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Indian Pediatr 2011;48: 315-318 |
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Persisting Malnutrition in
Chandigarh: Decadal Underweight Trends and Impact of ICDS
Program |
Jarnail Singh Thakur, Shankar Prinja and Satpal Singh Bhatia
From the School of Public Health and Department of
Biostatistics, Post Graduate Institute of Medical Education and Research,
Chandigarh 162 001, India.
Correspondence to: Dr JS Thakur, Associate Professor,
School of Public Health, PGIMER, Chandigarh, India.
Email: [email protected]
Received: February 22, 2010;
Initial review: March 29, 2010;
Accepted: July 23, 2010.
Published online. 2010 October 30.
PII:
097475591000157-2 |
Abstract
Decline in malnutrition levels has been dismal since
the 1990s. We ascertained decadal trend in childhood nutritional status
between 1997 and 2007 in Chandigarh, India and assessed impact of
Integrated Child Development Services (ICDS) on childhood undernutrition.
A total of 803 under-five children, 547 children between 12-23 months
age, and 218 women with an infant child were recruited for the study.
Findings of present study were compared with another methodologically
similar study (1997) from Chandigarh and Reproductive and Child Health
Rapid Household Survey (1998) to draw decadal trends. Prevalence of
underweight among under-five children remained almost stagnant in the
last one decade from 51.6% (1997) to 50.4% (2007). There was
insignificant difference (P=0.3) in prevalence of underweight
among children registered under ICDS program (52.1%) and those not
registered (48.4%) in 2007. Other health and service provision
indicators had mixed results in the past decade. Health services
utilization was poorest in urban slums.
Key words: Child health, Growth monitoring, ICDS, India,
Malnutrition.
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I ndia is currently home to more than half of world’s underweight
children [1,2]. According to the WHO Global Database on Child Growth and
Nutrition, the prevalence of malnutrition among under-five children
in rural India fell from over 70% in the late 1970s to below 50% at the
end of the 1990s, for both underweight and stunting measures [3].
However, the trend of decline in malnutrition levels
has not been very encouraging since the 1990s. Recently, a strong
Government commitment is voiced in its various policy documents and
programs for child health and reducing under-nutrition, in particular
[4,5]. There is also a renewed impetus on universalizing the Integrated
Child Development Services program (ICDS) in India. The present study was
thus conducted to ascertain decadal trend in childhood nutritional status
between 1997 and 2007 in Chandigarh, India and to assess impact of ICDS
program on childhood undernutrition.
Methods
Data for the present study were collected from April to
August 2007 using a multistage stratified random sampling. A total of 45
Anganwadi centres (AWCs) in Chandigarh were selected, 15% each from
urban (8), rural (16) and urban slum (21) centers. A sample size of 769
children under five years was estimated to ascertain underweight, assuming
a prevalence of 5% severe under-weight (with worst acceptable result of
3.5%) at 5% significance level. Using systematic random sampling, 10%
children registered (n=441) and unregistered (n=365) under
ICDS program, respectively were selected.
All the selected children were weighed with the help of
Salter weighing machine (Salter England Model No 235 6S), which had a
range of 25 kg with an accuracy of 100 grams. Standard precautions were
taken while weighing children [6]. Children were graded into different
grades of malnutrition using the Indian Academy of Pediatrics (IAP)
standards and the new WHO child growth standards of weight for age.
Coverage of routine immunization was evaluated by
interviewing 547 mothers having children between the age group of 12 to 23
months. Data on reproductive and child health service delivery was
obtained from 218 mothers of infant. All women with first order child
delivered in a duration of <1year from the date of survey were interviewed
using a semi structured questionnaire to evaluate the coverage of
provision of maternal and child health service, nutritional counseling and
health education.
We adopted an ecological study design to determine
trends. Findings on underweight among under-five year old children from
present study was compared with results of a previous research with
similar methodology conducted in Chandigarh in 1997, Base line study [7].
Determinants of childhood malnutrition were compared with those from
Reproductive and Child Health- Rapid Household Survey (RCH-RHS) [8], and
decennial Census surveys [9]. Underweight prevalence rates were compared
between children by registration status under ICDS program, to elicit
impact of ICDS program on nutritional status of children.
Data were analyzed using Epi Info statistical software
version 3.2. Since the 1997 study used IAP classification to grade
malnutrition, severity of underweight in the present study was graded
according to IAP classification using the growth charts being used under
ICDS program. Prevalence of malnutrition by WHO child growth standards has
been published elsewhere [10]. Trend analysis using 1997 data on
underweight and present study results was performed and statistical
significance computed using chi-square test for trend at 5% significance
level.
Results
Majority of children recruited in both the studies
(present study, 43.5%; baseline study, 40.7%) were in 3-6 years age group.
(55.2% and 55.9% males, respectively). A significantly higher proportion
of children in the baseline study (68.9%) were registered under ICDS
program compared to 54.7% children in present study (P<0.001). The
findings of present study for maternal health service provision were
compared with RCH- Rapid Household Survey (RCH-RHS), conducted in 1998. No
significant difference was found among maternal characteristics according
to sex of the child and maternal education.
Prevalence of underweight among under-five year old
children remained almost stagnant in the last one decade from 51.6% (1997)
to 50.4% (2007) (Table I). In the present study, prevalence
of underweight among children registered under ICDS program (52.1%) and
those not registered (48.4%) was not significant. However, proportion of
fully immunized children was significantly higher (P<0.001) among
children enrolled under ICDS program (90.2%) as compared to non-enrolled
(79.1%).
Table I
Decadal Trend of Nutritional Status Among 0-6 Year Children, Chandigarh, 1997-2007
Weight for
age |
Number of
children (%) |
|
0-1 year |
1-3 year |
3-6 year |
Overall |
|
1997 |
2007 |
1997 |
2007 |
1997 |
2007 |
1997 |
2007 |
Normal |
140 (58.8) |
122 (72.2) |
248 47.3) |
118 (41.4) |
234 (44.6) |
158 (45.3) |
622 (48.4) |
398 (49.6) |
Grade 1 |
67 (28.1) |
26 (15.4) |
196(37.4) |
106 (37.2) |
171 (32.6) |
117 (33.5) |
434 (33.7) |
249 (31.0) |
Grade 2 |
19 (7.9) |
16 (9.5) |
68 (12.9) |
48 (16.8) |
88 (16.8) |
66 (18.9) |
175 (13.6) |
130 (16.2) |
Grade 3 |
9 (3.8) |
5 (3.0) |
8 (1.5) |
13 (4.6) |
18 (3.4) |
7 (2.0) |
35 (2.7) |
25 (3.1) |
Grade 4 |
3 (1.3) |
0 |
4 (0.8) |
0 |
13 (2.5) |
0 |
20 (1.6) |
0 |
Total children |
238 |
169 |
524 |
285 |
524 |
349 |
1286 |
803 |
Stratified results for coverage of health care services
according to geographic area (urban, rural and slum) revealed that
coverage of all reproductive and child health services were significantly
lower in urban slums (P<0.05), except TT-2 coverage, fully
immunized children and enrolment under ICDS program (Table II).
Table II
Trends in Determinants of Childhood Nutritional Status 1998-2007
Determinants |
1998# |
2007* |
|
|
Urban |
Rural |
Total |
Urban |
Rural |
Urban |
Total |
|
|
|
|
|
|
Slum |
|
Low birth weight |
12.8 |
0 |
12.6 |
17.6 |
15.2 |
41 |
26.3 |
Exclusive breast feeding (4mo) |
81.9 |
100 |
83.6 |
73 |
46.8 |
46.1 |
50.9 |
Exclusive breast feeding (6mo) |
NE |
NE |
18.9 |
38 |
43.1 |
37.2 |
|
Maternal health services |
|
ANC checkup (³3) |
79.3 |
7.1 |
73.3 |
96.4 |
91.2 |
53.8† |
74.7 |
TT injections (2) |
72.9 |
42.8 |
70.4 |
97.3 |
100 |
97.0 |
98.2 |
IFA tablet consumption (³100) |
66.4 |
7.1 |
61.5 |
47.3 |
42.7 |
26.0† |
35.7 |
ANM visit |
10.9 |
7.1 |
10.6 |
18.9 |
26.2 |
04.3† |
32.9 |
Breastfeeding counseling |
68.5 |
57.1 |
67.6 |
83.8 |
65.8 |
55.9† |
63.8 |
Child health services |
Fully immunized |
67 |
16.6 |
67 |
89 |
88.6 |
81.7 |
85.4 |
Birth weight recorded |
70.3 |
14.3 |
65.7 |
94.6 |
83.5 |
60.8† |
74.8 |
Coverage under ICDS |
NE |
NE |
NE |
61.3 |
50.6 |
43.6 |
49.7 |
Diarrhoea cases treated with ORS |
55.5 |
0 |
35.7 |
48.7 |
44.2 |
19.3† |
33.3 |
# Reproductive and Child Health Rapid household survey report findings (except literacy and income);
* Present study findings (except literacy and income): †P-value <0.05 (urban, rural and slum difference; 2007);
NE: not evaluated.
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Discussion
We found that despite major strides made in economic
progress reflected in per-capita income of Chandigarh (increased from Rs.
19,761 in 1994 to Rs. 60,105 in 2004), malnutrition continues to remain a
public health problem, with half the children being underweight. This
finding assumes significance when viewed in light of increasing unplanned
urbanization, proliferation of urban slum population, and mixed progress
in health services provision. Moreover, ICDS program is not associated
with better nutritional outcomes.
NFHS surveys also report similar findings for
malnutrition [2,11-12]. Malnutrition levels have increased in neighboring
state of Haryana from 35% to 42% between NFHS 1(1992-93) and NFHS 3
(2005-06), respectively. Punjab recorded a decline in underweight
prevalence from 46% to 27% in the corresponding period. However, much of
this progress was reported between 1992-93 to 1998-99, with underweight
prevalence stagnating from 29% to 27% in 1998 and 2006, respectively.
Given the stagnating underweight prevalence in
Chandigarh and at the National level, it becomes imperative to understand
the context of the situation. An economic boom alone is not likely to
yield the dividends. Moreover, the present study shows geographic
inequities in service utilization for reproductive and child health. Urban
slums have poorest process and impact indicators. Another study from
Chandigarh also demonstrated an inequitable service provision in urban
slums [13]. This is especially pertinent in view of rising growth of urban
slums [14]. Together, these findings suggest that there is a need to
re-orient the focus of ICDS program towards a meaningful process of growth
monitoring that involves mothers and builds their capacity for child
feeding. Secondly, services need to be strengthened in the urban slums for
better outreach and effectiveness.
Contributors: All authors contributed to study
design and data collection, and approved the final draft.
Funding: Department of Women and Child, Ministry of
Social Welfare, Chandigarh (UT) Administration.
Competing interests: None stated.
What This Study Adds?
• No significant change was found in the
prevalence of malnutrition in children in Chandigarh compared to a
similar study done in 1997.
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