Literature DB >> 25356667

Local distributions of wealth to describe health inequalities in India: a new approach for analyzing nationally representative household survey data, 1992-2008.

Diego G Bassani1, Daniel J Corsi2, Michelle F Gaffey3, Aluisio J D Barros4.   

Abstract

BACKGROUND: Worse health outcomes including higher morbidity and mortality are most often observed among the poorest fractions of a population. In this paper we present and validate national, regional and state-level distributions of national wealth index scores, for urban and rural populations, derived from household asset data collected in six survey rounds in India between 1992-3 and 2007-8. These new indices and their sub-national distributions allow for comparative analyses of a standardized measure of wealth across time and at various levels of population aggregation in India.
METHODS: Indices were derived through principal components analysis (PCA) performed using standardized variables from a correlation matrix to minimize differences in variance. Valid and simple indices were constructed with the minimum number of assets needed to produce scores with enough variability to allow definition of unique decile cut-off points in each urban and rural area of all states.
RESULTS: For all indices, the first PCA components explained between 36% and 43% of the variance in household assets. Using sub-national distributions of national wealth index scores, mean height-for-age z-scores increased from the poorest to the richest wealth quintiles for all surveys, and stunting prevalence was higher among the poorest and lower among the wealthiest. Urban and rural decile cut-off values for India, for the six regions and for the 24 major states revealed large variability in wealth by geographical area and level, and rural wealth score gaps exceeded those observed in urban areas.
CONCLUSIONS: The large variability in sub-national distributions of national wealth index scores indicates the importance of accounting for such variation when constructing wealth indices and deriving score distribution cut-off points. Such an approach allows for proper within-sample economic classification, resulting in scores that are valid indicators of wealth and correlate well with health outcomes, and enables wealth-related analyses at whichever geographical area and level may be most informative for policy-making processes.

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Year:  2014        PMID: 25356667      PMCID: PMC4214688          DOI: 10.1371/journal.pone.0110694

Source DB:  PubMed          Journal:  PLoS One        ISSN: 1932-6203            Impact factor:   3.240


Background

Worse health outcomes including higher morbidity and mortality are most often observed among the poorest fractions of the population [1]. This is in part due to lower health service use, more limited access to health interventions and poorer nutritional status [1], [2], but health inequalities are a consequence of complex processes including multidimensional drivers reflecting differences in economic status and social characteristics such as gender and ethnicity. The growing need to better understand the influence of poverty on health has dramatically increased the interest in research [3], [4] and also the programmatic attention on health inequalities in low- and middle-income countries [2], [5], [6], [7]. The development of new methods for estimating household economic status has facilitated new research on the effects of wealth disparities on health [8], [9]. Preferred measures of economic status require data on household income or consumption, but these indicators are hard to define in some settings, difficult to collect on a large scale and prone to misclassification [10]. Conversely, data on ownership of durable goods, housing characteristics and access to infrastructure are easier to measure and commonly available from household surveys, and these can be used compositely to classify households’ relative wealth [11]. As such, asset-based wealth indices derived through principal components analysis are increasingly being used to characterize economic status in household survey analyses of health inequalities [12], [13] In addition, such surveys are often repeated periodically in a given population, allowing indices to be updated as needed to ensure the most relevant assets are included. While asset-based wealth indices are typically constructed at the national level, the use of national wealth score distributions for sub-national analyses is problematic [14], [15], [16]. For example, ignoring the wealth score distribution at the geographic level of interest (e.g. district, state, or region) may result in a large proportion of one population (e.g. state) being assigned to the top or bottom of the wealth distribution of another population (e.g. region), thereby hiding level-specific wealth gradients. The use of geographical-level wealth distributions allows one to correctly classify households according to the most appropriate wealth score distribution, enabling proper comparisons across different states, regions or countries and across different geographical levels. In India, due to the large, socio-economically diverse population and the decentralized decision-making and policy-setting structures, the use of wealth distributions at multiple geographic levels is especially important for analyzing and addressing health inequalities. However, while national and sub-national wealth distributions in India have been devised and employed previously [17], [18], [19], a comprehensive set of wealth distributions at multiple geographic levels in India has not been made available in the literature before now. In this paper we present national, regional and state-level distributions of national wealth index scores, for urban and rural populations separately, derived from household asset data collected in the three rounds of the Demographic and Health Survey, known as the National Family Health Survey (NFHS) in India [17], [18], [20], and in three rounds of the District Level Household Survey (DLHS) [21], [22], [23]. The six surveys cover a period between 1992–3 and 2007–8 and allow for a standardized measure of wealth that can be used in survey-specific analyses as well as for comparisons across surveys/time-points. We validate our indices by analyzing height-for-age as one example of a health inequality which has previously been shown to have marked differences by wealth quintile [24]. Further, we illustrate the important misclassification of households that may result from sub-national analyses that use national wealth distributions. We propose that the urban and rural wealth score decile cut-off values that we present for different geographical levels can be used to improve future analyses of health inequalities in India and ultimately inform the decentralized policy-making processes by which such inequalities can be effectively addressed.

Methods

Ethics statement

This secondary analysis of anonymized survey data available in the public domain did not require prior approval from an ethics review board. The original surveys received approval by the relevant ethics review boards.

Data

The National Family Health Survey (NFHS) is a large-scale, nationally representative survey of Indian households providing state- and national-level estimates of key demographic and health indicators. Three rounds of the survey have been conducted to date (NFHS-1 in 1992–3, NFHS-2 in 1998–9 and NFHS-3 in 2005–6), each using an equivalent multi-stage sampling approach and including more than 85,000 households, with an overall response rate above 98%. Sampling design, sample size and response rate details are published in the round-specific survey reports [17], [18], [20]. In addition to demographic and health information, the NFHS collects data on household socioeconomic characteristics, including ownership of various assets, housing construction materials, and access to electricity. The assets included in the survey questionnaire varies between rounds. The District Level Household Survey (DLHS) has been conducted in four rounds to date: DLHS-1 in 1998–9, DLHS-2 in 2002–4 DLHS-3 in 2007–8 and DLHS-4 in 2012–13. This survey collects information similar to the NFHS surveys but uses a sampling frame tailored to be representative at the district level [21], [22], [23]. Here we use data from the first three DLHS rounds, as datasets from the most recent round are not yet available in the public domain.

Wealth indices

We initially constructed separate indices for urban and rural setting in each survey, using different lists of assets. While there are fundamental differences in infrastructure and lifestyle between urban and rural areas, our comparison of the separate indices to a single national index revealed that the national index performed as well as the separate urban and rural indices in all states, with the advantage of being simpler to develop and implement in future research. However, because the assets on which data were collected through the surveys differed over time, a separate national index was constructed for each of the six surveys. We derived our indices through principal components analysis (PCA) using Stata 12 [25]. PCA is a multivariate statistical technique for reducing a larger number of variables to a smaller number of dimensions [26]. PCA can summarize the variance of different types of variables with no specific distribution, generating a score that captures, in its first component, the greatest amount of data variability explained by one linear combination of variables. This approach is well-suited for handling the mixture of discrete and continuous data typically collected in household surveys [13]. The use of variables measured on different scales can result in different variances and this may produce quite different results in the PCA depending on whether one uses covariance or correlation matrices for the calculations. Large variances will dominate the first principal component if covariance matrices are used. For this reason, the PCA was performed using standardized variables from a correlation matrix, which minimizes the differences in variance. To generate valid indices that were as simple as possible, each index was constructed with the minimum number of variables/assets that would produce scores with enough variability to allow us to define unique cut-off points for each urban and rural area of all states. The indices include 16 assets for NFHS-3 (2005–6), 14 assets for NFHS-2 (1998–9) and 11 assets for NFHS-1 (1992–3). The index for DLHS-3 (2007–8) includes 14 assets, the index for DLHS-2 (2002–4) includes 10 assets and the index for DLHS-1 (1998–9) includes 9 assets (Tables 1–6). Binary coding (i.e. yes/no) was applied to all but two assets; highest education level achieved by the household head was categorized as none/primary/secondary/higher than secondary, while the number of bedrooms in the dwelling was categorized as one/two/three/four or more (thereby ensuring that at least 5% of households were included in the highest category).
Table 1

Assets selected to create a national wealth index from the NFHS-3 (2005–6) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.2481.02824
Refrigerator1 = Yes 0 = No0.2700.36075
Scooter/Motorcycle1 = Yes 0 = No0.2530.37867
Telephone1 = Yes 0 = No0.2530.34873
Electric Fan1 = Yes 0 = No0.2430.46752
Pressure Cooker1 = Yes 0 = No0.3100.48564
Chair1 = Yes 0 = No0.2830.49857
Table1 = Yes 0 = No0.2980.49660
Sewing Machine1 = Yes 0 = No0.2190.38956
Number of bedrooms1 = 1 2 = 2 3 = 3 4 = 4+0.1590.81620
Mobile-phone1 = Yes 0 = No0.2590.37469
Mattress1 = Yes 0 = No0.2340.49447
Electricity1 = Yes 0 = No0.2430.46752
Television1 = Yes 0 = No0.3020.49761
Radio1 = Yes 0 = No0.1610.46235
Bed1 = Yes 0 = No0.1310.37735
rho = 38.5

SD: Standard Deviation.

Table 6

Assets selected to create a national wealth index from the DLHS-1 (1998–9) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.3321.11730
Car1 = Yes 0 = No0.1530.16195
Scooter/Motorcycle1 = Yes 0 = No0.3130.33095
Electric Fan1 = Yes 0 = No0.4400.49988
Bicycle1 = Yes 0 = No0.1760.50035
Sewing Machine1 = Yes 0 = No0.3390.42380
Electricity1 = Yes 0 = No0.3790.48678
Television1 = Yes 0 = No0.4380.48490
Radio1 = Yes 0 = No0.3060.49162
rho = 37.0

SD: Standard Deviation.

SD: Standard Deviation. SD: Standard Deviation. SD: Standard Deviation. SD: Standard Deviation. SD: Standard Deviation. SD: Standard Deviation. An index coefficient c for each asset was calculated using the expression rounded to the nearest integer. The wealth scores for each household were then calculated using the expression where c represents the index coefficient and v the coded value of the ith asset. From the resulting score assigned to each household, the national, regional and state score distributions were derived for each survey round, for urban and rural areas separately, and the score value for each stratum-specific decile was then identified. To account for the complex survey design, the sampling weights provided with the survey datasets were used for all analyses.

Results

Tables 1–6 give the indexed variables for each survey respectively, with their factor loadings, standard deviations and index coefficients. For the NFHS-3 (Table 1), the first component explained 38.5% of the data variability. The first component explained 43.1% of the variability in the NFHS-2 data (Table 2), and 40.0% of the variability in the NFHS-1 data (Table 3). For the DLHS surveys, the first component explained 39.8% of the data variability in DLHS-3 (Table 4), 36.0% of the variability in the DLHS-2 data (Table 5), and 37% of the variability in DLHS-1 (Table 6).
Table 2

Assets selected to create a national wealth index from the NFHS-2 (1998–9) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.2501.06224
Refrigerator1 = Yes 0 = No0.2640.30886
Scooter/Motorcycle1 = Yes 0 = No0.2450.31678
Telephone1 = Yes 0 = No0.2310.26288
Electric Fan1 = Yes 0 = No0.3090.49862
Pressure Cooker1 = Yes 0 = No0.3140.45669
Chair1 = Yes 0 = No0.2940.49859
Table1 = Yes 0 = No0.3000.48961
Sewing Machine1 = Yes 0 = No0.2350.38761
Number of Rooms1 = 1 2 = 2 3 = 3 4 = 4+0.2141.11419
Mattress1 = Yes 0 = No0.2750.49955
Electricity1 = Yes 0 = No0.2530.49052
Television1 = Yes 0 = No0.3160.47367
Radio1 = Yes 0 = No0.2100.48543
rho = 43.1

SD: Standard Deviation.

Table 3

Assets selected to create a national wealth index from the NFHS-1 (1992–3) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.2990.96831
Refrigerator1 = Yes 0 = No0.2920.251116
Scooter/Motorcycle1 = Yes 0 = No0.2760.273101
Electric Fan1 = Yes 0 = No0.3610.46877
Sofa set1 = Yes 0 = No0.3030.290104
Clock1 = Yes 0 = No0.3010.50060
Sewing Machine1 = Yes 0 = No0.2800.38473
Number of Rooms1 = 1 2 = 2 3 = 3 4 = 4+0.2101.10819
Electricity1 = Yes 0 = No0.2940.50059
Television1 = Yes 0 = No0.3600.40689
Radio1 = Yes 0 = No0.2800.48857
rho = 40.0

SD: Standard Deviation.

Table 4

Assets selected to create a national wealth index from the DLHS-3 (2007–8) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.2381.06022
Refrigerator1 = Yes 0 = No0.2850.33086
Scooter/Motorcycle1 = Yes 0 = No0.2610.36771
Telephone1 = Yes 0 = No0.2260.30175
Electric Fan1 = Yes 0 = No0.2970.49760
Pressure Cooker1 = Yes 0 = No0.3190.47767
Chair1 = Yes 0 = No0.2840.49957
Table1 = Yes 0 = No0.2960.49260
Sewing Machine1 = Yes 0 = No0.2380.37763
Number of bedrooms1 = 1 2 = 2 3 = 3 4 = 4+0.1740.88820
Mobile-phone1 = Yes 0 = No0.3040.47464
Mattress1 = Yes 0 = No0.2000.49241
Electricity1 = Yes 0 = No0.2540.47354
Television1 = Yes 0 = No0.3200.45171
rho = 39.8

SD: Standard Deviation.

Table 5

Assets selected to create a national wealth index from the DLHS-2 (2002–4) survey, with coding definitions.

VariableCodingLoadingSDCoefficient
Common assets
Highest educationlevel attained(head of the household)0 = No education1 = Primary2 = Secondary3 = Higher than secondary0.3201.12428
Scooter/Motorcycle1 = Yes 0 = No0.3330.36891
Telephone1 = Yes 0 = No0.3510.37394
Electric Fan1 = Yes 0 = No0.3420.46773
Car1 = Yes 0 = No0.1930.175111
Bicycle1 = Yes 0 = No0.1300.49926
Sewing Machine1 = Yes 0 = No0.3170.42175
Electricity1 = Yes 0 = No0.3420.46773
Television1 = Yes 0 = No0.4140.49683
Radio1 = Yes 0 = No0.2500.48052
rho = 36.0

SD: Standard Deviation.

Using the 2006 WHO growth standards [27] we analyzed the distribution of the mean height-for-age z-scores across wealth quintiles defined by local reference cut-off points. As expected, the mean height-for-age z-score increased from the poorest to the richest wealth quintiles, and similarly, prevalence of stunting was higher among the poorest and lower among the wealthiest. These trends were consistent for all three rounds of the NFHS. We calculated the Pearson correlation between the continuous wealth score and height-for-age z-score for all children under age 5. The values were 0.23 (p-value<0.0001) in urban areas and 0.18 (p-value<0.0001) in rural areas (NFHS-3). Spearman rank correlations had very similar results: 0.27 in urban areas and 0.20 in rural areas (p-value<0.001). These values were similar to correlations obtained between height-for-age z-score and the originally constructed NFHS-3 wealth index based on the DHS methodology [28]. The Pearson correlations were 0.25 and 0.19 (p-value<0.001) and the Spearman rank correlations were 0.28 and 0.21 (p-value<0.001) in urban and rural areas, respectively. In Figures 1 and 2 we present state-level analyses for Kerala and Uttar Pradesh in 2005–6 showing mean height-for-age z-score (Figure 1) and stunting prevalence (Figure 2) by wealth quintile, and comparing estimates for locally defined quintiles with estimates for the national quintiles originally defined in the NFHS-3. Kerala and Uttar Pradesh were chosen to represent the diverse levels of economic development and health indicators. Kerala is among the richest states in India and ranks highest in terms of conventional measures of health and economic development, while Uttar Pradesh is one of the poorest states and ranks among the lowest by infant mortality rate, literacy, and per capita income [18], [29], [30]. Based on the original NFHS-3 national quintiles, nearly 50% of children with survey height measurements in Kerala are classified in the richest quintile, whereas local cut-offs result in a much more even distribution of children across quintiles. The wealth gradient for child linear growth in Kerala appears steeper when the national quintiles are used compared to the locally defined quintiles. The strength of this relationship is likely overstated because, with fewer individuals classified in the poorest quintiles based on the national cut-offs, there is additional uncertainty in estimating the mean height-for-age in these groups. This exaggeration of the state-specific wealth gradient when using national quintiles is similarly shown in Uttar Pradesh, where only 10% of children were classified in the richest national quintile.
Figure 1

Mean height-for-age by wealth score quintiles derived from local state and urban/rural cut points and from NFHS national cut points in the states of Kerala and Uttar Pradesh, 2005–6.

Figure 2

Prevalence of stunting by wealth score quintiles derived from local state and urban/rural cut points and from NFHS national cut points in the states of Kerala and Uttar Pradesh, 2005–6.

For analyzing health inequalities, the importance of using reference distributions from the most appropriate geographical level is further illustrated in Figure 3. We compare the wealth score distributions of a sub-sample of eight rural villages in Himachal Pradesh with the full rural distribution for Himachal Pradesh (top panel) and with the rural distribution for all of India (bottom panel). If the sub-sampled villages had a similar wealth distribution to that of the state, all bars in the upper histogram (representing each quintile) would include approximately 20% of the sub-sampled village households. However, the sub-sample distribution is in fact largely skewed towards the lowest state-specific wealth quintile. Alternately, when compared to the rural wealth distribution of the whole country the sub-sample distribution is skewed to the higher national quintiles.
Figure 3

Distribution of wealth scores from a subsample of the rural Himachal Pradesh population by reference wealth quintiles for the rural state (top) and for rural India (bottom) in 2005–06 (NFHS-3).

The plotted distributions of household wealth scores by urban and rural areas for each survey round are given in Figures 4 and 5. For the most recent round of the NFHS, in 2005–6, score values for urban households across India ranged from 20 to 955, with a mean score of 547 (standard deviation of 230) and a median score of 552. In rural India, the mean score was 317 (standard deviation of 221) and the median score was 268.
Figure 4

Distribution of wealth scores by urban and rural areas of India across three rounds of the National Family Health Survey (NFHS).

Figure 5

Distribution of wealth scores by urban and rural areas of India across three rounds of the District Level Household Survey (DLHS).

Urban and rural decile cut-off values for India, for the six regions and for the 24 major states are presented by survey round in in Tables 7–12. These wealth score distributions reveal large variability between states, regions, and urban and rural areas. For the most recent NFHS round (2005–6), median scores in urban areas were highest in Delhi (665), followed by Goa (663), Uttaranchal (653), Himachal Pradesh (649), and Punjab (648), with all but Goa located in the North region. The North region’s median score (646) is similar or higher than the seventh decile cut-off values of all other regions. The poorest urban areas were in the states of Tamil Nadu (382) and Andhra Pradesh (394), with median scores that are lower than the third decile cut-off values of 11 other states.
Table 7

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the NFHS-3 survey (2005–6) household sample.

Percentile
Region/State102030405060708090
Rural South 75 121 174 234 294 352 419 518 674
APAndhra Pradesh78136192243301339391455578
KAKarnataka7075123163211272350447582
KEKerala264375463525588665733795885
TNTamil Nadu70107155203254305374464607
Central 54 76 100 114 148 193 259 366 534
RJRajasthan547699115155200273367538
UPUttar Pradesh547692108144192265388557
CHChhattisgarh5478107131167199254336465
MPMadhya Pradesh5478102115145181243328487
East 46 54 76 102 130 175 240 336 487
BHBihar445476102124169233320476
WBWest Bengal446090121159205269371518
JHJharkhand44547698114131169230375
OROrissa44547589114161243356519
Northeast 78 137 197 235 274 323 398 499 638
SKSikkim174264327389444488522588683
ARArunachal Pradesh6097141199259353444540674
NANagaland122196249298356416484554661
MNManipur167240302365424474534611704
MZMizoram199293336374422465511603740
TRTripura107182241296352396452509610
MGMeghalaya76143183235281327385470589
ASAssam76122182228252290353470630
North 173 253 334 412 496 583 671 767 883
JMJammu and Kashmir135205256308370434516603722
HPHimachal Pradesh225341429501577636722802886
PJPunjab240341427515597682758848928
UCUttaranchal107184257337425498582677830
HRHaryana153221288354425520614727841
DLDelhi257350417529608697752848914
West 70 107 163 221 291 368 454 558 704
GJGujarat99144200280347412497610762
MHMaharashtra5499139188256334419519658
GOGoa168303395496595699785867942
Rural India 54 78 108 155 207 276 359 471 632
Urban South 139 210 292 361 440 511 596 684 776
APAndhra Pradesh139208271332394461544634745
KAKarnataka144261340418499562627698774
KEKerala288392472532594656709755807
TNTamil Nadu113174239303382450560666781
Central 139 223 321 407 485 565 657 748 826
RJRajasthan196283383468534630715795852
UPUttar Pradesh109209296388473541636728812
CHChhattisgarh139202277386472561653738816
MPMadhya Pradesh135218315391475556644745821
East 135 204 283 377 449 530 608 691 769
BHBihar113177240344424494560643757
WBWest Bengal144231299384449532615691757
JHJharkhand104210323410493577667750816
OROrissa97148229322443537648733795
Northeast 196 279 358 429 485 537 603 684 790
SKSikkim362444476511538588626676713
ARArunachal Pradesh117213305388475537596679774
NANagaland235331388449485534590653736
MNManipur235323388442492546608681776
MZMizoram331388434493560611665736793
TRTripura212275327384420499570656736
MGMeghalaya244323380414461511569642734
ASAssam170263349429489537608691794
North 231 343 455 560 646 707 764 795 852
JMJammu and Kashmir257334410515595681738793852
HPHimachal Pradesh297424515597649705736774826
PJPunjab234342459560648712764800852
UCUttaranchal209370475570653710764795852
HRHaryana205322405520619679731769826
DLDelhi235367488582665724767800852
West 239 344 418 477 537 603 662 722 781
GJGujarat261366423475534596658719781
MHMaharashtra231331410476538603665722781
GOGoa266389494594663719755786826
Urban India 149 257 334 418 495 570 651 724 795
Table 12

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the DLHS-1 survey (1998–9) household sample.

Percentile
Region/State102030405060708090
Rural South 0 65 97 140 200 258 316 378 443
APAndhra Pradesh007897166228288346411
KAKarnataka307890138168200258323413
KEKerala6095138200260316378411488
LKLakshadweep261288316323353403431463498
PYPondicherryNANANANANANANANANA
TNTamil Nadu3078122173228288323383446
ANAndaman and Nicobar Islands97168230267321371408458523
Central 0 35 78 97 140 198 263 353 458
RJRajasthan06095166226288348413488
UPUttar Pradesh30356595115166237335443
CGChhattisgarhNANANANANANANANANA
MPMadhya Pradesh06078113143201261341433
East 0 0 35 60 92 97 157 235 353
BHBihar0035609097152187323
WBWest Bengal030356595122166261362
JHJharkhandNANANANANANANANANA
OROrissa00356095125173291413
Northeast 0 30 60 78 95 138 183 261 370
SKSikkim307878108138168200230290
ARArunachal Pradesh000607878138168290
NANagaland06080122168228291370441
MNManipur0606295138157200265353
MZMizoram78108138168200218280310383
TRTripura03060108166256323378413
MGMeghalaya030606292140170230308
ASAssam0035606597157228381
North 140 201 260 311 368 401 446 488 526
JMJammu and Kashmir140168226258310355398458493
HPHimachal Pradesh108170230306368398458458493
PJPunjab201281341373431436493526588
UCUttaranchalNANANANANANANANANA
HRHaryana95201256306351398431493528
CHChandigarhNANANANANANANANANA
DLDelhiNANANANANANANANANA
West 35 78 138 173 226 263 321 381 458
GJGujarat60113170226256288323381446
DDDaman & Diu166201231263306326358413463
DNDadra & Nagar Haveli6578113166201258318381458
MHMaharashtra3078108138185235316371446
GOGoa138226286323370.5411458508588
Rural India 0 35 78 108 157 223 290 370 458
Urban South 122 228 291 348 378 413 448 503 556
APAndhra Pradesh78173256316351383441493538
KAKarnataka78168256316356411448508583
KEKerala110200286316351383426488538
LKLakshadweep283323371413443493508558588
PYPondicherry108226288323378383413458508
TNTamil Nadu196288325378411418476508583
ANAndaman and Nicobar IslandsNANANANANANANANANA
Central 143 256 316 366 413 458 493 528 618
RJRajasthan226291351403443488493526591
UPUttar Pradesh95201286346396433493526618
CGChhattisgarhNANANANANANANANANA
MPMadhya Pradesh166261321368413458493538618
East 60 157 261 323 373 413 443 508 583
BHBihar6097201306353413488523618
WBWest Bengal95226288323353396413458523
JHJharkhandNANANANANANANANANA
OROrissa60166291351401443500538618
Northeast 90 140 200 260 310 351 408 465 553
SKSikkim170226228290316336370411545
ARArunachal Pradesh78108140198238306348408478
NANagaland90166226280310338378413495
MNManipur95138173203235290353413523
MZMizoram138170200250280325396458553
TRTripura30108196288318351383443488
MGMeghalaya138200260290290320370408488
ASAssam95203321381443488523583618
North 286 353 413 441 491 523 553 588 618
JMJammu and KashmirNANANANANANANANANA
HPHimachal Pradesh336398458461493523583583648
PJPunjab311381431461493526556588621
UCUttaranchal261341396431463493526588618
HRHaryanaNANANANANANANANANA
CHChandigarhNANANANANANANANANA
DLDelhiNANANANANANANANANA
West 218 288 321 378 396 413 458 503 556
GJGujarat226291351381413446493528588
DDDaman & Diu265318351383413443493508568
DNDadra & Nagar Haveli306351381411441503538583618
MHMaharashtra196268316351378408431476523
GOGoa226316378413458503528583618
Urban India 127 228 306 351 386 431 473 523 588
Rural wealth score gaps are even larger than those observed in urban areas. Median scores in rural areas for 2005–6 (NFHS) were highest in Delhi (608), followed by Punjab (597), Goa (595) and Kerala (588), with very low median scores in the Eastern states of Jharkhand (114), Orissa (114), Bihar (124) and the Central states of Madhya Pradesh (145) and Uttar Pradesh (144). The median scores of Jharkhand and Orissa are lower than the first decile cut-off values for 11 other states, and lower than the second decile cut-off values for 17 other states. The region with the richest rural areas is the North, with a median score of 496, followed from a considerable distance by the West region with a median score of 291.

Discussion

PCA has been previously evaluated and used for the development of wealth scores based on household asset data, including the NFHS itself [17], [18], [20]. The present analysis adds a careful consideration of the sub-national variation in wealth and the differences in wealth index scores and components by rural and urban areas. As has been shown previously in Brazil [15], there is large variability in sub-national distributions of scores and there are many benefits in taking the variation into account. For example, it allows for within-sample economic classification, and for comparisons across geographical and urban/rural distributions. Unlike the original PCA-based wealth score that is made available with the NFHS datasets, which has a common number of items and scores for a national distribution, the indices were constructed so as to allow for the identification of regional and state-level decile cut-off points for urban and rural households separately. This enables the scores to be used for comparisons at different levels of aggregation, and the importance of local distribution cut-off points is illustrated by the state-level examples in Figures 1 and 2. In addition, changes in the index components and in their coefficients over time – from 1992–3 (NFHS-1) to 2005–06 (NFHS-3) for example – illustrate the need to revise indices periodically. The items that we included in the national wealth indices are relatively simple to measure in population surveys, and are limited 15 or fewer assets, thereby limiting the time needed to collect wealth data during a household interview. In addition, future analyses of the NFHS datasets can take direct advantage of the wealth indices and the sub-national score distributions presented here. Other variables that were available in the NFHS surveys were not included because they did not contribute importantly to the score and/or were not required to improve the distribution. Radio and bed are two examples of items that had a lower loading (less than 0.2) and were kept in the calculations to improve the distribution of the score by avoiding accumulation of households in a specific decile (a function of having too many households reporting ownership of a very limited number of items, especially in rural areas). The resulting scores are valid indicators of wealth that correlate well with health outcomes, as seen by the variation in the mean height-for-age scores (Figure 1) and in stunting prevalence across the wealth score quintiles (Figure 2). The proportion of the total variability explained by the first component of the urban (ranging from 39.5% and 41.4%) and rural scores (ranging from 33.6% to 33.8%) can be considered high given the size of India’s population and its income inequality (Gini index: 33.9 in 2010 [31]). In summary, we constructed valid asset-based wealth indices from six nationally representative surveys of households in India conducted between 1992–3 and 2007–8, and we present the regional and state-level distributions of these wealth scores for urban and rural areas separately. These scores can be used for analyses within the source surveys to understand differences within and across geographical levels, and for ecological analyses that combine the source surveys with other datasets. In addition to the wide variety of scenarios in which these indices can be currently applied, they are also based on data that could be collected relatively easily in future studies.
Table 8

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the NFHS-2 survey (1998–9) household sample.

Percentile
Region/State102030405060708090
Rural South 42 83 114 153 201 262 332 420 554
APAndhra Pradesh216791132178225288364475
KAKarnataka427091132160215287382529
KEKerala148212258307374420498586746
TNTamil Nadu4486113139183238310405545
Central 21 44 67 88 112 153 204 298 459
RJRajasthan214483107137183252364528
UPUttar Pradesh21426584107134194284451
CHChhattisgarhNANANANANANANANANA
MPMadhya Pradesh42637093116156202284443
East 21 42 63 84 104 132 192 275 434
BHBihar2142638391132191258400
WBWest BengalNANANANANANANANANA
JHJharkhandNANANANANANANANANA
OROrissa2142636788130183286475
Northeast 44 88 136 191 216 258 306 390 521
SKSikkim133219265319379426495554661
ARArunachal Pradesh70114162208245299385491603
NANagaland88150198240286338391445557
MNManipur88153202247287335389475607
MZMizoram178275303326368393416460512
TRTripura70132180216260290353410494
MGMeghalaya426591136193235265320414
ASAssam4284127170212237281350502
North 137 215 288 368 443 514 582 648 748
JMJammu and Kashmir108172225280332393471548648
HPHimachal Pradesh168258348420483546603649756
PJPunjab160267360440509571628699790
UCUttaranchalNANANANANANANANANA
HRHaryana91170241300374452520590690
DLDelhi295410469536586631707759864
West 42 70 109 137 186 260 335 440 589
GJGujarat4287116176240306390471600
MHMaharashtra426793132171227303406572
GOGoa159263351410479571658767891
Rural India 42 63 86 111 153 206 282 387 543
Urban South 115 203 272 336 399 464 537 645 761
APAndhra Pradesh113182261314380445515624739
KAKarnataka115229317399464520603716788
KEKerala227317361405470519603698768
TNTamil Nadu113178230288338401476581721
Central 113 203 289 369 442 509 563 655 765
RJRajasthan134215300383448516586676786
UPUttar Pradesh125227306384445511578655763
CHChhattisgarhNANANANANANANANANA
MPMadhya Pradesh88165247333420489553650761
East 94 164 245 312 399 464 533 624 724
BHBihar88150227307380451514586694
WBWest BengalNANANANANANANANANA
JHJharkhandNANANANANANANANANA
OROrissa5075140242332421513619761
Northeast 177 277 337 397 445 495 558 631 743
SKSikkim265349380399449514562612721
ARArunachal Pradesh140240290355420464489560677
NANagaland226330370399445489536590714
MNManipur201266315355388442495567667
MZMizoram330355377402442491560653743
TRTripura152246334380419464541628703
MGMeghalaya203290334380405445500587696
ASAssam139241324439489536586675790
North 293 414 489 558 630 697 763 807 857
JMJammu and Kashmir253330370417489539620711793
HPHimachal Pradesh332420467525586651703761807
PJPunjab414486555619694760793832857
UCUttaranchalNANANANANANANANANA
HRHaryana243345444514605672757807857
DLDelhi290407492561644711765807857
West 155 246 317 395 450 514 597 676 760
GJGujarat153262370439486556642714788
MHMaharashtra157230311376432493565650735
GOGoa202312405496570650721786832
Urban India 125 222 299 376 445 511 584 677 782
Table 9

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the NFHS-1 survey (1992–3) household sample.

Percentile
Region/State102030405060708090
Rural South 22 53 82 104 135 166 219 304 454
APAndhra Pradesh22446684106137178250346
KAKarnataka224482104128159191241368
KEKerala88119168219287349445561721
TNTamil Nadu22537588113148197283431
Central 22 44 66 84 104 128 157 213 356
RJRajasthan22445382104135181262401
UPUttar Pradesh2244538288119150193318
CHChhattisgarhNANANANANANANANANA
MPMadhya Pradesh22448288113135175241388
East 22 44 44 66 84 106 137 169 284
BHBihar224444667588119150241
WBWest BengalNANANANANANANANANA
JHJharkhandNANANANANANANANANA
OROrissa2244446675104137181315
Northeast 22 44 66 88 104 128 166 227 396
SKSikkimNANANANANANANANANA
ARArunachal Pradesh446682104129166210308472
NANagaland75116140.5166210256296366487
MNManipur6688113129157188222303488
MZMizoram5375128157182220253304422
TRTripura22537588115146181250388
MGMeghalaya44667597119148197272432
ASAssam2244667597119150196370
North 104 178 224 284 326 388 455 535 700
JMJammu and Kashmir82135193253325387472552691
HPHimachal Pradesh104135179222273326391495585
PJPunjab135200263316366431504619824
UCUttaranchalNANANANANANANANANA
HRHaryana82140200262306347409494598
DLDelhi204262308396451517586725993
West 22 53 82 106 135 175 231 315 463
GJGujarat225384113144206271356527
MHMaharashtra225382104135166200284419
GOGoa104144188251326431536690901
Rural India 22 44 66 88 106 144 188 266 423
Urban South 97 152 224 299 353 412 473 541 627
APAndhra Pradesh77155247316374428478547645
KAKarnataka97151203263339420474548641
KEKerala122195249303366417478556641
TNTamil Nadu77149212293337391451504600
Central 96 170 247 320 381 450 510 600 696
RJRajasthan97166251326391452504600696
UPUttar Pradesh77151224300365433510611713
CHChhattisgarhNANANANANANANANANA
MPMadhya Pradesh121205291351412464523596677
East 69 106 180 263 347 420 475 553 644
BHBihar52104177297397451525600692
WBWest BengalNANANANANANANANANA
JHJharkhandNANANANANANANANANA
OROrissa4697146220293359426502620
Northeast 81 150 209 278 351 412 482 552 648
SKSikkimNANANANANANANANANA
ARArunachal Pradesh75120149195255355428487570
NANagaland173248309365420457507527598
MNManipur92127178204255305407499573
MZMizoram149201227262296331384.5441574
TRTripura148203255305351388450517560
MGMeghalaya174205262302341400430475556
ASAssam69123203284381451525600696
North 199 282 350 404 465 527 604 671 738
JMJammu and Kashmir277345404448504567626677721
HPHimachal Pradesh227310366408469510577638700
PJPunjab224301369420481541619677721
UCUttaranchalNANANANANANANANANA
HRHaryana193275335397439500571638715
DLDelhi180270345404464540625686738
West 106 180 253 307 365 420 476 554 646
GJGujarat97180253305353405458548654
MHMaharashtra106180253307370422478554642
GOGoa151247321386444524611667713
Urban India 97 166 239 307 374 428 493 573 671
Table 10

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the DLHS-3 survey (2007–8) household sample.

Percentile
Region/State102030405060708090
Rural South 74 106 153 198 251 299 362 438 560
APAndhra Pradesh7496151191232271315366449
KAKarnataka7474116141189235291366465
KEKerala192276347407460509578648719
LKLakshadweep312394442496556593628670731
PYPondicherry77143191235277319366449560
TNTamil Nadu7499153191234273319381482
ANAndaman and Nicobar Islands96151219295360425489564665
Central 20 42 74 94 125 165 225 319 474
RJRajasthan206183116159215289387527
UPUttar Pradesh20406181105146210314487
CGChhattisgarh219370467528592620646707762
MPMadhya Pradesh407484115135172219298438
East 40 61 74 83 105 138 182 253 386
BHBihar616181103118141182242365
WBWest Bengal20426484121170227312430
JHJharkhand162283379449509567620666741
OROrissa2040426277100161267426
Northeast 84 141 191 224 265 316 363 426 510
SKSikkim179239287335361403427462517
ARArunachal Pradesh131191233272304344390443516
NANagalandNANANANANANANANANA
MNManipur137183228262296340385447529
MZMizoram137204264299321343385430520
TRTripura4299157200254314356408489
MGMeghalaya80122159198231260296354427
ASAssam62104157181220252313403514
North 150 219 281 341 402 466 536 617 707
JMJammu and Kashmir135192242286331381441513615
HPHimachal Pradesh205286345399448498550607689
PJPunjab218312392472550616665707762
UCUttaranchal123179229283339390449512599
HRHaryana121178241306376448532624708
CHChandigarh40627496118153193255372
DLDelhi163265336409476556619687736
West 61 105 151 197 254 314 379 454 560
GJGujarat83135175223274325388465560
DDDaman & Diu232286328377412465509580644
DNDadra & Nagar Haveli94137175219252292346409502
MHMaharashtra4074117160220283348427537
GOGoa191262330390472542624697749
Rural India 42 74 105 145 198 256 328 420 547
Urban South 156 249 314 375 433 495 560 642 718
APAndhra Pradesh202276336392447509577646721
KAKarnataka119202277344407461521594678
KEKerala300399469525582643673729773
LKLakshadweep379475.5553604654688.5715746.5778
PYPondicherry214295359426493562626673731
TNTamil Nadu134213276326381437498573666
ANAndaman and Nicobar Islands311396467509553584636666719
Central 94 188 279 363 443 516 595 669 749
RJRajasthan173282370450526599665729802
UPUttar Pradesh62134219310399484558643729
CGChhattisgarh399529616666708729781804822
MPMadhya Pradesh119217300374446515583666747
East 103 192 290 376 447 509 578 646 721
BHBihar81118182271367450529599687
WBWest Bengal134242324390445494569640702
JHJharkhand162283379449509567620666741
OROrissa74156255352433513580652735
Northeast 252 341 400 443 487 528 578 644 718
SKSikkim343405429448489515535584636
ARArunachal Pradesh274343390428466497529584666
NANagalandNANANANANANANANANA
MNManipur226313381425471514560602672
MZMizoram299343401427478530583647722
TRTripura257336385427487538592657729
MGMeghalaya199277341383427465506560644
ASAssam182316406467500550583649729
North 264 365 445 526 593 646 707 733 800
JMJammu and Kashmir302370419467526595667711773
HPHimachal Pradesh321429486538586636684729782
PJPunjab289419528600647707727776804
UCUttaranchal286374443500560618666729782
HRHaryana227326423509580644707729802
CHChandigarh118195266345425502580663729
DLDelhi249343429509576638687729782
West 235 322 387 445 493 553 622 666 729
GJGujarat261343403456508564633666739
DDDaman & Diu381465500557606644675719741
DNDadra & Nagar Haveli276340366410467489553624649
MHMaharashtra204299363423473528575646719
GOGoa292410498573625670709741782
Urban India 158 265 347 418 482 547 614 673 741
Table 11

Decile cut-off values from regional, state and rural/urban distributions of the national wealth index score calculated from the DLHS-2 survey (2002–4) household sample.

Percentile
Region/State102030405060708090
Rural South 26 73 101 146 182 229 283 337 431
APAndhra Pradesh07378146172221255285360
KAKarnataka267373101129179229290391
KEKerala5280136202254309363429504
LKLakshadweep200266315341374401429457496
PYPondicherry73146200229283311363428520
TNTamil Nadu2673101155202254287337421
ANAndaman and Nicobar Islands73146202257309337412459532
Central 0 26 52 73 99 134 182 256 363
RJRajasthan005273127172229308412
UPUttar Pradesh026265682108157238363
CGChhattisgarh184256293311339363403480595
MPMadhya Pradesh0287382101153200256348
East 0 0 26 52 56 82 129 182 301
BHBihar0026285682106153246
WBWest Bengal026285480106155228313
JHJharkhand78172255311363414482557628
OROrissa0026525683146228335
Northeast 0 52 73 99 129 162 212 287 386
SKSikkim73101125153184212264323386
ARArunachal Pradesh0527399129181235307391
NANagaland05673125129181256337433
MNManipur56101129153181212280337454
MZMizoram2873101129153181211256355
TRTripura2873106153202254285335391
MGMeghalaya00285273101125163236
ASAssam026285680106147252363
North 73 146 200 247 284 330 382 433 523
JMJammu and Kashmir73125157208254281309356412
HPHimachal Pradesh101153208275311360410450524
PJPunjab172229255311355386438506571
UCUttaranchal05278127174238303367459
HRHaryana82172224255304337386438529
CHChandigarh026547899127155224311
DLDelhi200229285311337388438503623
West 26 73 101 146 174 228 281 335 426
GJGujarat2673127146198228268321411
DDDaman & Diu129172202229281311348402477
DNDadra & Nagar Haveli7373125146198230280315405
MHMaharashtra05673127156208262313404
GOGoa125198273323376431492548623
Rural India 0 28 73 99 134 182 252 311 410
Urban South 146 228 280 311 355 401 456 522 576
APAndhra Pradesh146228255285313365413496557
KAKarnataka129212275311363414470540609
KEKerala125202265311363410459522597
LKLakshadweep226281323369401454480548567
PYPondicherry174255307351402456513550623
TNTamil Nadu146228281309337376438501571
ANAndaman and Nicobar Islands229307337398431466506550597
Central 99 200 255 311 358 404 466 534 623
RJRajasthan146229285341386450522573651
UPUttar Pradesh73156229285335386438508609
CGChhattisgarh224311374438529576625651736
MPMadhya Pradesh146228277311360410468543623
East 54 146 228 283 323 376 433 501 578
BHBihar2678150230307358414482578
WBWest Bengal82200254285313363403459532
JHJharkhand78172255311363414482557628
OROrissa56172255307335391451524599
Northeast 125 200 255 306 348 402 459 524 599
SKSikkim146212257285334358386449497
ARArunachal Pradesh101156212264309358407470550
NANagaland181240292358406458488550593
MNManipur108155207254298337391456557
MZMizoram146204256311369433498550625
TRTripura172230285313363405454496576
MGMeghalaya108157212250298334386445498
ASAssam56181280311363412480534619
North 229 283 330 365 412 461 529 573 645
JMJammu and Kashmir208281296337371412456531625
HPHimachal Pradesh254329383438466531560623651
PJPunjab247307358386454515571619656
UCUttaranchal172257311367412461508569645
HRHaryana229285339386424477534597651
CHChandigarh99172255307339402477548623
DLDelhi229281307339382414479545623
West 200 255 285 335 376 423 470 529 597
GJGujarat200255285321374414480529597
DDDaman & Diu202281311349402451494524596
DNDadra & Nagar Haveli230285321379428496524571633
MHMaharashtra184255285337376412459522581
GOGoa157273309365423478545597659
Urban India 129 224 281 311 363 409 466 532 623
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Journal:  Int J Hyg Environ Health       Date:  2021-10-23       Impact factor: 5.840

5.  Cheaper Medicines for the Better Off? A Comparison of Medicine Prices and Client Socioeconomic Status Between Chain and Independent Retail Pharmacies in Urban India.

Authors:  Rosalind Miller; Catherine Goodman
Journal:  Int J Health Policy Manag       Date:  2022-05-01

6.  IndEcho study: cohort study investigating birth size, childhood growth and young adult cardiovascular risk factors as predictors of midlife myocardial structure and function in South Asians.

Authors:  Senthil K Vasan; Ambuj Roy; Viji Thomson Samuel; Belavendra Antonisamy; Santosh K Bhargava; Anoop George Alex; Bhaskar Singh; Clive Osmond; Finney S Geethanjali; Fredrik Karpe; Harshpal Sachdev; Kanhaiya Agrawal; Lakshmy Ramakrishnan; Nikhil Tandon; Nihal Thomas; Prasanna S Premkumar; Prrathepa Asaithambi; Sneha F X Princy; Sikha Sinha; Thomas Vizhalil Paul; Dorairaj Prabhakaran; Caroline H D Fall
Journal:  BMJ Open       Date:  2018-04-10       Impact factor: 2.692

7.  Milk consumption and childhood anthropometric failure in India: Analysis of a national survey.

Authors:  Shelley M Vanderhout; Daniel J Corsi
Journal:  Matern Child Nutr       Date:  2020-09-30       Impact factor: 3.092

  7 in total

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