Socio-religious differentials in the prevalence of malnutrition (stunting, wasting, and underweight)
The prevalence rates of malnutrition are presented in Table
2, which shows that while Muslims have a higher rate of stunting and lower rates of wasting and underweight compared to the Hindus as an aggregated group, the picture changes when we disaggregate the Hindus into HCs and LCs. Muslims have a lower prevalence of all three measures of malnutrition than the LCs. The prevalence of stunting and being underweight is higher among Muslims than among the HCs, while it still remains the lowest in the case of wasting when compared to both LCs and HCs.
Table 2
Religious group-wise prevalence of malnutrition among children under 5 years
Stunting (%) | 38.54 | 39.79 | 43.53 | 35.68 | 38.76 |
Wasting (%) | 21.5 | 19.42 | 23.47 | 20.37 | 21.13 |
Underweight (%) | 36.34 | 34.89 | 41.76 | 33.24 | 36.08 |
Table
3 shows the socio-religious differentials in all three indicators of malnutrition by select covariates. The prevalence rates of each group by covariates are shown in Appendix
1. On average, Muslim children have a lower rate of stunting than lower-caste Hindus and a higher rate of stunting than high-caste Hindus. This trend is uniform across all covariates barring a few exceptions. Muslim children with third or higher birth order and those born to mothers with no or below the secondary level of education had a marginally lower stunting rate than both caste groups of Hindus with similar attributes. Muslims belonging to poorer or middle-wealth quintiles or households with no toilet facilities had a higher rate of stunting than both HCs and LCs belonging to such households.
Table 3
Socio-religious differentials in the prevalence of malnutrition among children under 5 years by select covariates
Child's |
Sex |
Male | -4.0 | 4.6 | -4.1 | -0.6 | -7.1 | 2.2 |
Female | -3.5 | 3.5 | -4.0 | -1.3 | -6.7 | 1.0 |
Age (years) |
0 | -2.8 | 1.7 | -4.0 | -1.6 | -6.2 | 0.5 |
1 | -5.5 | 3.6 | -4.2 | 0.8 | -8.0 | 2.9 |
2 | -5.8 | 3.8 | -4.6 | -1.5 | -9.3 | 0.8 |
3 | -3.0 | 5.5 | -3.8 | -1.2 | -5.6 | 2.2 |
4 | -3.0 | 5.2 | -3.1 | -1.1 | -5.9 | 1.6 |
Birth order |
First | -4.0 | 3.8 | -3.6 | -0.7 | -6.9 | 1.2 |
Second | -4.5 | 3.1 | -4.4 | -1.5 | -8.6 | 0.4 |
Third | -5.8 | -0.3 | -3.9 | -0.9 | -7.4 | -1.1 |
Fourth or more | -4.8 | -0.6 | -5.0 | -1.8 | -7.7 | -2.4 |
Breastfed |
within 2 hours | -4.1 | 3.6 | -4.1 | -1.3 | -7.6 | 0.8 |
within 24 hours | -2.6 | 5.5 | -3.1 | -0.9 | -4.6 | 3.5 |
More than 24 hours after | -4.2 | 4.8 | -3.9 | 2.8 | -7.4 | 4.3 |
Never breastfed | -3.3 | 4.7 | -3.5 | -1.4 | -3.2 | 3.4 |
Mother's |
Age at birth |
Below 18 | -3.5 | 2.0 | -1.0 | -0.9 | -4.3 | -1.2 |
18-20 | -3.9 | 2.3 | -5.8 | -1.8 | -8.3 | -1.7 |
21-25 | -4.3 | 3.1 | -4.0 | -1.2 | -7.7 | 0.8 |
26-30 | -3.5 | 4.9 | -3.4 | -0.5 | -5.7 | 3.1 |
31-35 | -4.0 | 5.5 | -4.1 | -0.6 | -7.2 | 2.9 |
Above 35 | -4.0 | 7.7 | -4.0 | 0.9 | -5.3 | 7.1 |
Education |
No education | -2.6 | -0.5 | -5.4 | -1.8 | -6.5 | -2.3 |
Incomplete primary | 1.2 | 2.8 | -5.0 | -2.7 | -5.0 | -2.1 |
Primary | -6.1 | -1.7 | -3.0 | -2.8 | -7.4 | -3.3 |
Incomplete secondary | -6.0 | -0.2 | -2.8 | -0.8 | -7.5 | -2.1 |
Secondary | -3.2 | 0.9 | -5.3 | -1.8 | -9.2 | -1.4 |
Higher | -3.8 | 0.3 | -2.0 | 0.2 | -7.0 | -2.2 |
BMI |
Normal | -2.4 | 4.4 | -2.2 | -0.4 | -4.0 | 2.3 |
Underweight | -2.8 | 3.1 | -6.2 | -2.0 | -8.0 | 0.0 |
Overweight | -1.2 | 6.3 | -0.5 | -0.3 | -2.5 | 4.2 |
'Household's |
Residence |
Rural | -2.3 | 5.9 | -1.2 | 0.2 | -2.7 | 4.3 |
Urban | -1.8 | 4.8 | -4.9 | -1.5 | -6.4 | 1.5 |
Wealth Index |
Poorest | -0.4 | 0.8 | -5.7 | -1.9 | -6.1 | -2.0 |
Poorer | 0.8 | 1.9 | -4.1 | -3.2 | -3.4 | -1.8 |
Middle | 2.4 | 5.6 | -2.5 | -0.1 | 0.3 | 3.2 |
Richer | -1.4 | 2.9 | -1.9 | -0.3 | -1.9 | 1.9 |
Richest | -2.1 | 3.3 | 2.2 | 0.4 | -2.7 | 1.9 |
Drinking water |
Not Treated | -1.7 | 4.2 | -3.8 | -0.5 | -5.1 | 2.0 |
Treated | -9.5 | 0.8 | -4.7 | -1.6 | -11.9 | -1.5 |
Toilet |
Some facility | 1.0 | 7.0 | -2.4 | -0.5 | -1.7 | 4.0 |
Open defecation | 1.0 | 4.8 | -3.8 | -0.8 | -3.1 | 2.6 |
Region |
North | 3.7 | 7.3 | -1.5 | 0.1 | -0.8 | 3.5 |
Central | -6.2 | 3.4 | -1.7 | 1.5 | -6.7 | 2.6 |
East | -11.8 | 0.0 | -6.2 | -1.9 | -14.1 | -2.8 |
Northeast | -8.1 | -0.5 | -6.9 | -2.8 | -13.7 | -3.9 |
West | -7.8 | 7.2 | -9.8 | -4.6 | -14.6 | 0.5 |
South | -1.0 | 6.1 | -3.0 | -0.5 | -3.1 | 4.7 |
Total | -3.7 | 4.1 | -4.1 | -0.95 | -6.9 | 1.7 |
In the case of wasting, Muslims, on average, had the lowest rate of prevalence. This trend was consistent in all covariates except for a few like children aged one year, breastfed more than 24 h after birth, born to mothers with higher education, residing in rural India, north and central region, in which case, Muslims had a higher rate of wasting than high-caste Hindus but lower rate than LCs. However, among the children born to the wealthiest households, Muslims had the highest rate of wasting compared to both caste groups of Hindus.
Finally, in the case of the prevalence of underweight, Muslims had an advantage over low-caste Hindus and a disadvantage compared to high-caste Hindus, on average. This pattern remained consistent for all covariates, albeit with certain exceptions. The high-caste Hindu advantage over Muslims reversed in favor of Muslims in the case of children born in birth order of three or more, born to mothers below the age of 20 years, belonging to poorest/ poorer households, those with access to safe drinking water, and residing in the east and northeast regions of India. Also, Muslim children exhibited an advantage over both LCs and HCs in the prevalence of underweight across all categories of mothers’ education. This differential, however, was the widest in the case of primary education and lowest for the secondary level of education.
All p-values for chi-squared test statistic were below 0.05.
Source: Authors’ calculations from National Family Health Survey, 2015-16 (NFHS-4).
Association between socio-religious affiliation and prevalence of malnutrition
The crude and adjusted odds ratios computed through logistic regression to assess the effect of socio-religious affiliation on the prevalence of malnutrition have been presented in Table
4. The results of the crude analysis indicated that the odds of stunting are 17% higher among LCs and 16% lower among HCs with reference to Muslim children. However, both caste groups of Hindus have a higher likelihood of wasting than Muslims, by 16% and 6%, respectively. After controlling for the effect of a vector of covariates, the direction of socio-religious differentials remained the same, although the magnitude shrunk in both stunting and wasting. In the case of underweight, LCs have 34% higher odds, while HCs have 7% lower odds with respect to Muslims. In the adjusted model, however, the high-caste Hindu advantage over Muslims is reversed, and HCs show a controlling 4% higher odds of being underweight than Muslims.
Table 4
Association between socio-religious affiliation and malnutrition among children under 5 years
Religion/Caste |
Muslims® |
Low-caste Hindu | 1.17*** (1.12-1.21) | 1.05** (1.01-1.10) | 1.27*** (1.21-1.34) | 1.16*** (1.10-1.22) | 1.34*** (1.29-1.39) | 1.16*** (1.12-1.22) |
High-caste Hindu | 0.84*** (0.81-0.87) | 0.96** (0.92-1.00) | 1.061** (1.01-1.11) | 1.06** (1.01-1.12) | 0.93*** (0.90-0.96) | 1.04* (0.99-1.08) |
Child's Age |
Child's age (months) | | 1.64*** (1.60-1.69) | | 0.74*** (0.71-0.76) | | 1.18*** (1.15-1.22) |
Child's age-squared | | 0.99*** (0.99-1.00) | | 1.00*** (1.00-1.00) | | 0.99*** (0.99-1.00) |
Sex |
Male® | | | | | | |
Female | | 0.94*** (0.92-0.97) | | 0.89*** (0.86-0.92) | | 0.95*** (0.93-0.98) |
Birth-order |
First® | | | | | | |
Second | | 1.16*** (1.12-1.20) | | 0.99* (0.95-1.03) | | 1.12*** (1.08-1.16) |
Third | | 1.25*** (1.20-1.31) | | 0.99 (0.94-1.05) | | 1.19*** (1.14-1.24) |
Fourth or more | | 1.46*** (1.38-1.53) | | 1.01 (0.95-1.08) | | 1.36*** (1.29-1.43) |
Breastfed |
within 2 hours® | | | | | | |
within 24 hours | | 1.00 (0.96-1.04) | | 0.92** (0.88-0.96) | | 1.01 (0.98-1.06) |
More than 24 hours after | | 1.12***(1.07-1.17) | | 1.01 (0.95-1.07) | | 1.13*** (1.08-1.19) |
Never breastfed | | 1.02 (0.96-1.08) | | 0.9** (0.84-0.97) | | 0.95(0.89-1.010) |
Mother's age |
Mother's age at birth (years) | | 0.94*** (0.92-0.96) | | 0.99 (0.97-1.02) | | 0.95*** (0.93-0.97) |
Age at birth squared | | 1.00*** (1.00-1.00) | | 1.00 (1.00-1.00) | | 1.00** (1.00-1.00) |
Mother's Education |
Years of education | | 0.960*** (0.957-0.964) | | 0.99*** (0.99-1.00) | | 0.96*** (0.96-0.97) |
Mother's BMI |
Normal® | | | | | | |
Underweight | | 1.21*** (1.17-1.24) | | 1.35*** (1.31-1.40) | | 1.56*** (1.52-1.61) |
Overweight | | 0.79*** (0.75-0.82) | | 0.70*** (0.66-0.74) | | 0.68*** (0.65-0.72) |
Residence |
Urban® | | | | | | |
Rural | | 0.93*** (0.90-0.97) | | 0.90*** (0.86-0.95) | | 0.87*** (0.84-0.91) |
Wealth Index |
Poorest® | | | | | | |
Poorer | | 0.89*** (0.86-0.92) | | 0.90*** (0.87-0.94) | | 0.87*** (0.84-0.9) |
Middle | | 0.78*** (0.74-0.81) | | 0.84*** (0.80-0.89) | | 0.74*** (0.71-0.77) |
Richer | | 0.66*** (0.62-0.69) | | 0.84*** (0.79-0.9) | | 0.65*** (0.62-0.69) |
Richest | | 0.56*** (0.52-0.60) | | 0.80*** (0.73-0.86) | | 0.53*** (0.49-0.57) |
Drinking water |
Not treated® | | | | | | |
Treated | | 0.92*** (0.89-0.95) | | 1.10*** (1.06-1.14) | | 0.96** (0.93-0.99) |
Toilet Facility |
Some facility® | | | | | | |
Open Defecation | | 1.16*** (1.12-1.2) | | 1.06** (1.02-1.11) | | 1.14*** (1.10-1.18) |
Region |
North® | | | | | | |
Central | | 1.21*** (1.14-1.27) | | 1.03 (0.97-1.10) | | 1.10** (1.04-1.16) |
East | | 1.14*** (1.08-1.21) | | 1.43*** (1.34-1.53) | | 1.28*** (1.21-1.36) |
Northeast | | 1.20*** (1.14-1.27) | | 1.38*** (1.30-1.47) | | 1.2*** (1.14-1.27) |
West | | 0.90** (0.83-0.98) | | 1.01 (0.93-1.09) | | 0.92* (0.85-1.00) |
South | | 1.13*** (1.08-1.18) | | 1.04 (0.98-1.10) | | 1.01 (0.97-1.07) |
Wald Statistic | 532.03 | 7278.78 | 150.08 | 2443.97 | 674.96 | 7007.72 |
Degrees of freedom | 2 | 28 | 2 | 28 | 2 | 28 |
Prob > chi2 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
Pseudo R2 | 0.0038 | 0.0591 | 0.0014 | 0.0242 | 0.0047 | 0.0569 |
No. of observations | 194111 | 194111 | 194111 | 194111 | 194111 | 194111 |
The results of the adjusted models further indicate a monotonic increasing function of stunting and underweight by child’s age until a turning point is reached, after which the function starts to decrease. Female children have lower odds of malnutrition than males in the case of all three indicators. The odds of undernutrition increase with increasing birth order and vice versa. Also, the earlier the child is put to the breast after birth, the lower the odds of malnourishment. The mother’s age at the child’s birth is a significant determinant only in stunting and underweight. The odds of undernutrition decrease with the increasing age of the mother up until a point post which the chances of undernutrition are higher with increasing mother’s age. There is a monotonic decreasing function of malnutrition by the mother’s years of education. Children of underweight mothers are more likely to be malnourished compared to mothers with BMI in the normal range. Rural children have lower odds of undernutrition compared to their urban counterparts. The odds of malnourishment keep declining as we move up along the wealth index gradient. Children belonging to households that do not treat the water to make it safe to drink and practice open defecation have higher odds of malnutrition than those with access to safe drinking water and toilet facilities. Children residing in the western region have the lowest odds of stunting and being underweight. In contrast, those residing in the eastern region have the highest odds of wasting and being underweight among all other regions.
Major contributors to the Muslim-Hindu (HC/LC) gap in the prevalence of stunting, wasting, and underweight
The results of the decomposition analysis, presented in Table
5, shed light on the relative contribution of the socio-religious differential in each covariate to the Muslim-Hindu (HC/LC) gap in the prevalence of malnutrition among the under-5 children in India. The set of predictors considered in the model explains roughly 79% of the high-caste Hindu advantage over Muslims in stunting prevalence. The differences in birth order, mother’s level of education, and wealth index are the major contributors, accounting for 22.4%, 51%, and 14.5% of the differences, respectively. However, in the case of the prevalence of wasting that is lower among Muslim children by roughly 1%-points compared to HCs, the differences in the select covariates suggest it should have been marginally higher than HCs by 0.4%-points, given the advantage of HCs in mother’s education and birth order. In the case of underweight, the decomposition results indicate that the HCs should have had a marginally higher advantage (2.8%-points) instead of the current advantage of 1.7%-points. The differentials in birth order (41.1%) and economic status (43%) contributed to expanding the Muslim disadvantage over high-caste Hindus in underweight. Better access to sanitation among Muslim children than among high-caste Hindus resulted in offsetting a part (27%) of their nutritional disadvantage in being underweight.
Table 5
Decomposition of the socio-religious differential in malnutrition among children under-5 years
| Stunting | Wasting | Underweight | Stunting | Wasting | Underweight |
High/ Low Caste Hindu | 0.3568 | | 0.2037 | | 0.3324 | | 0.4353 | | 0.2347 | | 0.4176 | |
Muslim | 0.3979 | | 0.1942 | | 0.3489 | | 0.3979 | | 0.1942 | | 0.3489 | |
Difference | -0.0411 | | 0.0095 | | -0.0165 | | 0.0374 | | 0.0406 | | 0.0687 | |
Explained | -0.032 | | -0.0035 | | -0.0284 | | 0.0258 | | 0.0143 | | 0.032 | |
|
Coefficient
|
%
|
Coefficient
|
%
|
Coefficient
|
%
|
Coefficient
|
%
|
Coefficient
|
%
|
Coefficient
|
%
|
Age | -0.0003* | 0.74 | 0.0004* | 3.86 | -0.0003* | 2.05 | 0.0003* | 0.85 | 0.0001 | 0.36 | -0.0003* | -0.43 |
Sex | 0.0001* | -0.24 | -0.00004 | -0.43 | 0.0001* | -0.48 | -0.0001* | -0.39 | -0.0003* | -0.62 | -0.0001* | -0.16 |
Birth Order | -0.0092* | 22.36 | 0.0001 | 1.13 | -0.0068* | 41.14 | -0.0045* | -11.93 | 0.0002 | 0.4 | -0.0035* | -5.05 |
Breastfeeding | -0.0003* | 0.8 | 0.0003* | 3.13 | -0.0001 | 0.72 | -0.0005* | -1.43 | 0.0006* | 1.57 | -0.0001 | -0.19 |
Mother’s age at birth | 0.0027* | -6.67 | -0.0001 | -1.25 | 0.0021* | -12.62 | 0.0027* | 7.10 | -0.0002 | -0.37 | 0.0025* | 3.68 |
Mother’s education | -0.0209* | 50.89 | -0.0037* | -38.96 | -0.0191* | 115.69 | -0.0004* | -1.15 | 0.0001 | 0.22 | -0.0007* | -1.00 |
Mother’s BMI | 0.0002* | -0.57 | 0.0002* | 2.18 | 0.00005 | -0.28 | 0.0006* | 1.72 | 0.0005* | 1.15 | 0.0001 | 0.18 |
Residence | -0.0012* | 2.91 | -0.0016* | -17.25 | -0.0023* | 14.23 | -0.0024* | -6.44 | -0.0026* | -6.48 | -0.0043* | -6.23 |
Economic Status | -0.0059* | 14.47 | -0.0012* | -12.81 | -0.0071* | 43.02 | 0.0212* | 56.83 | 0.0087* | 21.37 | 0.0255* | 37.14 |
Drinking Water | -0.0016* | 3.78 | 0.0009* | 9.68 | -0.0007* | 4.04 | -0.0003* | -0.70 | 0.0001 | 0.16 | -0.0001* | -0.12 |
Toilet | 0.0052* | -12.54 | 0.0016* | 16.65 | 0.0045* | -27.02 | 0.0122* | 32.69 | 0.0053* | 13.03 | 0.0125* | 18.19 |
Region | -0.0011* | 2.65 | -0.0003 | -3.18 | 0.0012* | -7.51 | -0.003* | -8.01 | 0.0016* | 3.85 | 0.0006 | 0.83 |
Explained | -0.0323 | 78.59 | -0.0035 | -37.26 | -0.0285 | 172.98 | 0.0258 | 69.13 | 0.0141 | 34.65 | 0.0322 | 46.84 |
Unexplained | -0.0088 | 21.41 | 0.0130 | 137.26 | 0.0120 | -72.98 | 0.0115 | 30.87 | 0.0265 | 65.35 | 0.0365 | 53.16 |
Compared to the low-caste Hindus, Muslims consistently have an advantage in all three indicators of malnutrition considered in this study. While our model explains 69% of the differences in stunting prevalence, the majority of the Muslim advantage over LCs is explained by the socio-religious differences in wealth index (57%) and access to toilet facilities (33%). However, a part of this advantage gets offset due to the Muslim disadvantage in birth order (12%) and regional factors (8%). Moreover, less than 50% of the Muslim advantage is explained by the chosen set of variables in the case of wasting and being underweight. This implies that Muslims are favored by some unobservable attributes that work to the advantage of their nutritional status in the under-5 age group. In the case of both wasting and underweight, better economic status and access to sanitation translated into better nutritional outcomes for Muslim children in comparison to their low-caste Hindu counterparts.
Discussion and conclusion
This paper attempted to contribute to the scarce body of research dedicated to investigating the inequalities in child nutrition status along the axis of socio-religious affiliation by quantifying the socio-religious differential in indicators of child undernutrition and decomposing the same to shed light on the major contributory factors of these differences. The study produced several interesting findings. We found the Muslims and lower-caste Hindus to be equally at a disadvantage in terms of socioeconomic status compared to the high-caste Hindus. This disadvantage exists probably because when Islam made its way to the subcontinent, it was mainly the low-caste Hindus who took refuge in Islam through religious conversions to circumvent the oppressions by the higher-caste Hindus [
46]. This could, therefore, be the reason for persisting low socioeconomic conditions among Indian Muslims. The caste system, which continues to play a significant role in the country’s social and political interactions, has forced many people who belong to the lower castes into poverty [
47]. To date, most of those still trapped in poverty are Dalits and tribes, especially women [
48]. Dalits or ‘untouchables’ have the most menial jobs, no assets, poor education levels, and experience restricted occupational mobility [
49]. The historical disadvantage of the lower caste Hindus in terms of socioeconomic status (a legacy, the traces of which is still suffered by the converted Muslims) was found to have penetrated to under-5 nutritional outcomes. Corroborating the findings of previous studies, our results indicate that Muslim and lower-caste Hindu children have a higher prevalence of stunting and being underweight than their high-caste Hindu counterparts [
50]. In the case of wasting, however, Muslim children had the lowest prevalence rate, a paradox that we attempted to find an answer to at the later stage of the analysis.
The findings of this study build on existing work that illustrates the need to address socioeconomic factors to improve health outcomes. The regression analysis showed that maternal characteristics such as BMI, age at birth of the child, education, and initiation of early breastfeeding are significantly associated with nutrition outcomes of children, echoed by the findings of several other studies [
51‐
55]. Early initiation of breastfeeding protects against diarrhea-related morbidity, reduces hospitalization episodes, and has a significant association with nutritional status [
56]. But, early initiation of breastfeeding is less common among Muslims than Hindus, as highlighted in the study. It was revealed in the decomposition results that this disadvantage in breastfeeding practices among Muslims contributed to offsetting their nutritional advantage over low-caste Hindus. Moreover, educated mothers possess improved information acquisition skills, positive caring behavior, follow dietary recommendations, interact with health professionals effectively, and improve the intrahousehold allocation of resources in favor of the children [
52‐
55]. The ramifications of the intergenerational cycle of malnutrition are well documented. Mothers who have lower BMI have higher odds of stunted children [
57]. The lower the mother’s weight, the higher the risk of infants being born underweight due to intrauterine growth rate reduction[
58]. The odds of stunting tend to be lower among children whose mother’s age at birth falls in the age group of 20–34 years than those below 20 years of age [
51,
59]. However, Muslim mothers fare worse than high caste Hindus in the case of each of these maternal characteristics, which have a significant association with the nutrition outcomes of the children, the effect of which was seen to be expanding the Muslim disadvantage in stunting and underweight than high-caste Hindus in the decomposition results. The relation of higher birth order with poor nutritional status is also well-established. Postnatal care for children of higher birth order is neglected as the intrahousehold resource allocation decreases with increasing birth order [
60,
61]. In our study, Muslims were found to have a higher birth order (of 4 or more) than both high-caste and low-caste Hindus. Resultantly, birth order acted in favor of both caste-disaggregated groups of Hindus in the decomposition. Regarding household-level factors, access to sanitation has a vital role in determining the prevalence of undernutrition with higher odds of stunting among the children who practice open defecation than the users of improved toilet facilities [
62]. Compared to Hindu households, a lesser proportion of Muslim households practice open defecation, translating into Muslim advantage in nutrition status over Hindus [
21].
The relatively poor socioeconomic characteristics of Muslims compared to high-caste Hindus and, at times, even lower-caste Hindus should put Muslims at a nutritional disadvantage. However, their nutritional advantage over high-caste Hindus in wasting is a paradox. While the poor performance of Muslim children compared to high-caste Hindus, in stunting and underweight, is explained mainly by the chosen set of variables in our model, their comparatively better performance in wasting remained a puzzle, nonetheless. The cultural factors such as washing hands before prayers which improves personal hygiene; closely-knit social networks and kinship structures expressed by endogamy; and lower prevalence of dowry and son preference might reflect a comparatively higher status accorded to women in Muslim households [
24,
28]. This suggests that the Muslim advantage over high-caste Hindus in wasting may have been rendered by behavioral and cultural differences and can be explained by the Particularized Theology Hypothesis. On the flip side, the Muslim advantage over lower-caste Hindus could be partially ascertained by the former’s better economic status than lower-caste Hindus, as highlighted by the decomposition analysis results. The economic status of the households has a significant association with undernutrition, as wealthier households are known to have a lesser prevalence of undernutrition than poorer households [
63,
64]. Muslim households were found to be poorer than upper-caste Hindus but better off than Hindu lower castes on average, as also noted in the post-Sachar evaluation report. The differential in the prevalence of undernutrition between Muslims and low-caste Hindus is, thus, better explained by the Selectivity Hypothesis.
Studies show discrimination against SC/ST women and children in access to food security-related services- mid-day meal scheme, ICDS services, public distribution system, primary health services, etc., which adversely affects their nutrition status [
65‐
67]. This calls for the implementation of instruments designed to address the child malnutrition crisis in India through efficient targeting of beneficiaries. While the budgetary allocation to the various existing schemes, such as ICDS, POSHAN Abhiyan, etc., needs to be significantly increased, the shortfalls in implementation also need to be improved. Audit reports have revealed deficits in the disbursal of funds as well as actual spending of disbursed funds compared to the budgetary allocations made for child nutrition schemes [
68]. Malnourished children are nine times more likely to die than healthy children [
69]. There are significant direct and indirect economic losses due to undernutrition. Direct productivity losses have been estimated at more than 10% of lifetime personal income and roughly 3% loss to the Gross Domestic Product in India [
70]. Besides, adverse health shocks during early childhood have been proven to cast long-lasting adverse spill-over effects well into adulthood, leading to poor health stock and increased healthcare costs, constituting indirect losses [
71].
Our study reinforces the findings from the previous studies that the position of Muslims, SCs, and STs is noticeably more vulnerable than that of high-caste Hindus. Equitable access to education, poverty alleviation and better employment opportunities also need policy attention as they have demonstrated a strong bearing on child nutrition outcomes. Although levels of income, education, and access to public health care are all strongly correlated with nutritional status, social membership also plays a role in exacerbating nutritional inequality [
72]. These findings have two distinct policy implications. They demand targeted policy measures that specifically protect against the marginalization of the SC, ST, and Muslim populations in addition to general policy measures that are common to all socio-economically poorer sections of the society (irrespective of the socio-religious affiliation). Uplifting the socioeconomic status of the poor through redistributive mechanisms ensuring greater access to assets and wages, which is necessary for better diet and access to healthcare, is another important policy implication of this study. Besides, in the case of the SC and ST, who often experience discrimination when trying to access sources of livelihood, education, public health services, food security, etc., in addition to these common measures, supplemental policy measures are imperative to circumvent the barriers imposed by social exclusion and marginalization.
The present study was not without limitations. In the absence of a multilevel analytical model, the variation in nutrition outcomes attributable to different population levels, such as neighborhoods, wards, etc., within which individuals are nested, could not be captured in our single-level analysis. Also, the cross-sectional design of the study did not allow for making definitive inferences about the direction of cause and effect. However, despite these limitations, the study made a modest yet integral contribution to the understanding of the determinants of socio-religious differences in the prevalence of undernutrition among children below five years of age in India, drawing evidence from the most recent nationally representative sample survey dataset available.