003cem\u003eBMJ Nutr Prev Health.\u003c/em\u003e 2023;6(2):357.\u003c/li\u003e\n\u003cli\u003eBharati S, Pal M, Sen S, Bharati P. Growth and nutritional status of preschool children in India. In: Dasgupta R, editor. \u003cem\u003eAdvances in growth curve and structural equation modelling.\u003c/em\u003e Singapore: Springer; 2018. p. 113-25.\u003c/li\u003e\n\u003cli\u003eBhutia DT. Protein energy malnutrition in India: The plight of our under-five children. \u003cem\u003eJ Fam Med Prim Care.\u003c/em\u003e 2014;3(1):63-7.\u003c/li\u003e\n\u003cli\u003eMenon P, Headey D, Avula R, Nguyen PH. Understanding the geographical burden of stunting in India: a regression‐decomposition analysis of district‐level data from 2015\u0026ndash;16. \u003cem\u003eMatern Child Nutr.\u003c/em\u003e 2018;14(4):e12620.\u003c/li\u003e\n\u003cli\u003eBanerjee S, P S. Exploring the paradox of Muslim advantage in undernutrition among under-5 children in India: a decomposition analysis. BMC pediatrics. 2023 Oct 16;23(1):515.\u003c/li\u003e\n\u003cli\u003eMurarkar S, Gothankar J, Doke P, Pore P, Lalwani S, Dhumale G, et al. Prevalence and determinants of undernutrition among under-five children residing in urban slums and rural area, Maharashtra, India: a community-based cross-sectional study. \u003cem\u003eBMC Public Health.\u003c/em\u003e 2020;20:1-9.\u003c/li\u003e\n\u003cli\u003eStatistics times. 2025. [cited 2025 Mar 3]. Available from: https://statisticstimes.com/india.php\u003c/li\u003e\n\u003cli\u003eMangal DK, Sivaraman S. Community management of acute malnutrition in Rajasthan, India. Field Exchange. 2020(63):49.\u003c/li\u003e\n\u003cli\u003eKhera R, Somanchi A. A Review of the Coverage of PDS. Ideas for India. 2020 Aug 19;19.\u003c/li\u003e\n\u003cli\u003eAuthors\u0026rsquo; interviews with policy makers and academics in Rajasthan. 2023 Dec-2024 Apr.\u003c/li\u003e\n\u003cli\u003eAuthors\u0026rsquo; interviews with policy makers and academics in Himachal Pradesh. 2023 Dec-2024 Apr.\u003c/li\u003e\n\u003cli\u003eBhatnagar GV. Despite nutrition benefits, most BJP states keep eggs out of mid-day meals [Internet]. \u003cem\u003eThe Wire\u003c/em\u003e; 2018 Jul 9 [cited 2024 Mar 3]. Available from: https://science.thewire.in/politics/bjp-states-health-children-eggs-mid-day-meal-nutrition/\u003c/li\u003e\n\u003cli\u003ePetrikova I. Food-security governance in India and Ethiopia: a comparative analysis. \u003cem\u003eThird World Q.\u003c/em\u003e 2019;40(4):743-62.\u003c/li\u003e\n\u003cli\u003eSuri S, Kapur K. POSHAN Abhiyaan: fighting malnutrition in the time of a pandemic. \u003cem\u003eObserver Res Found.\u003c/em\u003e 2020.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Since 2020, the subsidy for the 5 kg per month is 100%; i.e., the 5 kg are free.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e This programme is of less interest here as our main focus are nutrition outcomes amongst pre-school-aged children.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eA panel could not be constructed since each round of NFHS surveys different households. As a robustness test, data are also analysed separately for each wave.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Southern states (Andaman and Nicobar Islands, Andhra Pradesh, Karnataka, Kerala, Lakshadweep, Puducherry, Tamil Nadu, Telangana), North-Eastern states (Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura), Eastern states (Bihar, Jharkhand, Odisha, West Bengal), Northern states (Chandigarh, Haryana, Himachal Pradesh, Jammu and Kashmir, Ladakh, Delhi, Punjab, Rajasthan), Central states (Chhattisgarh, Madhya Pradesh, Uttar Pradesh, Uttarakhand), and Western states (Dardra, Nagar Haveli, Daman, and Diu, Goa, Gujarat, Maharashtra).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e At the time of writing, the US has just cancelled funding for all Demographic and Health Surveys (DHS), on which the NFHS is also based. The authors hope that India, which is now self-funding the 6th round of NFHS, will follow previous practice of releasing the final datasets to academic researchers for analysis. The cancellation of the DHS is to grave detriment to global health research, particularly in low- and middle-income countries, and should be resurrected through other financial means.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"child nutrition, India, NFHS, pandemic, WASH, animal-sourced food, Rajasthan, Himachal Pradesh","lastPublishedDoi":"10.21203/rs.3.rs-6195701/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6195701/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImprovements in child nutrition outcomes have lagged behind India’s recent rapid economic growth, a phenomenon known as the ‘Indian enigma.’ Between 2015-16 and 2019-21, stunting and wasting rates declined only slightly, with some Indian states even experiencing worsening malnutrition. This study investigates the factors driving these trends, focusing on the impact of the COVID-19 pandemic, children’s dietary quality, access to water, sanitation, and hygiene (WASH), and the role of government nutrition programmes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study employs a mixed-methods approach, combining a quantitative analysis of data from India’s National Family Health Surveys (NFHS) IV (2015-16) and V (2019-21) with a qualitative comparative case study of Rajasthan and Himachal Pradesh—two states with contrasting malnutrition trends. Individual- and district-level regression models were used to assess the effects of dietary diversity, WASH access, and government programs, whilst interviews with policy makers in Rajasthan and Himachal have provided insights into programme implementation and local responses during the pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings confirm that dietary diversity, particularly consumption of animal-sourced foods, and improved WASH access are key drivers of better nutrition outcomes in India. However, contrary to expectations, our study does not find a consistently negative relationship between the COVID-19 pandemic and child malnutrition. Instead, flexible expansion of some of the welfare programmes during the pandemic along with reductions in children’s disease rates and improvement in some sanitation practices may have mitigated the expected deterioration. Findings from the comparative study of Rajasthan and Himachal further highlighted the importance of tailoring the welfare programmes to specific local conditions, such as the large proportion of migrant labourers in Himachal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study challenges assumptions about the pandemic’s uniformly negative effects on child nutrition and highlights the importance of resilient, locally tailored safety nets. The findings underscore the need for policy interventions that enhance dietary diversity, sustain WASH improvements, and strengthen the adaptability of food and nutrition programmes to crises.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e","manuscriptTitle":"Progress in child nutrition outcomes: Insights from India’s recent experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 07:53:00","doi":"10.21203/rs.3.rs-6195701/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-17T12:04:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-13T06:45:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-13T06:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-10T12:41:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57ab2fa2-0ac2-4f19-8302-5681b07f3902","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:06:03+00:00","versionOfRecord":{"articleIdentity":"rs-6195701","link":"https://doi.org/10.1186/s12889-025-24436-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-09-30 15:57:31","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2025-03-18 07:53:00","video":"","vorDoi":"10.1186/s12889-025-24436-y","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24436-y","workflowStages":[]},"version":"v1","identity":"rs-6195701","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6195701","identity":"rs-6195701","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}