India Health Report Documentation

PROJECT STUDIO 3 SEMESTER 4 10 WEEKS

STUDENT AKSHAN ISH S1101106 PGDPD ‘11 GRAPHIC DESIGN

PROJECT DOCUMENTATION

INDIA HEALTH REPORT

GUIDE RUPESH VYAS

INDIA HEALTH REPORT PROJECT DOCUMENTATION

AKSHAN ISH S1101106 PGDPD ‘11 GRAPHIC DESIGN E akshan.i@nid.edu T +91 846 901 7051

Every second child in India under the age of 5, is stunted (lesser height for age)

Every fifth child in India under the age of 5, is wasted (lesser weight for age)

INDEX 02

Chapter 1 INTRODUCTION

42

Chapter 6 VISUAL LANGUAGE

06

Chapter 2 CONTEXTUAL STUDY

58

Chapter 7 PROTOTYPE

14

Chapter 3 PUBLICATION STRUCTURE

62

18

Chapter 4 DATA TO INFORMATION

64

32

Chapter 5 INFORMATION DASHBOARDS

COLOPHON Typeface, ITC Officina Serif Std & Sans Std Document dimensions, 7.5” x 10” Print Version October 8, 2013

CONCLUSION REFERENCES

CHAPTER 1

INTRODUCTION PROJECT CONTEXT

The Public Health Foundation of India (PHFI) has proposed a biennial India Health Report (IHR) aimed at a broad national and international policy and academic audience, as an opportunity to highlight progress made in key health indicators in India as well as shortfalls. IHR will provide periodic assessment of health in India; it will present detailed information on selected measures of India’s morbidity, mortality, health care utilization, health risk factors, prevention, health insurance, and personal health care expenditures. The goal is to use information to better design, implement, and evaluate policies that can improve access, equity and efficiency in health outcomes in India. Each issue of IHR will focus on a specific area of health challenge in India. The inaugural issue will focus on nutrition.

PHFI

The Public Health Foundation of India (PHFI) is a public private initiative that has collaboratively evolved through consultations with multiple constituencies including Indian and international academia, state and central governments, multi & bi-lateral agencies and civil society groups. PHFI is a response to redress the limited institutional capacity in India for strengthening training, research and policy development in the area of Public Health.

Structured as an independent foundation, PHFI adopts a broad, integrative approach to public health, tailoring its endeavours to Indian conditions and bearing relevance to countries facing similar challenges and concerns. PHFI focuses on broad dimensions of public health that encompass promotive, preventive and therapeutic services, many of which are frequently lost sight of in policy planning as well as in popular understanding.

INTRODUCTION

Public Policy

MOTIVATION

IHR

Information Design

The decision to take this project up came quite naturally to me. It fell right at the intersection of information design and public-policy advocacy – a domain I’m interested in working with. My initial objective was to pick out some of the human development indicators and visualize the transformation and impact of various public policies on those indicators, but I could not focus on any one indicator as each seem equal or more important than the other. The opportunity to design the India Health Report came as a boon as it eliminated the need to find a design brief and focus on the actual aspects of content generation, information visualization and publication design.

Can information be designed in a manner that facilitates effective decision-making? The nature of the project was such that it required me to be extremely objective with the content, and visualize the data for clear understanding and quick identification of problem areas. I have been dabbling in the field of data visualization and infographics, and have often faced a dilemma between creative story telling and analytical clarity. Since the purpose of this publication was to facilitate decision-makers and public health researchers with information regarding malnutrition in India with a view to improve evidence based planning and enhance political will, this was a good opportunity for me to find an aesthetic in the objectivity and austerity of analytical information visualization.

There was also the huge incentive of seeing a publication designed by me to have a wide reach across the nation and be used by researchers and policymakers to help in their decision making process to eradicate malnutrition.

3

PROJECT SCOPE

Reimagine the structure and delivery of public interest information. Gain a thorough understanding of the content and design the required information architecture for the report. Design necessary infographics and illustrations to support the content and create narratives from the data. Design a standardized layout template for subsequent issues of the report which would deal with other public health issues.

Understand Content

Gather Narratives

Information Architecture

Visual Language

Visual Content Generation

Data Visualization

Production with Publisher

INTRODUCTION

PROJECT METHODOLOGY & TIMELINE WEEK ONE

TWO

THREE

FOUR

FIVE

SIX

SEVEN

EIGHT

NINE

TEN

Contextual Study Design Development Design information architecture. Take physical format and production decisions.

Set visual language.

Design Execution Guideline Development Documentation Documentation of the entire process.

Content collation and organization.

Understand context and target audience. Study publication formats and structures. Study existing work done in the field of information visualization for healthcare and public interest issues.

Visualize data and generate necessary illustrations for the inaugural issue. Bring the content, structure, imagery, infographics, typography together into one cohesive publication.

Use the inaugural issue as a model to develop a stylesheet and guidelines for subsequent issues of the India Health Report.

5

CHAPTER 2

CONTEXTUAL STUDY VISION OF THE REPORT

The India Health Report is to be a biennial publication that brings to the forefront various public health issues and recommendations on dealing with them at the state as well as the national level. The initial vision of the report was that it would be data-driven, highly analytical, visually bold and essentially a primer for action. It would have to play a transformational role in broadening the view of nutrition from food intake to a multi-sectorial approach including issues like water & sanitation, mother’s education, and agriculture. There are already a large number of reports that inform the governments on the state of the people, but the India Health Report would have to make sure that the development train actually leaves the platform.

The focus of the report would change with each issue, but the core objective would be to highlight health challenges that India is facing and push for multi-sectorial action. Therefore, it was important to understand that some editions might target specific issues like nutrition and take into account various other factors that determine the state of nutrition and other editions might target large scale health systems like Urban Health which would require zooming in to smaller units and sub-parts of the macro issue.

A broad structure of the report had also been decided in the initial discussions. The report would be divided in to two sections—section one would have the main content, editorials and chapters written by the authors accompanied with case studies, photographs and information graphics; section two would comprise of state wise tabular information on selected core indicators for demography, health, education, and health-nutrition related socioeconomic indicators.

The India Health Report would have a solution-oriented outlook, which is what sets it apart from other reports and publications in this domain.

Instead of only presenting the problem areas, the report would enable decision makers to solve complex public health issues by gearing them with appropriate information as well as policy recommendations which are a result of much study and research at PHFI and other partner organizations.

CONTEXTUAL STUDY

TARGET AUDIENCE

The objective of the India Health Report itself is to update information with a view to facilitate policy makers, development programmers, socialscientists, public health specialists and nutritionists to understand the malnutrition issues in correct perspective for enhancing political commitment and for facilitating evidence based planning with adequate investment for accelerating measures for effective implementation for improving nutrition of women and children.

National level policy makers are aware of the nutrition scenario (1000 days, etc.) State-level government and planners, however have a lack of clarity about this. States like Madhya Pradesh and Maharashtra that have nutrition missions are ahead in terms of tackling malnutrition issues, but others lag behind. The aim of the report thus became to help these states quickly absorb the global recommendations.

Center for Disease Dynamics, Economics & Policy, Washington, DC

7

ADVOCACY REPORTS

Several organizations produce reports on a yearly basis that pertain to advocacy and contain updated information regarding various development and health indicators. These reports are used mainly to highlight key developments in research and field studies, and to showcase the organization’s activities and annual involvement.

the child development index 2012 progress, challenges and inequality

Child Development Index 2012, Save The Children

CONTEXTUAL STUDY

The world healTh reporT 2007

A sAfer

future Global public healTh SecuriTy in The 21ST cenTury

UNMASKING AND OVERCOMING HEALTH INEQUITIES IN URBAN SETTINGS

Nutrition in the First 1,000 Days State of the World’s Mothers 2012

The World Health Report 2007, World Health Organization

Hidden Cities, World Health Organization

State of the World’s Mothers 2012, Save The Children

food for thought

WITHIN REACH

GLOBAL DEVELOPMENT GOALS

tackling child malnutrition to unlock potential and boost prosperity

2013 HUNGER REPORT

VOLUME 3 ISSUE 1 2013

MEASURING

HUNGER FR O M TH E G R O U N D U P

ETHIOPIA’S PLAN TO TRANSFORM AGRICULTURE

AG R IC U LTU R AL EXTEN SIO N 2.0

WHAT’S THE BEST WAY TO SHARE INFORMATION WITH FARMERS?

2013 Hunger Report, Bread for the World Institute

Food for Thought, Save The Children

Insights 2012, International Food Policy Research Institute

9

CONTENT COLLATION

Most of my first five weeks of the project were spent in helping the researchers gather content for the report from various sources, edit and structure them to fit in the larger scheme of the publication. Large part of the content would mainly come out of commissioned authors who were responsible for writing chapters about developments in nutrition & health, define the various challenges that undernutrition presents to India as a nation, evaluate the various government schemes, and highlight practices that have had a positive impact on eradicating malnutrition. This would make the first section of the report as discussed earlier.

Photographs needed to be sourced from partner organizations who had researchers in the field, and their image banks. A thorough process of selection had to be done by sifting through hundreds of photographs. This process was undetermined and difficult as the text which these photographs would accompany was not finalized. Although, having these image banks at my disposal helped me in creating imagery and setting the tone and the visual language for the report.

Discussing the content of the report with PHFI researchers, New Delhi

CONTEXTUAL STUDY

For the second section of the report, a list of data sources was collated.

The biggest data sources were the National Family Health Survey (NFHS), Census Sample Registration System (SRS), and the District Level Household & Facility Survey (DLHS). Other data sources included Coverage Evaluation Survey (CES) by WHO & UNICEF, Indiastat, Lancet reports and IFPRI datasets. Depending on our core indicator list, these data sets had to be studied and relevant data had to be scraped.

These data would primarily be used to design infographics which would support the main content of the report, and a health & nutrition profile for each state. These indicators and their data sources were tabulated in an excel file for ease of access and sharing. This process also helped me get acquainted with the content and the data more intimately.

Excel file with core indicators and data sources

11

UNDERSTANDING CONTENT

Sketch noting nutrition CONTEXTUAL STUDY

In order to be able to communicate the urgency and the need to focus on nutrition as a nation-wide issue—it was important for me to first get a holistic understanding of the problem, the different factors that have an impact on nutrition of mothers & children, various stakeholders and mechanisms that are already in place to deal with nutrition.

While studying the content of the report and background papers that were taken into consideration, I began to understand the multi-fold impact that poor nutrition has on a child’s growth and overall development—poor cognition, low performance at school, reduced employability, reduced economic income, strong anaemia prevalence among teenage girls and pregnant women and eventually a leading cause to pull large populations below the poverty line.

It was also important to be able to detach myself from individual case studies and remain objective in order to be able to study the problem from a macro perspective and deliver a design solution that lets the target audience experience the scale of malnourishment and depth of the problem while providing clear information to encourage a problem solving approach.

Photo Credit: Save The Children 13

CHAPTER 3

PUBLICATION STRUCTURE PHYSICAL FORMAT

Since the report was going to be published by the Cambridge University Press (CUP), the physical format had to be discussed with them to make sure that there was no ambiguity in the vision of the report. CUP is essentially an academic publisher, so they had already set constraints on the dimensions and the layout of the publication. It took a few meetings and some prototyping to get them to agree to our vision.

The main issue was in deciding whether to handle this report as a magazine or an academic publication. It would be a recurring publication which needed to be easy to consume but one that needs to have a long shelf life.

This consideration also influenced the visual language of the report. It was decided that the report would be a four colour printed standard paperback in crown quarto size (7.5 x 10 inches) with roughly 250 pages.

7.5 inches

10 inches

Dimensions scaled to 30% of original size

PUBLICATION STRUCTURE

INCLUSION OF STORIES

The content of the report was extremely straight forward and objective.

When I started laying it down on flat-plan to see the flow, I realized that the entire report had deemed people into quantifiable measures that would evoke no emotional response from the readers. If this report was to be a primer for action, it had to connect with the emotions of the policy makers.

It was imperative that they realize that it is real people that the dialogue revolved around.

In order to do this, I suggested the inclusion of excerpts and interviews of people working in the field and first hand accounts of people who have both benefited from health programmes as well as those who have not been recipients of any help. We would contact local NGOs, government officials, Anganwadi workers to share their experiences and stories with us. This could also be a way to bring to the forefront work being done in remote areas, and establish unorthodox practices that have had a positive impact on maternal and child nutrition.

Boat Clinics in Assam, Center for North East Studies and Policy Research (C-NES) 15

CALL FOR STORIES

A call for stories was made and sent out to all PHFI employees to get in touch with their contacts so that we could have a collection of humaninterest stories that would showcase unnoticed practices, and give an account of the actual situation at the ground level. We received a total of 12 stories that were then edited and a selection of 8 was made to be included in the report.

WE NEED

STORIES FOR THE INDIA HEALTH REPORT nutrition

We are looking for stories, interviews and images relevant to the different aspects of nutrition.

SHARE WITH US (THEMATIC AREAS) Stories on nutrition: its impact on academic / professional performance, ability to work, loss of wages and anything else you might think is relevant

Women’s empowerment & nutrition (for e.g. impact of women’s education, employment/microfinance/social protection schemes, self-help groups, etc.)

Nutrition and its impact on: maternal health, adolescent/youth health, anemia

Agriculture & nutrition (for e.g. impact of type of livelihood/occupation, crop diversification, agricultural techniques, prices, etc.)

WASH & nutrition

Programs/policies on nutrition (for e.g. PDS, ICDS, Food Security Bill, mid-day meals, etc.)

THINGS TO KEEP IN MIND We want to connect readers to the subject matter beyond numbers. Health is about real people, real actions and real consequences. type of story

style

We’re looking for human interest stories. It’s not a research piece, but it should be based on real life, and on the author’s own experience, interactions in the field, or anecdotes and stories of people that the author has personally had a chance to interact with.

We’re looking for short narrative pieces. Short, relevant interviews are also welcome. Stories that focus on an individual or a family, and are personal and emotive in nature, would be great!

images

word limit

Stories should be accompanied with relevant photographs or images in high resolution (250-300 dpi / larger than 1200 x 720 pixels).

The piece must not exceed 300 words. The essence must be communicated within the limit.

The photographs must connect people to any of the aspects of nutrition—impact, causes, programmes, etc. The author can also present their perspective on nutrition through field notes, photographs and photo essays.

DEADLINE FOR SENDING IN STORIES – 24 th JUNE, 2013 we look forward to your contribution. write to: neha.raykar@phfi.org / radhika.arora@phfi.org

PUBLICATION STRUCTURE

STATE-WISE DASHBOARDS

For the second section of the report, it had been earlier decided that an annexure consisting of data in tabular form for various core indicators would be listed for each state. We figured that this data could be converted to an infographic dashboard which visualizes the core indicators instead of just presenting raw numbers. This could provide an easy way to compare indicators of different states and condense the most important information to just a double-sided spread, which can then be detached from the report by state level policy makers who want to focus on only their state.

The dashboard would have a solution focus. The indicators and information presented in the dashboard will only present the context to the customized recommendations that are provided for each state. This way, the dashboard provides a public-health profile for each state highlighting key problems and also stating possible solutions and methods to tackle the problems.

Upon consultation with experts in the field, it became evident that these state profiles could become the most important knowledge resource that the India Health Report would generate. It could quickly tell decision makers where to look, was extremely accessible, easy to share and become the ideal content to have a discussion over.

FINAL STRUCTURE

Main Chapters

Supporting Infographics

Human-Interest Stories

State-wise Information Dashboard

0 Approximate proportions of pages taken by each kind of content in the report.

Colour coded according to the icons above.

250

17

CHAPTER 4

DATA TO INFORMATION SENSE– MAKING

Klein et al. (2006) have presented a theory of sensemaking as a set of processes that is initiated when an individual or organization recognizes the inadequacy of their current understanding of events. Sensemaking is an active two-way cognitive process of fitting data into a frame (mental model) and fitting a frame around the data. Neither data nor frame comes first; data evoke frames and frames select and connect data.

When applied to data visualization, it becomes the designer’s role to construct a frame for the data to be presented in so as to make it easy for the viewer to make sense of the data. Raw data is often difficult to comprehend and draw conclusions from, but when visualized and presented in context, the same data has the potential to inform in a compelling manner, instill a spirit of inquiry in the viewer’s mind, or enable thorough understanding and analytical reasoning.

In the context of this report which was going to be extremely data heavy, the task of visualizing large number of data sets coherently and clearly was of utmost importance since the target audience that we were dealing with, comprised of social scientists and researchers with large attention spans and an analytical bent of mind, as well as state and national level policy makers with less time on their hands, who needed to know key points at a glance.

Data

Context Visualization

DATA TO INFORMATION

Sense

DATA VIZ. MODELS

Although visualization models cannot be accurately grouped into different models, there seems to be a visual distinction in the visualizations that are common place, which are in turn derived from a difference in intent, in designing the visualization. The purpose of the visualization is what usually defines the aesthetic representation of data, although an underlying principle is that the visualization should make the data comprehensible and fairly easy to make sense out of. A brief summary of different kinds of charts to visualize data is given in the diagram by A.Abela (2006) below, and a poster made by Santiago Ortiz that describes multiple ways of visualizing two quantities is shown on the next page.

19

75, 37 multiple ways to communicate two quantities 75, 37

1

a

b

16

31

17

32

c

2

a

3

18

33 a

4

b

c

b

19

34 a

b

a

5

20 c

b

75 6

35 a

b

a

b

75 75

37

37

37

0 a

21

36

22

37

23

38

24

39

25

40

0

b

c

7 a

b

75

37

a

8 b

75 9

37 37

10

75

a

y = cos(75x)cos(37x)

b

11

26

41 a

12

b

27

42

animation: two pulses with 75 and 37 beats per minute

28

43

animation: two points rotating with 75 and 37 revolutions per minute

14

29

44

two sounds, 75hz and 37hz

15

30

45

a

13 a

b

b

c

Santiago Ortiz 2012, from the post: http://blog.visual.ly/45-ways-to-communicate-two-quantities DATA TO INFORMATION

WHAT SHOULD The authors of the main chapters of the report had provided us with a list WE VISUALIZE of graphs that they would need to support their text. This provided a good starting point to start visualizing, and also get more intimate with the data in the process. Since there was no set visual language yet, these graphs would only be used to understand the content more comprehensively, and help in building narratives.

After a few discussions with the editors of the report, we managed to build a list of core messages that needed to go out by means of compelling infographics. These messages were written down in the form of stories, with a typical linear narrative structure of a beginning–middle–end.

It was essential to make sure that the infographics and visualizations fit seemlessly within the structure of the report and its visual language.

X number of children in India suffer from stunted growth.

Of these, X % live in just N states.

Children that are stunted are less able to complete school…

Are less productive as working adults….

Are more likely to suffer from chronic disease as adults.

Adolescent girls with poor nutrition are more likely to have children that are stunted…

Thereby perpetuating the problem across generations.

Although India spends Rs X of budget on food intake programs … the lack of water and sanitation, and poor maternal education is a barrier to improving nutrition.

If X more families had access to sanitation, Y more mothers were educated and X more villages had effective ICDS programs, Z fewer children would be stunted.

Infographic story to explain the causes of stunting and ways to improve it

21

A STUDY OF INFO VIZ.

I had studied Edward Tufte’s books on visualization, and taken an online course with Alberto Cairo to understand and be able to practice data visualization. However, for this project, I browsed through some of the more inspiring work done in recent years to understand the methodology and decisions made by experts while dealing with this kind of content. I found the work of a research lab in Italy called Density Design extremely interesting in terms of the information design and visual appeal. The work of Francesco Franchi, Nicholas Feltron, Moritz Stefaner and Giorgia Lupi also influenced my design process.

Mothers Matter, Density Design DATA TO INFORMATION

Feltron Annual Report, Nicholas Feltron

Sol-itudine, il destino della Terra, Fracesco Franchi 23

SKETCHING STRUCTURES

In order to organize the data, figure out narratives, establish hierarchy of information, and generate visual ideas—I find it helpful to generate basic graphs using Microsoft Excel or Adobe Illustrator to get a sense of the story that the data is telling, and then sketch ideas on paper using the general structure of the generated graphs. It is a back and forth process that often involves quick sketches and rapid iterations on the computer.

An initial idea for a visualization was to create a timeline of the 1000 days from pregnancy to two years after child birth, which is often referred to as the Window of Opportunity, and highlight the various systemic problems that hinder a healthy delivery, and the impact of undernutrition on the child’s growth in the early stages.

Below are snapshots of the research content used to create the infographic, process sketch and iterations generated in Adobe Illustrator using the charting tools. This graphic was not completed as it was decided not to use it in the report.

DATA TO INFORMATION

25

PROPORTION SYMBOL MAPS

The first visualizations I started with were proportional symbol maps of India marking undernutrition as a proportion of population geographically to get a sense of what is happening where. Proportional symbols were used instead of choropleth maps, which typically use varying colour hues or shading to denote differences in a quantity because the data that I had to visualize had three variables­­­—population that is undernourished below the mean value, population that isStunting undernourished severely (3 happens levels below (or stunted growth) is what to a child’s brain and of body when theystates. don’t get standard deviation), and the relative percentages different

7 STATES WITH MORE THAN 50% STUNTED CHILDREN UNDER-5. the right kind of food or nutrients in their first 1,000 days of life.

The damage is irreversible. That child will never learn, nor earn, as much as he or she could have if properly nourished in early life.

JAMMU & KASHMIR 35 / 14.9

HIMACHAL PRADESH 38.6 / 16

PUNJAB

36.7 / 17.3

UTTARANCHAL

ARUNACHAL PRADESH

44.4 / 23.1

43.3 / 21.7

SIKKIM

HARAYANA

45.7 / 19.4

UTTAR PRADESH 56.8 / 32.4

BIHAR

38.3 / 17.9

MEGHALAYA

55.1 / 29.8

DELHI

42.2 / 20.4

RAJASTHAN

43.7 / 22.7

ASSAM

46.5 / 20.9

55.6 / 29.1

JHARKHAND

NAGALAND

49.8 / 26.8

38.8 / 19.3

MANIPUR

GUJARAT

35.6 / 13.1

51.7 / 25.5

MADHYA PRADESH

WEST BENGAL

50 / 26.3

44.6 / 17.8

CHATTISGARH 52.9 / 24.8

MAHARASTRA

46.3 / 19.1

ANDHRA PRADESH 42.7 / 18.7

GOA

TRIPURA

35.7 / 14.7

MIZORAM

39.8 / 17.7

ORISSA

45 / 19.6

Purple circles represent percentage of under-5 children who are stunted below -2 SD [ values denoted in purple ] 100%

25.6 / 10.2

KARNATAKA

43.7 / 20.5

KERALA

24.5 / 6.5

50%

TAMIL NADU

30.9 / 10.9

25%

Red circles represent percentage of under-5 children who are stutned below -3 SD [ values denoted in red ] States with more than 50% stunted children under-5

DATA TO INFORMATION

JAMMU & KASHMIR 14.8 / 4.4 / 2.3

HIMACHAL PRADESH 19.3 / 5.5 / 1.1

PUNJAB

MEGHALAYA

9.2 / 2.1 / 1.5

30.7 / 19.9 / 2.6

ARUNACHAL PRADESH

UTTARANCHAL

18.8 / 5.3 / 2.3

HARAYANA

UTTAR PRADESH

19.1 / 5 / 1.4

14.8 / 5.1 / 1.2

15.3 / 6.1 / 3.4

SIKKIM

BIHAR

9.7 / 3.3 / 8.3

27.1 / 8.3 / 0.3

ASSAM

13.7 / 4 / 1.2

DELHI

15.4 / 7 / 4

RAJASTHAN

NAGALAND

20.4 / 7.3 / 1.6

13.3 / 5.2 / 4.7

JHARKHAND

MANIPUR

32.3 / 11.8 / 0.6

9 / 2.1 / 2.2

MIZORAM GUJARAT

9 / 3.5 / 4.3

MADHYA PRADESH

18.7 / 5.8 / 1.2

35 / 12.6 / 1

WEST BENGAL

16.9 / 4.5 / 1.9

CHATTISGARH

19.5 / 5.6 / 1.3

TRIPURA

24.6 / 8.6 / 2.2

ORISSA

19.5 / 5.2 / 1.7

MAHARASHTRA

16.5 / 5.2 / 2.8

ANDHRA PRADESH

12.2 / 3.5 / 2.2

GOA

14.1 / 5.6 / 4.3

INDIA

KARNATAKA

19.8 / 6.4 / 1.5

17.6 / 5.9 / 2.6

TAMIL NADU

22.2 / 8.9 / 3.6

KARNATAKA

15.9 / 4.1 / 1.2

Percentage of under-5 children who are wasted, below -2 SD

Percentage of under-5 children who are severly wasted, below -3 SD

Percentage of under-5 children who have high body mass compared to height, above +2 SD

Proportional Symbol Map denoting the proportion of children who are wasted (state-wise)

27

RADIAL GRAPHS

A very interesting part of this study on nutrition was to see how the background characteristics of children like mother’s education, religion, age, caste, place of residence, wealth index, etc. effect their nutritional status.

This enables researchers to see what socioeconomic and cultural factors contribute to the health of children.

To visualize this phenomenon, I made use of multiple radial graphs laid out on a three column grid. The layout enables the viewer to identify patterns at a glance, and on further examination, one can understand how each socioeconomic factor impacts child nutrition. Radial graphs are also used to keep the visual style coherent, although they are less accurately perceived by the eye than bar graphs, since area is harder to perceive than length.

Since the focus here is on comparison rather than accurate comprehension, radial graphs seemed to be the ideal choice. They also present a more compelling emotional visual than bar charts.

12+ YEAR S COMPLETE

12.8 / 4 / 2.6

NO EDUCATION

22.7 / 8.1 / 1.1

10-11 YEAR S COMPLETE

<5 YEARS COMPLE TE

14.3 / 3.9 / 2.2

20.8 / 6.2 / 1.1

8-9 YEAR S COMPLETE

17.5 / 5.2 / 1.9

5-7 YEAR S COMP LETE 18.8 / 5.5 / 1.8

MOTHER’S EDUCATION This radial graph shows the impact of mother’s education on a child’s undernutrition, specifically weight-for-age. The facing page illustrates how these radial graphs present a picture of the impact of socioeconomic backgrounds on child nutrition.

DATA TO INFORMATION

<6

48-59

30.3 / 13.1 / 4.1

15.7 / 4.1 / 1.3

6-8

36-47

MALE

24-35

17.8 / 5.4 / 2

20.4 / 6.9 / 1.7

9-11

16.7 / 5.0 / 0.9

FIRST BIRTH

48+

29.3 / 10.1 / 3.1 20.5 / 6.8 / 1.7

15.5 / 4.7 / 1

FEMALE

28.9 / 10.9 / 1.6

19.1 / 6.1 / 1.4

24-47

<24

21.8 / 7.3 / 1.2

18.9 / 6.1 / 1.4

12-17

18-23

22.2 / 7.6 / 1.1

23.3 / 7.3 / 1.7

SEX

AGE IN MONTHS

6+

1

24.5 / 8.7 / 0.9

17.8 / 5.4 / 1.9

BIRTH INTERVAL

AVERAGE OR LARGER

VERY SMALL

18.2 / 5.9 / 1.6

28.7 / 9.6 / 1

URBAN

16.9 / 57 / 2.5

RURAL

20.7 / 6.7 / 1.2

4-5

2-3

21.8 / 7.6 / 1

SMALL

19.6 / 6.3 / 1.6

25.8 / 8.2 / 1.5

BIRTH ORDER

12+ YEARS COMPLETE

12.8 / 4 / 2.6

RESIDENCE

SIZE AT BIRTH

NO EDUCATION

22.7 / 8.1 / 1.1

OTHER

HINDU

33.6 / 10.5 / 1.3

20.3 / 6.6 / 1.5

JAIN

SCHEDULED CASTE 21 / 6.6 / 1.3

MUSLIM

15.8 / 5.2 / 0.8

10-11 YEARS COMPLETE

DON’T KNOW

14.1 / 3.1 / 1.4

18.4 / 6.1 / 1.6

<5 YEARS COMPLETE

14.3 / 3.9 / 2.2

20.8 / 6.2 / 1.1

OTHER

BUDDHIST / NEO-BUDDHIST 8-9 YEARS COMPLETE

17.5 / 5.2 / 1.9

5-7 YEARS COMPLETE

CHRISTIAN

SCHEDULED TRIBE

16.3 / 5.2 / 2.1

27.6 / 9.3 / 1.5

15.5 / 5.1 / 3.1

21 / 7 / 3.1

18.8 / 5.5 / 1.8

SIKH

OTHER BACKWARD CLASS

RELIGION

CASTE

20 / 6.6 / 1.3

11 / 2.8 / 1.9

MOTHER’S EDUCATION

LOWEST

NOT MEASURED

19.6 / 7.7 / 1.4

UNDERWEIGHT (BMI < 18.5)

25.2 / 7.9 / 1.1

LIVING WITH NEITHER PARENT

15.8 / 4.3 / 1.9

25 / 8.7 / 1

LIVING WITH BOTH PARENTS

19.6 / 6.4 / 1.5

HIGHEST

SECOND

12.7/ 4.2 / 2.7

OVERWEIGHT (BMI > 25)

9.3 / 2.7 / 3

NORMAL (BMI 18.5-24.9)

17.4 / 5.9 / 1.7

MOTHER’S NUTRITIONAL STATUS

LIVING WITH ONLY FATHER

18.8 / 6.8 / 3.8

LIVING WITH ONLY MOTHER

21.2 / 7 / 1.8

CHILD’S LIVING ARRANGEMENTS

22 / 6.7 / 1.1

FOURTH

MIDDLE

16.6 / 5 / 2.1

18.8 / 6.2 / 1.3

WEALTH INDEX 29

61 million children under the age of 5 in India, suffer from stunted growth

LESSER HEIGHT THAN NORMAL FOR THAT AGE

Stunting (or stunted growth) is a reduced growth rate in human development. It is a primary manifestation of malnutrition in early childhood; what happens to a child’s brain and body when they don’t get the right kind of food or nutrients in their first 1,000 days of life.

The damage is irreversible. That child will never learn, nor earn, as much as he or she could have if properly nourished in early life.

Of these 50% children live in just 7 states

PUTTING IT TOGETHER

A few lines of body text here. A few lines of body text here. A few lines of body text here. A few lines of body text here. A few lines of body text here. A few lines of body text here. A few lines of body text here.

JAMMU & KASHMIR 35 / 14.9

HIMACHAL PRADESH 38.6 / 16

PUNJAB

36.7 / 17.3

UTTARANCHAL

ARUNACHAL PRADESH

44.4 / 23.1

43.3 / 21.7

SIKKIM

HARAYANA

45.7 / 19.4

UTTAR PRADESH 56.8 / 32.4

38.3 / 17.9 55.6 / 29.1

46.5 / 20.9

MEGHALAYA

55.1 / 29.8

DELHI

RAJASTHAN

ASSAM

BIHAR

42.2 / 20.4

43.7 / 22.7

JHARKHAND

NAGALAND

49.8 / 26.8

38.8 / 19.3

MANIPUR

35.6 / 13.1

GUJARAT

51.7 / 25.5

MADHYA PRADESH

WEST BENGAL

50 / 26.3

44.6 / 17.8

CHATTISGARH 52.9 / 24.8

MAHARASTRA

TRIPURA

35.7 / 14.7

MIZORAM

39.8 / 17.7

ORISSA

45 / 19.6

46.3 / 19.1

ANDHRA PRADESH 42.7 / 18.7

GOA

25.6 / 10.2

KARNATAKA

INDIA

43.7 / 20.5

KERALA

24.5 / 6.5

DATA TO INFORMATION

48 / 23.7

States with more than 50% stunted children under-5

TAMIL NADU

30.9 / 10.9

Purple circles represent percentage of under-5 children who are stunted, below -2 SD [values denoted in purple]

Red circles represent percentage of under-5 children who are severely stunted, below -3 SD [values denoted in red]

Children that are stunted are less able to complete school...

Percentage of under-5 children who are stunted, below -2 SD for a particular background charactericstic.

Values are in purple.

Percentage of under-5 children who are stunted, below -3 SD for a particular background charactericstic.

Values are in red.

Every concentic circle represents 2% children

<6

48-59

20.4 / 8.4

50.3 / 23.9

MALE

36-47

6-8

48+

48.1 / 23.9

44.7 / 20.9

25.9 / 10.8

54.3 / 27.8

24-35

9-11

55.9 / 28.9

32 / 12.8

18-23

FEMALE

12-17

57.8 / 30.4

48 / 23.4

46.9 / 21.7

AGE IN MONTHS

SEX

6+

1

4-5

2-3

61 / 37.2

47.8 / 22.2

53.4 / 28.2

AVERAGE OR LARGER

21.9 / 7

53.9 / 27.3

SIZE AT BIRTH

NO EDUCATION 57.2 / 31.6

OTHER

RESIDENCE

HINDU

58.5 / 34

48 / 23.4

JAIN

<5 YEARS COMPLETE

10-11 YEARS COMPLETE

33 / 10.9

50.3 / 26.2

OTHER

BUDDHIST / NEO-BUDDHIST 40.7 / 15.6

5-7 YEARS COMPLETE

DON’T KNOW

45.8 / 22.3

MUSLIM

31.2 / 5.9

50.4 / 24.1

8-9 YEARS COMPLETE

URBAN

39.6 / 17.6

SMALL

46.5 / 22.7

BIRTH ORDER

12+ YEARS COMPLETE

BIRTH INTERVAL IN MONTHS

VERY SMALL

41 / 17.9

54.3 / 30.4

24-47

51.2 / 26

CHRISTIAN

40.7 / 17.8

39 / 17.9

56.1 / 23.2

SIKH

OTHER BACKWARD CLASS

29.8 / 13.4

45.6 / 20.3

MOTHER’S EDUCATION

48.8 / 24.5

RELIGION

CASTE LOWEST

46.9 / 21.7

NOT MEASURED

51.7 / 28.9

UNDERWEIGHT (BMI < 18.5) 53.5 / 27.3

LIVING WITH NEITHER PARENT

43.5 / 19.5

LIVING WITH BOTH PARENTS 48.4 / 23.9

HIGHEST

46.9 / 21.7

OVERWEIGHT (BMI > 25) 31.2 / 12

NORMAL (BMI 18.5-24.9) 46.3 / 22.5

MOTHER’S NUTRITIONAL STATUS

LIVING WITH ONLY FATHER

52.4 / 25.5

LIVING WITH ONLY MOTHER

FOURTH

46.9 / 21.7

46.6 / 23

CHILD’S LIVING ARRANGEMENT

WEALTH INDEX

31

CHAPTER 5

INFORMATION DASHBOARDS FIXING INDICATORS

The first step towards conceptualizing the dashboard was to fix on the indicators that needed to be visualized. A long list was already prepared for the annexures earlier, but these were too many to go into the dashboard.

The dashboard initially was meant only to give the most important information so it was conceived as a 2 page (front and back) layout.

Consequently, the need for the annexure was replaced by a 4 page dashboard that would consist of a demographic profile, issue specific indicators (nutrition in this case), other health and systemic indicators that effect the specific issue, and recommendations and projections to set tangible targets for each state, based on their status and dynamics.

INFORMATION DASHBOARDS

EXPLORING VISUALLY

I started designing the dashboard with a view point to make it extremely exciting visually. Sections were demarcated using icons and a combination of Neurath’s isotypes and graphs were used to visualize the information. This approach made it very heavy on the eye, and there was a lot of visual clutter that made it hard to comprehend the information. Colour variations and typographic styles were explored at this stage. A coding system was devised to use a single accent colour that represented the nutritional status of the state and arrange the states region-wise.

Assam 6%

2340503

TOTAL POPULATION

46%

% LITERATE WOMEN

46%

54%

MALE

FEMALE

46%

46%

URBAN

RURAL

4.6

46%

DEMOGRAPHICS SC / ST

6%

POPULATION BELOW POVERTY LINE

46%

46%

46%

CHILDREN <5 YRS

CHILDREN <2 YRS

CHILDREN <1 YR

stunting / wasting / underweight

stunting / wasting / underweight

40

40

30

30

2340503

6-8

9-11

12-17

18-23

24-35

36-47

48-59

age in months

AGE WISE PREVALENCE OF UNDERNUTRITION

NFHS - 1 (1995)

NFHS - 2 (2000)

40

30

19

23 14

46%

1995

ACCESS TO IMPROVED SANITATION

HUNGER INDEX

2005

2000

TRENDS IN IMR, U5MR, NMR (/1000 DEATHS)

male

urban

scheduled caste

lowest

no education

female

rural

scheduled tribe

second

<5 yrs complete

10

<6

42

ACCESS TO PORTABLE DRINKING WATER

20

10

41 36

46%

4.6

PREGNANT WOMEN

FERTILITY RATE

20

NUTRITIONAL STATUS

46%

% WOMEN WHO HAVE PASSED 8TH GRADE 46%

56

other backward classes

middle

5-7 yrs complete

other

fourth

8-9 yrs complete

don’t know

highest

10-11 yrs complete

NFHS - 3 (2005)

UNDERNUTRITION ACROSS THE YEARS

STUNTING BY BACKGROUND CHARACTERICSTICS

12+ yrs complete

10% CHILDREN

40 30

4.6

4.6

4.6

boys (1-3 yrs)

20 10

initiated to breast exclusively breastfed INFANT FEEDING milkwithin one hour for 6 months PRACTICES BREASTFEEDING FOR UNDER-3’S

girls (1-3 yrs)

4.6

introduced to water within 6 months

breastfed during sickness

<6

6-8

non-pregnant,

adolescent pregnant lactating non-lactating women girls women women

energy protein vitamin a iron calcium

12-17

18-23

24-35

36-47

48-59

age in months

<6

6-8

9-11

12-17

CHILDREN CONSUMING COMPLEMENTARY FOODS

receiving antenatal contacts

ors usage for diarrhea

pregnant women consuming > 100 ifa tablets

vitamin a supplementation in the last six months

36-47

48-59

age in months

breast milk, milk, other products

46% under-5 children

low bmi

46%

46%

high bmi

HEIGHT < 145 cms

ANEMIA PREVALANCE

adoloscent women (15-19)

46%

minimum no. of times

appropriate no. of food groups

INFANT & YOUNG CHILD FEEDING PRACTICES (% FED)

no education

46%

HIGH BMI (>30)

46%

<5 yrs

5-7 yrs

8-9 yrs

10-11 yrs

12+ yrs

age at birth emotional domestic violence

ANEMIA PREVALENCE FOR DIFFERENT GROUPS

HOW THEIR EDUCATION EFFECTS MOTHERS

4.6 4.6 4.6 4.6 4.6

access to institutional delivery

CHILDREN (<5 YRS)

24-35

46%

MOTHERS

full immunization

18-23

LOW BMI (<18.5)

other women (20-49)

DIETARY INTAKE DIETARY INTAKE OF SELECTED NUTRIENTS (% NOT RECEIVING NECESSARY INTAKE)

HEALTH SERVICES

9-11

CHILDREN UNDER 3 WHO ARE EXCLUSIVELY BREASTFED

MOTHERS (15-49 YRS)

PROGRAMME COVERAGE

HEALTH SUB-CENTRES ICDS CENTRES ANM / 1000 WOMEN AWW / 1000 RURAL AGAINST SANCTIONED AGAINST SANCTIONED POPULATION

ASHAs IN POSITION

33

Assam 6%

2340503 54%

FEMALE

46%

46%

URBAN

RURAL

46%

4.6

DEMOGRAPHICS SC / ST

46%

46%

CHILDREN <5 YRS

CHILDREN <1 YR

stunting / wasting / underweight

stunting / wasting / underweight

40

40

30

30

20

20

10

10

6-8

9-11

12-17

18-23

24-35

36-47

48-59

NFHS - 1 (1995)

age in months

AGE WISE PREVALENCE OF UNDERNUTRITION

41

NFHS - 2 (2000)

42

36

40

30

19

46%

4.6

PREGNANT WOMEN

FERTILITY RATE

<6

2340503

POPULATION BELOW POVERTY LINE

% LITERATE WOMEN

46%

MALE 46%

NUTRITIONAL STATUS

6%

46%

TOTAL POPULATION

56

23

ACCESS TO PORTABLE DRINKING WATER

14

46%

1995

ACCESS TO IMPROVED SANITATION

HUNGER INDEX

male

urban

female

rural

2005

2000

TRENDS IN IMR, U5MR, NMR (/1000 DEATHS)

scheduled caste

lowest

no education

scheduled tribe

second

<5 yrs complete

other backward classes

middle

5-7 yrs complete

other

fourth

8-9 yrs complete

don’t know

highest

NFHS - 3 (2005)

UNDERNUTRITION ACROSS THE YEARS

STUNTING BY BACKGROUND CHARACTERICSTICS

10-11 yrs complete 12+ yrs complete

10% CHILDREN

40 30

4.6

20

4.6

10

INFANT FEEDING PRACTICES BREASTFEEDING FOR UNDER-3’S initiated to breast milkwithin one hour

exclusively breastfed for 6 months

girls (1-3 yrs)

boys (1-3 yrs)

<6

6-8

9-11

18-23

24-35

36-47

non-pregnant,

adolescent pregnant lactating non-lactating women girls women women

48-59

<6

age in months

CHILDREN UNDER 3 WHO ARE EXCLUSIVELY BREASTFED

energy protein vitamin a iron calcium

6-8

9-11

12-17

18-23

24-35

48-59

age in months

no education

46%

46%

46%

LOW BMI (<18.5)

HIGH BMI (>30)

under-5 children

low bmi

46%

46%

46%

high bmi

HEIGHT < 145 cms

ANEMIA PREVALANCE

adoloscent women (15-19)

receiving antenatal contacts

ors usage for diarrhea

pregnant women consuming > 100 ifa tablets

5-7 yrs

8-9 yrs

10-11 yrs

12+ yrs

emotional domestic violence

ANEMIA PREVALENCE FOR DIFFERENT GROUPS

full immunization

<5 yrs

age at birth

46%

MOTHERS

vitamin a supplementation in the last six months

36-47

CHILDREN CONSUMING COMPLEMENTARY FOODS

other women (20-49)

DIETARY INTAKE DIETARY INTAKE OF SELECTED NUTRIENTS (% NOT RECEIVING NECESSARY INTAKE)

HEALTH SERVICES

12-17

HOW THEIR EDUCATION EFFECTS MOTHERS

4.6 4.6 4.6 4.6 4.6

access to institutional delivery

CHILDREN (<5 YRS)

PROGRAMME COVERAGE

MOTHERS (15-49 YRS)

HEALTH SUB-CENTRES ICDS CENTRES ANM / 1000 WOMEN AWW / 1000 RURAL AGAINST SANCTIONED AGAINST SANCTIONED POPULATION

ASHAs IN POSITION

Assam 6%

2340503

TOTAL POPULATION 54%

MALE

FEMALE

46%

46%

URBAN

RURAL

DEMOGRAPHICS SC / ST

46%

46%

CHILDREN <5 YRS

CHILDREN <1 YR

stunting / wasting / underweight

stunting / wasting / underweight

40

40

30

30

20

20

10

10

<6

6-8

9-11

12-17

18-23

24-35

36-47

AGE WISE PREVALENCE OF UNDERNUTRITION

48-59

age in months

41

NFHS - 1 (1995)

NFHS - 2 (2000)

42

36

40

30

19

46%

4.6

PREGNANT WOMEN

FERTILITY RATE

2340503

POPULATION BELOW POVERTY LINE 46%

4.6

46%

NUTRITIONAL STATUS

6%

46%

% LITERATE WOMEN

46%

56

23

ACCESS TO PORTABLE DRINKING WATER

14

46%

1995

ACCESS TO IMPROVED SANITATION

HUNGER INDEX

2005

2000

TRENDS IN IMR, U5MR, NMR (/1000 DEATHS)

male

urban

scheduled caste

lowest

no education

female

rural

scheduled tribe

second

<5 yrs complete

other backward classes

middle

5-7 yrs complete

other

fourth

8-9 yrs complete

don’t know

highest

10-11 yrs complete

NFHS - 3 (2005)

UNDERNUTRITION ACROSS THE YEARS

STUNTING BY BACKGROUND CHARACTERICSTICS

12+ yrs complete

10% CHILDREN

40 30

4.6

20

4.6

10

initiated to breast exclusively breastfed INFANT FEEDING milkwithin one hour for 6 months PRACTICES BREASTFEEDING FOR UNDER-3’S

girls (1-3 yrs)

boys (1-3 yrs)

<6

6-8

12-17

18-23

24-35

36-47

non-pregnant,

adolescent pregnant lactating non-lactating women girls women women

48-59

age in months

CHILDREN UNDER 3 WHO ARE EXCLUSIVELY BREASTFED

energy protein vitamin a iron calcium

<6

6-8

9-11

12-17

CHILDREN CONSUMING COMPLEMENTARY FOODS

receiving antenatal contacts

ors usage for diarrhea

pregnant women consuming > 100 ifa tablets

vitamin a supplementation in the last six months

INFORMATION DASHBOARDS

36-47

48-59

age in months

no education

46%

46%

HIGH BMI (>30)

under-5 children

low bmi

46%

46%

46%

high bmi

HEIGHT < 145 cms

ANEMIA PREVALANCE

adoloscent women (15-19)

46%

<5 yrs

age at birth emotional domestic violence

ANEMIA PREVALENCE FOR DIFFERENT GROUPS

HOW THEIR EDUCATION EFFECTS MOTHERS

4.6 4.6 4.6 4.6 4.6

access to institutional delivery

CHILDREN (<5 YRS)

24-35

46%

MOTHERS

full immunization

18-23

LOW BMI (<18.5)

other women (20-49)

DIETARY INTAKE DIETARY INTAKE OF SELECTED NUTRIENTS (% NOT RECEIVING NECESSARY INTAKE)

HEALTH SERVICES

9-11

MOTHERS (15-49 YRS)

PROGRAMME COVERAGE

HEALTH SUB-CENTRES ICDS CENTRES ANM / 1000 WOMEN AWW / 1000 RURAL AGAINST SANCTIONED AGAINST SANCTIONED POPULATION

ASHAs IN POSITION

5-7 yrs

8-9 yrs

10-11 yrs

12+ yrs

It was clear that this approach was not feasible both in terms of clarity and space, so a more compact system was devised that eliminated the icons and concentrated solely on the content. I tried as much to simplify the visualizations so they would convey the messages without any obstruction.

NUTRITION

INDIA HEALTH REPORT

Demographics

Nutritional Status

Total Population

234053 24

6% of the total population of India Population below internatinoal poverty line of US $1.25 per day

34053

24

36% of the total population of Arunachal Pradesh 36%

36%

64%

Male

Female

64%

3

36%

64%

36%

Urban

Rural

Pregnant Women

% of population under-five

36%

64%

SC/ST

Others

Fertility Rate

Hunger Index

2

13.4

36%

36%

36%

Anaemia prevalence 24 (non-pregnant)

Antenatal care (at least 4 visits)

13 2

43.3% children under-5 are stunted and 21.7% are severly stunted.

13.4

2

micronutrient deficiency / anaemia prevalence

Age wise prevalence of undernutrition (percentage of children < 5 years old) 24 24 24

24 24 24

25

24

Children under the age of five who are stunted by background charactericstics

Stunted / Wasted / Underweight

Year

Infant & Young Child Feeding

1995

2000

2005

48%

Girls

Boys 36%

48%

Urban

Rural

(in months) <6

36% 6-8

9-11

12-17

18-23

24-35

36-47

48-59

Poorest

Health Services & Programme Coverage

Infant feeding practices Exclusively breastfed / Breastfed and solid/semi-solid foods /

Trends in exclusive breastfeeding (percentage of infants < 6 months old who are exclusively breastfed)

36% 36 36 48%

Richest Spending

Breastfed and other milk/formula / Breastfed and non-milk liquids / Breastfed and plain water only / Weaned (not breastfed)

100%

24

60% 20%

48

48

36%

50% 30% 10%

10

Arunachal Pradesh

13 2

15.3% children under-5 are wasted and 6.1% are severly wasted.

24

40

36%

2

36%

Mothers with low BMI 24 (<18.5)

Have access to improved sanitation

44

Dotted & dashed lines represent national averages

64%

Number / % of births

70%

24

60%

64%

Trends in Infant mortality rate, Under-five mortality rate, Neonatal mortality rate (deaths per 1000 live births)

Have access to portable drinking water

38

40%

36%

Literate Women

(in months) 0-6

6-8

9-11

12-17

18-23

24-35

36-47

48-59

20%

20% 1992-93

1998-99

2000

2005-06

60% 100%

Recommendations

Key & Sources x

national ranking among states All indicators are colourcoded corresponding to the depiction in the graphic

08 state dashboard

09

NUTRITION

INDIA HEALTH REPORT

DEMOGRAPHICS

MATERNAL NUTRITION

Total Population

16.4%

1383727

50.6%

Mothers with low BMI (<18.5) 24

24

0.11% of India's total population Population below internatinoal poverty line of US $1.25 per day

29.9%

Anaemia prevalence (non-pregnant) 24

Antenatal care (at least 4 visits) 24

350000

24 (15.3% / 6.1%)

Wasted

51.6%

48.4%

Female

22.7

77.3%

Urban

24

Underweight

35.8%

Others

40.2%

Piped water

12.4% 24

Tube well

24

Non-improved source

24

14.8%

24

Flush toilet

24

Arunachal Pradesh

52.7% 24

22%

Public tap

(32.5% / 11.1%)

Pit latrine

24

7.1%

No facility

24

Dotted lines represent national averages, -2SD values in black and -3SD in white

WOMEN'S STATUS

State-wise comparison of stunting in children under-5

Arunachal Pradesh Other states

60% 50% 40% 30%

Rural

64.2%

SC/ST

Access to sanitation

85%

48.4%

24

25.9% of the total population of Arunachal Pradesh Male

Access to safe drinking water Improved source

NUTRITIONAL STATUS 24 (43.3% / 21.7%)

Stunted

WATER & SANITATION

20% North

57.7%

Central

North East

East

West

South

Age wise prevalence of undernutrition (percentage of children < 5 years old)

Literate Women

Stunted (-2SD / -3SD) / Wasted (-2SD / -3SD) / Underweight (-2SD / -3SD)

4.9%

HEALTH SERVICES & SPENDING

24 24 24

70%

Pregnant Women 50%

64%

Number of live births

30%

14.7%

10%

Under-five population (in months) <6

Fertility Rate 2

Hunger Index 2

6-11

12-23

24-35

48-59

Children under the age of five who are stunted by background charactericstics

N.A

36%

48%

36%

48%

Boys

Girls

Urban

Rural

Trends in Infant mortality rate, Under-five mortality rate, Neonatal mortality rate (deaths per 1000 live 24 24 24 births) 100

36%

36% 36 36 48%

Poorest

Richest

INFANT & YOUNG CHILD FEEDING

CHILD MORTALITY

87.7

Infant feeding practices Exclusively breastfed / Breastfed and solid/semi-solid foods /

Breastfed and other milk/formula / Breastfed and non-milk liquids / Breastfed and plain water only / Weaned (not breastfed)

100%

60.7 34

20

(in months) 0-6

RECOMMENDATIONS

KEY & SOURCES

x

national ranking among states All indicators are colourcoded corresponding to the depiction in the graphic

60% 20%

60

Year

36-47

2.7

6-8

9-11

12-17

18-23

24-35

36-47

48-59

20% 1992-93

1998-99

2005-06

60% 100%

08 state dashboard

09

35

This version proved to be easier to understand and engaging as it drew the viewer into the visualizations, and they could find their way through each indicator taking in chunks of information. The focus was on clarity of content as there could be no ambiguity in information representation. When the decision was made to make the dashboard a 4 page layout, it gave me a lot more space to accommodate indicators in a clear form, using graphs that did justice to the data. When the readers moved from one information block to another, a narrative for the particular state would appear. A state-wise ranking for most of the indicators was also included.

NUTRITION

NUTRITIONAL STATUS

24 (43.3% / 21.7%)

Stunted

Arunachal Pradesh

Solid circles represent this state's nutritional status (-2SD / -3SD). Dotted lines represent national averages, -2SD values in black and -3SD in white

24 (15.3% / 6.1%)

Wasted

Underweight

24

(32.5% / 11.1%)

DEMOGRAPHICS Total Population

1383727 24

0.11% of India's total population Population below internatinoal poverty line of US $1.25 per day

51.6%

48.4%

Male

Female

22.7

77.3%

Urban

Rural

64.2%

35.8%

SC/ST

Others

57.7%

350000

24

14.7%

Under-five population Life Expectancy

?

2

Fertility Rate

2.7

Hunger Index

?

2

Literate Women 4.9%

2

Pregnant Women

25.9% of the total population of Arunachal Pradesh

64%

Number of live births

MORTALITY

BURDEN OF DISEASE

Trends in Infant mortality rate, Under-five mortality rate, Neonatal mortality rate (deaths per 1000 live births) 24 24 24

100

87.7

60

60.7 34

20 Year

1992-93

EXPENDITURE ON HEALTH

1998-99

2005-06

IMMUNIZATION COVERAGE 30% Fully Immunized Children

22%

Drop-Out Rate

Full Immunization Coverage 24 24

INFORMATION DASHBOARDS

INDIA HEALTH REPORT

MATERNAL NUTRITION

CHILD NUTRITION State-wise comparison of stunting in children under-5

16.4%

Mothers with low BMI (<18.5) 24

Arunachal Pradesh Other states

60% 50% 40% 30%

50.6%

Anaemia prevalence (non-pregnant) 24

20% North

Central

North East

East

South

Age wise prevalence of undernutrition (percentage of children < 5 years old) Stunted (-2SD / -3SD) / Wasted (-2SD / -3SD) / Underweight (-2SD / -3SD)

29.9%

West

24 24 24

70% 50%

Antenatal care (at least 4 visits) 24

30%

<6 6-11 12-23 24-35 36-47 48-59

<6 6-11 12-23 24-35 36-47 48-59

(in months)

<6 6-11 12-23 24-35 36-47 48-59

10%

Children under the age of five who are stunted by background charactericstics 36%

48%

36%

48%

36%

Boys

Girls

Urban

Rural

Poorest

36%

36%

SC

ST

36%

36 36 48%

Richest

36

36

OBC

Other

48%

Donâ&#x20AC;&#x2122;t know

INFANT & YOUNG CHILD FEEDING 100% 80% 60% 40% 20% 0 (in months) <6

6-8

Early initiation of breastfeeding Exclusive breastfeeding under 6 months Continued breasfeeding at 1 year Introduction of solid, semi-solid or soft foods

9-11

12-16

17-23

Minimum dietary diversity Minimum meal frequency Minimum acceptable diet Consumption of iron-rich or iron-fortified foods

08 state dashboard

37

This exploration went through a large number of iterations as content was being added and deleted, the layout was restructured numerous times after testing, and the visual style was made simpler with each iteration.

INFORMATION DASHBOARDS

FINAL LAYOUT

This section will change according to the focus are of each report, but state-standing will be done for all the issues

The final layout for the dashboard has bold section dividers, clear annotations, a cohesive colour scheme and a repeatable structure that can be followed for the future editions of the report. The dashboard is still in process of finalization, as a few indicators are yet to be decided on.

Arunachal Pradesh

NUTRITIONAL STANDING State-wise comparison of stunting in children under-5

Arunachal Pradesh Other states

60% 50 40 30 20 North

This section will remain in its place for all issues of the IHR with only the values for indicators changing over time

Central

East

North East

West

South

DEMOGRAPHICS

NUTRITIONAL STATUS

Total Population

Population below state specific poverty line

1383727

350000

0.11% of India’s population

25.9% of Arunachal Pradesh’s population 68.8%

32.2%

Female Urban

48.4%

Rural SC/ST

Others

4.9%

19.8

51.6%

Male

22.7%

57.7%

Literate Women 14.6%

Children under five

77.3%

Pregnant Women

2.7

Stunting (43.3 / 21.7)

Wasting (15.3 / 6.1)

Underweight (32.5 / 11.1)

Solid circles represent this state's nutritional status in percentages (-2SD / -3SD). Dotted lines represent national averages, -2SD values in grey and -3SD in white

Birth Rate (per 1000 population)

?

Fertility Rate

Hunger Index

MORTALITY

WATER & SANITATION

Trends in Infant mortality rate, Under-five mortality rate, Neonatal mortality rate (deaths per 1000 live births)

Access to improved source of water

100%

Time taken to obtain drinking water

98.1% 87.7%

80

92.8%

72% 63.1%

60 40

40%

20

17.5%

60.7%

41.8%

34%

0

40% 31%

66.4% have water on premises

27.1% take less than 30 minutes

5.9% take 30 minutes or longer

48.4% have no access to improved

1990

‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99

sanitation facility and 11.3% of them ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 2000 2010 have no toilet facility

IMMUNIZATION COVERAGE 30%

Fully immunized children

22%

Drop out rate

48%

Not immunized children

39

Section headers and bold lines to demarcate areas

Graph headers with legends under them so referencing becomes easy

MATERNAL NUTRITION

CHILD NUTRITION

16.4%

Age-wise prevalence of undernutrition among children

Mothers with low BMI (<18.5)

Stunting (-2SD / -3SD)

Wasting (-2SD / -3SD)

Underweight (-2SD / -3SD)

60%

Tints and shades of the same hue are used to create a harmonious yet distinct colour palette

Severe (1.6%)

Moderate (12.5%)

Mild (36.6%)

Anaemia prevalence (non-pregnant)

50 40

13.3% 30

Mother’s height less than 145cm

20

0

20

40

-3SD Boy Girl 80 100 (%)

-2SD

-2SD

60

-3SD Urban Rural 80 100 (%)

60

-3SD -2SD Scheduled Caste Scheduled Tribe Other Backward Class Others 80 100 (%)

60

-3SD -2SD Underweight (<18.5) Normal (18.5-24.9) Overweight (>25) 80 100 (%)

60

-3SD Lowest Second Middle Fourth Highest 80 100 (%)

60

Place of Residence

0

20

40

Caste

0

20

40

0

Age in months

<6 6-11 12-23 24-35 36-47 48-59

Sex

<6 6-11 12-23 24-35 36-47 48-59

Graphs for each indicator in this section are vertically aligned so comparison can be made across indicators as well

10

<6 6-11 12-23 24-35 36-47 48-59

NUTRITION (STUNTING) BY BACKGROUND CHARACTERISTICS

Anaemia prevalence among children Mild

80%

Moderate

Severe

60 40 20 0

6-11

Age in months

12-23

24-35

36-47

48-59

INFANT & YOUNG CHILD FEEDING Mother’s BMI

0

20

40

Wealth Index

0

20

40

Mother’s Education

0

20

40

60

INFORMATION DASHBOARDS

-2SD

-3SD -2SD No Education <5 Years Complete 5-9 Years Complete >10 Years Complete 80 100 (%)

Breast feeding initiation

Children ever breasfed (95.5%) Breasfed within 1 hour of birth (58.6%)

Breastfed within one day of birth (87%) Breastfed within half an hour of birth (58.1%)

78.3%

Exclusive breast feeding of infant <6 months of age

16.6%

children <6 months

Introduction of (solid, semi solid or soft) complementary foods

33.8%

63%

Children aged 6-23 months who are breastfed and received food from three or more food groups

Children aged 6-23 months who receive meals at least twice a day

34.3%

Children aged 6-35 months who consumed foods rich in iron in last 24 hours preceding the survey

80.4%

children between 6-9 months

4.1%

Children aged 6-59 months who consumed iron rich supplement in past 7 days preceding the survey

4%

Children given bottle feeding in the last three years preceding survey

WOMENâ&#x20AC;&#x2122;S STATUS

?

EXPENDITURE 8%

Gender gap index

25.3%

Women married below the age of 18 years

Women employed in agriculture

Data for these sections is yet to come, and hence are left blank

Years of education completed by women

Women allowed to make decisions about

Women involved in different types of earning

43%

Married women who have experienced any form of physical/sexual/ emotional violence

The colour identifies the nutritional status range that the state lies in

70.8%

Own health care (27.9%) Major household purchase (19.6%) Daily household purchases (59.4%) Visit friends or relatives (30.9%)

Cash only (24%) Cash and in-kind (13%) In-kind only (24.4%) Not paid (38.5%)

Women who justify hitting/beating of wife

AGRICULTURE 14.6Kg

59.3%

Food crop production to total production

12.6Kg

Urban Rural Monthly average consumption of cereals per person

HEALTH SERVICES 46.3%

51.3%

Women who have taken at least 3 antenatal visits

Women who have taken 2+ TT injections

Women given advice on

Breastfeeding (61.2%) Nutrition (48.2%) Institutional Delivery (42.8%)

18%

Women who have received IFA tablets/syrup for 3 months

1.2%

47.6%

Women whose home delivery was assisted by a skilled person

Women who had an institutional delivery

Similar graphs are used throughout so that the focus is on the content and ease of comprehension rather than decoding the graphs

41

CHAPTER 6

VISUAL LANGUAGE TYPE CHOICE

The India Health Report will be set in Myriad Pro & Minion Pro. A variety of sans-serif and serif pairing was explored, but the typeface choice was restricted by the fact that the future editions of the report would have to be designed, and there is no control over who would be designing it. Myriad Pro & Minion Pro come bundled with the Adobe Creative Suite and the Adobe Reader, so there would be no need to buy a separate license.

Both Myriad Pro & Minion Pro are available in OpenType format with close to 40 weights each, which gives the designer a lot of flexibility and wide variety of weights and styles to use. In a publication of this scale, where there are multiple levels of information, section headers, chapter headings, footnotes, references, numbers and raw data, it is useful to have a large palette of type weights and styles.

VISUAL LANGUAGE

PT Serif / 11 / 14 "Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua."

Thesis Serif / 11 / 14

Signika / 11 / 14

"Lorem ipsum dolor sit amet, consectetur "Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua." incididunt ut labore et dolore magna aliqua."

Trade Gothic / 10 / 12

Whitney / 10.5 / 12

"Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua."

"Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua."

Minion Pro / 11 / 13.2

Myriad Pro / 11 / 13.2

"Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua.

Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat."

"Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat."

43

PAGE LAYOUTS

The layout of the report had to be designed for ease of reading medium length (5000 words) chapters and to accommodate supporting photographs and infographics. I decided to use magazine-style layouts, breaking the text into columns and leaving space for referencing and footnotes as a lot of the facts that were stated had to be backed by supporting reading material.

Explorations that lead to the final layout are shown in the following pages.

INTRODUCTION This India Health Report aims to enhance the richness of policy dialogue in India by focusing on data, statistics and objective information, input from the best experts on specific topics from within and outside the country, and lead to more informed policy change in the health and allied sectors.

india is on the move. after many decades of stagnating economic grow th, household incomes are increasingly rapidly. over the past two decades, india has also achieved improvements in agricultur al productivity and reductions in under-five mortality.

Between 1990 and 2010, as the average income of Indians doubled, crop yields (kilograms/hectare) of all food grains rose by an average annual growth rate of about 2.4% and 2.9% fewer children died in the first five years of their life on an average annually. The improvements in health indicators have lagged those seen in India’s poorer neighbours including Bangladesh and Nepal. Even among these, child nutrition stands out as the one area of persistently poor performance. Child malnutrition rates in India are among the highest in the world – with nearly one-half of all children under 3 years of age being either underweight or stunted. Further, the incidence of child malnutrition has remained stubbornly high even after nearly two decades of post-reform growth and prosperity in the country. That child malnutrition is weakly correlated with income is additionally borne out by the findings that a quarter of the children of mother with 10 or more years of schooling and an equivalent proportion of children from the top income quintile are underweight. These children are very unlikely to face food insecurity. Even in a relatively prosperous and dynamic state like Gujarat, child malnutrition rates have been stagnant over the past decade.

08 INTRODUCTION

VISUAL LANGUAGE

Between 1992 and 2005, rates of stunting have declined only by 8.3%. Over the same period, stunting rates in Bangadesh declined from

65% to 42% (UNICEF, 2007) while those in Nepal reduced from 57% to 49% (NDHS, 2007). Further, the average per capita per day caloric intake may have actually declined in India. However, the performance of nutrition across states was not uniform. Some states, including Tripura, Arunachal Pradesh and Assam had remarkable rates of reduction in stunting while the situation in states like Nagaland and Gujarat remained virtually unchanged.

Even more surprising is the stagnancy of child malnutrition rates in the face of declining infant and child mortality. This incongruence is difficult to understand as most factors that are associated with low rates of infant and child mortality (e.g., delivery and utilization of high-quality health services, high female literacy, and good environmental hygiene) typically also improve child nutrition.

This phenomenon is often referred to as the “Indian enigma” – viz., child malnutrition rates are much higher in India than even in Sub-Saharan Africa even though infant and child mortality in India is lower. The Asian enigma throws up many interesting questions – is it culture and dietary habits (e.g., extensive vegetarianism) that account for high child malnutrition in India? Is it the poor nutritional status of mothers and their low weight gain during pregnancy that leads to low birth-weight babies who grow on to become malnourished children?

The problem of undernutrition in India now coexists with the problem of overnutrition and associated noncommunicable diseases for a different segment of the population. Indeed, there is some speculation that the two might be related; children who are underweight and undernourished are more likely to develop chronic illnesses, such as diabetes, later in life. India has the largest number of adults with type 2 diabetes and their number is growing rapidly – having doubled over the past 10 years. Indeed, India has a higher rate of diabetes than many Western countries with much higher levels of economic prosperity.

In this first India Health Report: Nutrition we survey the levels of and trends in maternal and child malnutrition in India. It will focus on disparities in these outcomes across geographical regions, socio-economic classes, and demographic groups. It will also review the existing literature on the determinants and consequences of maternal and child malnutrition in the country. The focus will be on understanding the puzzle of why malnutrition rates have remained stagnant despite agricultural productivity growth, economic prosperity, and rising levels of female schooling. We explore why programs like ICDS have not had better success in reducing child malnutrition and how the proposed Right to Food bill can achieve real improvements in child nutrition. We explore the Indian evidence on the productivity impacts of nutrition and more generally on the lifetime economic benefits from early childhood nutritional interventions. And we end by recommending the most costeffective interventions for reducing child malnutrition and hunger in India?

INDIA HEALTH REPORT

INDIA HEALTH REPORT

INTRODUCTION

CHAPTER ZERO

INTRODUCTION india is on the move. after many decades of stagnating economic growth, household incomes are increasingly rapidly. over the past two decades, india has also achieved improvements in agricultural productivity and reductions in under-five mortality.

Between 1990 and 2010, as the average income of Indians doubled, crop yields (kilograms/hectare) of all food grains rose by an average annual growth rate of about 2.4% and 2.9% fewer children died in the first five years of their life on an average annually. The improvements in health indicators have lagged those seen in India’s poorer neighbours including Bangladesh and Nepal. Even among these, child nutrition stands out as the one area of persistently poor performance. Child malnutrition rates in India are among the highest in the world – with nearly one-half of all children under 3 years of age being either underweight or stunted. Further, the incidence of child malnutrition has remained stubbornly high even after nearly two decades of post-reform growth and prosperity in the country. That child malnutrition is weakly correlated with income is additionally borne out by the findings that a quarter of the children of mother with 10 or more years of schooling and an equivalent proportion of children from the top income quintile are underweight. These children are very unlikely to face food insecurity. Even in a relatively prosperous and dynamic state like Gujarat, child malnutrition rates have

been stagnant over the past decade.

Between 1992 and 2005, rates of stunting have declined only by 8.3%.

Over the same period, stunting rates in Bangadesh declined from 65% to 42% (UNICEF, 2007) while those in Nepal reduced from 57% to 49% (NDHS, 2007).

Further, the average per capita per day caloric intake may have actually declined in India. However, the performance of nutrition across states was not uniform.

Some states, including Tripura, Arunachal Pradesh and Assam had remarkable rates of reduction in stunting while the situation in states like Nagaland and Gujarat remained virtually unchanged.

Even more surprising is the stagnancy of child malnutrition rates in the face of declining infant and child mortality. This incongruence is difficult to understand as most factors that are associated with low rates of infant and child mortality (e.g., delivery and utilization of high-quality health services, high female literacy, and good environmental hygiene) typically also improve child nutrition.

This phenomenon is often referred to as the “Indian enigma” – viz., child malnutrition rates are much higher in India than even in Sub-Saharan Africa even though infant and child mortality in India is lower. The Asian enigma throws up many interesting questions – is it culture and dietary habits (e.g., extensive vegetarianism) that account for high child malnutrition in India? Is it the poor nutritional status of mothers and their low weight gain during pregnancy that leads to

08 INTRODUCTION

low birth-weight babies who grow on to become malnourished children?

The problem of undernutrition in India now coexists with the problem of overnutrition and associated noncommunicable diseases for a different segment of the population. Indeed, there is some speculation that the two might be related; children who are underweight and undernourished are more likely to develop chronic illnesses, such as diabetes, later in life. India has the largest number of adults with type 2 diabetes and their number is growing rapidly – having doubled over the past 10 years. Indeed, India has a higher rate of diabetes than many Western countries with much higher levels of economic prosperity.

In this first India Health Repor t: Nutrition we survey the levels of and trends in maternal and child malnutrition in India. It will focus on disparities in these outcomes across geographical regions, socio-economic classes, and demographic groups. It will also review the existing literature on the determinants and consequences of maternal and child malnutrition in the country. The focus will be on understanding the puzzle of why malnutrition rates have remained stagnant despite agricultural productivity growth, economic prosperity, and rising levels of female schooling. We explore why programs like ICDS have not had better success in reducing child malnutrition and how the proposed Right to Food bill can achieve real improvements in child nutrition. We explore the Indian evidence on the productivity impacts of nutrition and more generally on the lifetime economic benefits from early childhood nutritional interventions. And we end by recommending the most costeffective interventions for reducing child malnutrition and hunger in India?

india is on the move. after many decades of stagnating economic growth, household incomes are increasingly rapidly. over the past two decades, india has also achieved improvements in agricultural productivity and reductions in under-five mortality.

Between 1990 and 2010, as the average income of Indians doubled, crop yields (kilograms/hectare) of all food grains rose by an average annual growth rate of about 2.4% and 2.9% fewer children died in the first five years of their life on an average annually. The improvements in health indicators have lagged those seen in India’s poorer neighbours including Bangladesh and Nepal. Even among these, child nutrition stands out as the one area of persistently poor performance. Child malnutrition rates in India are among the highest in the world – with nearly one-half of all children under 3 years of age being either underweight or stunted. Further, the incidence of child malnutrition has remained stubbornly high even after nearly two decades of post-reform growth and prosperity in the country. That child malnutrition is weakly correlated with income is additionally borne out by the findings that a quarter of the children of mother with 10 or more years of schooling and an equivalent proportion of children from the top income quintile are underweight. These children are very unlikely to face food insecurity. Even in a relatively prosperous and dynamic state like Gujarat, child malnutrition rates have been stagnant over the past decade.

Between 1992 and 2005, rates of stunting have declined only by 8.3%. Over the same period, stunting rates in Bangadesh declined from 65% to 42% (UNICEF, 2007) while those in Nepal reduced from 57% to 49% (NDHS, 2007). Further, the average per capita per day caloric intake may have actually declined in India. However, the performance of nutrition across states was not uniform.

Some states, including Tripura, Arunachal Pradesh and Assam had remarkable rates of reduction in stunting while the situation in states like Nagaland and Gujarat remained virtually unchanged.

Even more surprising is the stagnancy of child malnutrition rates in the face of declining infant and child mortality. This incongruence is difficult to understand as most factors that are associated with low rates of infant and child mortality (e.g., delivery and utilization of high-quality health services, high female literacy, and good environmental hygiene) typically also improve child nutrition.

This phenomenon is often referred to as the “Indian enigma” – viz., child malnutrition rates are much higher in India than even in Sub-Saharan Africa even though infant and child mortality in India is lower. The Asian enigma throws up many interesting questions – is it culture and dietary habits (e.g., extensive vegetarianism) that account for high child malnutrition in India? Is it the poor nutritional

08 INTRODUCTION

INDIA HEALTH REPORT

INTRODUCTION

NUTRITION

CHAPTER ZERO

india is on the move. after many decades of stagnating economic growth, household incomes are increasingly rapidly. over the past two decades, india has also achieved improvements in agricultural productivity and reductions in under-five mortality.

Between 1990 and 2010, as the average income of Indians doubled, crop yields (kilograms/ hectare) of all food grains rose by an average annual growth rate of about 2.4% and 2.9% fewer children died in the first five years of their life on an average annually. The improvements in health indicators have lagged those seen in India’s poorer neighbours including Bangladesh and Nepal. Even among these, child nutrition stands out as the one area of persistently poor performance. Child malnutrition rates in India are among the highest in the world – with nearly one-half of all children under 3 years of age being either underweight or stunted.

Further, the incidence of child malnutrition has remained stubbornly high even after nearly two decades of post-reform growth and prosperity in the country. That child malnutrition is weakly correlated with income is additionally borne out by the findings that a quarter of the children of mother with 10 or more years of schooling and an equivalent proportion of children from the top income quintile are underweight. These children are very unlikely to face food insecurity. Even

08 INTRODUCTION

this india health report aims to enhance the richness of policy dialogue in india by focusing on data, statistics and objective information, input from the best experts on specific topics from within and outside the country, and lead to more informed policy change in the health and allied sectors.

in a relatively prosperous and dynamic state like Gujarat, child malnutrition rates have been stagnant over the past decade.

Between 1992 and 2005, rates of stunting have declined only by 8.3%. Over the same period, stunting rates in Bangadesh declined from 65% to 42% (UNICEF, 2007) while those in Nepal reduced from 57% to 49% (NDHS, 2007).

Further, the average per capita per day caloric intake may have actually declined in India.

However, the performance of nutrition across states was not uniform. Some states, including Tripura, Arunachal Pradesh and Assam had remarkable rates of reduction in stunting while the situation in states like Nagaland and Gujarat remained virtually unchanged.

Even more surprising is the stagnancy of child malnutrition rates in the face of declining infant and child mortality. This incongruence is difficult to understand as most factors that are associated with low rates of infant and child mortality (e.g., delivery and utilization of high-quality health services, high female literacy, and good environmental hygiene) typically also improve child nutrition.

This phenomenon is often referred to as the “Indian enigma” – viz., child malnutrition rates are much higher in India than even in Sub-Saharan

Africa even though infant and child mortality in India is lower. The Asian enigma throws up many interesting questions – is it culture and dietary habits (e.g., extensive vegetarianism) that account for high child malnutrition in India?

Is it the poor nutritional status of mothers and their low weight gain during pregnancy that leads to low birth-weight babies who grow on to become malnourished children?

The problem of undernutrition in India now coexists with the problem of overnutrition and associated non-communicable diseases for a different segment of the population. Indeed, there is some speculation that the two might be related; children who are underweight and undernourished are more likely to develop chronic illnesses, such as diabetes, later in life. India has the largest number of adults with type 2 diabetes and their number is growing rapidly – having doubled over the past 10 years.

Indeed, India has a higher rate of diabetes than many Western countries with much higher levels of economic prosperity.

the existing literature on the determinants and consequences of maternal and child malnutrition in the country. The focus will be on understanding the puzzle of why malnutrition rates have remained stagnant despite agricultural productivity growth, economic prosperity, and rising levels of female schooling. We explore why programs like ICDS have not had better success in reducing child malnutrition and how the proposed Right to Food bill can achieve real improvements in child nutrition. We explore the Indian evidence on the productivity impacts of nutrition and more generally on the lifetime economic benefits from early childhood nutritional interventions.

And we end by recommending the most costeffective interventions for reducing child malnutrition and hunger in India?

In this first India Health Report: Nutrition we survey the levels of and trends in maternal and child malnutrition in India. It will focus on disparities in these outcomes across geographical regions, socio-economic classes, and demographic groups. It will also review

INTRODUCTION 09

45

VISUAL LANGUAGE

47

Recurring element on all pages to indicate IHR and chapter numbers

Plenty of white space around the chapter headings

Space for footnotes and references

VISUAL LANGUAGE

Identifier for the focus issue and chapter name

Pull out quotes to highlight main points

49

A one/two line summary of the chapter

VISUAL LANGUAGE

Space for photographs or supporting graphs

51

IMAGE CHOICES

The image banks from partner organizations provided a lot of choice in terms of the kind of images we wanted to use for the report. Most photographs though were portraits of mothers and children, in rural settings. We also received a few photographs from health programmes and most of the human interest stories were also accompanied by relevant photographs.

Apart from the standard resolution and format specifications of 300 dpi and CMYK image format, we decided to use photographs that were subtle and positive. Since the report needs to have a solution driven approach, we wanted to highlight key areas of improvement and programmes that have been working well and should be replicated. Cut out images were used in the narratives to support analytical infographics. Icons were overlaid on top of images to drive the message across in some places.

VISUAL LANGUAGE

53

COVER IMAGE

The cover of the India Health Report needed to be inviting enough to draw people to pick it up, as is the case with most publicationsâ&#x20AC;&#x201C;but more importantly, it had to communicate the multi-faceted view point that is discussed in the report, or it had to communicate the urgency of the issue at hand and draw people towards thinking about the problem and possible interventions that would improve the nutritional status of children in India.

It would also need to have a repeatable element, or a mast-head which would identify the report and bind all the different editions together. I tried two approaches for the coverâ&#x20AC;&#x201C;one was an analytical graphic showcasing the multitude of issues that comprise the core problem of nutrition as I felt that this would be visually striking, and a similar style could be repeated for other issues and it would set the report apart from other similar reports which mostly use a full page photograph. The second approach was to use a photograph overlaid with illustrations to communicate the need to discuss the problem. Explorations are shown on the following pages.

india health report

india health report

NUTRITION

URBAN HEALTH

ISSUE 01 / 2013

ISSUE 02 / 2015

VISUAL LANGUAGE

IND INDIA IND IN NDI NDIA DIAA DIA HEALTH HHE EAALLT LTH TH RREPORT RE EPOR ORT RT NUTRITION

55

INDIA HEALTH REPORT NUTRITION

INDIA HEALTH REPORT a two-yearly publication by the public health foundation of india

space for tag line

nutrition

ISSUE 01 / 2013

space for tag line

ISSUE 01 / 2013

a two-yearly publication by the public health foundation of india

Nutrition

INDIA HEALTH REPORT a two-yearly publication by the public health foundation of india

nutrition space for tag line

INDIA HEALTH REPORT

VISUAL LANGUAGE

ISSUE 01 / 2013

57

CHAPTER 7

PROTOTYPE

PROTOTYPE

59

PROTOTYPE

61

CONCLUSION CURRENT STATUS

The report has not been sent into production yet, but the templates for the chapters, infographics and information dashboards have been designed.

A colour coding scheme and information hierarchy has been devised. The content for the report is yet to be finalized, and the data from many states has not come in yet. The report will take its final form once these are received, but the structure and visual language are set, so it would only be a matter of replicating the page templates.

The infographics that are made for the report would also be used widely FURTHER DEVELOPMENT for advocacy purposes so they need to be translated to powerpoint

presentations and possibly motion graphics that could be shared over social media and used in research presentations as well as academic journals with relative ease.

Photograph selection also needs to be done in accordance with the content and the vision of the authors.

LAUNCH PLAN

CONCLUSION

The report is scheduled to launch in the end of November in four different states. There would be a consortium before the launch, to finalize the report and send the report into production.

LEARNING EXPERIENCE

Apart from having to design the report and learning information design principles as well as developing my own visualization methodology from experience, I had to play a major role in setting the vision for the report and collate content, and take part in discussions and workshops from the conceivement of the report.

It was also a challenge to do justice to the vast content of the report and figure out methods to automate repetitive work. This project required me to think about the system and the report 10 years down the line while setting the template for the layouts and visual language.

ACKNOWLEDGMENTS

This report has been a collaborative effort which would not have been possible without the support of my guide, Rupesh Vyas, the guidance and vision of Prof. Ramanan Laxminarayan (PHFI), the whole Transform Nutrition teamâ&#x20AC;&#x201C;especially Neha Raykar and Moutushi Majumdar, the folks at the CDDEP office, Julia Vivalo and Purnima Menon from IFPRI, the continuos encouragement from my parents and friends at NID.

63

REFERENCES BOOKS

_Alberto Cairo. The Functional Art. New Riders, 2012. _Nathan Yau. Visualize This. Wiley Publishing, Inc., 2011. _Edward Tufte. Visual Display of Quantitative Information. Graphics Press, 2001. _Stephen Few. Information Dashboard Design. O’Reilly Publishers,2006

REPORTS

_Save The Children. The Child Development Index 2012. _Save The Children. Food For Thought. 2013 _The Hunger and Nutrition Commitment Index. Measuring the Political Commitment to Reduce Hunger and Undernutrition in Developing Countries, 2013 _UNICEF. Improving Child Nutrition. 2013. _Save The Children. State of the World’s Mothers. 2013 _National Family Health Survey, 2005. _Sample Registration Survey, 2011.

WEBSITES

_Rhode Island School of Design. Making It Understandable. < http:// makingitunderstandable.tumblr.com/post/16533281030/understandinghealthcare-by-richard-saul-wurman> _CatalogTree. <http://catalogtree.net/projects/information%20design> _The Chronicle of Philanthrophy. Nonprofit data visualization: a Gallery. <http://philanthropy.com/blogs/innovation/nonprofit-data-visualization-agallery/667> _Adobe. InDesign Scripting. <http://help.adobe.com/en_US/indesign/cs/ using/WS0836C26E-79F9-4c8f-8150-C36260164A87a.html> _Scott Murray. D3 Tutorials. <http://alignedleft.com/tutorials/d3/ fundamentals/> _Thousand Days. Mapping nutrition in the 1000 day window. <http://www. thousanddays.org/resources/nutrition-map> _John Grimwade. < http://www.johngrimwade.com/>

REFERENCES

INDIA HEALTH REPORT PROJECT DOCUMENTATION AKSHAN ISH S1101106 PGDPD ‘11 GRAPHIC DESIGN E akshan.i@nid.edu T +91 846 901 7051