A Rank Aggregation Approach to Identify High-Priority Districts for Malnutrition Intervention in India: A Cross-Sectional Analysis of NFHS-5 Data Using the Spearman Footrule Method

Background Child malnutrition remains a major public health challenge in India and continues to hinder progress toward national development priorities and the Sustainable Development Goals. Despite large-scale initiatives such as the Integrated Child Development Services and POSHAN Abhiyaan, substantial disparities in stunting, wasting, and underweight persist across states and districts. These indicators are linked to increased morbidity, mortality, impaired cognitive development, and long-term economic consequences. National averages often obscure significant subnational variation, limiting effective targeting of interventions. Furthermore, most assessments evaluate indicators separately, making it difficult to identify districts with compounded nutritional burdens. This study examined the prevalence and regional disparities of child malnutrition in India using NFHS-5 data and identified high-priority districts through a composite rank aggregation approach. Methods NFHS-5 data were analyzed to determine the prevalence of stunting, wasting, and underweight among children under five years of age, categorized by background characteristics such as age, sex, residence, maternal education, and socioeconomic status. State- and district-level variations were assessed, and a composite malnutrition rank was developed using the Spearman Footrule distance method, which effectively integrates multiple indicators into a single aggregated rank. This method was selected because it provides a statistically robust and transparent approach that minimizes the influence of any single indicator, ensuring that the final rankings accurately reflect the overall burden of malnutrition across districts. Results The findings revealed that malnutrition remains widespread, with higher prevalence observed among children from rural areas, lower wealth quintiles, and mothers with no formal education or low BMI. States such as Bihar, Jharkhand, and Gujarat and districts including Pashchimi Singhbhum (Jharkhand) and Arwal (Bihar) emerged as high-priority regions. The rank aggregation method effectively identified areas requiring urgent policy attention. Conclusion The study underscores persistent inequalities in child nutrition across India and highlights the need for region-specific, multi-sectoral interventions focusing on maternal health, education, and poverty reduction. The use of a composite ranking approach provides a transparent and evidence-based framework for policymakers to prioritize interventions and track progress toward national nutrition goals.