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Original Articles

Indian Pediatrics 1998; 35:959-966 

Nutritional Status, Psychosocial Development and the Home Environment of Indian Rural Children


Shahnaz Vazir, A. Nadamuni Naidu and P. Vidyasagar

From the National Institute of Nutrition, Indian Council of Medical Research, Hyderabad 500 007, India.

Reprint requests: Dr. Shahnaz Vazir, National Institute of Nutrition (ICMR), Jamai-Osmania, P.O.,
Hyderabad-500 007, A.P., India.

Manuscript received: December 12, 1997; Initial review completed: March 4, 1998;
Revision accepted: April
23, 1998



Objective: To assess the psychosocial development of well nourished and malnourished children aged 0-6 years and to identify the microenvironmental factors influencing their growth and development. Design: Multicentric cross-sectional, Setting: Rural Communities. Subjects: Total of 3668 children of whom 2212 were well nourshied and 1456 were malnourished. Methods: Weight for age index to assess nutritional status. Cut-off <75% NCHS standards used based on Gomez grades II and III 'being malnourished and Normal and grade I being well nourished. ICMR Developmental Screening Test to assess psychosocial development and modified WHO parental interview schedule to assess family and micro-environmental factors. Results: Malnourished children attained developmental milestones at a later age. Developmental delay among the malnourished was especially observed in areas like vision and fine motor, language and comprehension and personal social. The delay was to the extent of 7-11 months in these areas in different age groups. Paternal involvement with child care especially, father spending time, telling stories and taking child for outings was found to be important for positive psychosocial development. Other significant factors included parents teaching child, small family size and paternal occupation. Child's appetite, absence of health problems, parental age and family having own house and electricity were the factors significantly related to better nutritional status of children. Conclusion: Factors identified in the study are important for the development of relevant intervention at the home level. Appropriate multifaceted community based programmes such as the [CDS are also required for stimulating growth and development of backward rural children.

Key words: Developmental delay, Home environment, Nutritional status, development, Synergistic influence.

A cause and effect relationship has not been established between malnutrition and psychosocial development, even after more than two decades of research efforts. This is due to the fact that malnutrition and other deprivations always coexist in an environment of poverty(1). It is extremely difficult to disentangle individual environmental effects as measurable impact variables causing delay in mental development. Also combining with environmental factors, are intra-uterine growth retardation and other genetic attributes. These can synergistically influence and limit the attainment of cognitive skills(2).

Despite the complicated nature of the problem, much can still be done if develop- mental delay is detected early and the required stimulation and training are pro- vided for children living in deprived environments. For this, it is important to use culture-appropriate screening tests for early identification of developmental de- lay. It is also crucial to find out the nature of the factors within such environments and to focus appropriate intervention.

In order to understand and assess the relationship between developmental out- comes, nutritional status and home environmental factors, a WHO-ICMR multicentric cross-sectional study was conducted in rural areas of Hyderabad, Chandigarh and tribal areas of Jabalpur in India(3). The objectives of the study were to assess the psychosocial development of children aged 0-6 years using a culture-appropriate screening test and to identify relevant nutritional and micro-environmental factors influencing psychosocial development of children. The results pertaining to the influence of nutritional status and home environmental factors on psychosocial development of children in the Hyderabad center are being presented.

Subjects and Methods

The study was cross-sectional and conducted in the rural areas of Hyderabad. Two blocks, Narsapur and Medchal in the Ranga Reddy district, were selected randomly and all the thirty eight villages under these blocks were covered. The study design, instruments and tests used and the approximate number of children covered in Chandigarh and Jabalpur were same as in Hyderabad(3). The study at the three centers was coordinated by the research team of the National Institute of Nutrition (NIN), Indian Council of Medical Research (ICMR), Hyderabad. Also, the center wise data analysis as well as the pooled data ,analysis of the three centers was carried out at the NIN with technical guidance from the WHO consultants(3).


Data on psychosocial development was collected by 7-10 trained field level workers recruited from each of the study villages(4). Since the study was also looking at operational feasibility of incorporating the process of growth and developmental screening as part of the primary health care activities, the workers resembled the community health workers (CHWs) in their educational qualifications. Reliability coefficients were calculated based on each worker's performance while administering the test over the training period of 3 weeks. Anthropometric measurement and parental interviews were carried out by the research team from the NIN who also supervised the field workers. Details of training, reliability measures and quality control have already been published( 4).

(i) Psychosoical Development

Using the culture appropriate ICMR Psychosocial Developmental Screening Test developed and standardized on more than 13,000 children aged 0-6 years(4,5), the age of attainment of developmental skills by well-nourished and undernourished children was compared(6). The screening test comprised of five major developmental areas, namely (i) gross motor, (ii) vision and fine motor, (iii) hearing, language and concept development, (iv) personal skills and (v) social skills. A lag in the attainment of skills in any of these develop- mental areas was estimated.

(ii) Nutritional Status

Children were weighed using the Salter weighing scales with an accuracy of
100 grams. These scales were periodically checked for zero error, using known weights during data collection. Nutritional status was assessed by comparing the individual weights of children against the NCHS reference standards(7) and percent- age of standard weight for age of NCHS standards was calculated for each child.

(iii) Home Environment

Details on the home environmental factors were collected from parents using a family interview schedule. This schedule was developed by the WHO and was modified and standardized for the purpose of this study. It consisted initially of an item pool of 200 questions. The final schedule after pretesting and item analysis(3) constituted 120 culture-appropriate questions which addressed seven major home-environmental factors influencing quality of child care. These included: (i) location and shelter, (ii) caste and type of the family, (iii) parental education and socio-economic status (iv) detailed health and behavioral profile of the child from birth, (v) behavioral and health information of key family members, (vi) parental! caretaker involvement with child, and (vii) maternal aspiration for child and self.


Data on psychosocial development were analyzed to assess the age of attainment (months) for each milestone in the screening test using the Grostat software developed by WHO(6). This analysis pro- vided age of attainment of the sample children from the 3rd to the 97th centile. The age of attainment at the 50th centile was used as the average age of attainment. Details of this analysis have already been pub- lished(4). The weights of children were also analyzed using the above software for constructing centiles. Since these centiles are based on a large sample of children, they are useful as local reference values.

The Gomez distribution was used to classify children into two groups, i.e., normals + Grade I and Grade II + Grade III. Hence, children having body weights more than or equal to 75% of the NCHS standards were classified as better or well-nourished and those with weights less than 75% of the standard were grouped as malnourished.

The 50th centile age of attainment of each of the psychosocial developmental milestones was utilized for analyzing the relationship between the nutritional status and development. This was done to find out if nutritional status influenced the age of attainment of different milestones in the various areas of development.

The data on the family interviews were analyzed in relation to psychosocial development and nutritional status. For this, children were divided into two groups ac- cording to their mean Z score on psychosocial development falling either above or below the mean Z score of the sample. Similarly, well nourished malnourished children were separated into two groups. The family factors associated with better nutritional status and higher psychosocial Z scores of the children using Chi square and Kendall's Tau test is depicted as probability levels from p <0.001 to P <0.05 with a plus-minus (:1:) direction indicating positive or negative association. The direction of significance for each factor was interpreted according to the direction of each question posed in the interview schedule, i.e., positive or negatively framed questions. This preliminary univariate analysis was done as a prelude to the more comprehensive multivariate techniques to assess factors directly related to growth and development. Multivariate analysis is being carried out for the pooled data of all the centers to derive interrelationship and synergistic influences.


The total population of the selected villages was approximately 40,000 which pro- vided 3,668 children (9.2%) below six years of age, all of whom were included for the study.

The mean body weights of children were compared with ICMR(8) and NCHS(7) values. While the mean weights of the study children were comparable with the ICMR values, they were much lower than the NCHS weight for age standards.
Table I gives the distribution of the children into two 'groups, namely, well nourished ( 75% weight of standard) and undernourished <75% weight of standard). An increasing trend in the percent- age of malnourished children was observed with increasing age.

The results of age of attainment of mile- stones according to nutritional status are given in Table II. The well nourished children were able to attain the milestones at a younger age in the five areas of development compared to undernourished children, The difference in the age of attainment of skills ranged from as less as 0 to 3 days to as much as 14.3 months (Table II). Compared to the 50th centile, i.e., the mean average of the sample, the well nourished children consistently attained milestones at an earlier age across the five area of development. Results also indicate that malnourished children attained milestones at a later age compared to the average age of attainment of the sample children
(Table II).

The family / microenvironmental factors significant for better psychosocial development, i.e., more than mean Z score and, for better nutritional, status of children are given in Table III. The factors positively associated with the nutritional status were mainly those related to socio-economic status, while for psychosocial development, the factors identified related to parent-child interaction.

The factors significant for better psychosocial development were: (i) mother/father teaching the child, (ii) father spending time with the family, (iii) father telling stories, (iv) father taking the child for outings, (v). nursery and secondary school within easy reach, (vi) fewer children and small family size, (vii) indepen
dent behavior in children above one year of age, (viii) mother alive, (ix) child without fears/phobias, and (x) paternal occupation. The statistical significance attained ranged between p<0.001 for these factors (Table III).


 Percentage Distribution of Children According to Gomez Classification
(Pooled as
<75 and 75 Weight for Age % Standard*)

  (n) Normal + Mild grade
Moderate + Severe grade
0-12 (1220) 76.1 (928)

23.9 (292)

13-24 (652) 56.1 (366) 43.9 (286)
25-36 (632) 54.1 (342) 45.9 (290)
37-48 (593) 55.1 (327) 44.9 (266)
49-60 (368) 44.0 (162) 56.0 (206)
61-72 (203) 42.9 (87)

57.1 (116)

Total (3668)   (2212)


* NCHS reference standards



Average Age of Attainment of Milestones (months) According to Nutritional Status



Age of attainment (mo)  

age of
(50th centile)
= 3668)
75% of
= 2212)
< 75% of
= 1456)

Gross Motor
Lifts head on stomach 3.7 3.3 3.5 0.2
No head lag in sitting position 3.8 3.7 4.3 0.6
Sits alone 6.6 6.7 8.4 1.7
Crawls 6.4 6.3 7.6 1.3
Stands alone 11.8 11.5 12.8 1.3
Walks backwards 24.1 22.2 26.3 4.1
Gets up from squatting 
position without help 25.3 23.0 28.8 5.8
Vision and Fine Motor  
Regards object momentarily 0.7 0.7 0.8 0.1
Sustained attention of object 1.8 1.8 2.0 0.2
Reaches for object 4.4 4.3 4.2 -0.1
Grasps object 4.2 4.0 4.5 0.5
Picks up pebble 6.3 5.8 7.7 1.9
Attempts imitation of scribble 13.1 12.6 14.2 1.6
Draws circle in imitation 39.3 36.6 42.2 5.6
Threads bead with nylon wire 20.8 19.5 22.9 3,4
Hearing, Language and Concept Development
Manipulates bell 7.8 7.5 9.2 1.7
Rings bell 9.9 10.4 10.7 0.3
Says one word 17.3 17.0 18.5 1.5
Identifies an object 18.6 17.8 19.4 1.6
Points to 2 body parts 22.4 20.8 24.6 3.8
Says 2 words together 30.4 28.1 33.7 5.6
Names 3 objects 27.5 25.0 30,8 5.8
Relates 2 objects 25.4 22.7 28.7 6.0
Concept of big and little 33.3 32.3 '35.5 3.2
Repeats 2 numbers 35.4 32.4 39.4 7.0
Understands prepositions 29.4 27.1 32.6 5.5
Completes sentence 50.4 46.4 53.5 7.1
Understands money 23.3


25.4 3.9
Sings 2 lines of song/folklore       60.7 51.7 66.0 14.3
Self-Help Skills
Feed self in any way 7.6 7.2 8.2 1.0
Bladder control - day 23.0 21.8 24.2 2.4
Bowel control - day 20.5 18.9 21.4 2.5
Cleans teeth 33.0 30.7 36.3 5.6
Washes hands 24.4 23.6 26.7 3.1
Washes face 26.7 25.7 28.6 2.9
Dresses self without help 55.9 50.6 60.3 9.7
Social Skills
Smiles in response 1.7 1.7 2.3 0.6
Vocalizes in response 2.9 2.8 2.9 0.1
Awareness of strangers 9.4 9.4 9.4  0.0

Factors significant for better nutritional status were: (i) appetite of the child, (ii) no health problems in the preceding year, (iii) presence of electricity in the home, (iv) father's age, (v) family possessing own house, (vi) younger parents, (vii) father alive, (viii) managing child perceived as easy by parents, (ix) upper caste, higher family income and better type of dwelling, (x) punishment if used is mild, and (xi) mother is the primary caretaker for child from birth.


Results of the study indicate that children who were better nourished attained milestones at an earlier age as compared to the poorly nourished children. Similar results were also obtained in the other two centers at Jabalpur and Chandigarh(3). It is important to note that the children's chronological age ranged from less than one month to seventy two months. The difference between the better nourished and undernourished children was especially noticed in the "vision and fine motor", "hearing, language and concept development" and "personal-social" areas. These results are supported by earlier studies(9,10) on severely undernourished children.

The difference in the age of attainment of psychosocial skills between undernourished and better nourished children was seen to increase with age. This finding is in line with results reported in earlier studies(11,12). However, the findings of the present study indicate that as the child grows older and enters the weaning stage,
he is more susceptible to malnutrition and infection due to poverty, poor availability of weaning foods and unhygienic conditions which are all components of a deprived environment. Combined with a non-stimulating micro-environment, these factors can. synergistically limit learning and delay the attainment of skills even at older ages.



Family and Environmental
Factors Significant for Better Nutritional Status and Positive Psychosocial Development

Level of significance
(p value)

Factors significant for better nutritional status (Wt/age >75% std.)
Factors significant for positive psychosocial development (2 scores)
- Child has good appetite
- Nursery and Secondary school within easy reach
  - Child from upper / forward  caste - Mother /Father teaching child during leisure time
  - Mother as primary care taker since birth  
  - No/Mild punishment only  
  - Presence of electricity  
0.01 - Better dwelling - Smaller family size
  - Higher family income - Fewer children in the family
  - Managing child perceived as easy by parents  
  - Younger paternal age  
- Own house
-Independent behavior in children above one year of age
  -No health problems during last year - Child without fears/phobias
  - Father alive - Mother alive
   - Younger caretaker - Better paternal occupation
    - Father spends time with family
     - Father tells stories to child
    - Father takes child for outings

The micro-environmental factors critical for growth and development which were identified in this study are logical and are supported by research work in other parts of the developing world(13,14). These findings also highlight the fact that growth and psychosocial development are influenced by different sets of factors although they are components of the same micro environment. The specific factors identified are hence more useful for directing appropriate intervention programmes at the parental and family levels to improve the situation of children growing up in deprived environments. Several other studies(15,16) have also highlighted the importance of identifying the culturally relevant micro- environmental factors, which influence growth and development of children. Some of the factors identified in the present study can be addressed effectively in the existing intervention programmes such as the Integrated Child Development Services for better impact.


The Indian Council of Medical Research and the World Health Organization are gratefully acknowledged for their support and technical training in the software.



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