Knowledge Brief 2 Determinants of Nutrition in Nagaland, India Household Access to and Practices pertaining to Food, Water and Sanitation Hidden hunger is present in Nagaland, especially among lower income groups. Other factors affecting nutritional status include high consumption of smoked and fermented food, tobacco and alcohol, indoor air pollution and poor hand washing practices. While improvements in agriculture and access to markets will reduce food insecurity, dietary and hygiene practices may be susceptible to aggressive community and household-level behaviour change interventions. Introduction infections.3 A study of five countries found that poor sanitation leads to diarrhoea, which is estimated to Several household-level factors are associated account for 25 percent of the burden of stunting in with better nutrition outcomes. These include food children up to 24 months of age.4 access and availability, practices pertaining to food preparation and consumption practices, and Water, Sanitation and Hygiene (WASH) practices Methods and access. Availability of markets, and access to The mixed-method study included focus group them, for a diverse range of foods is considered a discussions with mothers and fathers of young essential for food security and improving nutrition children (0-5 years), conducted in selected villages outcomes. Some practices related to food in two pilot districts of the Nagaland Health preparation, such as use of biofuels for cooking Project, Tuensang and Peren. This was followed resulting in indoor air pollution, have been observed by a quantitative survey across all districts in the to adversely affect health and nutrition, especially state. The survey was done in 55 villages, which for infants, contributing to respiratory infections were purposively selected from among those such as pneumonia1 as well as stunting.2 Similarly, participating in the Nagaland Health Project, and the UNICEF framework of nutrition determinants covered 728 households with a woman who had highlights the “sanitation-nutrition” nexus, describing had a pregnancy in the past two years. From each three pathways through which poor sanitation sampled household, the woman who had had a adversely affects nutritional outcomes: diarrhoeal pregnancy in the past two years and the household diseases, environmental enteropathy and nematode head were interviewed. July 2019  |  Page 1 Findings meat, milk, eggs, tea, sugar and spices from the market. Grains were typically sourced equally from This brief describes findings on household access home and market. During focus group discussions to food, and practices for food preparation, with community members, many described the consumption and WASH that affect health and consumption of a predominantly vegetarian daily nutrition outcomes in Nagaland. diet due to poor availability and high cost of meat, especially in remote areas. Food Insecurity Consumption of Alcohol and Tobacco Among the sampled households, 62 percent reported to have two meals daily, while 38 percent 67 percent of households (n=706) reported that at reported three meals. Over 80 percent of households least one adult male had consumed tobacco daily ate most meals together. while in 42 percent of households one adult male had consumed alcohol in the last 30 days. While 17 5th Quintile percent of household heads reported that at least one adult woman consumed tobacco daily in their 4th Quintile household, findings from qualitative interviews with women suggest a higher proportion. During focus 3rd Quintile group discussions, most respondents considered a disruption to communal harmony or domestic abuse 2nd Quintile to be the harmful effects of consuming alcohol and tobacco, but not other forms of ill health. 1st Quintile 0% 20% 40% 60% 80% 100% Food Preparation Faced No Food Insecurity (Score: 0) A majority of households (n=728) used wood Faced Food Insecurity Rarely (Score: 1-9) (75 percent) as a source of biofuel, while a smaller Faced Food Insecurity Sometimes (Score: 10-18) proportion used LPG/natural gas (21 percent). In When asked whether any member of the household addition, the cultural food preferences of the Naga experienced an instance of food insecurity, community include preparation techniques of 50 percent of households reported facing none, smoking and fermenting. Food was mainly cooked 43 percent rarely (once or twice in a month) and in a separate room but on an open fire and usually 4 percent sometimes (three to ten times in a month) without a chimney. Cooking was predominantly over the past month prior to the survey. As depicted done by adult/married women of the household. in the adjoining figure, those belonging to the lowest wealth quintiles faced a greater frequency of food WASH insecurity5 as compared to those among the higher quintiles.6 59 percent of households had a piped well connection as the main source of drinking water, Food Sources followed by 14 percent who used a protected well. Thus, about a quarter of households did not Households largely produced vegetables and fruits have a safe source of drinking water. However, at home and purchased items such as lentils, nearly all households reported treating their water Page 2  |  July 2019 (93 percent), with most stating that they boiled it to once or twice in a month. The lowest 40 percent make it safer to drink. Water was mainly fetched by of households ranked by wealth were more likely the adult woman of the household an average of to report instances of food insecurity. At the same three times a day, with 30 minutes as the maximum time, possibly in contrast with popular perception, time taken to fetch water. Most households most households, especially in remote areas, do not reported having enough water available for all their regularly consume meat or other high-protein foods. members. Among other possible nutrition determinants, indoor air pollution due to the widespread use of wood Almost all (99 percent) households had a toilet for cooking is likely to be hazardous to household facility on their premises. Most used a septic tank members’ health and nutrition outcomes, especially inside their dwelling (43 percent), followed by pit for the women involved in food preparation as latrine inside (38 percent), and flush toilet inside well as children who are more susceptible. High the dwelling (15 percent). Outside facilities were consumption of smoked and fermented food, along much less commonly used, and open defecation with tobacco and alcohol, have short- and long-term was reported only by 0.5 percent of households. nutrition and health effects. More positively, three- Around 12 percent of households reported sharing quarters of households have an improved source of the toilet with others, with most sharing the facility water, most people treat their drinking water, and with less than ten households. On the other most households have adequate toilet facilities. hand, smaller proportions of respondents (n=727) However, poor handwashing practices are likely to reportedly always washed their hands after urination have an impact on health and nutrition. Reducing (19 percent) and defecation (35 percent), and before food insecurity will depend on improvements in cooking (15 percent), eating (21 percent) and feeding a child (18 percent). agriculture and access to markets, and indeed poverty reduction more generally. At the same time, dietary and hygiene practices may be susceptible Conclusion to aggressive community and household-level behaviour change interventions. The findings There is hidden hunger in Nagaland, as almost half of of this study should inform the content of such households reported facing food insecurity at least interventions. Footnotes 1 World Health Organization. 2016. Ambient Air Pollution: A global assessment of exposure and burden of disease. Geneva, Switzerland. 2 Danaei G., Andrews K.G., Sudfeld C.R., Fink G., McCoy D.C., Peet E., Sania A., Fawzi M.C.S., Ezzati M., Fawzi W.W. Risk factors for childhood stunting in 137 developing countries: A comparative risk assessment analysis at global, regional, and country levels. PLoS Med. 2016;13:e1002164. doi: 10.1371/journal.pmed.1002164. 3 UNICEF (n.d.) Policy brief: The impact of poor sanitation on nutrition. SHARE Research Consortium, London School of Hygiene and Tropical Medicine. 4 Checkley et al (2008). Multi-country analysis of the effects of diarrhoea on childhood stunting. International journal of epidemiology, 37(4), 816-830. 5 The food insecurity index has been calculated using nine questions related to inadequacy of food intake in the past month due to lack of resource availability. 6 The chi2 test shows that the difference is statistically significant with negative association between wealth quintile and food insecurity. Page 3 © 2019 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some Rights Reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution Please cite the work as follows: “World Bank. 2019. India: Nutrition Determinants and Strategies in Nagaland, Knowledge Brief - Determinants of Nutrition in Nagaland, India - Household Access to and Practices pertaining to Food, Water and Sanitation. © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Acknowledgements This work was led by Patrick Mullen and Aarushi Bhatnagar, with contributions from Young Eun Kim, Mohini Kak, Bathula Amith Nagaraj, Neesha Harnam, Avril Kaplan and Mamata Baruah, under the oversight of Rekha Menon. The World Bank team would like to thank the Directorate of Health and Family Welfare and Department of Social Welfare, Government of Nagaland, the Nagaland Health Project team, Oxford Policy Management Ltd., the Kohima Institute and all study participants for their contributions. This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. Page 4  |  July 2019