|Year : 2020 | Volume
| Issue : 1 | Page : 34-40
A study on epidemiological determinants of malnutrition and health status of under-5 children in the field practice area of rural health training center
Kailas S Ninama, Parul Manish Hathila, DV Bala
Department of Community Medicine, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
|Date of Submission||25-Feb-2019|
|Date of Acceptance||02-May-2019|
|Date of Web Publication||5-Jun-2020|
Parul Manish Hathila
Assistant Professor, Department of Community Medicine, Smt. NHL Municipal Medical College, Ellisbridge, Ahmedabad - 380 006, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Malnutrition is the condition that results from eating a diet in which certain nutrients are lacking, in excess, or in the wrong proportions. Child is the victim of interplay of nutrition, socioeconomic (SE), and health factors that cause malnutrition.
Aim: The aim is to study the epidemiological determinants of malnutrition and health status of under-5 children.
Material and Methods: The present cross-sectional study was carried out in 600 under-5 (0–59 months) children from March 1, 2012 to July 31, 2013, in Rural Health Training Center field practice area by house-to-house survey till the desired sample was achieved. Sociodemographic information, mother's obstetric history, clinical examination, and anthropometry measurement of under-5 children and immunization status (either by history or by available medical records) was obtained.
Results: Majority (534 [89%]) of children were Hindus, from lower SE Class III and IV, 337 (56.2%) and 193 (32.2%), respectively. Sex ratio was 980 females/1000 males. Quarter (122) of the children belonged to age group 0–11 months followed by 138 (23%) and 123 (20.5%) from 12 to 23 months and 48–59 months, respectively. The prevalence of wasting, stunting, and underweight was 151 (25.2%), 237 (39.5%), and 223 (37.2%), respectively. Acute morbidity rate was observed to be 47 (7.8%). Full immunization appropriate for age was 537 (89.5%). Under-5 mortality rate was 30/1000 under-5 years children per year (n = 18).
Conclusion: Prevalence of malnutrition was high in males and lower SE Class (III and IV). Acute morbidity was higher in males than females.
Keywords: Acute morbidity, health status, immunization, malnutrition, under-5 children
|How to cite this article:|
Ninama KS, Hathila PM, Bala D V. A study on epidemiological determinants of malnutrition and health status of under-5 children in the field practice area of rural health training center. Indian J Community Fam Med 2020;6:34-40
|How to cite this URL:|
Ninama KS, Hathila PM, Bala D V. A study on epidemiological determinants of malnutrition and health status of under-5 children in the field practice area of rural health training center. Indian J Community Fam Med [serial online] 2020 [cited 2020 Jul 11];6:34-40. Available from: http://www.ijcfm.org/text.asp?2020/6/1/34/286018
| Introduction|| |
Malnutrition among under-5 children is a major health problem in India. It is observed that the malnutrition in India is a concentrated phenomenal that is a relatively small number of states, districts, and villages account for a large share of the malnutrition burden. One in every three malnourished children in the world lives in India. Proportion of under-5 children is 12.5% in India. Malnutrition is the most widespread condition affecting the health of children. The prevalence of malnutrition in India is 30% and 43.7% in urban and rural area, respectively. The prevalence of malnutrition in Gujarat is 47%. Globally, more than one-third of the child deaths are attributable to undernutrition. Nutrition plays a key role in physical, mental, and emotional development of children, and much emphasis has been given to provide good nutrition to growing populations, especially in the formative years of life.
| Material and Methods|| |
This was a community-based cross-sectional study.
The study was conducted in the field practice area of Rural Health Training Center (RHTC) of the department.
Children between 0 to upto 5 years of age.
Children in the age group 0–5 years (0–59 months) whose parent/guardian gave informed verbal consent were included in the study.
If more than one eligible child available in one family, only elder child was taken and younger child (ren) were excluded from the study.
The study period was 17 months (March 1, 2012–July 31, 2013).
Purposive till the desired sample was achieved.
Proportion of malnutrition was (40%) chosen as the variable for calculating the sample size according to the National Family Health Survey (NFHS)-III. An allowable error of 10% at 5% level of significance was kept. The sample size of 600 was arrived.
A predesigned, pretested pro forma was used to collect information. Pro forma was finalized after a pilot study. Tailor's measure tape (nonstretchable) for height/length and UNICEF digital weighing scale for weight were used.
Method of study
In this study, 600 under-5 children were taken from the RHTC field practice area by house-to-house survey. Sociodemographic information, mother's obstetric history, clinical examination, and anthropometry measurement of under-5 children and immunization status (either by history or by available medical records) was obtained. The height/length and weight were measured.
Weight for age (W/A), height for age (H/A), and weight for height (W/H) of the World Health Organization (WHO) growth standard (2006, Z score) was used as the reference indices for this study. Underweight is used here to indicate children whose weight for age was <−2 standard deviation (SD) and stunted referred to children whose height for age was <−2 SD. This is an index of shortness and has been proposed as an indicator of chronic malnutrition. Wasted referred to children whose weight for height was <−2 SD. This is an index of thinness and is claimed to be an indicator of acute malnutrition.
The study was started after seeking permission from the Institutional Review Board Committee. Verbal informed consent of mothers/guardian of under-5 children was obtained and confidentiality of all the data was maintained.
The data were analyzed using appropriate statistical software and appropriate statistical tests were applied.
| Results|| |
In our study, children of age group 0–11 months were 79 (54.8%) and 65 (45.2%) males and females, respectively, but in 48–59 months age group, females were higher, 66 (53.7%) as compared to males 57 (46.3%).
On comparing the gender and nutritional status, H/A (stunting), W/A (underweight), and W/H (wasting) were more in males than females [Table 1]. More percentage of females falls in normal ranges of nutritional status as compared to males. In overweight range, males were affected more as compared to females [Table 1].
|Table 1: Distribution of children with respect to nutritional status and gender (n = 600)|
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According to the WHO growth standard (Z score), overall wasting (W/H) was seen in 151 (25.2%) children (P = 0.0003) and among those 34 (33.7%) were in age group 24–35 months. The prevalence of underweight (W/A) was 37.2% (223) (P = 0.0032), among them 47.2% (58) belonged to age group 48–59 months. While stunting (H/A) was 237 (39.5%) (P ≤ 0.0001) and out of them 59 (58.4%) were from age group 24 to 35 months. There was significant association between age group and undernutrition [Table 2].
|Table 2: Distribution of children with respect to age group and malnutrition (n =600)|
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Stunting (214 [40.5%]) and underweight (192 [36.3%]) was more as compared to wasting 122 (23.1%) in children belonged to nuclear family. While in joint family, underweight was 43.7% (31) higher as compared to other parameter. Among socioeconomic (SE) Class III, 136 (40.4%) were stunted, while 73 (21.7%) were wasted. As per family members, stunting was 60.6% (128), while wasting was 29.4% (62) in family with 4–7 members. In illiterate mothers, underweight was 43.4% (95). There was significant association between education and stunting (P = 0.00). Stunting was more in children with siblings (n = 370) [Table 3].
|Table 3: Distribution of children with respect to socio-demographic profile and nutritional status (n = 600)|
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Wasting (26.5%), underweight (43.9%), and stunting (41.8%) were higher in children with low birth weight (LBW) as compared to children with normal and over birth weight. Stunting was more in normal (39.1%) birth weight children [Table 4].
|Table 4: Horizontal and vertical percentages are written as 1st and 2nd %age|
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There were no significant differences observed in the occurrence of acute morbidity and its distribution in different age groups and gender, but in age group 12–23 months, it was slightly higher 17 (12.3%) as compared to other age groups. Males 25 (8.3%) were affected more with acute morbidity than females 22 (7.4%). In children of illiterate mothers, acute morbidity was 8.3% (19). In SE Class IV, 8.8% (17) of children were more suffered with acute morbidity [Table 5].
|Table 5: Distribution of under-5 children with respect to acute morbidity and family variables (n = 600)|
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With regard to immunization, there was no gender difference observed. The status of fully immunized for age was more in infants 138 (95.8%). Immunization coverage was 89.1% (123). Among children of illiterate mothers, 193 (88.1%) and 6 (2.7%) were fully immunized and unimmunized for age, respectively. In nuclear family, 475 (89.8%) children were fully immunized. In Class III, 302 (89.6%) children were fully immunized for age and 8 (4.1%) were unimmunized in SE Class IV [Table 6].
|Table 6: Distribution of immunization status of under-5 children with respect to other family variables (n =600)|
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| Discussion|| |
In this study, all the mothers (n = 600) were homemakers. The study population comprised 297 (49.5%) females and 303 (50.5%) males. Similar study in Nigeria was observed 48% females and 52% males. The sex ratio was 980 females/1000 males which was better as compared to census 2011 where it was 914 in Gujarat state and 940 in India. According to age group, 144 (24%) belonged to 0–11 months and 138 (23%) from 12 to 23 months followed by 123 (20.5%) from 48 to 59 months. Similar study by Singh et al. showed inverse relationship between age group and gender with increasing age, percentage of males increased, and females decreased. Majority (89% (534)) were Hindu and 88.2% (529) belonged to nuclear family. A study by Damor Raman et al. showed 91.8% children were from Hindu families. More than half, 337 (56.2%) were from SE Class III followed by Class IV 193 (32.2%) according to the Modified Prasad's classification. Half of mothers, 312 (52%) were educated up to primary school, followed by illiterate 219 (36.5%). In NFHS-3, 49% mothers were illiterate and 59.3% of fathers had completed primary school. Majority (491 [81.8%]) of fathers were unskilled worker. Nuclear family comprised 529 (88.2%), 453 (75.5%) of the children with normal birth weight (>2500 g), and 98 (16.3%) with LBW (<2500 g). The first order children were 230 (38.4%) followed by the second order as 203 (33.8%). More than half, 232 (57.9%) had only one sibling and 48 (12%) had ≥3 siblings. Preceding birth interval of 2–3 years was seen in 54.3%. A study by Agrawal, birth space of <2 years and >2 years was 38.5% and 31.1%, respectively.
According to the WHO growth standard (Z score) out of 600, overall wasting (W/H) was seen in 151 (25.2%), among that 34 (33.7%) was in age group 24–35 months followed by 41 (33.3%) in 48–59. A study by Solanki et al. showed peak wasting in 36–47 months (53.5%) and Bhatia et al. showed in 6–12 months., The prevalence of underweight (W/A) was 223 (37.2%), and among them, 58 (47.2%) belonged to age group 48–59 months followed by 46 (45.5%) in 24–35 months. In NFHS-3 survey, underweight was 40%, and a study by Joshi et al. showed 49.44% children were underweight, while in this study, the prevalence for same was less. While overall stunting was 237 (39.5%), it was found to be more prevalent in the age group 24–35 months 59 (58.4%). In NFHS-3, stunting was found to be 45%. There was significant association between higher age group and undernutrition [Table 2] which is comparable with a study of Singh et al. (P ≤ 0.001). Similar study by Solanki et al. showed that the prevalence of stunting was 50%, while underweight and wasting were 42.7% and 15%, respectively. NFHS-3 showed that at national level, the rates of undernutrition in under-5 children were 43% for underweight, 48% for stunting, and 20% for wasting and the corresponding values for Gujarat were 47%, 42%, and 17%. Another study in Nigeria was observed stunting, wasting, and underweight (23.6%, 14.2%, and 22%), respectively, which is much lower as compared to our study.
A study by Avachat et al. in Maharashtra rural area showed 50.46% malnutrition and Singh et al. showed the prevalence of malnutrition was 76.36%, among that stunting, wasting, and underweight was 43.22%, 60.67%, and 53.86%, respectively, which is very higher as compared to our study.
In our study, nutritional status of under-5 children in nuclear family, H/A and W/A were 214 (40.5%) and 192 (36.3%), respectively, which was more as compared to W/H 122 (23.1%) and in joint family W/A was higher 31 (43.7%) as compared to others. A study by Joshi et al. showed 50.9% and 49.1% in nuclear and joint family, respectively. As per the SE status (n = 600), majority (337 [56.2%]) of children were from lower SE Class-III. Among them, the prevalence of stunting 136 (40.4%) and underweight 122 (36.2%) were higher than wasting 73 (21.7%). A study by Avachat et al. showed 40.6% and 58.03% of children belonged to SE Class III and IV, respectively. Stunting was 39.8% (151) in family with < 4 members which was less as compared to in family with 4–7 members where stunting was 60.6% (128), underweight was 38.4% (81) followed by wasting 29.4% (62). Literacy of mother was significantly associated with underweight (P = 0.000). In children of illiterate mothers, stunting was 89 (40.6%) followed by wasting 59 (27.1%). Similar findings were observed by Avachat et al. where it was 65.32% in illiterate mother. While according to the NFHS-3, in illiterate mothers stunting, wasting and underweight were 57%, 23% and 52% respectively. Other studies by Chakravorty et al., Bishoni et al., and Harishanker et al. also reported malnutrition was decreased with increasing literacy rate in mothers. As per the preceding birth interval of children (370), stunting was 41.9% (132) followed by wasting 36.8% (116), and no major difference of malnutrition was observed with the increasing preceding birth interval [Table 3]. According to the NFHS-3, in children with birth interval <2 years, 48% were underweight, and in 2–3 years birth interval, 46% were underweight. A study by Agrawal birth space <2 years malnutrition (38.5%) and >2 years (31.1%), respectively.
Wasting (26.5%), underweight (43.9%), and stunting (41.8%) were higher in children with LBW as compared to children with normal and over birth weight. In NFHS-3, wasting (46%), underweight (23%), and stunting (47%) were more in children with LBW as compared to children with normal birth weight. A study by Avachat et al. showed more malnutrition in LBW (<2.5 kg) children 88.98% as compared to normal weight (>2.5 kg) (41.9%). Stunting is more prevalent in normal (39.1%) birth weight children as compared to wasting and underweight [Table 4]. In rural areas, half of the young children are stunted, almost half are underweight, and one out of every five is wasted.
In this study, there was no significant difference observed in the occurrence of acute morbidity and its distribution in different age groups and gender, but in the age group 12–23 months, it was slightly higher, i.e. 17 (12.3%) may be due to hygiene-related problems. A study by Prajapati et al., the prevalence of acute respiratory tract infection was 22% and severe acute respiratory infection (ARI) was 4.2%. More males 25 (8.3%) were affected with acute morbidity than females 22 (7.4%). A study by Grover et al. in resettlement colony of East Delhi showed similar difference with acute morbidity higher in males (63.4%) and females (26.4%). Contrast result was found by Goel et al. where males 46.53% and females 53.36% which is higher as compared to our study. In a study by Singh et al., higher rate of ARI (72.3%) was observed in malnourished as compared to normal children. While it was 67.1 % in malnourished children in a study done by Goel et al. Illiterate mothers children were affected more with ARI 19 (8.3%) than children of literate mothers which was 28 (7.4%). A study by Goel et al. observed 52.31% ARI in illiterate which is very high as compared to our study. In SE Class IV, more percentage of children (17 [8.8%]) were observed with acute morbidity than other classes [Table 5]. A study by Goel et al. observed acute morbidity in SE Class III, IV, and V 21.85%, 37.74%, and 52.31%, respectively. The prevalence of ARI was more in males (17%) than females (14.7%) and the total prevalence was 33% in a study by Grover et al. While Goel et al. observed ARI was more in females 53.64% than males 46.36%.
With regard to immunization, there was no gender difference observed. Majority of infants ([95.8%) were fully immunized for age and immunization coverage was 89.1 % in the age group 12–23 months. Coverage evaluation survey (2009) by the UNICEF of Gujarat indicates 56.6% of fully immunized children, and in NFHS-3 District-Level Household Survey-3, the prevalence of fully immunized children was 45.2% and 54.9%, respectively. A study by Damor Raman et al., Planning Commission of India and NFHS-3 retrieved December 23, 2014, a study by Gupta et al., DLRHS (2011) showed fully immunized children were 75.11%, 55.2%, 60.5%, 88.67%, and 69.4%, respectively, in rural area. Thus, substantial improvement was observed in this study. No significant association was found between the nutritional status of children and immunization. In children of illiterate mothers, 193 (88.1%) were fully immunized. Higher proportion of fully immunized 344 (90.3%) children were found in children of literate mothers. Unimmunization was marginally higher 6 (2.7%) in children of illiterate mothers as compared to literate mothers, i.e. 8 (2.1%) which is lower in this study as compared to the NFHS-3 (8.5%) in rural area. In nuclear family, 475 (89.8%) children were fully immunized. In SE Class III, 302 (89.6%) children were fully immunized and 8 (4.1%) children were unimmunized in SE Class IV [Table 6].
Under-5 mortality rate was observed to be 30/1000 under-5 years children. LBW accounted for 61% of mortality. Pneumonia and birth asphyxia were other causes contributing 22.2% and 16.7% of under-5 mortality. A study by Biswas et al. In rural West Bengal also observed ARI, diarrhea, and prematurity to be the important causes of infant and early childhood mortality.
| Conclusion|| |
The total population in this study was 600, taken from RHTC field practice area. Majority children were Hindus, from lower SE class, and nuclear family. Sex ratio was 980 females/1000 males. Almost one-fourth of the children were observed to be wasted (W/H <−2 SD).
Underweight prevalence was 37.2%. Stunting was more prevalent (39.5%). There was no significant association of age, education, and occupation of the mothers and gender of the children with their nutritional status. Acute morbidity rate was observed to be (7.8%) in rural area. Full immunization appropriate for age was observed to be 89.5% in rural area. Still, 2.3% of the children were unimmunized rural areas. There was no significant difference observed between immunization status and gender. Under-5 mortality rate was 30/1000 under-5 years children per year in rural area.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Park K. Textbook of Preventive and Social Medicine. 21st
ed. Jabalpur: Banarasidas Bhanot Publishers; 2013. p. 506.
National Family Health Survey (NFHS-III) Report; 2005-06. Available from: http://www.nfhsindia.org
. [Last accessed in 2013 Nov 26].
Kumar A, Kamath VG, Kamath A, Rao CR, Pattanshetty S, Sagir A. Nutritonal status assessment of under five beneficiaries of integrated child development services program in rural Karnataka. AMJ 2010;3:495-8.
World Health Organization. WHO Child Growths Standards: Methods and Development. Geneva: World Health Organization Department of Nutrition for Health and Development; 2007.
Babatunde RO. Prevalence and Determinant of malnutrition among under five children of farming households in Kwara State, Nigeria. J Agric Sci 2011;3:173-81. Available from: http://www.ccsenet/jas
. [Last accessed on 2012 Mar 18].
Singh JP, Gupta SB, Shrotriya VP, Singh PN. Study of nutritional status among under-5 children attending OPD at a primary care rural hospital, Barielly (UP). Sch J Appl Med Sci 2013;1:769-73.
Damor Raman D, Pithadia Pradeep R, Lodhiya Kaushik K, Mehta Jitesh P, Yadav Sudha B. A study on assessment of nutritional and immunization status of under five children in urban slums Jamnagar city, Gujarat. Healthline 2013;4:35-9.
Agrawal V. Integrated management of Neonatal and Childhood Illness: Continuing Medical Education Module Public Health Department; 2005. p. 6-8.
Solanki R, Patel T, Shah H, Singh US. Measuring under-nutrition through Z-scores and composite index of anthropometric failure (CIAF): A study among slum children in Ahmedabad city, Gujarat. National J Community Med 2014;5:434-39.
Bhatia V, Swami HM, Rai SR, Gulati S, Varma A, Prashar A, et al
. Immunization status in children. Indian J Pediatr 2004;7:313-5.
Joshi HS, Joshi MC, Singh A, Joshi P, Khan NI. Determinants of protein energy malnutrition (PEM) in 0-6 years children in rural community of Bareilly. Indian J. Prev Soc Med 2011;42:154-8.
Avachat SS, Phalke VD, Phalke DB. Epidemiological study of malnutrition (under nutrition) among under-5 children in a section of rural area. Pravera Med Rev 2009;4:20-2.
Chakravorty S, Gupta SB, Chakravorty SK. A study of protein energy malnutrition in children (0-6 years) in rural area Jhansi district, (UP). Indian J Community Med 2006;31:291-2.
Bishoni P, Sehal S, Kwatra A. Anthropometric measurement of preschool children as effected by socio-economic factors. Asia Pac J Clin Nutr 2004;13 Suppl:S132-S132.1/3p.
Harishanker, Dwivedi S, Dabral SB, Walia DK. Nutritional status of children under 6 years of age. Indian J Prev Soc Med 2004;35:156-62.
Prajapati B, Talsania N, Sonaliya KN. A study on prevalence of acute respiratory tract infection (ARI) in: Under-5 children in Urban and Rural communities of Ahmedabad, Gujarat. Natl J Community Med 2012;2:225-9.
Grover VL, Chhabra P, Malik S, Kannan AT. Pattern of morbidity and mortality amongst under five in an urban resettlement colony of East Delhi. Indian J Prev Soc Med 2004;35:22-6.
Goel K, Ahmad S, Agarwal G, Goel P, Vijay Kumar. A cross – Sectional study on prevalence of acute respiratory infection (ARI) in under-5 children of Meerut district, India. J Community Med Health Educ 2012;2:176.
Immunization Status of Children (12-23 months): Planning Commission, Government of India; 19 April, 2014. Available from: http://planningcommision.gov.in
. [Last retrieved on 2014 Apr 19].
Gupta PK, Pore P, Patil U. Evaluation of immunization coverage in the rural area of Pune, Maharashtra, using the 30 cluster sampling technique. J Family Med Prim Care 2013;2:50-4.
] [Full text]
Biswas AB, Basu M, Das KK, Biswas R. (Dr. P. C. Sen award on rural health practice). Infant and early childhood mortality in some rural ICDS blocks of West Bengal. Indian J Public Health 1993;37:81-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]