Looking upstream: enhancers of child nutritional status in post-flood rural settings

Submitted by Julia Barrott | published 6th Apr 2016 | last updated 13th May 2019
flooding. Photo by European Commission DG ECHO

Photo by European Commission DG ECHO (source: https://www.flickr.com/photos/69583224@N05/)

Introduction

Child undernutrition and flooding are highly prevalent public health issues in many developing countries, yet we have little understanding of preventive strategies for effective coping in these circumstances. Education has been recently highlighted as key to reduce the societal impacts of extreme weather events under climate change, but there is a lack of studies assessing to what extent parental education may prevent post-flood child undernutrition.

This article* explores the role of education in reducing the societal impacts of extreme flood events, particularly with regards to post-flood child undernutrition. It finds that education is a key investment in reducing the health impacts of extreme events under climate change risks while also promoting sustainable human development. 

*download from the right-hand column or via the links provided under Further Resources. A brief background to the report, an overview of the methods used and the key lessons and recommendations are provided below. See the full text for much greater detail.

Background (abridged)

Among all the disaster risks associated with a warming climate, flooding has become the most frequent and since the nineties it has been affecting around 100 million people a year. This is more than any other disaster type worldwide, climate-related or not (EM-DAT, 2015). Yet relative to their importance, the health consequences of flooding have been rarely investigated (Ahern et al., 2005Alderman, Turner & Tong, 2012).

A recent study of educational attainment as a promotor of disaster resilience found that higher-educated groups avoided high-risk areas to settle, were better prepared, reacted more efficiently to early warnings and had lessened impacts on health and social variables (Muttarak & Lutz, 2014). However, in the case of flooding, the evidence on the role of education as a promotor of positive health outcomes is scant and contentious (Lowe, Ebi & Forsberg, 2013). This is despite the fact that education is crucial for acquisition and processing of information (e.g., literacy), improvement of cognitive abilities, decision making and long-term planning, and generally leads to securing skilled jobs and ultimately higher income and better health.

The transgenerational effects of education on health have received substantial attention. However, although the effect of maternal education on child stunting and general child health has been studied (Milman et al., 2005Lindeboom, Llena-Nozal & Van der Klauuw, 2009), the effect of paternal education on child health has rarely been examined (Moestue & Huttly, 2008Semba et al., 2008). Assessing the impact of the education of the father on their child’s health is important for understanding both the relative contribution of fathers to the family wellbeing, and the synergies between father and mother education levels in the promotion of child’s health (Semba et al., 2008).

Despite adequate child nutrition being a key indicator of wellbeing and development, studies connecting flood-exposure to the nutritional status of children have been rare.  Additionally, none of them considered the role of father education in preventing the health impacts of floods among children (Phalkey et al., 2015). This is particularly the case for child wasting, which important as evidence suggest that stunting and wasting represent different processes of undernutrition (Ricci & Becker, 1996).


Figure 1 (from page 4 of the article): Study site, eligible villages and original sample of flooded and non-flooded villages in Jagatsinghpur district, Odisha, India. Triangles represent flooded villages; circles those non-flooded. Size of polygons is proportionate to village size as measured by number of households (see map legend). Polygons overimpressed identified villages selected. 

Methods and Tools (abridged)

The large floods occurring in rural Odisha, India in September 2008 produced massive damage to agriculture, water and sanitation, communication networks and severe disruption to the normal functioning of the entire rural society at large (Government of Orissa, 2008). One year after the floods, we conducted a two-stage cluster population-based survey of 6–59 months old children inhabiting flooded and non-flooded communities of Jagatsinghpur district, Odisha (India), and collected anthropometric measurements on children along with child, parental and household level variables through face-to-face interviews. Using multivariate logistic regression models, we examined separately the effect of maternal and paternal education and other risk factors (mainly income, socio-demographic, and child and mother variables) on stunting and wasting in children from households inhabiting recurrently flooded communities (2006 and 2008; n = 299). As a comparison, separate analyses on children in non-flooded communities were carried out (n = 385). All analyses were adjusted by income as an additional robustness check.

Lessons Learnt

The most striking finding is that paternal education, and not maternal education, appeared to be the strongest predictor of lower child stunting and wasting in these communities in Odisha, India. This is in contrast to non-flood settings, where large samples from India, Vietnam, Indonesia and Bangladesh on which the effect of parental education on child stunting was studied, have shown that comparable positive effects were found for both maternal and paternal education (Semba et al., 2008). This finding is in agreement with findings from other flood settings, were the mother's education appears to have no effect on child wasting recovery several months after large floods (Hossain & Kolsteren, 2003Del Ninno & Lundberg, 2005).

In our specific setting, the greater impact of paternal education could be partly explained by the low economic independence of women in our sample: nearly 98% of mothers in both exposure groups were housewives and were assumed to have no revenues. This topic is complex and more studies on this specific interaction should be conducted on datasets having larger samples than ours. However, in India there exists evidence pointing to low maternal economic and physical autonomy as a contributor to child stunting (Shroff et al., 2009Imai et al., 2014).

The effect of paternal education on child stunting was larger and more statistically significant in flooded communities than in non-flooded communities. In a disaster situation, decisions on allocation of the constrained resources available can be crucial. More educated parents might be able to invest in coping strategies with longer term benefits, have more savings or simply work in professions which are less affected by floods. Our results on child wasting showing that non-agricultural livelihoods better withstood the shock caused by flooding reinforce this point.

Young children of agricultural livelihoods were the most impacted regarding the prevalence of wasting one year after the floods, which was around 50% higher than in other livelihoods. Importantly, no effect was observed for similar analyses conducted in non-flooded communities, whether univariate or multivariate. This reinforces the hypothesis that crop destruction and overall food insecurity is a very likely pathway to child undernutrition among the flooded populations (Leaning & Guha-Sapir, 2013).

Another consistent result was the positive effect of income on child nutrition in flood-affected communities. For example, an increase in 5,000 rupees per capita in yearly income within households should be associated with 25% lower prevalence of child stunting. Sustainable livelihood economic development is then a plausible strategy to reduce the nutritional burden of floods according to our data.

In flood-affected livelihoods, lower caste was associated with the worst nutritional status for both wasting and stunting variables, suggesting that caste is still associated with lower opportunities. Our study findings show that these social determinants of differentiated impacts are made visible in extreme situations such as a disaster, but we were unable to offer an explanation on the mechanism explaining this pattern in the data. Qualitative research might plausibly be very useful to investigate the reasons further.

Mothers giving birth a greater period of time after the flood had a lower likelihood of having a wasted children. Our model suggest that by delaying five years the birth of a given child, the associated prevalence of child wasting in case of floods would be on average 17% lower. It is noteworthy to point that this result was independent from the effect of mother education, adjusted for in this model.

Notable methodological constraints

  • All the reported results were adjusted, as an additional robustness check, by annual per capita household income. As such, all effects reported were independent of income, and thus our results can be methodologically comparable to those recently published.
  • We often found in the literature maternal and paternal education jointly modelled (Semba et al., 2008). However, we found that these two variables were highly correlated in our data and provided enough evidence using variance inflation factor analysis such that they should be modelled separately. Future studies should be aware of this.
  • Father education was highly correlated to caste and mother’s age at birth of a child, and this is the reason why models modeling father education do not include these variables.

For a more complete discussion of the strengths and weaknesses of this study, please refer to the full text.

Recommendations

There is much to do to in terms of mitigation strategies to reduce the initial impact of floods on the livelihoods of these vulnerable populations.

There is an urgent need to reform and expand the relief response. After the 2008 floods the basic needs of the affected were only covered by the government on the first 15 days following the floods. We need to ensure that these livelihoods are satisfied on around a year after the floods and that we target most affected livelihoods, in particular agricultural-dependent livelihoods, which showed an associated 50% higher prevalence of child wasting. Crops take months to be harvested since they are planted. Animal stocks need time to recover fully; the same applies for repairing boats or buying new ones. Without more dedicated resources, there is the risk of perpetuating poverty cycles. 

Policies for relief should be reviewed to ensure a longer period of support and proper take up by development programs, which should give enough time and support to these households relying on agricultural activities to fully recover.

Education promotion in rural areas, especially among women, would be extremely efficient. In our study area about 30% of the mothers, and 20% of the fathers, did not complete middle school education, which is mandatory in India. Additionally, looking across all models in our study, primary education (up to 11 years of age) was not a significant contributor to better child nutrition in seven out of eight models reported. However, providing three additional years of schooling (up to 14 years) had a significant positive impact on child nutrition.

By promoting more education and adequate family planning (Van Braeckel et al., 2012), women might naturally delay motherhood, with potential benefits to children’s nutritional health. We hypothesize that mother education might lead to increased employment rates amongst women, and this would contribute to additional higher household income (with associated benefits shown by our study). 

Further resources