welcome to vinayaka missions research ......certificate by the guide i, dr. (mrs.). a. v. raman,...

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VINAYAKA MISSIONS UNIVERSITY

CERTIFICATE BY THE GUIDE

I, Dr. (Mrs.). A. V. RAMAN, Director, Nursing Education and Research,

West Fort College of Nursing, Thrissur (Former Dean of Omayal Achi College

of Nursing, Chennai – 600062) certify that the thesis entitled “The Prevalence

And Contributing Factors of Malnutrition Among Children Below Five

Year” submitted for the Degree of Doctor of Philosophy in Nursing by

Mrs. Suja Baby Y V is the record of research work carried out by her during

the period from 2008 to 2017 under my guidance and supervision and that this

work has not formed the basis for the award of any degree, diploma,

associate-ship, fellowship or other titles in this university or any other

university or institution of higher learning.

Signature of the Supervisor with designation

Dr. (Mrs.). A. V. RAMAN

Place: Salem

Date: 8th March, 2017

VINAYAKA MISSIONS UNIVERSITY

DECLARATION

I, SUJA BABY Y V, declare that the thesis entitled ““The Prevalence

And Contributing Factors of Malnutrition Among Children Below Five

Year” submitted by me for the Degree of Doctor of Philosophy is the record of

work carried out by me during the period from 2008 to 2017 under the

guidance of. Dr.(Mrs.). A. V. RAMAN, Director, Nursing Education and

Research, West Fort College of Nursing, Thrissur (Former Dean of Omayal

Achi College of Nursing, Chennai – 600062) and has not formed the basis for

the award of any degree, diploma, associate-ship, fellowship or other titles in

this University or any other University or institution of higher learning.

Place: Salem

Signature of the Candidate

Date: 8th March, 2017.

ACKNOWLEDGEMENT

The success of the study would not have been possible without the

Blessings of the God Almighty, teachers and well wishers. It is my honour to

thank all those who directly and indirectly helped me towards completion of

this project.

In the first place I would express my special sense of gratitude to the

Management of Vinayaka Missions University, Salem for giving me this

opportunity to do PhD under this esteemed University. I specially thank

Dr. K. Rajendran, Former Dean, research cell and Dr. Prabhavati , the

Controller of Examination and present Dean of research for all academic

suggestions and advices at each level of study to do this research with

perfection.

I humbly acknowledge my gratitude to the Management and

Chairman, Director and administrative officers of Dr. SMCSI Medical

College, Karakonam Trivandrum for their support and inspiration to do my

study during my tenure with them.

I am definitely accord my gratitude to Dr Rajashekharan my former

guide to select the research problem and guide me to present the same

before the Research proposal committee.

I am extremely indebted to extend my deep sense of gratitude, respect,

there are never ending words to express the gratefulness to my guide and

esteemed promoter Dr. (Mrs.) A. V. Raman, Director Nursing Education and

Research, Westfort College of Nursing, Thrissur, for accepting me as a PhD

student. Her warm encouragement, guidance, constant inspiration, moral

support, critical comments, correction of the thesis and untiring help

throughout my study, without whose initiative and enthusiasm, this study

would not have been possible. Her involvement has triggered and

nourished my intellectual maturity.

It is my bounden duty to express my heartfelt gratitude to Block

Development Officer and Village Panchayat Presidents for giving me

permission to conduct the study.

I owe my sincere thanks to the mothers of underfive, and their

children who participated in the study willingly and gave full co-operation

during the study period.

I extend my special thanks to all the experts in the field of nursing,

Community Health, Pediatrics, Nutrition and Obstetrics for validating the

content of tool, by providing valuable suggestions which helped me to finalize

the tools for the study.

I would like to express my gratitude to Dr. Ommen Philip, statistician

for his valuable help in the statistical analysis and interpretation.

I am thankful to the Librarians, who facilitated with resources to

complete the study.

I am grateful to the members of the Ethical Committee for approving

my study.

I am, thankful to Mrs. Geetha Rajendran, Head Mistress for editing the

whole thesis.

I thankfully remember the D K printers that made the manuscript to a

perfect shape in form of thesis.

It gives me immense pleasure to thank my friends, colleagues and

church members for their constant support and encouragement. I appreciate

their gift of time to me.

I am thankful to Rev. Sunildas for translating my tool in Malayalam.

There is no way to express my deepest gratitude, excellent assistance

and spiritual supports provided by my beloved husband Mr. Sunil, sweet

daughter Sibyl Sharon and loving son Steve Aaron. I also extend my thanks

to dear mother and mother-in-law for their affection, prayers and constant

support and sacrifices that have greatly contributed to the successful

completion of this study.

‘Thanks’ is a small word, but there is a meaning and appreciation on it.

It is extended with: Heartfelt and everlasting gratitude. I praise GOD THE

ALMIGHTY who has been the shepherd and guiding force behind all efforts.

His omnipresence has been the anchor at difficult and hard moments.

.

“It is the work of the Lord; Let His Name be glorified forever”

Mrs. Suja Baby Y V

ABSTRACT

A cross sectional descriptive survey to assess The Prevalence And

Contributing Factors of Malnutrition Among Children below five year at

Trivandrum was undertaken by Mrs.Suja Baby Y V, in partial fulfillment for the

award of Degree of Doctor of Philosophy in Nursing at Vinayaka Missions

University, Salem.

The objectives of the study were,

1. To assess the prevalence of malnutrition among under five children.

2. To identify the association of malnutrition among under five children with

their demographic variables.

3. To determine the association of malnutrition among under five children

with their anthropometric measurements.


with their hemoglobin status.

5. To determine association of malnutrition among under five children with

clinical variables of their mothers.

Research Hypotheses were formulated based on objectives.

The conceptual framework of the study was based on UNICEF’S

Malnutrition model. The sample size of the study was 1000 under five children

selected by using multistage random sampling technique. The instruments

used for the present study were structured questionnaire to collect

demographic data of child and clinical data of mother, Anthropometric

measurements (BMI & Mid Arm Circumference) and biochemical

measurement of Hemoglobin

Major findings of the study

• The prevalence of malnutrition was analyzed under 3 indices. i.e. stunting,

under weight and wasting and observed that the prevalence of stunting

was 24%, underweight 24.9% and wasting 37%. Prevalence of malnutrition

was the highest among the age group of 0-1 year in both male and female

infants and is more observed in male children.

• The study observed that factors like spacing between children (for one year

spacing), primary care taker (mother), occupation of father, water supply

(Tap water), frequency of diarrhea in preceding 2 years, decision maker in

the family (Mother), health habits of the care taker (Hand washing practice

after use of latrine), duration of breast feed (<1 year), age at which weaning

started (< 6months) and the maternal factors like obstetrical problems, food

choice during pregnancy, willingly accepted each pregnancy, conditions of

the last two children, whether deworm during pregnancy were associated

with stunting among underfive children.

• The factors like age (0-1 Year), gender (male), type of house (Kuchha),

primary care taker, food habits (vegetarian), how long the children got

breast feed (<1 year), the age at which weaning started and the maternal

factors like antenatal check up, condition of last two children, medical

condition of the mother were associated with under weight of children.

• The factors like age (0-1 year), total family income (>Rs. 40,000/ year),

water supply (Tap water), toilet facilities and maternal factors like food

choice of the mother during pregnancy influenced wasting among under five

children.

• The study analyzed the association of anthropometric measurements (BMI,

MAC) and malnutrition. The factors like age, total family Income in the

family per month in Rupees, type of house, toilet facilities, water supply

(public tap), frequency of diarrhoea in preceding 2 weeks were associated

with BMI for age.

• The factors like age, education of father and method of refuse disposal

were found associated with MAC among under five children.

• The factors like age of the child, frequency of diarrhoea in preceding 2

weeks, Health habits of the care taker of the child, habits of parents of the

children, previous iron and Vit A therapy and food habits were found

associated with HB of under five children.

The study concluded that the prevalence of stunting was 24%,

underweight 24.9% and wasting 37% respectively among under five children.

These findings strongly suggests for community based educational

intervention though the present study findings are below the percentage of the

national statistics.

Key words: Prevalence, Contributing factors, Malnutrition, Under five

children.

INDEX

Chapter No.

Contents Page No.

I. Introduction

1.1. Back ground of the study

1.2. Need for the study

1.3. Statement of the problem

1.4. Objectives of the study

1.5. Operational definitions

1.6. Assumption

1.7. Research Hypotheses

1.8. Delimitations

1.9. Conceptual framework

Summary

1-25

1

15

17

17

17

18

19

19

19

25

II. Review of Literature

Literature related to:

2.1. Prevalence of Malnutrition

2.2. Contributing factors of malnutrition

2.3. Mortality and Morbidity of protein energy

malnutrition.

Summary

26-48

27

34

42

48

III. Methodology

3.1. Research approach

3.2. Research design

49-65

49

49

Chapter No.

Contents Page No.

3.3. Variables under study

3.4. Setting of the study

3.5. Population

3.6. Sampling

3.7. Development of tools

3.8. Description of the tool

3.9. Validity and Reliability

3.10. Translation of the tools

3.11. Preparation of the final draft of the tools

3.12. Ethical consideration

3.13. Pilot Study

3.14. Data Collection Procedure

3.15. Plan for Data Analysis

Summary

49

50

50

51

55

56

59

61

61

61

62

63

64

65

IV Analysis and Interpretation of data

Section I: Description of Background

characteristics of the children and mothers

Section II: Prevalence of malnutrition among

under five children.

Section III: Association of malnutrition among

under five children with their demographic

variables

66-135

69

91

94

Chapter No.

Contents Page No.

Section IV: Association of malnutrition among

under five children with anthropometric

measurements

Section V: Association of HB of under five

children with demographic variables

Section VI: Association of malnutrition among

under five children with clinical variables of their

mothers

Section VII: The overall contributing factors for

malnutrition among underfive children.

Summary

109

122

126

130

134

V Discussion, Summary, Conclusion,

Implications, Recommendations and

Limitations.

Discussion

Summary

Conclusion

Implications

Recommendations

Limitations

135-156

135

147

150

151

155

156

References 157-170

Annexures i - lvi

LIST OF TABLES

Table No.

Title Page No.

4.1.1 Percentage distribution of demographic characteristics in terms

of gender, religion, birth weight of the child, spacing between

children and parental divorce.

69

4.1.2. Percentage distribution based on socioeconomic characteristics 75

4.1.3. Percentage distribution of environment and epidemiological

characteristics

78

4.1.4 Percentage distribution of Behavioral and health awareness

characteristics in terms of decision maker to use money in

family, Immunization status of the child and Previous iron or

vitamin Therapy.

82

4.1.5. Percentage distribution of nutritional awareness in terms of

number of meals, how long the children breast fed and the age

at which weaning started.

85

4.1.6 Percentage distribution based on clinical variables of mother in

terms of age, BMI, Consultation on sickness, place of delivery,

condition of last two children, ANC check-ups, IFA during

pregnancy, deworming, medical condition, contraceptive use,

food choice and acceptance of each pregnancy.

87

4.2.1 Percentage distribution of stunting by length / height –for-age. 91

4.2.2 Percentage distribution of stunting at 95% CI 91

4.2.3 Percentage distribution of underweight by BMI-for-age 92

4.2.4 Percentage distribution of underweight (BMI for age) based at 95% CI

92

Table No.

Title Page No.

4.2.5. Percentage of weight –for-age 92

4.2.6. Percentage distribution of underweight by weight –for-age at

95%CI

93

4.2.7. Percentage distribution wasting by weight –for length / height 93

4.2.8 Percentage distribution wasting by weight–for length/height at

95% CI

94

4.2.9 Percentage distribution of haemoglobin status based on age 94

4.3.1 Association of (stunting) height for age of under five children

with their demographic characteristics

95

4.3.2 Association of stunting (height for age) of under five children

with socioeconomic characteristics

96

4.3.3 Association of stunting (height/Length for age) of under five

children with environment and epidemiological characteristics

97

4.3.4 Association of stunting (Height/ Length for age) of under five

children with behavioral and awareness characteristics

98

4.3.5 Association of stunting (Height for age of under five children)

with nutritional characteristics

99

4.3.6. Association of underweight (weight for age) of under five


100

4.3.7 Association of underweight (weight for age) of under five

children with socio economic characteristics

101



102


children with behavioral and awareness characteristics

103

Table No.

Title Page No.


children with nutritional characteristics

104

4.3.11 Association of wasting ( weight for height ) of under five children

with demographic variables

105

4.3.12

Association of wasting (weight – for – length/height) of under

five children with socioeconomic characteristics

106

4.3.13 Association of wasting (weight – for – length/height) of under

five children with environment and epidemiological

characteristics

107

4.3.14 Association of weight – for – length/height of under five children

with behavioral and awareness characteristics

108

4.3.15 Association of wasting (weight – for – length/height) of under

five children with nutritional characteristics

109

4.4.1. Association of BMI for age of under five children with

demographic characteristics

110

4.4.2 Association of BMI for age of under five children with

socioeconomic characteristics

112

4.4.3 Association of BMI for age of under five children with

environment and epidemiological characteristics

114

4.4.4 Association of BMI for age of under five children with behavioral

and awareness characteristics

115

4.4.5 Association of BMI for age of under five children with nutritional characteristics

116

Table No.

Title Page No.

4.4.6 Association of Mid arm circumference(MAC) of under five


117

4.4.7. Association of Mid arm circumference of under five children with


118

4.4.8. Association of Mid arm circumference of under five children with

environment and epidemiological characteristics

119

4.4.9 Association of Mid arm circumference of under five children with

behavioral and awareness characteristics

120

4.4.10 Association of Mid arm circumference of under five children with

nutritional characteristics

121

4.5.1. Association of HB of under five children with demographic

characteristics

122

4.5.2. Association of HB of under five children with


123

4.5.3. Association of HB of under five children with environment and

epidemiological characteristics

124

4.5.4: Association of HB of under five children with behavoural and

awareness characteristics

125

4.5.5: Association of HB of under five children with nutritional

characteristics

126

4.6.1 Association of stunting ( height for age) of under five children

with clinical variables of mother

127

4.6.2 Association of underweight (weight for age ) of under five

children with clinical variables of mother

128

Table No.

Title Page No.

4.6.3. Association of wasting ( weight for length/height) of under five

children with clinical variables of mother

129

4.7.1 Overall contributing factors for malnutrition among under five

children based on demographic determinants

130

4.7.2 Overall contributing factors for malnutrition among under five

children based on maternal determinants

131

4.7.3 Association of Anthropometric measurements(BMI and MAC)

and Haemoglobin with demographic characteristics

132

LIST OF FIGURES

Figure No.

Title Page No.

1.1. Prevalence of malnutrition in developing

world(UNICEF 2001)

4

1.2. Severe infection causes malnutrition and death 12

1.3. Conceptual framework of Malnutrition based on

Unicef Model 1991.

24

3.1. Schematic Representation of Research

Methodology

51

3.2. Schematic Presentation of sampling technique. 53

4.1.1 Percentage wise distribution of under five

children according to their age.

70


children according to their age and gender.

71

4.1.3 Percentage wise distribution based on number of

under five children in the family.

72


children based on birth order

73

4.1.5 Percentage wise distribution based on primary

care taker of under five children.

74

4.1.6 Percentage wise distribution of underfive

children based on education of parents

76

Figure No.

Title Page No.


children based on occupation of parents

77


children based on type of house

79


children based on water supply.

79


children based on toilet facilities.

80


children based on Crowdedness.

80


children based on method of refuse disposal.

81


children based on seeking care for diarrhoeal

diseases.

81


children based on habits of parents

83

4.1.15. Percentage wise distribution of underfive

children based on health habits of parents

84


children based on Exposure to information on

malnutrition to parents.

84

Figure No.

Title Page No.


children based on Food habits.

86


children based on staple food.

86

4.1.19. Percentage wise distribution of mothers of

underfive children based on Obstetrics problems.

89

4.1.20. Percentage wise distribution of mothers of

underfive children based on post natal

complications

90

4.4.1 Distribution of BMI of underfive children based

on their age.

111

4.4.2 Distribution of BMI of under five children based

on total income of family.

113

LIST OF ANNEXURES

Annexure No.

Title Page No.

A Registration letter from University i

B Permission letter from University regarding

change of guide

ii

C Approval letter from ethical committee iii

D Letter requesting permission for study setting v

E Permission obtained for conducting research

study.

vi

F Letter requesting the experts to validate tools

content

vii

G List of experts ix

H Instruments used in the study in English and

Malayalam

xii

I Criteria for Instrument /tool validity xxxix

J Certificate of Validation xliii

K Information sheet in English and Malayalam xliv

L List of the blocks and Panchayats xlviii

M Certificate of Editing li

N Certificate of Translation lii

O Procedure of recording height, weight, mid arm

circumference and haemoglobin estimation.

liii

1

CHAPTER I

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Concepts and Definition of Malnutrition

Malnutrition is a man-made disease of human society. It begins quite

from womb and ends in the grave. It is a major public health issue which is

estimated to contribute more than one third of all child death. Children of today

are citizens of tomorrow, the young children under five years of age are the

most vulnerable to the vicious cycles of malnutrition.

The first twenty eight days of life in a child is the dreadful time. To

prevent these deaths safe delivery and essential new born care is needed.

Preterm births, complications during labor, asphyxia respiratory problems and

infections are the major causes of newborn deaths that accounts for 45% of all

child deaths (WHO Fact sheet 2016).

Among the causes of child mortality, deaths due to malnutrition accounts

for 45% among the age group of 0-5 years because this age group is more

susceptible for malnutrition and infection. According to W H O fact sheet

(2016), 6.3 million deaths occur among under five children. 50% of such early

child mortality is preventable or managed with locally available and cost

effective management. It is reported that the mortality in Africa is 15 times

more before the children reached to five years of age than children in

developed countries (W H O, Fact sheets, Media centre, 2016). Malnutrition

2

progresses slowly and many times it becomes a silent killer if undiagnosed

and it becomes an emergency situation for the child and care takers.

Inadequate or non availability of food, exposed to childhood infections

that are preventable but are not prevented, poor management, consumption of

unsafe water and poverty are accountable for about 12 million deaths each

year in developing countries among under five children. As per the report of

FAO (2008) about 1000 people were under nourished which showed a

gradual increase of 80 million from the year 1990-92 (FAO, 2015). Malnutrition

is one of the current public health concerns in our country.

The term malnutrition has varied connotations based on their etiology.

When there is an imbalance between protein and energy to meet the

requirements of the body needs is termed as malnutrition. As per World

Health Organization (2010) in human life early childhood is very important with

regards to physical, mental and social development of an individual.

Malnutrition plays a crucial role in hampering such development, if not

diagnosed or treated promptly and it will hamper permanent impairment in

adult life.

Protein Energy Malnutrition is classified as underweight, stunting and

wasting. The prevalence of stunting among under five was 48%, wasting 20%,

and underweight was 43% globally as reported by WHO in its report 2010.

Undernutrition is a condition caused by deficiency of protein and other

nutrients in quality and quantity, manifested by health problems among

children. Whereas over nutrition is caused by the intake of nutrients that are

3

consumed more than the requirement. The impact of under nutrition in

pregnancy or the age of child below two years may have the negative impact

on the growth and development of the child according to ICMR study (2009).

Starvation due to severe under nourishment is manifested by stunt growth,

thin built edematous legs, and lethargic abdomen. Under nutrition in children

is manifested by itself in many ways, and it is commonly assessed through the

anthropometric measurements, a child can be stunted, wasted, or

underweight. A child who is underweight can also be stunted or wasted or

both (Ann M Veneman, 2009).

Magnitude of the problem: World scenario

The most important forms of malnutrition prevalent globally are anemia,

micronutrient deficiencies and protein calorie malnutrition. 50% of deaths were

caused by underweight among children below five years in developing world

Stunting in developing countries declined from 36% in 1995 to 32.5% in 2000;

the numbers of children affected (excluding China) are expected to decrease

from 196.59 million to 181.92 millions. Stunting was prevalent 48% of children

of South Central Asia, 48% of Eastern Africa, 38% of South Eastern Asia, and

13-24% in Latin America. According to World Bank report (2010) Bangladesh

has highest prevalence of malnutrition among under fives where as India

stands in the second place that is 47%. Stephenson L S, (2000) reports that

under weight children in India were as double of Sub-Saharan Africa.

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percent were stunted due to chronic under nutrition and those accounts for 61

Million children. In Global scenario 3 out of 10 were stunted children in India in

which a major share was observed in rural children than urban. Some of the

factors associated with underweight were short birth intervals, whose mothers

were not literate, mothers whose BMI was < 18.5 in comparison to mothers

with normal BMI.

With regards to prevalence of wasting, children according to reports from

NFHS 3, (2005-2006) scheduled tribes had the poorest nutritional status and

accounted for 28%. Prevalence of low birth babies were found in India that

accounts for 7.4 Million posed a serious public health concern .Only, 25 per

cent of newborns were breast fed within an hour of their birth, and 46 per cent

mothers practiced exclusive breast feeding for less than 6 months of age of

the child. Only 20 per cent children aged 6-23 months who followed the

recommended nutritional practices had appropriate nutrient fed. Other

alarming factor observed was 70 per cent of children of the age group of 6

months to < 5 years were anemic.

Other factors that showed an impact on nutritional status of these age

group were children of mothers suffering from severe anemia, 51% of

households utilizing idolized salts, inadequate utilization (33%) of any service

from an Anganwadi centre; limited practice (25 %) of implementing

supplementary food through ICDS; and no (18%) regular growth assessment

in Anganwadi centre. As per the reports published in the Times of India, 2013,

it is said that around 48% under five children, had stunted growth and were

6

malnourished in India. This number was equal to 165 million children of the

world. In 2011 there were 52 million children affected by wasting, and 100

million children were underweight in the world, out of these children 90 per

cent of children were in Asia and Africa, and Africa region had more number of

stunting children.

The National Nutrition Mission is a multi-sectoral nutritional programme

aiming to prevent maternal and child under nutrition that is highly prevalent in

200 districts .The main objective of this program is prevention and reduction of

under nutrition among children below 3 years of age.

Malnutrition in Kerala

According to Sneha Mary Koshy (2014), out of 4,841 under five children

lived in Attapady, tribal village in Palakkad district, Kerala, 572 were

malnourished; of which 127 were severely malnourished. However, it was

observed that only 250 children in the region were malnourished according to

official documents. Though Kerala state is much advanced in providing health

care services, as per WHO, the percentage of malnourished children in Kerala

state was 36.92% and severely malnourished children was 0.08% comparing

Tamil Nadu statistics which had 35.22 % and 0.02 % malnourished and

severely malnourished children (National Rural Health Mission data, 2014).

According to the India State Hunger Index of 2008 reports, in Kerala

state, 19 % of under five children accounted for underweight, and 28.6% were

inadequately nourished. The Infant Mortality rate accounted the lowest in

Kerala state among all states in the country that is 1.6%.

7

As per NHFS India-3 (2006) report, in Kerala state, anemia was prevalent

among 56.1% children aged between 6-35 months, 32.7 % single women

aged between 15-49 and 33.8% pregnant women aged between 15-49, Infant

mortality was 15 per 1000 live birth, Under-five mortality was 16 deaths per

1,000, perinatal mortality was found 11 per 1,000 pregnancies, after viability of

the fetus perinatal mortality in rural areas was 15, per 1,000 pregnancies that

was higher than in the urban population.

Classification of malnutrition

Gomez Classification:

In 1956, Gomez and Galvan classified malnutrition as: first, second, and

third degree. Three categories of under nutrition in Gomez classification were

based on standard weight for age

a. First degree : 90-75% of standard weight for age

b. Second degree : 75-60% of standard weight for age

c. Third degree : less than 60% of standard weight for age

NCHS (National Center for Health Statistics) standards,

Center for Disease Control (CDC) and NCHS (National Center for Health

Statistics) came up with new anthropometric classifications in 1974 widely

known as NCHS curves. They were revised in year 2000. They served as

international growth standards till WHO growth standards-2004 were accepted

as international reference. Indian Association of Pediatrics also accepted this

chart as reference.

8

Indian Academy of Pediatrics standards

IAP classification uses NCHS standards for defining under nutrition. It is

more similar to Gomez classification, except for the cut off points used to

determine the severity of malnutrition

a. Grade I : 71 - 80 % of standard weight for age

b. Grade II : 61 - 70 % of standard weight for age

c. Grade III : 51 - 60% of standard weight for age.

d. Grade IV : 50% of standard weight for age

4. Garrow's Classification:

There were 4 major criteria used in Garrow's classification.

a. No child is considered to be severely malnourished unless his weight is

below 70% of the expected weight for age, using Harvard standards.

b. Kwashiorkor: Child at minimum weight not less than 60% of expected

weight for age; edema present, plus either hepatomegaly or dermatosis.

c. Marasmus: Child with less than 60% of expected weight for age; no edema

or other specific signs.

d. Marasmic Kwashiorkor: child with less than 60% of expected weight for age

with edema or other signs.

5. WHO Classification

WHO classification is universally accepted for diagnostic assessment

criteria of under nutrition. Apart from these criteria WHO also defines severe

under nutrition, any nutritional parameter (weight-for-age, height-for-age or

weight-for-height) less than -3SD is considered as severely under nourished.

9

WHO provides range of other parameters for measuring nutritional status

apart from growth standards. These parameters are developed based on multi

centric growth reference study. These parameters include MAC (Mid Arm

Circumference) for age, Body Mass Index for age, Head circumference for

age, sub scapular skin fold for age, triceps skin fold for age, motor

development milestones, weight velocity, length velocity and head

circumference velocity.

a. Stunting: Child with Height-for-age (HFA) z-score that is at least 2 standard

deviations (SD) below the median.

b. Wasting: Child with weight-for-height (WFH) z-score that is at least 2 SD

below the median.

c. Under weight: Child with weight-for-age (WFA) z-score that is at least 2 SD

below the median.

In India, nearly 60 million children who are< 3years of age covering

46%, a figure representing only a small decline from the rates recorded in

1992-1993 (51%) and 1998-1999 (47%).

Weight for age is the most widely used index for assessment of under

nutrition in clinical practice in India. Under ICDS programme Anganwadi

workers monitor children's growth at monthly intervals. Weight is then plotted

for each child in growth charts, recommended by IAP which is based on

Harvard growth standards. In April 2006, WHO released new references for

children from birth to 5years These references, known as the WHO Child

10

Growth Standards, In February 2017 it was agreed to a change over from the

IAP growth curves in use at the time to WHO child growth curves.

Classification of protein energy malnutrition

Kwashiorkor, Marasmus, and Marasmic Kwashiorkor come under the

classification of Protein energy malnutrition Kwashiorkor term is derived from

a language in Ghana used to describe the sickness of weaning which was

introduced by a British Nurse to Medical literature in 1933. When intake of

protein is deficient in quantity and quality, kwashiorkor is resulted. This

condition is clinically manifested by swelling in legs and abdomen, wasting of

muscles, enlargement of liver, change in color of skin and hair.

The extreme lack of protein causes an osmotic imbalance in the gastro-

intestinal system causing swelling of the gut diagnosed as an edema or

retention of water. This condition is observed in children between the ages of

1-5 years. The disease is more common when there is small gap period

between pregnancies. In this disease, swelling of body is observed due to

retention of fluids. Wasting of muscles is not evident.

Symptoms of kwashiorkor

Children appear smaller than their age, skin is pale, dry and flaky, hair

turns reddish, muscles are limp and underdeveloped, children frequently have

digestive problems, fluid retention in the body causes a distended abdomen,

swollen hands and ankles, called edema, very thin limbs, liver may be

enlarged. Children lack enthusiasm and look lethargic.

11

Marasmus

Marasmus is derived from the Greek word meant by decay. Inadequate

intake of protein and carbohydrates is the major cause of marasmus. It is

clinically manifested by severe wasting, without edema, reduced

subcutaneous fat and decreased serum albumen.

The affected child reduces < 60 % of body weight for the age. Marasmus

occurs in children below the age of 1 year. This disease is more common

among children whose mothers discontinued breast-feeding early. No swelling

of body takes place in Marasmus, wasting of muscles is quite evident. The

child is reduced to skin and bones. Skin does not change colour and does not

break. It occurs due to a deficiency of proteins, carbohydrates and fats.

Marasmus is the childhood equivalent of starvation in adults and is more

serious than Kwashiorkor.

Symptoms of marasmus

A large face over a shrunken body, eyes are sunken, cheeks are hollow giving

a premature aged look, edema is absent, abdomen is curved inwards, and

skin is dry, loose and wrinkled due to loss of fat below the skin. Hair may be

normal or dry, thin and light colored. Muscles are wasted and have poor tone

are prominent due to absence of fat around them.

Marasmic Kwashiorkor

It is a condition in which children show the signs of both kwashiorkor and

marasmus.

12

Determinants of Malnutrition

Factors contributing to malnutrition are described by nutritional experts and

the primary determinants of malnutrition, are due to

1. Inadequate food intake and repeated infections: When protein and

micro nutrients are deficient in quality and quantity for a child according to his

age, under nutrition can happen. Assessment of children's growth is a

desirable indicator for ensuring the wellbeing of children, as well as for

inspecting the household’s access to food, health and care. The vicious cycle

of infection and under nutrition go hand in hand.

Inadequate dietary intake

Appetite lossNutrient lossMalabsorptionAltered metabolism

Weight lossGrowth falteringImmunity loweredMucosal damage

Disease: incidence, duration severity

Fig 1.2: Malnutrition/ infection cycle.

(Modified and adapted from Park K. ,2009, Pg553)

2. Socio-cultural factors affecting feeding practices: Illiteracy and poor

socio-economic status are leading to faulty feeding practices, which are found

to be the factors still predominant in developing countries resulting in

increased incidence of malnutrition in children. In a study done by Dwivedi and

13

Agrawal (2012) on 400 children, 123 (30.75%) were found to be moderately

malnourished while 30 (7.5%) were severely malnourished with slight female

predominance (53.4 and 54.6% respectively). Low birth weight, higher birth

order (≥4), delayed initiation and early interruption of breast-feeding, mixed

feeding, bottle-feeding, delayed initiation of complementary feeding; irregular

Anganwadi visits and illiteracy of parents were significantly associated with

malnutrition.

3. Maternal nutrition - Maternal nutrition is closely related with nutritional

status of infants. Mothers with < 142 cm height and <18.5 BMI are likely to

deliver low birth weight infants and demonstrate feeding problems. Infection is

an influencing factor of malnutrition, for 54% of the 10.8 million deaths per

year among under five children, that is responsible for 53% of deaths caused

by infections. In developing countries, it is a vicious cycle that malnutrion and

infection goes hand in hand (Hasnain & Hashmi, 2009).

4. Gender – As per National Health and Family survey-II (1988-99) report the

prevalence of underweight was of 48.9% among girls as compared to 45.5%

in boys. The ratio of severe underweight was observed higher (18.9%) for girls

than boys 16.9%.

5. Mother's literacy status - It has been observed that mother's literacy

status influences nutritional condition of under five children. Children of

illiterate mothers were twice as likely to show signs of underweight and

stunting as against those mothers who are literate.

14

6. Poverty and income - Poverty and income closely associated with under

nutrition or malnutrition. Under nutrition is more common among children of

lower income parents and malnutrition is usually seen among children of

parents with higher income.

7. Urban- rural difference - According to NFHS-3 (2006) reports data

showed that except Tripura, the prevalence of under nutrition was higher in

rural than urban children in all states. The urban and rural variations were

large with prevalence of 50% in rural children when compared with 38% in

urban children. Stunting was seen more among the rural children (74.5 %,) but

under nutrition was lower among urban children, and majority (30.3%) were

wasted.

8. Life-style and behavior - The life-style and behavior of the mother and

care takers with regards to child bearing and child rearing methods have an

impact on under nutrition or malnutrition.

9. Angawadi services- The ICDS centers where Anganwadi workers are

posted do growth monitoring, nutrition supplementation and arrange for

regular health check up for under five children under their health unit and have

a specific role in preventing undernutrition. The quality, access and availability

of this care influence the health of the beneficiaries of ICDS program.

10. Age- NFHS II (1996-99) reported that the prevalence of underweight –

rapidly increased from 11.9% (6 months) to 37.5% (6-11 months) to 58.5%

among 12-23 months old children. Stunting prevalence also rose from 15.4%

(6 months) to 57.5% among 12-23 months.

15

11. Birth order and birth interval - Lower the birth order the risk for

undernutrition is reduced. The proportion of undernutrition in higher birth order

(3) is more at risk of undernutrition than those with first birth order. NFHS II

observed in their survey that that lower birth orders were an advantage. The

prevalence of undernutrition declined from a birth order of 3 (48.5%) to 1

(20.38%). Severe undernutrition was not seen in children with first birth order.

12. Low birth weight - Low birth weight babies encounter problems of

feeding, they also prone to infection and diseases. Improved nutrition during

pregnancy may reduce delivery of low birth weight babies. (Usha, 2004).

13. Food taboos - Traditional practices and nutritional taboos influence

maternal and Perinatal outcome. A study by Alexandra Marie (2013) reported

that cultural practices and food taboos associated with maternal nutrition

which has an impact on maternal and child nutritional status.

14. Broken homes - Broken families or one parent children were neglected in

their care affect their nutritional status.

15. High pressure advertising baby foods- Commercialized baby food may

not compensate the requirement of newborn or infants nutritional needs. A

study by Alissa, et.al (2016) reported that there is a need to develop strategies

to enhance child nutritional practices among children less than 24 months of

age and concluded that consumption of commercial food to be discouraged.

1.2. NEED FOR THE STUDY

The Sustainable Development Goals (SDG) 2015-2030 aims to end

poverty in community, to end hunger, and to ensure healthy lives and promote

16

well being of all ages. In June 2014, WHO, UNICEF as partners of health

issued the first-ever global plan to end preventable newborn deaths and

stillbirths by 2035. The Every Newborn Action Plan recommends for all

countries to take steps to provide basic, cost-effective health services-in

particular at the time of delivery, caring the sick and underweight infants to

enhance the quality of care.

Since 44% of all child deaths occur within the first month of life, providing

skilled care to mothers during pregnancy, as well as during and after birth,

greatly contributes to child survival. Member States have set targets and

developed specific strategies to reduce child mortality and monitor progress.

(Mathad, 2011).

The role of community health nurses is expanding and extending. The

nursing process of assessment, diagnosis, planning, implementation and

evaluation provides a solid framework to identify, diagnose and do appropriate

referral to nearby health facility for children suffering from malnutrition. Nurses

play a key role in educating parents, school teachers and other care takers

regarding the consequences of untreated malnourished child. Nurses have

extensive expertise in assessing the knowledge base and learning needs of

parents. Under nutrition jeopardizes children's survival, health, growth and

development, and it slows national progress towards development goals.

Under nutrition is often an invisible problem. The Rapid Survey on Children

reports recommends the world adopts the Sustainable Development Goals.

The goals determine to bring down prevalence of malnutrition by 2030, the

17

goals also aimed to achieve, the internationally agreed targets on stunting and

wasting in children under five years of age, by 2025. Thus nurses are in

position to contribute to the achievement of SDG 2015-2030 by identifying

determinants of malnutrition and proper management.

1.3. STATEMENT OF THE PROBLEM

A study to assess the prevalence and contributing factors of malnutrition

among children below five year at Trivandrum district, Kerala State.

1.4. OBJECTIVES OF THE STUDY










1.5. OPERATIONAL DEFINITIONS

Prevalence:

In this study it refers to the proportion of under five population found to have

malnutrition.

18

Contributing Factors:

In this study, it refers to back ground characteristics of child include

demographic (personal) characteristics, socio economic, environmental and

epidemiological factors, behavior and health awareness of parents and

nutritional factors of the child and maternal factors, measured by interview

questionnaire. Anthropometric factors like Body Mass Index, Mid Arm

Circumference, and bio chemical factor like hemoglobin are assessed by

measuring height, weight and mid arm circumference and assessing

hemoglobin by Sahli’s hemoglobinometer.

Malnutrition:

It is the condition that results from eating a diet in which certain nutrients

are lacking, in excess (too high in intake), or in the wrong proportions. It is

measured by Anthropometric measurement (Height, Weight, Mid arm

circumference); bio chemical examination (assessment of hemoglobin)

assessed under three indices i.e. stunting, underweight and wasting.

Under five Children: It refers to children between births to 59 months of age

based on the birth certificate verification.

1.6 ASSUMPTION

There are numerous factors that cause malnutrition among under five

children.

19

1.7. RESEARCH HYPOTHESES

RH 1 There will be a significant association of malnutrition score among under

five children with their demographic, socioeconomic, environmental and

epidemiological, behavioral and health awareness and nutritional factors.

RH 2 There will be a significant association of malnutrition score among

under five children with their anthropometric measurement.

RH3 There will be a significant association of malnutrition score among under

five children with their hemoglobin measurement.

RH4 There will be a significant association of malnutrition score among under

five children with Maternal factors score.

1.8. DELIMITATIONS

1. The study is delimited to under five children of selected Panchayats of

Trivandrum district.

2. It is further delimited to period of data collection of the study.

1.9. CONCEPTUAL FRAME WORK

The present study used conceptual framework based on UNICEF

Malnutrition model (1991)

The conceptual model identifies three levels of causality of malnutrition

1.. Basic causes that act on entire societies but have a greater or lesser

impact on specific groups within society

2. Underlying causes that act on households and communities.

3. Immediate causes that act on the individual.

The basic factors described in this model reflects

20

1. Political factors: Certain political factors, such as policy decisions and

economic situations caused by inflation or war can cause undernutrition.

Though the Government is providing subsidiary through ration shops and

nutrients through anganwadis, under panchayats, many families are

dependent on this, and not much benefitted. In the present study this factors

are discussed under nutritional factors.

2. Ideological factors: The effects of cultural beliefs, traditions and

customs on nutrition are enormous. Generally, men take advantage of the

opportunity to eat better than their wives or children. Some of the cultural

practices are abrupt weaning due to pregnancy; certain foods are considered

inferior foods while others are considered superior foods. In the present study,

these factors are discussed as maternal factors.

3. Environmental and social factors: Natural disasters like drought,

floods, earthquake and human generated disaster such as wars can cause

undernutrition. The most affected are children and women. Poverty is the

reason that some families cannot produce or buy more food which leads to

malnutrition. In the present setting where the study was conducted there was

no incidents id not exposed to any type of natural disaster at recent times, this

factor is discussed under behavioural and health awareness factor.

The present study included the Nutritional factors, maternal factors and

behavioral and health awareness factors as basic factors responsible for

malnutrition among underfive children.

21

Nutritional factors included food habits, staple food, and number of

meals per day, how long the children got breast feed, specifies the age at

which weaning started.

Maternal factors included age at marriage, at the time of sickness of

the child whom do they consult, place of delivery, obstetrics problems,

antenatal check up, iron and folic acid tablets taken during pregnancy,

whether deworm done during pregnancy, contraceptive use, food choice

during pregnancy, acceptance of pregnancy, .

Behavioral and health awareness factors consisted of habits of

parents, decision maker to use money in family, health habits of care taker,

immunization status of the child, previous iron or vitamin therapy, exposure to

information on malnutrition to parents.

These are affected by inadequate or improper education of the family

members particularly of women, is often exacerbates their inability to generate

resources for improved nutrition for their families these leads to underlying

causes of malnutrition.

The present study assessed under lying causes of malnutrition grouped

under demographic factors, socio-economic factors, environmental and

epidemiological factors by structured questionnaire.

Demographic factors like age, gender, religion, number of under five

children in the family, birth weight of child, birth order of the child, spacing

between children, primary care taker and parental divorce can cause

malnutrition.

22

Socio-economic factors like type of family, education status of father

and mother, occupation of the father and mother, total family income in the

family per month in rupees and place of residence also influence malnutrition.

Environment and epidemiological factors such as type of house,

water supply, toilet facilities, crowdedness, method of refuse disposal,

frequency of diarrhea in preceding 2 weeks, seeking care for diarrheal

diseases, frequency of ARI in preceding 2 weeks, seeking care for ARI

conditions, manifestation of parasitic infection during the past 3 months,

regular deworming practices are important causes of malnutrition.

These factors in turns becomes immediate causes like inadequate

dietary intake and diseases due to malnutrition as per the model

Inadequate dietary intake The present study included (Micronutrient

Status/Supplementation) Feeding Patterns for Infants (below 6 Months: and

exclusive Breastfeeding, 6-9 Months, Complementary Feeding, 10-24 Months:

weaning and Continued Breastfeeding). Infections affect nutrient utilization.

Diseases due to malnutrition. Acute diarrhoea, or persistent diarrhoea,

respiratory infections, and helminthic infection contribute to malnutrition.

These are assessed by Identification of malnutrition. The present study

assessed the causes and severity of malnutrition by a Structured

questionnaire, anthropometric measurement and Bio chemical measurement

Thus the model reflects relationships of malnutrition described as mild,

moderate and severe whereas the present study investigated malnutrition

under stunting, under weight and wasting that is directly related to food intake

23

and infectious diseases such as diarrhea, acute respiratory infection, malaria,

and measles. Both food intake and infectious diseases reflect underlying

social and economic conditions at the household, and community that are

supported by nutritional, maternal, behavior and health awareness factors of

the individual or family within a community.

24

INADEQUATE EDUCATION

Figure:1.3. Conceptual framework based on UNICEF Malnutrition model

(1991)

Inadequate dietary intake Identification of malnutrition-

- Anthropometric measurement - Structured questionnaire - Bio chemical measurement (Hb)

Disease (Diarrhoea, helminthic infection,

history of immunization,, respiratory infections) assessed

by questionnaire

Immediate Causes

Malnutrition • Stunting • Under weight • Wasting

Underlying Causes

Environmental & epidemiological factors Type of house, water supply, toilet facilities, crowdedness, method of refuse disposal, diarrhea, ARI, seeking care, deworming assessed by questionnaire

Socio-economic factors

Type of family, education status of father & mother, occupation of father & mother, total family income in the family, place of residence assessed by questionnaire

Demographic factors Age, gender, religion, no.of under five, birth weight and birth order of the child, spacing, primary care taker assessed by questionnaire

Basic Causes

Maternal factors Age at marriage, BMI, place of delivery, health care, antenatal checkup, condition of mother &

child, contraceptive use, willingly accepted pregnancy, food choice assessed by questionnaire

Nutritional factors Food habits, staple food, no.of meals,

duration of breast feed, weaning assessed by

questionnaire

Behavioural & health awareness factors

Health habits, decision maker, immunization, exposure to information assessed by questionnaire

25

SUMMARY

This chapter dealt with Background of the Study, Need for the Study,

Statement of the Problem, Objectives, Operational Definitions, assumptions,

research Hypotheses, Delimitations and conceptual Framework.

OUTLINE OF THE REPORT

Further aspects of the study are presented in the following chapters

Chapter II : Review of Literature

Chapter III : Research Methodology which includes Research

Approach, Design, Setting, Population, Sample and

Sampling Techniques, Data Collection, Description of

Tools, Validity and Reliability of Tools, Ethical

considerations, Pilot study, Data collection procedures and

data analysis.

Chapter IV : Analysis and interpretation of data

Chapter V : Discussion of the Study, Summary, Conclusion,

Nursing implications, Recommendation and Limitations.

26

CHAPTER II

REVIEW OF LITERATURE

The purposes of an extensive survey of literature review are to identify as

what had been done in the past, what type approach, design and methodology

adopted, the various instruments used by previous researchers in their studies

that are similar to present study. Literature review involves identification,

selection, critical analysis and reporting of existing information on the topic of

interest. It also refers to activities involved in identifying and searching for

information and developing a comprehensive picture of the state of knowledge

on the topic.

In the present study the researcher carried out an extensive review of

literature related to the present study to obtain a deeper insight into the

problem under study and to collect maximum relevant information for building

up the study in a scientific manner so as to achieve the desired results.

THE REVIEW OF LITERATURE IN THIS CHAPTER HAS BEEN

PRESENTED UNDER FOLLOWING AREAS

The Literature related to:

1. Prevalence of Malnutrition

2. Contributing factors of malnutrition

3. Mortality and Morbidity of protein energy malnutrition

27

1. Studies related to Prevalence of Malnutrition

Chukwuma, (2015) carried out a cross-sectional descriptive study

among under-five children in households in rural communities in Imo State,

Nigeria. A multi-stage sampling technique was used for the selection of 416

subjects. Data was collected by anthropometric measurements as well as by

a semi-structured questionnaire to obtain caregivers’ information. The study

revealed that the prevalence of overweight/obesity, underweight, wasting

and stunting were, 9.8%, 28.6%, 23.6% and 28.1% respectively. The study

concluded that, there was high prevalence of malnutrition among under-five

children in the studied communities.

Ram Milan Prasad, et.al, (2014) found in their study, the prevalence of

PEM was 54.8%, Underweight 71.2% that was significantly higher in 1-3 years

children (p 0.001) as compared to 3-6 years children (46.6%) in rural

Lucknow, Uttar Pradesh. Girls (61.8%) were significantly more malnourished

than boys (48.6%) in all grade of underweight (p=0.008). PEM was

significantly higher in children belonging to Hindu religion, schedule caste,

nuclear family, among 3 siblings, illiterate father, lower socioeconomic status,

poor housing & environmental sanitation (p=< 0.05).

Egata .G, et.al., (2013) carried out a longitudinal study In Ethiopia on

influence of seasonal difference in the prevalence of under nutrition among

children aged 6 to 36 months. The aim of the study was to investigate the

prevalence as well as factors influencing undernutrition in wet and dry

seasons. Data were collected from 2,132 mother-child pairs using a pre-test

28

structured questionnaire and the UNICEF recommended anthropometric

measuring instruments after standardization. The prevalence of acute child

under-nutrition was 7.4%, in wet season and 11. 2 %, in dry seasons. Child

wasting was more common among children of poor households. Poverty and

poor access to health services were associated with wasting of children in

Ethiopia.

Chagas D.C, et al., (2013) conducted a household survey on the

prevalence, socioeconomic and demographic factors associated to

malnutrition and overweight among1214 under five children in the six largest

cities of Maranhao in 2006/2007. Two-stage cluster sampling was used to

select the samples. Standardized questionnaire was administered to mothers

or care takers to collect the data. Anthropometric measurement were taken.

The study revealed that children of families headed by women had lower

prevalence of malnutrition however socioeconomic variables were not

associated with malnutrition or overweight. Overweight among under five

children was more prevalent than malnutrition.

Uush .T, (2013) reported that The Fourth National Nutrition Cross-

Sectional Survey was conducted in 21 provinces of 4 economic regions of

Ulaanbaatar (Magnolia) in 2010 on under five aged children and non-pregnant

women of reproductive age. The study aimed to assess rickets and vitamin D

deficiency among the subjects. Clinical examinations were performed on 706

under five aged children and Interviews were used to assess vitamin D

supplement use. The serum level of 25-hydroxyvitamin D was measured in

29

women of reproductive age. This survey found that 21.8% of children had

vitamin D deficiency, 20.6% had low vitamin D reserve, and 30.0% of women

had vitamin D deficiency and 22.2% had low vitamin D reserve. The study

revealed that there was a high prevalence of classic signs and symptoms of

rickets in children of age under five years. The prevalence of vitamin D

deficiency in children was 35.0% and in women was 54.9%.

Hemant, (2013) reported that the prevalence of Sever acute malnutrition

in 300 children from Puducherry, India was found moderate wasting 26(8.5%),

moderate underweight 23(7.5%), severe underweight, 15 (4.9%), moderate

stunting 24(7.8%), severe stunting 17(5.5%).

Fahmina Anwar, et.al., (2013) found the prevalence of stunting,

underweight and wasting in Chiraigaon, Community Development block of

Varanasi district as 43.1%, 35.2% and 31.5%, respectively. The Composite

Index of anthropometric failure (CIAF) showed 62.5% of children suffering

from anthropometric failure. As much as 88 (42.9%) children were suffering

from malnutrition (<13.5cm). Nearly two thirds of the children were in the zone

of anthropometric failure.

Poonam, (2013) revealed that out of 150 children studied in urban slum

of Nagpur, the total prevalence of malnutrition was 63.33%. The factors

associated with malnutrition were low birth weight (85%), mother’s literacy

(77.78%), and father’s literacy (73.97), lack of exclusive breast feeding

(81.25%), socio-economic status (74.44%) and incomplete immunization

(76.19%).

30

Sanjana Gupta, et.al., (2013) in their study among under-five children in

a rural area of Jammu found the prevalence of malnutrition was 28.87%.

Majority were having Grade I malnutrition.

MeshRam, et.al. (2012) undertook community-based cross-sectional

survey; on Indian tribal population to assess trends in nutritional status,

nutrient and food intake among children of under five age for two years .The

samples were 14,587 children of 0-5 years old. The researchers assessed

underweight, stunting and wasting among subjects. The study revealed that

the prevalence of underweight was 49 %, stunting 51% and wasting was 22%.

Under nutrition among children was associated with literacy status of mothers,

household wealth index and morbidities.

Alom J, et.al., (2012) carried out a study to assess the nutritional status

of under-five children and investigated the influence of demographic,

socioeconomic, environmental and health-related factors on the nutritional

status among under-five children in Bangladesh. The researchers on analyses

revealed that 16% of the children were severely stunted, 25% were

moderately stunted, 3% were severely wasted, 14% were moderately wasted,

11% were severely underweight and 28% were moderately underweight. The

factors associated with malnutrition among the children were the child's age,

education of mother, education of father, father's occupation, family wealth

index, currently breast-feeding, and place of delivery.

Shit S,et.al. (2012) conducted a community-based cross-sectional study

to find out the prevalence of nutritional status by composite index of

31

anthropometric failure among 117 slum dwelling under-five children in

Bankura town, West Bengal and its association with selected common socio-

economic factors. The study revealed that, the prevalence of underweight was

41.6%, whereas composite index of anthropometric failure was 80.3%. The

factors associated with malnutrition were, children who were unimmunized,

with more number of siblings, living in a nuclear family, or with illiterate

mothers.

Mithun .S, (2012) conducted a cross-sectional study on prevalence of

malnutrition among 511 Mising children of Northeast India. The researcher

used four different sets of Body Mass Index references to study thinness and

overweight among children. The study found that the prevalence of thinness

varied from 17.18% to 27.73% among the boys and from 19.21% to 28.23%

among the girls. However the prevalence of overweight varied from 1.95% to

7.81% among the boys and 1.96% to 9.41% among the girls.

Raphael Babatunde, et.al. (2011) carried out a study on prevalence and

determinants of malnutrition among under-five children of farming households

in Kowari State, Nigeria. This study examined the prevalence and

determinants of malnutrition among under-five children of farming households.

Descriptive and regression analyses were used to analyze anthropometrics

data collected from 127 children selected randomly from 40 rural villages in

the State. Descriptive results indicated that 23.6%, 22.0% and 14.2% of the

sample children were stunted, underweight and wasted respectively.

Regression analysis showed that the significant determinants of malnutrition

32

were gender and age of child, education and body mass index of mother,

calorie intake of the households, access to clean water and presence of toilet

in the households.

Mulugeta .A, et.al. (2010) conducted a survey on child malnutrition in

Tigray-Northern Ethiopia. The main aim of the study was to estimate levels of

malnutrition and identify factors contributing to child malnutrition. 318 under

five children representing 587 randomly selected households were included in

the study. The study observed that 46.9%, 33.0% and 11.6% were stunted,

underweight and wasted, respectively. 80% of mothers initiated feeding of

newborns with pre-lacteal feeds primarily of butter or water. Family foods and

cereal-based porridge were the main complementary foods given to infants

after six months. Factors influencing malnutrion among the children were child

age, maternal anthropometric characteristics, inadequate complementary

foods, use of prelacteal feeds and area of residence.

Shubhada .S, et.al. (2009) carried out a cross sectional study in randomly

selected six villages in North India to estimate the prevalence, demographic

and socioeconomic factors associated with malnutrition. The prevalence of

malnutrition among the under five children were 50.46%. Children from lower

socioeconomic status, with low birth weight were significantly malnourished.

The study concluded that prevalence of malnutrition was very high in India;

especially in rural area.

Philomena Ochurus (2007) who carried out a cross-sectional

descriptive study at Namibia and assessed the prevalence of malnutrition

33

among 350 children between the age of one to five years and correlated

possible causes, with nutritional status. The Researcher studied the three

main indices of nutritional status of children: stunting, under weight and

wasting. The study revealed wasting rate 19.7%, caused by chronic

malnutrition, the stunting rate was 28.8% and underweight rate was 35.7%.

The prevalence of malnutrition among under five children in terms of age and

gender stunting 25 (30.5%) was observed in male children among 0-1 year

group. The same percentage with little difference was observed in 1-3 year

male children as 29.9% and 29.8% in female children. In female children

stunting was observed 35(28%) in 1-2 year age group followed by 7 (25%)

among 4 - 5year age group. Underweight was observed in both genders it was

more or less equal that is 41.5% in male and 41.6% in female. Underweight

was found in decreasing order of percentage in both male and female children

from 1 - 5 years.

Shanti G and Dheeraj .S, (2004) carried out a study on nutritional

problems in urban slum children revealed that protein energy malnutrition

(PEM), anemia and vitamin A deficiency were major problems. Apart from

these problems of faulty infant feeding practices, impaired utilization of

nutrients due to infections especially parasitic infections, inadequate food and

health security, poor environmental conditions and lack of proper child care

practices and place of residence like urban and slum areas.

Raja ram, et. al., (2003) studied the childhood malnutrition in Kerala and

Goa revealed that the confounding factors that influence the nutritional status

34

of children in these states was underweight and wasting, high in Kerala, but

the prevalence of stunting was medium.

Joseph B, et.al. (2002) conducted a study on prevalence of malnutrition

in rural Karnataka, South India: among 256 rural children below 5 years

belonged to Anganwadi schools. The prevalence of wasting, stunting, and

underweight was 31.2%, 9.4%, and 29.2% respectively. Wasting was more

predominant among the younger age groups. z

Abidoye and Sikabofori (2000) studied three hundred and seventy pre-

school children in rural Benue State, Nigeria on the prevalence of protein

energy malnutrition among the children and were observed 41.6% (154). One

hundred and fifty one (40.8%) of them was found to have weight-for-height

below -2SD indicating level of stunting among the children. This study also

showed the following factors were statistically significant with PEM:

educational status of mothers (p<0.05), marital status (p<0.05) of mothers,

occupational status of mothers (p=0.000), parental income per annum

(p=0.000), length of breastfeeding (p=0.000), water supply and regularity, type

of housing and toilet facilities.

2. Studies related to contributing factors of malnutrition.

Dechenla Tshering Bhuti (2014) in his article on Protein Energy

Malnutrition in India discussed PEM under three indices like underweight

stunting and wasting. The article revealed that prevalence of stunting among

under five was 48% and wasting was 19.8% and with an underweight

prevalence of 42.5%. With reference to various determinants of PEM the

35

article described that environmental factor including the physical and social

environment, behavioral factors, health-care service and biological factors.

Socio-cultural factors, low birth weight, infections, age of the child, mother’s

literacy and lack of proper health-care affects child’s nutrition. However there

was no impact of family income on child nutritional status.

Jai Prakash Singh, et. al., (2013) carried out a cross-sectional study

regarding nutritional status among under five children who were attending

OPD at a Primary Care Rural Hospital, Bareilly with the aims to determine the

stunting, wasting and underweight among 516 under five children and bio

social characteristics associated with malnutrition. Data was collected by

predesigned, pre-tested questionnaires from July 2013 to September 2013.

Children detailed history, and anthropometric measurements were taken . The

malnutrition was graded according to WHO classification. Total malnutrition

cases were 394 with a prevalence of 76.36% and were prevalent in male

children than females. The researchers observed that 53.86% children were

underweight, 43.22% children were stunted and 60.67% were wasted.

Malnutrition was more prevalent in 1-5 age group children. In conclusion, high

percentage of malnutrition was found in under five rural male children. The

percentage of malnutrition was increased, as age increased among under five

rural children.

Solomon Demissie, (2013) carried out a community based, cross-

sectional study to assess prevalence and the factors associated with

malnutrition in children 6-59 Months of age in Pastoral Community of Dollo

36

Ado District, Somali Region, Ethiopia. The sample size was 541 mother-child

pairs of 6-59 month old children. Anthropometric measurements of height and

weight of 541 study children were taken with physical examination to identify

the severe form of malnutrition and the socio-demographic characteristics of

the subjects were collected using a questionnaire. Both bivariate and

multivariate regression analysis used to find out the determinants of child

malnutrition. The study findings showed that the overall prevalence of

malnutrition in the community was high with 42.3% of the children being

wasted, 34.4% for stunting and 47.7% for underweight. All three forms of

malnutrition were more prevalent among boys than girls.

Basit .A, et.,(2012) carried out case control study among 162 children

aged one to five years attending the Pediatric outpatient department in six

rural health care centers in Udupi Taluka of Karnataka state with the

objectives of determining the risk factors for under-nutrition. A semi-structured

questionnaire was used to interview the caregivers of the children and the

nutritional status was graded as per IAP grading for PEM. The study found

that under-nutrition was associated with illness in the last one month [OR-

4.78 (CI: 1.83 -12.45)], feeding diluted milk [OR-14.26 (CI: 4.65 - 43.68)] and

having more than two children with a birth interval ≤2 years [OR- 4.93 (CI:

1.78 - 13.61)]. Lack of exclusive breast feeding, level of education of the

caregiver and environmental factors like source of water did not had an

association. Childhood illness, short birth interval and consumption of diluted

37

milk were some of the significant contributory factors revealed among this

population.

Rina Tiwari, et.al. (2011) identified factors associated with stunting and

severe stunting among 2380 children aged 0 to 59 months in Nepal. The

researchers identified the complete anthropometric measurements from the

2011 Nepal Demographic and Health Survey (NDHS). On multiple logistic

regression analyses the study revealed that the prevalence of stunting and

severe stunting were 26.3% [95% confidence Interval (CI): 22.8, 30.1] and

10.2% (95%CI: 7.9, 13.1) for children aged 0–23 months, respectively, and

40.6 (95%CI: 37.3, 43.2) and 15.9% (95%CI: 13.9, 18.3) for those aged 0–59

months, respectively. The study identified that poorest households and

prolonged breastfeeding more than one year led to increased risk of stunting

and severe stunting among Nepalese children.

Janevic .T, et.al., (2010) carried out a study in Roma settlements in

Serbia on risk factors for childhood malnutrition. The objective of the study

was to identify risk factors for malnutrition among 1192 under five aged

children. Anthropometric and socio demographic measures were collected On

multiple regression analysis the study revealed the prevalence of stunting,

wasting, and underweight was 20.1%, 4.3%, and 8.0%, respectively. The

factor associated with stunting was maternal education, and maternal literacy

was significantly associated with wasting.

Harsha .A, et.al., (2008) conducted a study on the determinants of child

weight and height in Sri Lanka. Using quantile regressions, this study explored

38

the effects of variables such as a child’s age, sex, birth order, household

expenditure per capita, parental schooling, and infrastructure on child weight

and height at different points of the conditional distributions. The study

showed that all the above factors had effect on weight and height of children.

Israt and Sekander (2006) conducted a study on factors influencing

malnutrition among under five children in Bangladesh. The researchers

studied impact of demographic, socioeconomic, environmental and health

related factors on nutritional status by using Bangladesh Demographic and

Health Survey 1999-2000 (BDHS) data. The study revealed that 45 percent of

the children under age five were suffering from chronic malnutrition, 10.5

percent were acutely malnourished and 48 percent had underweight problem.

Previous birth interval, size of the baby at birth, mother’s body mass index at

birth and parent’s education were observed as some of the determining

factors for malnutrition among under five children.

Mary J and Trudy H. (2006) studied the association of maternal social

capital and child nutritional status in four developing countries revealed that

social capital had been shown to be positively associated with a range of

health outcomes.

Salah E.O, et. al., (2006) conducted a cross-sectional descriptive survey

on factors affecting prevalence of malnutrition among children under three

years of age in Botswana with the objective to evaluate the level of

malnutrition and the impact of some socio-economic and demographic factors

of households on the nutritional status of children under 3 years of age. The

39

sample size was four hundred households and mothers of children under

three. The findings revealed that the level of wasting, stunting, and

underweight in children under three years of age was 5.5 %, 38.7 %, and 15.6

% respectively. Malnutrition was significantly higher among boys than among

girls (p < 0.01). Underweight was prevalent among children whose parents

were involved in informal business, children reared by single parents, family

income, mother’s education and breastfeeding practices.

Michelle Bellessa .F et.al.,(2005) conducted a study to assess an

association of Maternal education and child nutritional status in Bolivia: The

study focused on collecting data based on socioeconomic status, health

knowledge, modern attitudes towards health care, female autonomy, and

reproductive behavior. Logistic regression revealed that socioeconomic

factors, maternal education and attitude about health care. And health care

knowledge had 60 percent effect of maternal education on child nutritional

status.

Silva, (2005) did a study on effect of environmental factors and children’s

malnutrition in Ethiopia. The researcher used the Ethiopia Demographic and

Health Survey data (2000) and studied the influence of access to basic

environmental services, such as water and sanitation; on stunting and

underweight. The study revealed that biological factors such as child’s age

and mother’s height, social economic factors such as household wealth and

mother’s education, environmental factors such as access to water and

40

sanitation at the community level were the determinants of underweight

among children below five years.

Bloss, et.al., (2004) carried out a cross-sectional survey to assess the

health and nutritional status of 175 children below 5 years in three villages in

Siaya District of western Kenya during the year 2002. The researchers

interviewed 121 Primary caretakers of children during home visits to explore

agricultural and sanitation resources, child feeding practices, and the

nutritional status of their children. The prevalence of underweight, stunting and

wasting was determined through anthropometric measurements: The study

revealed that 30 per cent of children were underweight, 47 per cent were

stunted, and 7 per cent were wasted. The factors associated with

undernutrition were age, sex, and SES. Other findings were children in their

second year of life were more prone underweight and stunted, children who

were introduced to supplementary foods early had an increased risk of being

underweight, upper respiratory infections or other illness in the past month

predicted underweight and living with non-biological parents significantly

increased risk of stunting.

Jayanta .B, et.al., (2004) studied the relationship of nutritional status,

poverty and food insecurity for household members of various ages. The

study revealed that poverty is predictive of poor nutrition among pre-school

children.

Radhakrishna and Ravi (2004) carried out a study on the trend analysis

of Malnutrition in India and their determinants showed that level of malnutrition

41

was high among half of the preschool children who were malnourished and

were exposed to the risk of functional impairments. Some middle-income

states such as Kerala and Tamilnadu have comparatively better nutritional

achievements than higher income states like Maharashtra and Gujarat.

Northeastern states were comparatively better performing states and some of

them had even out-performed Kerala.

Uma Sanghvi, et. al., (2004) conducted a study to assess the potential

risk factors for child malnutrition in rural Kerala. Risk factors for underweight

status in children under 3 years of age were assessed. Mothers of 34 children

weighing below -1 SD for their age and 59 children weighing more than 1 SD

for their age, were interviewed to reveal maternal health information, child

feeding practices, number of sibling, gender and age data. On statistical

analysis the study showed that current maternal weight, maternal body mass

index, infant birth weight and excessive maternal vomiting during pregnancy

were significant risk factors for current child underweight status.

Chen M, et. al., (2003) undertook a study in order to analyze the major

factors contributing to malnutrition of children aged under five at 40 inspective

spots. The results revealed that the determining factors of child malnutrition in

urban is less than in rural children, education level of mother, breast feeding

and water supply.

Khadka, et.al.,(2003) conducted a study to assess the impact of socio

economic and maternal determinants on the nutritional status of 2372 children

less than 5 years of age in an urban African area. The random sample of 1368

42

households by home visits and anthropometric measurements were

performed using standardized procedures on preschool children and 1512

mothers. The result of this study revealed that socio economic factors had

impact on the nutritional status of children.

3. Studies related to mortality and morbidity about protein energy

malnutrition

WHO (2016) reported that the leading causes of death in children under

5 years are preterm birth complications, pneumonia, birth asphyxia, diarrhoea

and malaria. About 45% of all child deaths are linked to malnutrition. It was

found that the decline in neonatal mortality from 1990 to 2015 has been

slower than that of post-neonatal under-5 mortality, 47% compared with 58%

globally. If this current trend continues, around half of the 69 million child

deaths between 2016 and 2030 will occur during the neonatal period.

UNICEF (2016) reported that undernutrition contributes to nearly half of

all deaths in children of under 5 and is widespread in Asia and Africa.

The Times of India (2015) reported that India has the highest number of

deaths of children of under five years of age. A new policy paper said that it

accounts for 50% of such deaths caused mainly due to malnutrition. One in

every 21 children being born in India are dying before reaching their fifth

birthday as the country recorded the highest number of under five deaths in

2015 globally. The under-five mortality rate (U5MR) in India is about seven

times higher than in high-income countries where 1 in 147 is dying.

43

Tendai Munthali, et.al., (2015) conducted a study on Mortality and

morbidity patterns in under-five children with severe acute malnutrition in

Zambia: a five-year retrospective review of hospital-based records (2009–

2013) and found that an overall (n = 9540) under-five children with severe

acute malnutrition were admitted during the period under review, comprising

5148 (54%) males and 4386 (46%) females. Kwashiorkor was the most

common type of severe acute malnutrition (62%) while diarrhoea and

pneumonia were the most common co-morbidities. Overall mortality was

found to be 46% with children with marasmus having the lowest survival rates

on Kaplan Meier graphs.

Shaili, et.al., (2014), conducted a study on morbidity profile and

associated risk factors for malnutrition in a rural area of Dehradun and found

that out of 500 under children of three years of age 47.9% had diarrhea,

22.21% had ARI and 9.21% children had worm infestation.

Lawoyin (2013) conducted a Case-Control Study on Morbidity and

mortality rates associated with malnutrition among under-five-Year olds in an

Inner City Community in Ibadan. The study observed that morbidity rate was

associated with malnutrition in the under-five-year children were high

especially among children from the low socio-economic strata. A significantly

higher proportion of subjects than controls had primary caretakers who were

not their parents (16.9 percent vs 6.2 percent; p<0.0001), and were

commenced on complementary diet earlier (t=2.06, p=0.04). There were no

significant differences in morbidity pattern among subjects and controls for

44

fever, acute respiratory tract infections and diarrheal diseases (p>0.05). In the

case-control analysis, low paternal education (incomplete primary school

education and less)(p<0.0001), not being up to date with immunization

(p=0.037), and starting complementary feeds before the age of six months

(p=0.026), were associated with an increased risk of malnutrition. When

confounding covariates were controlled in multivariate analysis, only age less

than six months at adding complementary feeds was significant (p=0.038).

Saju, (2012) reported that malnutrition constituted 22% of the country’s

disease burden because it severely weakens a child’s immune system, raising

their mortality rates from common diseases such a pneumonia, malaria,

measles and diarrhoea. Children with SAM (Severe Acute Malnutrition) have

extremely high mortality rates between 20-30% - a rate of death approximately

20 times higher than wee-nourished children. A recent report estimated that

37% deaths registered between 0-4 years in Madhya Pradesh were due to

chronic hunger and malnutrition. It is found that backward classes especially

Scheduled Castes (SC) and Scheduled Tribes (ST) were the worst affected in

the state. Incidentally, these two communities constitute a sizeable chunk of

the state’s population. Tribal communities in Madhya Pradesh are the most

marginalized communities in the country, having almost zero access to any

health services and also the worst development indicators in the country. In

Madhya Pradesh the percentage of underweight children is 51.9 where as the

prevalence of stunting and wasting is 48.9% and 25.0% respectively.

45

Salman Shah, (2011) conducted a study on determinants of child

mortality and concluded that out of the 700 live births, 82 deaths among under

- five children were caused due to birth asphyxia, diarrhea, pneumonia,

prematurity (including Low birth weight) and malnutrition. The deaths in

children 1-5 years age group were mainly due to diarrhoea, malnutrition,

pneumonia and meningitis.

UNICEF, (2009) reported that India is home to 40 % of worlds

malnourished children and 35% of developing world low birth weight infants.

Every year 2 million children die in India, accounting for one in five child

deaths in the world. India ranks 117th of 119 countries on child malnutrition,

right before Bangladesh and Nepal and after countries such as Sudan,

Cambodia, and Ethiopia.

Worlds children’s reports (UNICEF 2008 ) shows India has the worst

indicators of child malnutrition in South Asia. It claimed that 50 million of

Indian children were affected by malnutrition and 48% of under fives in India

were stunted, compared to 43% in Bangladesh and 37% in Pakisthan

Vivian, et.al., (2006) examined 140 out of the 1,450 patients admitted

during the period of their study, found severe anemia (prevalence 9.7%) and

malaria either alone or in combination was the found to be the most common

cause of severe anemia [n=90 (64.3%)]. 117 patients (83.6%) recovered,

while 4(2.8%) left against medical advice and 19 died (case fatality rate

13.6%). The variables associated with mortality were malnutrition (P=0.02),

tachycardia (P= 0.03), coma (P<0.001), and absence of blood transfusion

46

(P=0.001). On logistic regression analysis coma (P=0.002), not receiving

blood transfusion (P=0.002) and female gender (P=0.04) predicted poor

outcome were the findings.

Ray S. K, (2005) carried out a study on action for tackling malnutrition:

and growth monitoring or surveillance. Mortality due to malnutrition is a multi-

causal factor in which malnutrition is an important factor directly or indirectly

contributing 55% mortality of children under-five years of age with specific

reference to girl child, under 3 years of age. The families, where there were

large number of children.

Cartmell, et.al.,(2005) conducted a study with 7631 children in Nairobi,

Kenya, between April 2002 and April 2005 with a diagnosis of measles, 7447

cases had the diagnosis confirmed clinically. Only children with some

secondary complications were admitted. An attempt was made to record the

age, weight, and sex of every patient. Children were then divided into age

groups and their nutritional status was rated according to the Wellcome

classification. The youngest child was a 2-week old neonate whose 20-year

old mother had measles. The peak age was 7-12 months accounting for 39%

of all children, while 9.8% were aged under 6 months. The highest mortality

was recorded in children aged 12 months and below who accounted for 43.5%

of the deaths. The weight of 5961 (80%) children were obtained. 4872 (82%)

had weight for age less than 80% of the Harvard median. 46% of 2697

children were actually marasmic (they had weight for age less than 60% of the

Harvard median) and 2175 (36%) children were underweight with some

47

having overt Kwashiorkor. Patients whose weight for age was less than 60%

of the Harvard median had the highest duration of hospital stay with total

patient days of 4997 and a mean duration of stay of 4.0 days. The overall

mortality rate was 17.5/1000 admissions. The mortality rate was highest

among marasmic children with 39.6/1000 admissions. Children who were

underweight had an overall mortality of 14.3/1000 admissions, while those

whose weight for age was normal had a mortality rate of only 7.4/1000.

Vijay, et.al.,(2004) in their study on pattern of morbidity and mortality

amongst under fives in an urban resettlement colony of East Delhi concluded

that more than half of the children (53.7%) were suffering from some form of

illness. Acute respiratory infections were the most common cause (16.01%)

followed by diarrhea and malnutrition (10.2%). A total of 7 deaths were

reported, 3 were infant deaths of which 2 were neonatal deaths.

Shanti, (2000) in a study of morbidity in preschool age children

concluded that out of 1.349 children examined 15(25%) girls and 25 (3.3%)

boys did not had any disorder. Anemia and worm infestation were found more

significant in girls (p<0.05) while Vitamin A deficiency were found significant in

boys (p<0.05).

Amy .L, et.al., (2000) reported in their study titled malnutrition as an

underlying cause of childhood deaths associated with infectious diseases in

developing countries observed that there is a strongest and most consistent

relation between malnutrition and an increased risk of death was observed for

diarrhoea and acute respiratory infection. The evidence, although limited, also

48

suggests a potentially increased risk for death from malaria. A less consistent

association was observed between nutritional status and death from measles.

Although some hospital-based studies and case–control studies reported an

increased risk of mortality from measles, few community-based studies

reported any association

SUMMARY

This chapter dealt with the review of research literature related to the

problem stated. It helped the researcher to understand the impact of the

problem under study. It has also enabled the investigator to design the study,

select conceptual framework, develop the tools and plan for data collection

procedure and various methods to analyze the data. Though food products

are grown in the country in an increased manner, the poverty and malnutrition

is still prevalent in many parts of the country including Kerala State.

Next chapter will focus on Methodology

49

CHAPTER III

METHODOLOGY

This chapter on Methodology of research is very vital part of the

research report as it is a blue print of the research study under investigation.

This chapter include research approach, design of the study, variables

under investigation, setting , description of population, sampling, instruments

used in the study, and their validity and reliability, ethical consideration, pilot

study, method of data collection and plan for data analysis.

3.1 RESEARCH APPROACH

A quantitative research approach was used by the investigator because

the main objective of the investigation was to assess the prevalence and the

contributing factors of malnutrition among children below five year of age,

3.2 RESEARCH DESIGN

Research design is a blue print for conducting the study that maximizes

control over factors that could interfere with the validity of the findings (Nisha,

2015). A cross sectional non experimental descriptive survey design was

adopted for the present study.

3.3. VARIABLES UNDER STUDY

3.3.1. Background variables

Demographic variables of under five children that included personal

profile of the child, socio-economic, environmental, epidemiological, behavior

and health awareness and Nutritional factors; anthropometric measurements;

hemoglobin level and maternal factors

50

3.3.2 Study variable

Malnutrition (Stunting, Wasting and Underweight.)

3.4. SETTING OF THE STUDY

The study was conducted in selected Panchayats of

Thiruvananthapuram district. Thiruvananthapuram District is the southernmost

district of the coastal state of Kerala, in South India. Thiruvananthapuram

district has 12 blocks and 77 Panchayats with a child population (0-6 years) of

3, 07,061 (census 2011). The setting includes both rural and urban population.

These Panchayats were selected by simple random sampling method.

3.5. POPULATION

According to Burns.N. (2002), the population is the entire group of

persons or objects being studied and is often referred to as the universe or the

target population.

The population for the present study was all the under five children

residing in Thiruvananthapuram district. The accessible population was

selected who met inclusion criteria.

51

Figure: 3.1.Schematic Representation of Research Methodology

3.6. SAMPLING

3.6.1 Sample.

The under five children from the population who met the inclusion

criteria were eligible as samples and selected as study samples for the study

3.6.2. Sampling Technique

Target population All the underfive children residing in

Thiruvananthapuram district

Design Cross Sectional Descriptive Survey

Sampling Technique and Sample Size Multistage random sampling and

Systematic random sampling technique (Total Sample = 1000)

Data Collection Instruments Structured interview schedule to assess the demographic data

of child and clinical data of mother Anthropometric measurements

Biochemical measurement of Haemoglobin

Analysis and Interpretation Descriptive and inferential statistics

Accessible Population Under five children in Thiruvananthapuram district who fulfilled the inclusive criteria

52

Multistage simple random sampling technique was used to select the

samples for the present study. There are 12 blocks in Thiruvananthapuram

district, having 77 Panchayats in total. In the first stage, by using simple

random sampling technique five blocks were selected for the study. Each

block consists of 5-8 Panchayats. In second stage, by simple random

sampling technique one Panchayat from each block was selected. In the third

stage, by systematic random sampling technique 200 samples from each

Panchayats were selected who fulfilled the inclusion criteria. The

diagrammatic presentation of sampling technique is presented below in Fig.

3.2

53

I stage

II stage

III stage

Figure 3.2. Schematic Presentation of sampling technique.

3.6.3. Size of the Sample.

Sample is the subject of the population selected for a particular study

and the members of a sample are the subjects (Burns.N, 2002).

The sample size was calculated by using the formula. Daniel WW (1999

and Yamane, T. (1967)

12 BLOCKS

TRIVANDRUM DISTRICT

I (2)

II (6)

III (7)

IV (6)

V (7)

VI (8)

VII (7)

VIII (5)

IX (8)

X (8)

XI (6)

XII (7)

Total Panchayats in each blocks presented in bracket

IV.ATHIYANOOR Athiyanoor Kanjiramkulam Karimkulam Kottukal Venganoor Vizhinjam

VIII. NEDUMANGAD Anadu Aruvikara Karakulam Panavoor Vembayam

IX.VELLANADAryanad Kattakada Kuttichal Poovachal Tholicode Uzhanakan Vellanadu Vithura

XI.PARASSALAChenkal, Karodu, Kulathoor Parassala Poovar Thirupuram

XII.PERUNKADAVILA Amboori Arayancode Kallikadu Kollayil Kunathukal Ottasekharam Perunkadavila Vellarada

FIVE BLOCKS SELECTED BY SIMPLE RANDOM SAMPLING

BY SIMPLE RANDOM SAMPLING TECHNIQUE ONE PANCHAYAT FROM EACH BLOCK WAS SELECTED, AS SUCH ONE URBAN AND FOUR RURAL

PANCHAYATS WERE SELECTED

BY SYSTEMATIC RANDOM SAMPLING 1000 SAMPLES WERE SELECTED FROM FIVEPANCHAYATS (200 samples from each Panchayats )

54

Z∞2 p(1 – p

N=-----------------------------

d2

Where n = Sample size

Z∞ = Z statistics for a level of confidence

P = Estimated proportion of an attribute present in the

population

d = Level of precision

Example: -

p = 0.33 (Prevalence of malnutrition for under five children)

d = 10% of p = 0.033

Z∞ = 1.96 for ∞ = 0.05

=780

Thus Sample size calculated was 780.

Attrition rate found in the pilot study =14%=110

Final sample size for the study considering 14% attrition rate) =780+110 =990,

but to make it as a round figure, total sample size was taken as 1000

3.6.4. Criteria for selection of study samples

Following were the inclusion criteria framed for the present study

• Under five children of both gender.

(1.96)2 x (0.33) x (0.67)

(0.033)2

N =

55

• Parents of under five willing to participate in the study.

• Parents of under five who were able to understand Malayalam.

• Parents of under five who were residing in the study setting.

Exclusion criteria

• Parents who’s under five children were sick.

• The parents of under five who were exposed to any information of

nutrition and rearing of children.

3.7. DEVELOPMENT OF TOOLS

Tools Used For the Study

Part I Section A: Structured interview schedule to collect data regarding back

ground characteristics of child that included demographic (personal)

characteristics of child, socio economic, environmental and epidemiological

factors, behavior and health awareness of parents and nutritional factors of

the child.

Part II: Anthropometric measurements (Height / Length, weight, BMI, Mid Arm

Circumference (MAC) measured with weighing machine, infantometer and

tailor’s inch tape.

Part III: Biochemical measurement of Hemoglobin (Sahli’s hemoglobinometer)

Part IV: Questionnaire to collect maternal clinical factors.

Preparation of the Tools

The investigator followed the following steps to develop tools

• Review of related literature.

• Preparation of blue print.

56

• Consultation with subject experts.

• Preparation of the final draft of the tools.

• Editing of the tools.

Review of literature

The investigator reviewed related books, journals, manuals, reports,

articles, published and unpublished research studies and news papers and

Web references to develop the tools.

Preparation of the blue print

The blue print of items was prepared as per objectives and theoretical

framework. The blue print included demographic variables of under fives,

clinical variables of mothers, anthropometric measurements, biochemical

measurement of hemoglobin.

Consultation with experts from the field

The tools were sent to the experts in various fields such as Community

Health Nursing, Child health Nursing, Social and Preventive Medicine,

Pediatrics Nutrition and Statistics. Their recommendations were incorporated

before constructing the final draft.

3.8. DESCRIPTION OF THE TOOL

3.8.1 Structured interview schedule to collect data regarding the back ground

characteristics of under five aged children

Part I - Back ground characteristics consisted of 38 items under following

heads:

57

A. Demographic characteristics (Personal factors) include nine items

consisted of age, gender, religion, number of underfive in the family, birth

weight of child, birth order of the child, spacing between children, primary

care taker and parental divorce.

B. Socio-economic characteristics include seven items consisted type of

family, education status of father and mother, occupation of the father

and mother, Total family income in the family per month in rupees and

place of residence.

C. Environment and epidemiological characteristics include eleven items

consisted of type of house, water supply, toilet facilities, crowdedness,

method of refuse disposal, frequency of diarrhea in preceding two weeks,

seeking care for diarrheal diseases, frequency of ARI in preceding two

weeks, seeking care for ARI conditions, manifestation of parasitic

infection during the past three months, regular deworming the child at

every six months.

D. Behavioural and health awareness characteristics include six items

consisted of habits of parents, decision maker to use money in family,

health habits of care taker, immunization status of the child, previous iron

or vitamin therapy, exposure to information on malnutrition to parents.

E. Nutritional characteristics include five items consisted of food habits,

staple food, number of meals per day, how long the children got breast

feed, specify the age at which weaning started.

Frequency and percentage were used to compute the data

58

Part II. Anthropometric measurements

The investigator herself has assessed the following measurements by

measured with calibrated weighing machine, infantometer and tailor’s inch

tape.

1. Weight

2. Height/ length

3. BMI

4. Mid arm circumference

Scoring of Anthropometric measurements of under five children was done as

per WHO classification of malnutrition based on three indices analyzed using

Z score, Mid arm circumference was analyzed as per IAP classification

(12.5 cm - Severe malnourished, 12.5-13.5cm -Mild to Moderate

malnourished, 13.5 cm – Normal).

Classification of malnutrition for weight for height, height for age and

weight for age based on Z-score. (WHO 2010)

( Z-score = Measured value – Median of reference population ) Standard deviation of the reference population

Sl No. Items Scoring

1 Height for age

-2 < Z-Score < + 2 - Normal -3 < Z-Score < - 2 - Moderate stunting Z-Score < - 3 - Severe stunting.

2 Weight for age

-2 < Z-Score < + 2 - Normal -3 < Z-Score< - 2 - Moderate underweight Z-Score < - 3 - Severe underweight

3 Weight for height -2 < Z-Score < + 2 - Normal -3 < Z-Score < - 2 - Moderate wasting Z-Score < - 3 - Severe wasting

3 Mid arm circumference(IAP)

<12.5 cm – Severe malnourished 12.5–13.5cm–Mild to Moderate malnourished, > 13.5 cm – Normal.

59

Part III. Biochemical measurement of Hemoglobin

The investigator used Sahli’s hemoglobinometer to collect blood to test

hemoglobin WHO norms was used scoring

Scoring

>10 gm% : Mild anemia

10gm – 7gm% : Moderate anemia

< 7 gm% : Severe anemia

< 5gm% : Very severe anemia

Part IV: interview questionnaire consisted of 13 items pertaining to the

Clinical data of mother developed by the researcher such as age at marriage,

BMI of the mother, at the time of sickness of the child whom do they consult,

place of delivery, condition of last two children, obstetrics problems, antenatal

check up, iron and folic acid tablets taken during pregnancy, whether deworm

done during pregnancy, medical condition of the mother, post natal

complications, contraceptive use, food choice during pregnancy if any,

willingly accepted each pregnancy or not

Frequency and percentage were used to compute the data

3.9. VALIDITY AND RELIABILITY

3.9.1. Validity

All the tools were validated by experts from the field of community

nursing, social and preventive medicine, nutritionists, obstetrician,

pediatrician, pediatric nursing and statistician. The tools were modified

according to the suggestions given by experts.

60

3.9.2 Reliability of the Tools

Reliability is the degree of consistency with which an instrument

measures the target attributes to which it is designed It is the major criteria for

assessing the quality and adequacy of an instrument (Dennis F.Polit and

Cheryl Tatano Beck 2008)

The investigator assessed the reliability of the weight of under fives, by

pediatric weighing machine, length/ height by infanto meter / height measuring

stand The Inter rater reliability for all the above instruments were found r=1.

Mothers’ weight was measured by calibrated adult weighing machine and

the reliability of Body Mass Index (BMI) calculated by the investigator as

mothers’ weight in kilogram divided by the square of their height in meters.

The inter rater reliability showed r=0.99

The reliability of Mid Arm Circumference was measured by stretchable

inch tape. The inter rater reliability showed r=1.

2. Reliability of the Sahli’s hemoglobinometer.

To test the reliability of the Sahli’s hemoglobinometer, the capillary blood

was collected and tested for Hb in gms for four times simultaneously in the

same hemoglobinometer showed r=1 Hence the Sahli’s hemoglobinometer

used for data collection was considered as reliable.

3. Reliability of the structured interview schedule.

Inter rater reliability was carried out to test the structured interview

schedule and found r=0.9.

61

3.10. TRANSLATION OF THE TOOLS

Validated tools were translated into Malayalam and again it was back

translated into English to determine its correctness in Malayalam translation to

obtain required information and again the reliability was checked and was

found 0.96.

3.11. PREPARATION OF THE FINAL DRAFT OF THE TOOLS

Final drafts of the tools were prepared after testing the validity and

reliability of the tools In consultation with all the experts and the research

guide the tools were finalized.

3.12. ETHICAL CONSIDERATION

The problem was approved by the protocol committee of the University

and the hospital ethical committee where the researcher’s work setting is

attached. The investigator followed the ethical principles preceding the

investigation. The investigator adhered to the following actions in order to

protect the ethical rights of the under fives and their mothers.

Human right

Human right principle was kept in mind by the investigator by taking a

written consent from the Panchayat presidents to conduct the study. The

mothers were given full information about the study Informed consent was

obtained from mothers of under five before proceeding the study under study.

The Content validity was done by the experts in the field, Community

health nursing, Social and preventive medicine Pediatrics, Nutrition, and Bio

statistician.

62

Dignity of the subjects

Parents were explained the information sheet regarding the purpose,

type of data and procedures done, and the nature of their obligation towards

the study before taking their consent to participate in the study.

Pilot study was executed to check the feasibility and time requirement to

continue the study.

Mothers of under fives were given the right to withdraw at any point of

time without assigning reasons.

Investigator’s contact information was disseminated to all the mothers

who participated in the study and freedom to interact and clarify the doubt with

the investigator was allowed.

Confidentiality

Confidentiality and anonymity was ensured through a pledge.

INTERRATER RELIABILITY

Prior to pilot study, the investigator trained a public health nurse to collect

accurate and relevant data along with the investigator. The inter rater

reliability was found 99%.

3.13 PILOT STUDY

Pilot study was conducted from January 2014 to April 2014. For pilot

study the investigator selected Balaramapuram panchayat under Nemon

block, Thiruvananthapuram. Before proceeding for pilot study a written

permission was obtained from the Panchayat president. A written consent

from mothers of under five children was taken. Total 100 under five children

63

were selected for the pilot study. The ethical aspect of the study was kept in

mind. The purpose of the study was explained to the mothers of the subjects.

The demographic data of mother and child was assessed by structured

interview schedule, height, weight, mid arm circumference and Hemoglobin

was checked and recorded. it took 60-75 minutes to collect the data and to

conduct interview schedule for each sample. Each day two to three samples

were assessed. Analysis was done to assess feasibility of continuing the main

study and it was found feasible for conducting main study in terms of study

instruments, timings and cooperation from samples. The researcher could not

complete the assessment of 14 (14%) samples because of various reasons

such as the sickness of the samples,(4) moved to city and not found at home

(6)mothers sickness(2) did not cooperate (2)

The samples used for Pilot study were excluded from the main study. .

3.14 DATA COLLECTION PROCEDURE

The data was collected from 1000 samples during 02.01.2015 to

15.12.2015. A written permission was taken from the presidents of all selected

Panchayats of Thiruvananthapuram, The investigator collected data in a

planned manner .From each Panchayats data collected from 200 samples in

10 weeks/20samples a week/3-4 samples per day excluding Sundays .As

such 1000 samples completed in 50 weeks from 5 Panchayats.

The mothers were explained about the information sheet and

permission from mothers was taken to participate in the study voluntarily The

investigator developed rapport with the mothers and explained the procedure

64

of data collection The interview was conducted in Malayalam Language that

took 20 minutes According to the age of the child, length / height was taken

with care that was completed in 15-20 minutes Then the weight was assessed

and that took 20 minutes Mid arm circumference was measured in 10-12

minutes and Hemoglobin was measured within 5-10 minutes Totally the

investigator spent 70-75 minutes to conduct interview, assess anthropometric

measurement and hemoglobin The data collected were recorded

simultaneously.

3.15. PLAN FOR DATA ANALYSIS

The study is planned to utilize descriptive and inferential statistics to

analyze the data collected. Demographic data will be analyzed using

frequency and percentage. The contributing factors of malnutrition will be

analyzed using inferential statistics.

The association is planned to analyze by univariate analysis by Pearson

Chi square test and the influencing factors by assessing Odds Ratio with 95%

Confidence interval [OR (95% CI)]

65

SUMMARY

Research approach and research design, variables under the present study,

study setting, , target and accessible population, Sampling, development and

description of study instruments, validity and reliability of the tools developed,

pilot Study, method of data collection and plan for data analysis were

described in the chapter.

The next chapter will focus on analysis of data collected and interpretation of

findings.

66

CHAPTER IV

ANALYSIS AND INTERPRETATION OF DATA

INTRODUCTION

The chapter deals with analysis and interpretation of data collected from

1000 samples to analyze the prevalence and contributing factors of

malnutrition among under five children at Trivandrum district

Data analysis is the systematic organization and synthesis of research

data and testing of hypothesis using data (Polit). Descriptive statistics allows

the researcher to summarize, describe the quantitative data and inferential

statistics used to determine the relationship and causality (Polit)

Data was computed after transferring the collected data in to a coding

sheet. The research data was processed, grouped organized and analyzed in

systematic manner, and presented in the form of tables, figures, texts and

diagrams. The data were entered into Excel Sheet and analyzed through

statistical package for social science / PC+ Ver.17.

The researcher used both descriptive and inferential statistics. To

analyze the data, demographic variables were assessed using frequency with

their percentages. The anthropometric measurements were given in mean

and standard deviation.

The contributing factors of malnutrition were analyzed using multiple

logistic regression, univariate analysis. The association was studied by

univariate analysis by Pearson Chi square test and the influencing factors was

assessed by using Odds Ratio with 95% Confidence interval [OR (95% CI)]

67

OBJECTIVES OF THE STUDY










68

ORGANIZATION AND PRESENTATION OF DATA

The findings of the study are organized and presented under following

sections.

Section I: Background characteristics of the children and mothers.

Distribution of under five children according to Demographic characteristics,

Socio economic characteristics, Environment and epidemiological

characteristics, Behavioral and health awareness characteristics, Nutritional

characteristics and Clinical factors of mother.

Section II : Prevalence of malnutrition among under five children

Section III : Association of malnutrition among under five children with their

demographic variables

Section IV : Association of malnutrition among under five children with their

anthropometric measurement

Section V : Association of malnutrition among under five children with their

hemoglobin status

Section VI : Association of malnutrition among under five children with the

clinical variables of their mother

Section VII : Overall contributing factors (determinants) of malnutrition

among under five children.

69

Section I: (A) Description of Background characteristics of the children

and mothers

Table 4.1.1 Percentage distribution of demographic characteristics in

terms of gender, religion, birth weight of the child, spacing between

children and parental divorce. N=1000

Demographic characteristics n % Gender Male

Female

434

566

43.4

56.6

Religion Hindu

Christian

Muslim

126

788

86

12.6

78.8

8.6

Birth weight of child Normal

Below normal

934

66

93.4

6.6

Spacing between

children

One year

Two years

Three years

>3 years

424

427

122

27

42.4

42.7

12.2

2.7

Parental divorce Yes

No

7

993

0.7

99.3

The above table 4.1.1 reveals that majority 566 (56.6%) of the children

were female. In terms of religion, majority of the children 788 (78.8%)

belonged to Christian community, remaining 126 (12.6%) and 86 (8.6%) of

them belonged to Hindu and Muslim community respectively. With reference

to the birth weight of children most of them 934 (93.4%) were found normal.

Majority 427 (42.7%) of the family were having two year spacing between

children. Most of them 993 (99.3%) lived with their father and mother and rest

of them 7(0.7%), parents were separated.

Fig: 4.1

to their

Wi

observe

number

years.

0

5

10

15

20

25

30

35

Perc

enta

ge o

f und

er fi

ve

1.1 Percen

r age.

ith referen

ed in the a

r 60(6.0%)

20.7%

0

5

0

5

0

5

0

5

0-1 ye

ntage wis

ce to age

age group

) of childre

%23

ear 1.1-2

se distribu

group of

of 2.1 - 3

en were fo

.2%

2

2years 2.1

Age i

70

ution of u

under five

3 years as

ound betwe

29.8%

1-3years

n years

under five

e children

s per figur

een the ag

20.3%

3.1-4years

children

majority 2

re 4.1.1 an

ge group o

6%

4.1-5 yea

accordin

298 (29.8%

nd the leas

of 4.1 - <

ars

g

%)

st

<5

Fig: 4.1

to their

Ac

children

group e

male ch

year.

05

10152025303540455055606570

Perc

enta

ge o

f und

erfiv

e

1.2 Percen

r age and

ccording fig

n accordin

except in t

hildren. Th

050505050505050

0-1 yea

39.6%

60

ntage wis

gender.

g 4.1.2 re

g to their

the age gr

e majority

ar 1.1-2year

46.1%

0.4%

5

se distribu

garding pe

age and

roup of 4.

125(60.4%

2 rs

2.1-yea

41.6%

53.9%5

Age and

71

ution of u

ercentage

gender, m

1 - < 5 ye

%) females

-3 rs

3.1yea

%43.8%

58.4%

Gender

under five

wise dist

majority we

ears, majo

s were und

1-4 ars

4.ye

%

5356.2%

children

ribution of

ere female

ority 32 (53

der the age

1-5 ears

3.3%

46.7%

accordin

f under fiv

e in all ag

3.3%) wer

e group 0-

MaleFemale

g

ve

ge

re

-1

e

Fig.4.1.

childre

Wi

five chil

only one

1

1

2

2

3

3

4

4

5Pe

rcen

tage

of u

nder

five

.3 Percen

n in the fa

ith regards

ldren in the

e under fiv

0

5

0

5

20

25

30

35

40

45

50

O

ntage wise

amily.

s to Perce

e family as

ve age chil

One

48.2%

e distribu

ntage wise

s per fig 4

ld in the fa

Two

42%

No.of unde

72

ution base

e distribut

.1.3 major

amily.

Th

%

r five in the

ed on nu

ion based

ity 482 (48

hree

9.5%

e family

mber of

on numbe

8.2% ) of f

> Three

0.3%

Under fiv

er of Unde

families ha

%

ve

er

ad

Fig.4.1.

birth or

Th

observe

number

Perc

enta

ge o

f und

erfiv

e

.4 Percen

rder

he above

ed were t

r of under f

05

101520253035

40

45

50

ntage wise

fig. 4.1.4

the first b

five childre

First

50%

e distribu

shows th

birth order

en belonge

Second

39.1%

Birth ord

73

ution of u

hat majori

r in the fa

ed to fourth

Third

%

1

der of the c

under five

ty 500 (5

amily and

h order of

dF

0%

hild

e children

50%) of th

negligible

birth.

ourth

0.9%

based o

he subject

e 9 (0.9%

on

ts

%)

Fig.4.1.

under f

Fig

taker of

care tak

(B) Fre

econom

and pla

.5 Percen

five childr

g.4.1.5 sho

f under five

ker of the c

equency

mic chara

ace of res

ntage wise

ren.

ows the pe

e children

children we

and per

acteristics

idence

e distribu

ercentage

observed

ere mothe

rcentage

s in terms

4.4%

Prima

74

ution base

wise dist

that majo

ers.

distribut

of type o

ry Caretak

ed on pri

ribution ba

rity 956 (9

ion of s

of family,

95.6%

ker

imary car

ased on p

95.6 %) of

subjects

total fam

%

MothFathe

re taker o

rimary car

the primar

by socio

mily incom

herer

of

re

ry

o-

me

75

Table 4.1.2. Percentage distribution based on socioeconomic

characteristics

N=1000

Socioeconomic characteristics n %

Type of family Nuclear Joint

539 461

53.9 46.1

Total family income >40,000 30,000-39,000 20,000-29,000 10,000-19,000

872 90 13 25

87.5 9.0 1.3 2.5

Place of residence Urban Rural

113 887

11.3 88.7

Data presented in table 4.1.2 reveals that regarding type of family a

maximum of 539 (53.9%) belonged to nuclear and 461 (46.1%) were

belonged to Joint family. Regarding total family income in the family

872(87.2%) had above Rs. 40,000/- income range and the remaining

128(12.8%) of the family earn less than Rs.40, 000 per year. In terms of place

of residence 887 (88.7%) resided in rural area and 113 (11.3%) lived in urban

area.

76

Fig.4.1.6 Percentage wise distribution of underfive children based on

education of parents

The above fig.no.4.1.6 depicts the rate of illiterate father and mothers

were equal about 11% and graduate parents were low about 1%. It can also

be seen that primary and middle education of fathers were better compared to

that of mothers where as in the case of high school under graduate and

graduate qualification it showed reverse in educational level.

11.6%

27.2%

31.6%

22.1%

7.2%

0.3%

11

20.9% 20.1%

33.7%

13.1%

1.2%

0

5

10

15

20

25

30

35

40

45

50

Perc

enta

ge o

f und

erfiv

e

Educatiion of father and mother

FatherMother

Fig.4.1.

occupa

It i

(1.8%)

911 (91

skilled w

.7 Perce

ation of pa

is evident

of the pa

.1%) com

worker or s

05

101520253035404550556065707580859095

100

9

Perc

enta

ge o

f und

erfiv

e

ntage wis

arents

from the

rents were

pared to u

shop keep

9.9%

91.1%

se distrib

fig.no.4.1

e professi

unemploye

per.

19.5%

%

Occupatio

77

ution of

.7 that a n

onal. Une

ed, fathers

%

5%

on of father

underfive

negligibly

employed

99 (9.9%

68.8%

3.5%

r/ mother

e children

small perc

mothers w

) and who

1.8% 0

based o

centage 1

were highe

o worked a

0.4%

FatherMother

on

8

er

as

78

(C)Frequency and percentage distribution of subjects by environmental and epidemiological characteristics in terms of frequency of diarrhoea in preceding 2 weeks and ARI in preceding 2 weeks, seeking care for ARI conditions, manifestation of parasitic infection and regular de worming the child at every 6months Table4.1.3. Percentage distribution of environment and epidemiological

characteristics N=1000

Environment and epidemiological characteristics n % Frequency of diarrhoea in preceding 2 weeks

No episode Three and less Four and more

703 283 14

70.3 28.3 1.4

Frequency of ARI in preceding 2 weeks

No episode Three and less Four and less

560 399 41

56.0 39.9 4.1

Seeking care for ARI conditions Yes No

641 359

64.1 35.9

Manifestation of parasitic infection during the past 3 months

No manifestation 1-2 manifestation 3-4 manifestations

777 198 25

77.7 19.8 2.5

Regular de worming the child at every 6months

Yes Sometimes No

808 139 53

80.8 13.9 5.3

The above table 4.1.3 depicts that majority of children 703 (70.3%) had

no episode of frequency of diarrhea in preceding 2 weeks and frequency of

ARI in preceding 2 weeks was 41(4.1%) very less. With regards to seeking

care of ARI conditions 641(64.1%) were higher in seeking care compared to

that of those who did not seek care for ARI was 359 (35.9%).

According to the manifestation of parasitic infection during the past 3

months 777 (77.7%) of the children had no manifestation of parasitic infection.

With respect to regular deworming the child at every 6 months

808(80.8%) had regular de worming the child at every 6 months and least

53(5.3%) did not de worm their child.

Fig.4.1.

type of

Wi

five chil

Fig.4.1.water s

Wi

five chil

supply.

.8 Percen

f house

ith regard

ldren lived

.9 Percensupply. ith regard

ldren depe

64%

ntage wis

to type of

in puccha

ntage wis

to water s

ended on

3

e distribu

f house, fig

a house an

e distribu

supply, fig

public tap

Type

3% 0.4%

Wate

79

ution of u

g.no.4.1.8

nd 640 (64

ution of u

g.no.4.1.9

water and

36

of house

96.6%

er supply

underfive

shows tha

.0%) lived

underfive

shows tha

d least 4 (

6%

%

children

at 360 (36

in kuccha

children

at 966 (96

0.4%) had

KuPu

PubliBore Well

based o

6.0%) unde

a house.

based o

6.6%) unde

d well wate

ucchauccha

ic tapwell

on

er

on

er

er

80


toilet facilities.

With regard to toilet facility, fig.no.4.1.10 shows that 858 (85.8%) families

of underfives had own toilet facility, whereas 60 (6.0%) shared toilet with other

families and 82 (8.2%) used open field.


Crowdedness.

85.8%

6% 8.2%

05

101520253035404550556065707580859095

Own toilet facility Shared with other famillies

Open field

Perc

enta

ge o

f und

erfiv

e

Toilet facilities

52.3%

47.7%

Crowdedness

No overcrowdingCrowding

Wi

overcro

Fig.4.1.

method

It i

five chi

refuse d

Fig.4.1.

seeking

ith refere

owding and

.12 Perce

d of refuse

s evident f

ldren used

disposal.

.13 Perce

g care for

0

10

20

30

40

50

60

70

80

90Pe

rcen

tage

of u

nder

five

37.

ence to

d 477 (47.7

entage wi

e disposa

from fig.no

d dumping

entage wi

r diarrhoea

83%

Dumpin

.1%

Seeking

crowdedn

7%) had cr

ise distrib

al.

o. 4.1.11 th

g method a

se distrib

al disease

ng

Method

g care for

81

ness 532

rowding as

bution of

hat majorit

and least 7

bution of u

es.

9.2%

Compostin

d of refuse d

62.

diarrhoea

2 (53.2%

s per the fi

underfive

ty 830 (83.

78 (7.8%)

under five

g Incine

disposal

.9%

al disease

) houses

ig.no.4.1.1

e children

.0%) paren

used incin

e children

7.8%

eration/burn

es

YesNo

s had n

2.

n based o

nts of unde

neration fo

n based o

ing

s

no

on

er

or

on

82

According to the seeking care for diarrhoeal diseases, fig.no.4.1.13

shows that the parents of under five children sought care for diarrhea were

629 (62.9%) and 371 (37.1%) did not seek care.

(D))Frequency and percentage distribution of subjects by behavioral and

health awareness characteristics

Table 4.1.4. Percentage distribution of Behavioral and health awareness

characteristics in terms of decision maker to use money in family,

Immunization status of the child and previous iron or vitamin Therapy.

N=1000 Behavioural and awareness characteristics n % Decision maker to use money in family

Father Mother Both jointly

918 37 45

91.8 3.7 4.5

Immunization status of the child Completely immunized Partially immunized Not immunized at all

860 133 7

86.0 13.3 0.7

Previous iron or vitamin Therapy Yes No

572 428

57.2 42.8

The above table 4.1.4 depicts the behavioural and health awareness

characteristics of under five children. According to the decision maker to use

money in family, 918 (91.8%) fathers were decision makers. Regarding the

immunization status of the child, 860 (86.0%) were completely immunized,

only 7 (0.7%) were not immunized at all. With regard to previous iron or

vitamin therapy, 572 (57.2%) had iron or vitamin supplementation.

Fig.4.1.

health

Th

consum

and 234

1

1

2

2

3

3

4

4

Perc

enta

ge o

f und

erfiv

e

.14. Perce

habits of

he figure

med alcoho

4 (23.4%)

26%

0

5

0

5

0

5

0

5

0

5

Smok

entage wi

parents

4.1.14 de

ol and a lea

possessed

%

ker Consa

ise distrib

epicts that

ast percen

d no bad h

39.8%

sumption of alcohol

H

83

bution of

t majority

ntage of th

habits.

1.2%

Drug addictio

Habits of paren

underfive

of the p

hem 12 (1.2

9.6%

n Chewing tobac

nts

e children

parents 39

2%) were

%

2

betel/ co

No b

n based o

98 (39.8%

drug addic

23.4%

bad habits

on

%)

ct

84

Fig.4.1.15. Percentage wise distribution of underfive children based on

health habits of care takers

The figure 4.1.15 shows that majority of the care takers 512 (51.2%)

washed their hands after use of latrine. Only a few 49 (4.9%) cleansed their

hands before food preparation and 43 (4.3%) had the habit of hand wash after

cleaning the child.

Fig.4.1.16. Percentage wise distribution of underfive children based on

exposure to information on malnutrition to parents.

51.2%

4.9% 4.3%

39.6%

0

10

20

30

40

50

60

Handwashing practice after use

of latrine

Before foof preparation

After cleaning the child

All of the above

Perc

enta

ge o

f und

erfiv

e

Health habits of care taker

63.2%

24.9%

1.6%10.3%

05

10152025303540455055606570

Health professionals

Mass Media Friends and relatives

No information

Perc

enta

ge o

f und

erfiv

e

Exposure to information on malnutrition

85

With reference to exposure to information on malnutrition to parents

632(63.2%) received information from health professionals and least 16

(1.6%) received information from friends and relatives, 103 (10.3%) of them

had no information and 249 (24.9%) of them were informed by mass media.

(E) Frequency and percentage distribution of subjects by Nutritional

awareness

Table 4.1.5. Percentage distribution of nutritional awareness in terms of Number of meals how long the children got breast feed and the age at which weaning started N=1000

Nutritional characteristics N % Number of meals per day Two meals

Three meals 656 344

65.6 34.4

How long the children got breast feed

<1year 1-2 year 2-3 year

343 644 13

34.3 64.4 1.3

Specify the age at which weaning started

< 6months 6-7 months >7 months

403 585 12

40.3 58.5 1.2

The above table 4.1.5. depicts nutritional awareness of the parents. With

regards to number of meals per day 656 (65.6%) had two times meals, while

344 (34.4%) had three time meals per day given to their children.

In terms of breast feed 644 (64.4%) children had breast feed till 1-2 year

and 585 (58.5%) started weaning at the age between 6-7months.

According to the age at which weaning started 403 (40.3%) of under five

children started weaning below the age 6months, while 12 (1.2%) started

weaning at the age above 7months.

Fig.4.1.

Food h

Th

non-veg

Fig.4.1.

staple f

.17. Perce

habits.

he fig. no.

getarian an

.18. Perce

food.

84.1%

05

101520253035404550556065707580859095

100105110

Perc

enta

ge o

f und

erfiv

e

entage wi

4.1.17 re

nd 159 (15

entage wi

%

Rice

99.1

ise distrib

veals that

5.9%) were

ise distrib

1

Food

1%

Sta

86

bution of

t the majo

e vegetaria

bution of

15.9%

d Habits

Wheat

0.2%

aple Food

underfive

ority 841 (8

an.

underfive

Any o

0

e children

84.1%) pa

e children

VegetarianNon-vegeta

other

0.7%

n based o

arents wer

n based o

arian

on

re

on

87

With regard to use of staple food, fig.no.4.1.18 depicts that 991 (99.1%)

used rice and others 9 (0.9%) used wheat as staple food.

(F) Percentage distribution based on clinical variables of mother.

Table 4.1.6 Percentage distribution based on clinical variables of mother

in terms of age, BMI, consultation on sickness, place of delivery,

condition of last two children, ANC check-ups, IFA during pregnancy,

deworming, medical condition, contraceptive use, food choice and

acceptance of each pregnancy

N=1000 Clinical variables of mother n % Age at marriage Below 18 years

18-35 years31 969

3.1 96.9

BMI of the mother Normal Above normal Below normal

941 49 10

94.1 4.9 1.0

At the time of sickness of your Child whom do you consult

Pediatrician (private) Govt. Hosp/health centre

3 997

0.3 99.7

Place of delivery Home Hospital/health centre

69 931

6.9 93.1

Condition of last two children Normal Low birth weight Not applicable

888 32 80

88.8 3.2 8.0

Antenatal check up Regular Irregular

989 11

98.9 1.1

Iron and folic acid tablets taken during pregnancy

Yes Sometimes No

910 51 39

91.0 5.1 3.9

Whether de worm during pregnancy Yes No

291 709

29.1 70.9

Medical condition of the mother Diabetes Hypertension Heart diseases None

81 62 2 855

8.1 6.2 0.2 85.5

Contraceptive use Yes No

158 842

15.8 84.2

Food choice during pregnancy, If any Yes No

249 751

24.9 75.1

Willingly accepted each pregnancy Yes No

904 96

90.4 9.6

The table 4.1.6 shows that majority of the subjects 969 (96.9%) were

married at the age of 18 to 35 and 941 (94.1%) of the mothers had normal

88

BMI. At the time of sick of the child, most of the mothers 997 (99.7%)

consulted Govt. Hospital or health centres. With regards to place of delivery,

most of the mothers 931 (93.1%) opted hospital delivery and only 69 (6.9%) of

them delivered at home.

With regard to the condition of last two children, 886 (88.6%) of them had

normal condition for last two children. Majority of the mothers 989 (98.9%)

regularly attended antenatal check up and 910 (91%) of them took iron and

folic acid tablets during pregnancy, Minority of mothers of around 288 (28.8%)

dewormed, 855 (85.5%) of mothers did not have any medical conditions, a

least rate 2 (2%) of them possessed heart diseases and others faced diabetes

and hypertension during pregnancy.

According to contraceptive use majority 842 (84.2%) did not use

contraceptives and only 158 (15.8%) used contraceptive measures, 249

(24.9%) opted food choice during pregnancy, 904 (90.4%) of the mothers

willingly and 96(9.6%) mothers of under five children unwillingly accepted

each pregnancy.

Fig.4.1.

based o

Wi

(93.6%)

pregnan

placent

oligohyd

and 158

.19. Perce

on Obstet

ith regard

) mothers

ncy. A ne

a and 10 (

dramnios,

8 (15.8%)

05

1015202530354045505560657075808590

Perc

enta

ge o

f und

erfiv

e

entage wis

trics prob

ds to obs

of under

egligible s

(1%) had p

anaemia

faced hype

4.1%

1

se distrib

blems.

stetrics pro

five 700 (

share of t

polyhydram

and gesta

eremesis g

15.8%

1%

Obs

89

ution of m

oblems, f

(70%) did

the mothe

mnios. A le

tional diab

gravidarium

5.5%

stetrics prob

mothers o

fig. no.4.1

not face

ers 4 (0.4

east share

betes melli

m.

0.4%3

blems

of underfiv

.9, shows

any probl

4%) faced

of the mo

tus during

.2%

70

ve childre

s that 93

ems durin

d abruptio

others face

g pregnanc

0%

en

36

ng

on

ed

cy

90

Fig.4.1.20. Percentage wise distribution of mothers of underfive children

based on post natal complications.

According to post natal complications among mothers of underfive

children, fig.no. 4.1.20 reveals majority 936 (93.6%) mothers had no

complication and very few 4 (0.4%) of them faced bleeding per vagina.

0.4%3.7% 2.3%

93.6%

05

101520253035404550556065707580859095

100

Increased bleeding per

vagina

Breast feeding difficulties

C-section wound Normal

Perc

enta

ge o

f und

erfiv

e

Post natal Complications

91

Section II: Prevalence of malnutrition among under five children.

Table 4.2.1 Percentage distribution of stunting by length / height –for-

age (Stunting) N= 1000

Length / height-for-age Count Percent Normal Stunted Stunted/ Severely stunted

760 84 156

76.0 8.4 15.6

Table number 4.2.1 shows Percentage distribution of stunting by

length/height-for-age. Majority 760 (76.0%) of children were normal for

length/height for age where as 84 (8.4%) were stunted and 156 (15.6%) were

severely stunted for length/height for age.

Table 4.2.2 Percentage distribution of stunting at 95% CI

N=1000 Length / height-for-age Count Percent

95% CI

Normal

Stunted/ Severely stunted

760

240

76.0

24.0

21.4 – 26.6

The above table no.4.2.2 depicts that 760 (76%) of the underfive children

were normal height for age and remaining 240 (24%) were stunted/severely

stunted in growth at 95% CI. with a mean height of 21.4-26.6.

92

Table 4.2.3 Percentage distribution of underweight by BMI-for-age N=1000 BMI - for-age Count Percent Normal Wasted Severely Wasted Over weight Obese

467 124 260 72 77

46.7 12.4 26.0 7.2 7.7

Table 4.2.3 shows Percentage distribution of BMI-for-age. Majority of the

under five children 467 (46.7%) were normal weight 124 (12.4%) were under

weight and 260 (26.0%) were found in the category of severe underweight.

However 72 (7.2%) were overweight and 77 (7.7%) were obese.

Table 4.2.4. Percentage distribution of underweight (BMI for age) based

at 95% CI N=1000

BMI - for-age Count Percent

95% CI

Normal Under weight/ severe underweight Over weight/Obese

467 384 149

46.7 38.4 14.9

35.4 – 41.4

Table 4.2.4. Shows that 46.7% of under five children were normal,

whereas 384 (38.4%) of them were under weight /severely under weight and

149 (14.9%) of them had over weight/obese at 95% CI with a mean weight

35.4 – 41.4.

4.2.5. Percentage of weight –for-age N=1000 Weight –for-age Count Percent Normal Under weight Severely Underweight

751 138 111

75.1 13.8 11.1

Table no. 4.2.5 shows percentage distribution of underweight by BMI for

93

age. Majority 751 (75.1%) were normal weight children. However, 188 (13.8%)

were underweight and 111 (11.1%) were severely underweight by weight for

age.

4.2.6. Percentage distribution of underweight by weight –for-age at

95%CI N=1000

Weight –for-age Count Percent 95% CI Normal Stunted/severely stunted

751 249

75.1 24.9

22.2 – 27.6

From the table no. 4.2.6 it is observed that the minimum weight of under

five children was 22.2 and maximum weight was 27.6 at 95% CI in which

three fourth of the subjects 751 (75.1%) were normal weight and a quarter 249

(24.9%) of them had underweight /severely under weight.

4.2.7. Percentage distribution wasting by weight –for length / height

N=1000 Weight –for-length/ height Count Percent Normal Wasting Moderate Wasting Severe Wasting Obese

511 131 239 52 67

51.1 13.1 23.9 5.2 6.7

Table 4.2.7 depicts the percentage wasting by weight-for-length/height.

Majority 511(51.1%) children were found normal for weight and height/length.

131(13.1%) children shown wasting, 239 (23.9%) were moderate wasting and

52(5.2%) severe wasting however few 67 (6.7%) showed obese

94

4.2.8. Percentage distribution wasting by weight–for length/height at

95% CI N=1000

Weight –for-age Count Percent 95% CI Normal Stunted/ Severely stunted Over weight/Obese

511 370 119

51.1 37 11.9

34 – 40

Table 4.2.8 shows that at 95% CI, the weight for length/ height of the

children of under five ranges from 34 to 40. About half of the subjects 511

(51.1%) had normal weight, 370 (37%) of them had stunted/severely under

weight and 119 (11.9%) of them were overweight/obese.

4.2.9. Percentage distribution of haemoglobin status based on age

N=1000 Age

Normal Mild Moderate Count Percent Count Percent Count Percent

0 - 1 year 152 73.4 49 23.7 6 2.9 1.1 - 2 years 166 71.6 55 23.7 11 4.7 2.1 - 3 years 229 76.8 46 15.4 23 7.7 >3 years 219 83.3 33 12.5 11 4.2

With regards to haemoglobin level and age of the under five children, it

was observed that Mild anemia was in age group 0-2 years, whereas

moderate anemia was observed in the age group 2-3 years.

Section III: Association of malnutrition among under five children with


95

Table4.3.1 Association of (stunting) height for age of under five children

with their demographic characteristics N=1000

Demographic characteristics Normal Stunting Odds (95 % CI) χ2 P Age

0-1 year 1.1-2years 2.1-3 years >3 years

155 (74.9) 165 (71.1) 228 (76.5) 212 (80.6)

52 (25.1) 67 (28.9) 70 (23.5) 51 (19.4)

1.39 (0.9 - 2.16) 1.69 (1.11 - 2.56) 1.28 (0.85 - 1.92) 1

6.28

0.099

Gender

Male Female

319 (73.5) 441 (77.9)

115 (26.5) 125 (22.1)

1.27 (0.95 - 1.7) 1

2.62 0.105

Religion

Hindu Christian Muslim

94 (74.6) 604 (76.6) 62 (72.1)

32 (25.4) 184 (23.4) 24 (27.9)

1 0.89 (0.58 - 1.38) 1.14 (0.61 - 2.11)

1.04

0.595

No. of under five in the family

One Two More than two

360 (74.7) 319 (76) 81 (82.7)

122 (25.3) 101 (24) 17 (17.3)

1.61 (0.92 - 2.83) 1.51 (0.85 - 2.66) 1

2.83

0.243

Birth weight of child

Normal Below normal

712 (76.2) 48 (72.7)

222 (23.8) 18 (27.3)

1 1.2 (0.69 - 2.11)

0.41 0.519

Birth order of the child

First Second Third/Fourth

371 (74.2) 298 (76.2) 91 (83.5)

129 (25.8) 93 (23.8) 18 (16.5)

1.76 (1.02 - 3.03) 1.58 (0.9 - 2.75) 1

4.25

0.120

Spacing between children

One year Two years More than two years

304 (71.7) 338 (79.2) 118 (79.2)

120 (28.3) 89 (20.8) 31 (20.8)

1.5 (0.96 - 2.35) 1 (0.63 - 1.59) 1

7.47*

0.024

Primary care taker

Mother Father

735 (76.9) 25 (56.8)

221 (23.1) 19 (43.2)

2.53 (1.37 - 4.68) 1

9.28*** 0.002

***:- Significant at 0.001 level **:- Significant at 0.01 level, *:- Significant at 0.05 level.

Table 4.3.1 shows the association of stunting (height for age) of under

five children with their demographic variables. Stunting was associated with

demographic variables like age, gender, religion, number of underfives in the

family, birth weight of the child, birth order of the child, spacing between

children and primary care taker. On analysis it was observed that stunting was

associated with primary care taker (mother) at Odds (95 % CI) 2.53 (1.37 -

4.68) with a χ² of 9.28 which is highly significant at 0.001 level of significance.

Stunting also associated with spacing between children( for one year spacing)

at Odds (95 % CI) 1.5 (0.96 - 2.35) with a χ² value of 7.47 with low significance

at 0.05 level.

96

Table 4.3.2 Association of stunting (height for age) of under five children with socioeconomic characteristics

N=1000 Socioeconomic characteristics Normal Stunting Odds (95 % CI) χ2 P

Type of family

Nuclear Joint

418 (77.6) 342 (74.2)

121 (22.4) 119 (25.8)

1.2 (0.9 - 1.61) 1

1.54 0.214

Education of father

Illiterate/Primary Middle High School/Metric Under graduate and above

302 (77.8) 246 (77.8) 158 (71.5) 54 (72)

86 (22.2) 70 (22.2) 63 (28.5) 21 (28)

1 1 (0.7 - 1.43) 1.4 (0.96 - 2.04) 1.37(0.78 -2.39)

4.43

0.219

Education of Mother


246 (77.1) 152 (75.6) 250 (74.2) 112 (78.3)

73 (22.9) 49 (24.4) 87 (25.8) 31 (21.7)

1.07 (0.67 - 1.73) 1.16 (0.7 - 1.94) 1.26 (0.79 - 2) 1

1.27

0.737

Occupation of father

Unemployed Skilled worker Others

70 (70.7) 171 (87.7) 519 (73.5)

29 (29.3) 24 (12.3) 187 (26.5)

1.15 (0.72 - 1.83) 0.39 (0.25 - 0.62) 1

18.53***

0.000

Occupation of mother

Unemployed Employed

697 (76.5) 63 (70.8)

214 (23.5) 26 (29.2)

1 1.34 (0.83 - 2.18)

1.46 0.228

Total Income in the family per month in Rupees

>40,000 <40,000

662 (75.9) 98 (76.6)

210 (24.1) 30 (23.4)

1.04 (0.67 - 1.6) 1

0.03

0.873

Place of residence

Urban Rural

82 (72.6) 678 (76.4)

31 (27.4) 209 (23.6)

1.23 (0.79 - 1.91) 1

0.82 0.364


Table 4.3.2 shows association of stunting (height for age) of under five

children and socioeconomic characteristics. Stunting was associated with

socio economic variables like type of family, education of the mother,

education of the father, occupation of father, occupation of mother total family

income monthly and place of residence. On analysis stunting was found

associated occupation of father (unemployed) at Odds (95 % CI) 1.15 (0.72 -

1.83) with a χ² of 18.53 which is moderately significant at 0.01 level.

97

Table 4.3.3 Association of stunting (height/Length for age) of under five


N=1000 Environment and epidemiological characteristics

Normal Stunting Odds (95 % CI) χ2 p

Type of house Kuccha Puccha

271 (75.3) 489 (76.4)

89 (24.7) 151 (23.6)

1.06 (0.79 -1.44) 1

0.16 0.688

Water supply Public tap Bore well

739 (76.5) 21 (61.8)

227 (23.5) 13 (38.2)

2.02 (0.99 - 4.09) 1

3.91* 0.048

Toilet facilities Own toilet Others

648 (75.5) 112 (78.9)

210 (24.5) 30 (21.1)

1.21 (0.79 - 1.86) 1

0.75 0.387

Crowdedness Index CI

No over crowdingCI<1 Crowding CI 1.1 – 4

399 (76.3) 361 (75.7)

124 (23.7) 116 (24.3)

1 1.03 (0.77 - 1.38)

0.05

0.822

Method of refuse disposal

Dumping Others

637 (76.7) 123 (72.4)

193 (23.3) 47 (27.6)

1 1.26 (0.87 - 1.83)

1.49 0.222

Frequency of diarrhea in preceding 2 weeks

No episode One and more

553 (78.7) 207 (69.7)

150 (21.3) 90 (30.3)

1 1.6 (1.18 - 2.18)

9.2***

0.002

Seeking care for Diarrheal

Yes No

486 (77.3) 274 (73.9)

143 (22.7) 97 (26.1)

1 1.2 (0.89 - 1.62)

1.49 0.222

Frequency of A R I in preceding 2 weeks


428 (76.4) 295 (73.9) 37 (90.2)

132 (23.6) 104 (26.1) 4 (9.8)

2.84 (1 - 8.09) 3.24 (1.13 - 9.3) 1

5.55

0.062

Seeking care for ARI conditions

Yes No

485 (75.7) 275 (76.6)

156 (24.3) 84 (23.4)

1.05 (0.78 - 1.43) 1

0.11 0.739

Manifestation of parasitic infection during the past 3 mths

No Manifestation Manifestations

590 (75.9) 170 (76.2)

187 (24.1) 53 (23.8)

1.02 (0.72 - 1.44) 1

0.01

0.926

Regular deworming child at every 6mth

Yes Sometimes No

602 (74.5) 115 (82.7) 43 (81.1)

206 (25.5) 24 (17.3) 10 (18.9)

1.47 (0.73 - 2.98) 0.9 (0.4 - 2.03) 1

5.21

0.074


Tale 4.3.3 shows association of stunting Height /length for age) of under

five children with their and environment and epidemiological characteristics.

On analysis it was observed that stunting was associated with water supply

(Tap water supply)at Odds (95 % CI) 2.02 (0.99 - 4.09) with a χ² value of

3.91and p value of 0.048 which low significance at 0.05 level. Stunting was

also associated with frequency of diarrhoea at Odds (95 % CI) 1.6 (1.18 -

2.18) with a χ² of 9.2 and p value of 0.002 which is moderately significant at

0.01 level.

98

Table 4.3.4 Association of stunting (Height/ Length for age) of under

five children with behavioural and health awareness characteristics

N=1000 Behavioral and awareness characteristics

Normal Stunting Odds (95 % CI) χ2 p

Habits of parents

Smoker Consumption of alcohol Others No bad habits

198(76.2) 302(75.9) 83 (76.9) 177(75.6)

62 (23.8) 96 (24.1) 25 (23.1) 57 (24.4)

1 1.02 (0.7 - 1.46) 0.96(0.57 - 1.63) 1.03(0.68 - 1.55)

0.07

0.996

Decision maker to use money in family


706(76.9) 21 (56.8) 33 (73.3)

212(23.1) 16 (43.2) 12 (26.7)

1 2.54 (1.3 - 4.95) 1.21(0.61 - 2.39)

8.1*

0.017


Hand washing practice after use of latrine Before food preparation After cleaning the child All of the above

376(73.4) 45 (91.8) 36 (83.7) 303(76.5)

136(26.6) 4 (8.2) 7 (16.3) 93 (23.5)

1.18 (0.87 - 1.6) 0.29 (0.1 - 0.83) 0.63(0.27 - 1.47) 1

10.04*

0.018

Immunization status of the child

Completely immunized Partially/No immunized

646(75.1) 114(81.4)

214(24.9) 26 (18.6)

1.45(0.92 - 2.28) 1

2.63

0.105

Previous iron or vitamin therapy

Yes No

429 (75) 331(77.3)

143 (25) 97 (22.7)

1.14(0.85 - 1.53) 1

0.73

0.392

Exposure to information on malnutrition to parents

Health professional Others No information

480(75.9) 208(78.5) 72 (69.9)

152(24.1) 57 (21.5) 31 (30.1)

1 0.87(0.61- 1.22) 1.36(0.86 - 2.15)

3

0.223


Table 4.3.4 depicts the association of stunting (Height /length for age) of

under five children and behavioural and health awareness characteristics.

On analysis it was observed that stunting was associated with decision

maker to use money in the family (father) Odds (95 % CI with a χ²value of 8.1

and p value of 0.017 which low significance at 0.05 level. Stunting also found

associated with health habits of the care taker (hand washing practice after

use of latrine) Odds (95 % CI) with a χ²value of 10.04 and p value of 0.018

which low significance at 0.05 level.

99

Table 4.3.5 Association of stunting (Height for age of under five

children) with nutritional characteristics

N=1000 Nutritional characteristics Normal Stunting Odds (95 % CI) χ2 p Food habits Vegetarian

Non-vegetarian

113(71.1)647(76.9)

46 (28.9) 194(23.1)

1.36(0.93-1.98) 1

2.52 0.112

Number of meals per day

Two meals Three meals

487(74.2)273(79.4)

169(25.8)71 (20.6)

1.33(0.97 - 1.83) 1

3.25 0.072


< 1 year >1 year

245(71.4)515(78.4)

98 (28.6) 142(21.6)

1.45(1.08 - 1.96) 1

5.98* 0.014


< 6 months >6 months

292(72.5) 468(78.4)

111(27.5) 129(21.6)

1.38(1.03 - 1.85) 1

4.65* 0.031


Table 4.3.5 shows association of stunting (height for age of under five

children) with nutritional characteristics of under five children. Stunting was

associated with nutritional variables like food habits, number of meals per day,

duration of breast feed and age which weaning started

On analysis, it was found that stunting was associated with how long the

child got breast feed (<one year) at Odds (95 % CI 1.45 (1.08 - 1.96) with a

χ² value of 5.98 and p value of 0.014 which shows low significance at 0.05

level

Stunting also associated with age at which weaning started (<6 months)

at Odds (95 % CI 1.38 (1.03 - 1.85) with a χ² value of 4.65 and a p value of

0.031 which shows low significance at 0.05 level

100

Table 4.3.6. Association of underweight (weight for age) of under five

children with their demographic variables N=1000

Demographic characteristics Normal Under weight

Odds (95 % CI) χ2 P

Age


121(58.5) 167(72) 246(82.6)217(82.5)

86(41.5) 65(28) 52(17.4) 46(17.5)

3.35(2.2 - 5.11) 1.84(1.2 – 2.82) 1(0.64 – 1.54) 1

48.44***

0.000

Gender Male Female

311(71.7) 440(77.7)

123(28.3) 126(22.3)

1.38(1.04-1.84) 1

4.86*

0.028

Religion


95(75.4) 593(75.3) 63(73.3)

31(24.6) 195(24.7) 23(26.7)

1 1.01(0.65-1.56) 1.12(0.6-2.09)

0.17

0.917



354(73.4) 321(76.4) 76(77.6)

128(26.6) 99(23.6) 22(22.4)

1 1.25(0.75-2.09) 1.07(0.63-1.8)

1.42

0.492


Normal Below normal

706(75.6) 45(68.2)

228(24.4) 21(31.8)

1 1.45(0.84-2.48)

1.81

0.179



380(76) 282(72.1) 89(81.7)

120(24) 109(27.9) 20(18.3)

1.41(0.83-2.38) 1.72(1.01-2.93) 1

4.57

0.102



311(73.3) 331(77.5) 109(73.2)

113(26.6) 96(22.5) 40(26.8)

1 0.8(0.58-1.09) 1.01(0.66-1.54)

2.33

0.312

Primary care taker

Mother Father

724(75.7) 27(61.4)

232(24.3) 17(38.6)

1 1.96(1.05-3.67)

4.64* 0.031


Table 4.3.6 shows the association of underweight (weight for age) of

under five children with their demographic variables. Stunting was associated

with demographic variables like age, gender, religion, no. of underfives in the

family, spacing between children, birth weight and birth order of the child and

primary care taker. Analysis showed that underweight was associated with

age (0-1Year) Odds (95 % CI) 3.35 (2.2 - 5.11) with a χ² value of 48.44 (p

value of 0.000) which shows a moderate significance at 0.01 level,

underweight was associated with gender (male) Odds (95 % CI) 1.38 (1.04 -

1.84 with a χ² value 4.86 (p = 0.028) which shows a low significance at 0.05

level and with primary care taker (mother) Odds (95 % CI) with a χ² value of

4.64 and p value of 0.031which shows a low significance at 0.05 level.

101

Table 4.3.7 Association of underweight (weight for age) of under five

children with socio economic characteristics. N=1000

Socioeconomic characteristics Normal Under Weight


Type of family

Nuclear Joint

407(75.5) 344(74..6)

132(24.5) 117(25.4)

1 1.05(0.79-1.4)

0.11 0.746

Education of father


293(75.5) 244(77.2) 160(72.4) 54(72)

95(24.5) 72(22.8) 62(27.6) 21(28)

1 0.91(0.64-1.29) 1.18(0.81-1.71) 1.2(0.69-2.09)

2.04

0.564

Education of Mother


233(73) 149(74.1) 262(77.7) 107(74.8)

86(27) 52(25.9) 75(22.3) 36(25.2)

1.1(0.7-1.72) 1.04(0.63-1.7) 0.85(0.54-1.34) 1

2.09

0.554



71(71.7) 157(80.5) 523(74.1)

28(28.3) 38(19.5) 183(25.9)

1.13(0.71-1.8) 0.69(0.47-1.02) 1

4.05

0.132


Unemployed Employed

690(75.7) 61(68.5)

221(24.3) 28(31.5)

1 1.43(0.89-2.3)

2.25 0.134

Total family Income in the family per month in Rs

>40,000 <40,000

660(75.7) 91(71.1)

212(24.3) 37(28.9)

1.27(0.84-1.91) 1

1.26

0.262

Place of residence

Urban Rural

90(79.6) 661(74.5)

23(20.4) 226(25.5)

1 1.34(0.83-2.17)

1.41 0.235


Table 4.3.7 shows association of underweight (weight for age )of under

five children with socioeconomic characteristics, underweight was associated

with socio economic variables like type of family, education of the mother,

education of the father ,occupation of father, occupation of mother total family

income monthly and place of residence. On analysis underweight was

associated with none of the socioeconomic variables

102


children with environment and epidemiological characteristics. N=1000

Environment and epidemiological characteristics

Normal Under Weight



246(68.3) 505(78.9)

114(31.7) 135(21.1)

1.73(1.29-2.32) 1

13.77*** 0.000


730(75.6) 21(62.8)

236(24.4) 13(38.2)

1 1.91(0.94-3.88)

3.35 0.067


643(74.9) 108(76.1)

215(25.1) 34(23.9)

1.06(0.7-1.61) 1

0.08 0.776


No over crowding Crowding CI

395(75.5) 356(74.6)

128(24.5) 121(25.4)

1 1.05(0.79-1.4)

0.11

0.744


Dumping Others

614(74) 137(80.6)

216(26) 33(19.4)

1.46(0.97-2.2) 1

3.3 0.069



534(76) 217(73.1)

169(24) 80(26.9)

1 1.16(0.86-1.59)

0.94 0.333

Seeking care for Diarrheal disease.

Yes No

476(75.7) 275(74.1)

153(24.3) 96(25.9)

1 1.09(0.81-1.46)

0.3 0.584



414(73.9) 302(75.7) 35(85.1)

146(26.1) 97(24.3) 6(14.6)

2.06(0.85-4.99) 1.87(0.76-4.59) 1

2.8

0.247


Yes No

475(74.1) 276(76.9)

166(24.9) 83(23.1)

1.16(0.86-1.57) 1

0.95 0.330

Manifestation of parasiticinfection duringthepast3mth


577(74.3) 174(78)

200(25.1) 49(22)

1.23(0.86-1.76) 1

1.31 0.252


Yes Sometimes No

609(75.4) 109(78.4) 33(62.3)

199(24.6) 30(21.6) 20(37.7)

1 0.84(0.55-1.3) 1.85(1.04-3.31)

5.52

0.063


Table 4.3.8 depicts association of underweight (weight for age) of under

five children with environment and epidemiological characteristics.

Underweight was associated with variables like type of house, water supply,

toilet facilities, crowdedness index, method of refuse disposal, frequency of

diarrhoeal episode and ARI, seeking care for diarrhoeal conditions, seeking

care for ARI condition, manifestation of parasitic infection, and de worming of

the child. On analysis it was observed that underweight was associated with

type of house (Kuchha) Odds (95 % CI) 1.73 (1.29 - 2.32) with a χ² value13.77

and p value of 0.000 which shows a moderate significance at 0.01 level.

103


children with behavoural and health awareness characteristics

N=1000 Behavioral and awareness characteristics

Normal Under Weight

Odds (95 % CI) χ2 p

Habits of parents


195 (75) 290(72.9) 76 (70.4) 190(81.2)

65 (25) 108(27.1) 32 (29.6) 44 (18.8)

1 1.12 (0.78 - 1.6) 1.26 (0.77 -2.08) 0.69 (0.45 -1.07)

7.01

0.072



688(74.9) 27 (73) 36 (80)

230(25.1) 10(27) 9 (20)

1.34 (0.63-2.82) 1.48(0.53-4.15) 1

0.68

0.712



382(74.6) 35 (71.4) 37 (86) 297 (75)

130(25.4) 14 (28.6) 6 (14) 99 (25)

1.02(0.75-1.38) 1.2 (0.62 - 2.32) 0.49 (0.2 - 1.19) 1

3.18

0.365



638(74.2) 113(80.7)

222(25.8) 27 (19.3)

1.46(0.93-2.28) 1

2.74

0.098


Yes No

425(74.3) 326(76.2)

147(25.7) 102(23.8)

1.11(0.83-1.48) 1

0.46

0.499



469(74.2) 204 (77) 78 (75.7)

163(25.8) 61 (23) 25(24.3)

1 1.08(0.67-1.76) 0.93(0.55 - 1.59)

0.79

0.673


Table 4.3.9 depicts association of underweight (weight for age) of under

five children with behavioural and health awareness characteristics and

observed that underweight was not associated with any of the behavioural and

awareness variables.

104


children with nutritional characteristics

N=1000 Nutritional characteristics Normal Under

Weight Odds (95 % CI) χ2 p

Food habits Vegetarian Non-vegetarian

106(66.7) 645(76.7)

53 (33.3) 196 (23.3)

1.65 (1.14 - 2.37) 1

7.19***

0.007



486(74.1) 265 (77)

170 (25.9) 79 (23)

1.17 (0.86 - 1.59) 1

1.05 0.306


< 1 year >1 year

235(68.5) 516(78.5)

108 (31.5) 141 (21.5)

1.68 (1.25 - 2.26) 1

12.11*** 0.001



286 (71) 465(77.9)

117 (29) 132(22.1)

1.44 (1.08 - 1.92) 1

6.16* 0.013.


Table 4.3.10 shows association of underweight (weight for age) of under

five children with nutritional characteristics. Underweight was associated with

nutritional variables like food habits, number of meals per day, duration of

breast feed and age which weaning started. On analysis it was found that

underweight was associated with food habits (vegetarian) Odds (95 % CI)

1.65 (1.14 - 2.37) with a χ² value7.19 and p value of 0.007 which shows a

moderate significance at 0.01 level. A highly significant association was

observed underweight with how long the children got breast feed (<1 year)

Odds (95 % CI) 1.68 (1.25 - 2.26 with a χ² value 12.11 and p value 0.001.

Further underweight was associated with the age at which weaning started

(<6 months) Odds (95 % CI) 1.44 (1.08 - 1.92) with a χ² value 6.16 and p

value 0.013which shows a low significance.

105

4.3.11 Association of Wasting (weight for height) of under five children

with their demographic variables (N=1000)

Demographic characteristics Normal Stunted / severely stunted

Over weight/ Obese

χ2 P

Age


90 (43.5) 122(52.6) 145 (48.7) 154 (58.6)

96 (46.4) 74 (31.9) 114 (38.3) 86 (32.7)

21 (10.1) 36 (15.5) 39 (13.1) 23 (8.7)

19.29***

0.004

Gender Male Female

212 (48.8) 299 (52.8)

175 (40.3) 195 (34.5)

47 (10.8) 72 (12.7)

3.79 0.151

Religion


66 (52.4) 404 (51.3) 41 (47.7)

46 (36.5) 291 (36.9) 33 (38.4)

14 (11.1) 93 (11.8) 12 (14)

0.67

0.955



238 (49.4) 221 (52.6) 52 (53.1)

182 (37.8) 154 (36.7) 34 (34.7)

62 (12.9) 45 (10.7) 12 (12.2)

1.65

0.799


Normal Below normal

476 (51) 35 (53)

344 (36.8) 26 (39.4)

114 (12.2) 5 (7.6)

1.27 0.530



249 (49.8) 203 (51.9) 59 (54.1)

183 (36.6) 147 (37.6) 40 (36.7)

68 (13.6) 41 (10.5) 10 (9.2)

3.03

0.554



205 (48.3) 223 (52.2) 83 (55.7)

156 (36.8) 163 (38.2) 51 (34.2)

63 (14.9) 41 (9.6) 15 (10.1)

7.26

0.123

Primary care taker

Mother Father

495 (51.8) 16 (36.4)

350 (36.6) 20 (45.5)

111 (11.6) 8 (18.2)

4.37 0.112


Table 4.3.11 depicts association of Wasting (weight for height) of under

five children with their demographic variables. Wasting was associated with

demographic variables like age, gender, religion, number of under fives in the

family, birth weight of the child, birth order of the child, spacing between

children and primary care taker. On analysis it was observed that wasting was

associated with age with χ² value 19.29 and p value of 0.004.

106

Table 4.3.12 Association of wasting (weight – for – length/height) of

under five children with socioeconomic characteristics N=1000

Socioeconomic characteristics Normal Stunted / severely stunted

Over weight/ Obese

χ2 P

Type of family

Nuclear Joint

284 (52.7) 227 (49.2)

198 (36.7) 172 (37.3)

57 (10.6) 62 (13.4)

2.33 0.313

Education of father


182 (46.9) 168 (53.2) 120 (54.3) 41 (54.7)

162 (41.8) 112 (35.4) 70 (31.7) 26 (34.7)

44 (11.3) 36 (11.4) 31 (14) 8 (10.7)

7.71

0.260

Education of Mother


150 (47) 104 (51.7) 184 (54.6) 73 (51)

134 (42) 78 (38.8) 108 (32) 50 (35)

35 (11) 19 (9.5) 45 (13.4) 20 (14)

8.96

0.176



43 (43.4) 92(47.2) 376 (53.3)

41 (41.4) 83(42.6) 246 (34.8)

15 (15.2) 20 (10.3) 84 (11.9)

6.73

0.151


Unemployed Employed

473 (51.9) 38 (42.7)

329 (36.1) 41 (46.1)

109 (12) 10 (11.2)

3.56 0.169


>40,000 <40,000

451 (51.7) 60 (46.9)

310 (35.6) 60 (46.9)

111 (12.7) 8 (6.3)

8.32*

0.016

Place of residence

Urban Rural

60 (53.1) 451 (50.8)

36 (31.9) 334 (37.7)

17 (15) 102 (11.5)

2.07 0.356


Table 4.3.12 explains the association of Wasting (weight-for-

length/height) of under five children with socioeconomic characteristics.

Wasting was associated with socio economic variables like type of family,

education of the mother and the father, occupation of father and mother, total

family income monthly and place of residence. On analysis it was observed

that wasting was associated with total family Income in the family per month in

Rupees (>40.000Rs.) with a χ² value 8.32 and p value 0.016 at.05 level which

shows low significance.

107

Table 4.3.13 Association of wasting (weight– for– length/height) of under

five children with environment and epidemiological characteristics

N=1000 Environment and epidemiological characteristics

Normal Stunted / severely stunted

Over weight/ Obese

χ2 P


176 (48.9) 335 (52.3)

149(41.4) 221(34.5)

35 (9.7) 84 (13.1)

5.71 0.058


500 (51.8) 11 (32.4)

356(36.9) 14 (41.2)

110 (11.4) 9 (26.5)

8.87* 0.012


426 (49.7) 85 (59.9)

320(37.3) 50 (35.2)

112 (13.1) 7 (4.9)

9.39** 0.009


No over crowdingCI<1 Crowding CI1.1–4

267 (51.1) 244 (51.2)

196(37.5) 174(36.5)

60 (11.5) 59 (12.4)

0.24

0.889


Dumping Others

426 (51.3) 85 (50)

314(37.8) 56 (32.9)

90 (10.8) 29 (17.1)

5.54 0.063

Frequency of diarrhea in preceding2weeks


353 (50.2) 158 (53.2)

274 (39) 96 (32.3)

76 (10.8) 43 (14.5)

5.22

0.073


Yes No

319 (50.7) 192 (51.8)

244(38.8) 126 (34)

66 (10.5) 53 (14.3)

4.34 0.114



269 (48) 217 (54.4) 25 (61)

222(39.6) 137(34.3) 11 (26.8)

69 (12.3) 45 (11.3) 5 (12.2)

5.84

0.211


Yes No

326 (50.9) 185 (51.5)

240(37.4) 130(36.2)

75 (11.7) 44 (12.3)

0.17 0.917



391 (50.3) 120 (53.8)

298(38.4) 72 (32.3)

88 (11.3) 31 (13.9)

3.1

0.212


Yes Sometimes No

416 (51.5) 73 (52.5) 22 (41.5)

293(36.3) 52 (37.4) 25 (47.2)

99 (12.3) 14 (10.1) 6 (11.3)

3.13

0.537


Table 4.3.13 shows association of wasting (weight-for-length/height) of

under five children with environment and epidemiological characteristics like

type of house, water supply, toilet facilities, crowdedness index ,method of

refuse disposal, frequency of diarrhoeal episode and ARI, seeking care for

diarrhoeal and ARI condition, manifestation of parasitic infection, and regular

de worming of the child. On analysis it was observed that wasting was

associated with water supply at χ² value 8.87 and p value 0.012 at 0.05 level

of significance and with toilet facililties at χ² value 9.39 and p value 0.009.

108

Table 4.3.14 Association of weight – for – length/height of under five

children with behavioural and health awareness characteristics.

N=1000

Behavioral and awareness characteristics Normal Stunted / severely stunted

Over weight/ Obese

χ2 p

Habits of parents


139(53.5) 196(49.2) 53 (49.1) 123(52.6)

89 (34.2) 158(39.7) 44 (40.7) 79 (33.8)

32 (12.3) 44 (11.1) 11 (10.2) 32 (13.7)

4.29

0.637

Decision maker to use moneyinfamily


463(50.4) 19 (51.4) 29 (64.4)

349 (38) 10 (27) 11 (24.4)

106 (11.5) 8 (21.6) 5 (11.1)

7.87

0.096



261 (51) 25 (51) 15 (34.9) 210 (53)

189(36.9) 21 (42.9) 23 (53.5) 137(34.6)

62 (12.1) 3 (6.1) 5 (11.6) 49 (12.4)

8.21

0.223


Completely immunized Partially/Not immunized

449(52.2) 62 (44.3)

309(35.9) 61 (43.6)

102 (11.9) 17 (12.1)

3.39

0.184


Yes No

289(50.5) 222(51.9)

213(37.2) 157(36.7)

70 (12.2) 49 (11.4)

0.24

0.889



306(48.4) 148(55.8) 57 (55.3)

244(38.6) 92 (34.7) 34 (33)

82 (13) 25 (9.4) 12 (11.7)

5.65 0.227


Table4.3.14 shows association of wasting (weight-for-length/height) of

under five children with behavioral and health awareness characteristics. On

analysis it was observed that wasting was associated with none of the

behavioural and awareness variables.

109

Table 4.3.15 Association of wasting (weight – for – length/height) of

under five children with their nutritional characteristics (N=1000)

Nutritional characteristics Normal Stunted / severely stunted

Over weight/ Obese

χ2 P


77 (48.4) 434(51.6)

59 (37.1) 311 (37)

23 (14.5) 96 (11.4)

1.31 0.519



343(52.3) 168(48.8)

228(34.8) 142(41.3)

85 (13) 34 (9.9)

4.91 0.086


< 1 year >1 year

160(46.6) 351(53.4)

136(39.7) 234(35.6)

47 (13.7) 72 (11)

4.44

0.108



190(47.1) 321(53.8)

160(39.7) 210(35.2)

53 (13.2) 66 (11.1)

4.29

0.117


Table 4.3.15 Association of wasting (weight-for-length/height) of under

five children with nutritional characteristics. On analysis it was observed that

wasting was not associated with nutritional characteristics.

Section IV Association of malnutrition among under five children with

anthropometric measurements

110

Table 4.4.1. Association of BMI for age of under five children with their

demographic characteristics N=1000

Demographic characteristics Normal Stunted / severely stunted

Over weight/ Obese

χ2 P

Age


85 (41.1) 102 (44) 129 (43.3) 151 (57.4)

101 (48.8) 83 (35.8) 116 (38.9) 84 (31.9)

21 (10.1) 47 (20.3) 53 (17.8) 28 (10.6)

30.58***

0.000

Gender Male Female

190 (43.8) 277 (48.9)

181 (41.7) 203 (35.9)

63 (14.5) 86 (15.2)

3.66 0.161

Religion


60 (47.6) 374 (47.5) 33 (38.4)

47 (37.3) 300 (38.1) 37 (43)

19 (15.1) 114 (14.5) 16 (18.6)

2.83

0.586



219 (45.4) 197 (46.9) 51 (52)

187 (38.8) 162 (38.6) 35 (35.7)

76 (15.8) 61 (14.5) 12 (12.2)

1.72

0.787


Normal Below normal

438 (46.9) 29 (43.9)

359 (38.4) 25 (37.9)

137 (14.7) 12 (18.2)

0.63 0.729



226 (45.2) 187 (47.8) 54 (49.5)

188 (37.6) 154 (39.4) 42 (38.5)

86 (17.2) 50 (12.8) 13 (11.9)

4.31

0.366



188 (44.3) 200 (46.8) 79 (53)

160 (37.7) 172 (40.3) 52 (34.9)

76 (17.9) 55 (12.9) 18 (12.1)

7.27

0.122

Primary care taker

Mother Father

452 (47.3) 15 (34.1)

364 (38.1) 20 (45.5)

140 (14.6) 9 (20.5)

3.12

0.211


Table 4.4.1 shows association of BMI for age of under five children with

their demographic characteristics. BMI was associated with demographic

variables like age, gender, religion, number of under fives in the family, birth

weight of the child, birth order of the child, spacing between children and

primary care taker. On analysis it was observed that BMI for age was

associated with age with χ² value 30.58 and p value 0.000 at.0.01 level of

significance.

111

Fig:4.4.1. Distribution of BMI of under five children based on their age.

The figure 4.4.1. shows that only a small percent of children in each

group possessed over weight, a moderate percentage of them had stunted

growth and almost half percentage of them fell in the normal category.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-1 year 1.1-2years 2.1-3 years

>3 years

Over weight/ Obese

Stunted / severely stuntedNormal

112

Table 4.4.2 Association of BMI for age of under five children with


N= 1000 Socioeconomic characteristics Normal Stunted /

severely stunted

Over weight/ Obese

χ2 P

Type of family

Nuclear Joint

265 (49.2) 202 (43.8)

202 (37.5) 182 (39.5)

72 (13.4) 77 (16.7)

3.65 0.161

Education of father


168 (43.3) 156 (49.4) 108 (48.9) 35 (46.7)

165 (42.5) 116 (36.7) 76 (34.4) 27 (36)

55 (14.2) 44 (13.9) 37 (16.7) 13 (17.3)

5.8

0.446

Education of Mother


140 (43.9) 95 (47.3) 168 (49.9) 64 (44.8)

134 (42) 82 (40.8) 114 (33.8) 54 (37.8)

45 (14.1) 24 (11.9) 55(16.3) 25 (17.5)

7.03

0.318



36 (36.4) 91 (46.7) 340 (48.2)

43 (43.4) 81 (41.5) 260 (36.8)

20 (20.2) 23 (11.8) 106 (15)

7.33

0.119


Unemployed Employed

430 (47.2) 37 (41.6)

343 (37.7) 41 (46.1)

138 (15.1) 11 (12.4)

2.47 0.291


>40,000 <40,000

414 (47.5) 53 (41.4)

320 (36.7) 64 (50)

138 (15.8) 11 (8.6)

9.94**

0.007

Place of residence

Urban Rural

59 (52.2) 408 (46)

38 (33.6) 346 (39)

16 (14.2) 133 (15)

1.63 0.442


Table 4.4.2 shows association of BMI for age of under five children and

socio economic characteristics. The study observed that BMI for age was

associated with total family Income in the family per month in Rupees with χ²

value 9.94 and p value 0.007 at 0.01 level of significance.

Fig: 4.4income

Th

had tot

growth,

percent

0

10

20

30

40

50

60

70

80

90

100

4.2. Dise of family

he figure 4

al family

again alm

tage of the

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

>4

stribution y

.4.2. show

income gr

most half

em showed

40,000

of BMI o

ws that alm

reater than

of them s

d over weig

<40,0

113

of under

most half of

n and less

showed st

ght.

000

five child

f the childr

s than 40

tunted gro

Ov

Stu

No

dren base

ren from b

0,000 show

owth and

ver weight/ Ob

unted / severe

ormal

ed on tota

oth familie

wed norma

only a few

ese

ly stunted

al

es

al

w

114

Table 4.4.3 Association of BMI for age of under five children with

environment and epidemiological characteristics. N= 1000

Environment and epidemiological characteristics

Normal Stunted / severely stunted

Over weight/ Obese

χ2 p


167 (46.4) 300 (46.9)

154 (42.8) 230 (35.9)

39 (10.8) 110 (17.2)

9.06* 0.011


459 (47.5) 8 (23.5)

369 (38.2) 15 (44.1)

138 (14.3) 11 (32.4)

11.54** 0.003


385 (44.9) 82 (57.7)

334 (38.9) 50 (35.2)

139 (16.2) 10 (7)

11.62** 0.003


No over crowdingCI<1 Crowding CI

249 (47.6) 218 (45.7)

202 (38.6) 182 (38.2)

72 (13.8) 77 (16.1)

1.15

0.562


Dumping Others

382 (46) 85 (50)

328 (39.5) 56 (32.9)

120 (14.5) 29 (17.1)

2.71 0.258



328 (46.7) 139 (46.8)

282 (40.1) 102 (34.3)

93 (13.2) 56 (18.9)

6.25*

0.044


Yes No

292 (46.4) 175 (47.2)

253 (40.2) 131 (35.3)

84 (13.4) 65 (17.5)

4.21 0.122



252 (45) 191 (47.9) 24 (58.5)

229 (40.9) 143 (35.8) 12 (29.3)

79 (14.1) 65 (16.3) 5 (12.2)

5.13

0.275


Yes No

298 (46.5) 169 (47.1)

250 (39) 134 (37.3)

93 (14.5) 56 (15.6)

0.37 0.832



355 (45.7) 112 (50.2)

310 (39.9) 74 (33.2)

112 (14.4) 37 (16.6)

3.35

0.187


Yes Sometimes No

379 (46.9) 67 (48.2) 21 (39.6)

301 (37.3) 57 (41) 26 (49.1)

128 (15.8) 15 (10.8) 6 (11.3)

5.24

0.263


Table4.4.3. depicts association of BMI for age of under five children with

environment and epidemiological characteristics. On analysis it was observed

that B M I was associated with type of house with χ² value 9.06 and p value

0.001 at.0.05 level of significance. BMI for age was also associated with toilet

facilities) with χ² value 11.62 and p value 0.003 at.0.01 level of significance,

water supply (public tap) with χ² value 11.54 and p value 0.003 at.0.01 level

of significance and frequency of diarrhoea in preceding 2 weeks with χ² value

6.25 and p value 0.044 at 0.05 level of significance.

115

Table 4.4.4 Association of BMI for age of under five children with behavioral

and health awareness characteristics

N=1000 Behavioral and awareness characteristics Normal Stunted /

severely stunted

Over weight/ Obese

χ2 P

Habits of parents


125(48.1) 187 (47) 50 (46.3) 105(44.9)

92 (35.4) 162(40.7) 45 (41.7) 85 (36.3)

43 (16.5) 49 (12.3) 13 (12) 44 (18.8)

7.26

0.298



425(46.3) 16 (43.2) 26 (57.8)

362(39.4) 11 (29.7) 11 (24.4)

131 (14.3) 10 (27) 8 (17.8)

8.72

0.069



236(46.1) 26 (53.1) 14 (32.6) 191(48.2)

194(37.9) 21 (42.9) 23 (53.5) 146(36.9)

82 (16) 2 (4.1) 6 (14) 59 (14.9)

9.89

0.129


Completely immunized

Partially/No immunized

410(47.7) 57 (40.7)

321(37.3) 63 (45)

129 (15) 20 (14.3)

3.14 0.208


Yes No

258(45.1) 209(48.8)

226(39.5) 158(36.9)

88 (15.4) 61 (14.3)

1.37

0.505



274(43.4) 138(52.1) 55 (53.4)

256(40.5) 95 (35.8) 33 (32)

102 (16.1) 32 (12.1) 15 (14.6)

8.49

0.075


As per table 4.4.4 that shows association of BMI for age of under five

children with behavioural and health awareness characteristics. BMI was not

associated significantly with none of the behavioural and awareness variables.

116

Table 4.4.5 Association of BMI for age of under five children with nutritional

characteristics.

N= 1000 Nutritional characteristics Normal Stunted /

severely

stunted

Over

weight/

Obese

χ2 P

Food habits Vegetarian

Non-vegetarian

68 (42.8)

399(47.4)

62 (39)

322(38.3)

29 (18.2)

120 (14.3)

2.06 0.357

Number of meals per

day

Two meals

Three meals

313(47.7)

154(44.8)

238(36.3)

146(42.4)

105 (16)

44 (12.8)

4.22 0.121

How long the children

got breast feed

< 1 year

>1 year

144 (42)

323(49.2)

142(41.4)

242(36.8)

57 (16.6)

92 (14)

4.75 0.093

Specify the age at

which weaning started

< 6 months

>6 months

172(42.7)

295(49.4)

167(41.4)

217(36.3)

64 (15.9)

85 (14.2)

4.4

0.111


Table 4.4.5 depicts association of BMI for age of under five children with

nutritional characteristics and analysis showed that BMI for age was not

associated with none of the nutritional variables

117

Table 4.4.6 Association of Mid arm circumference (MAC) of under five

children with demographic variables. N=1000

Demographic characteristics Mean SD N Test statistics P Age


12.9 13.0 12.9 13.2

1.0 1.1 1.0 1.1

207 232 298 263

F 3.12*

0.025

Gender Male Female

13.1 13.0

1.1 1.0

434 566

t 1.69

0.091

Religion


13.1 13.0 13.0

1.0 1.0 1.1

126 788 86

F 0.48

0.620



13.0 13.0 13.1

1.0 1.1 1.0

482 420 98

F 0.68

0.508


Normal Below normal

13.0 13.0

1.1 0.9

934 66

t 0.27 0.784



13.1 12.9 13.1

1.0 1.0 1.1

500 391 109

F 1.38

0.253



13.1 13.0 13.0

1.1 1.1 1.0

424 427 149

F 1.57

0.209

Primary care taker

Mother Father

13.0 12.9

1.1 1.0

956 44

t 0.81 0.421


Table 4.4.6 shows association between Mid arm circumference (MAC)

of under five children with demographic characteristics. On analysis it was

observed that MAC was associated with age at F value 3.12 and p value

0.025.

118

Table 4.4.7. Association of Mid arm circumference of under five children

with socioeconomic characteristics.

N=1000

Socioeconomic characteristics Mean SD N Test statistics P Type of family

Nuclear Joint

13.0 13.1

1.1 1.0

539 461

t 1.19 0.234

Education of father


12.9 13.1 13.1 12.7

1.0 1.1 1.1 1.0

388 316 221 75

F 3.55*

0.014

Education of Mother


12.9 13.0 13.1 12.9

1.1 1.0 1.1 1.0

319 201 143 337

F 1.36

0.254



12.9 13.0 13.0

1.0 1.0 1.1

99 195 706

F 0.65

0.524


Unemployed Employed

13.0 12.9

1.0 1.1

911 89

t 0.58 0.562

Total family Income in the family per month in Rupees

>40,000 <40,000

13.0 13.0

1.1 1.0

872 128

t 0.22

0.827

Place of residence

Urban Rural

13.2 13.0

1.1 1.0

113 887

t 1.53 0.128


Table 4.4.7 depicts the association of Mid arm circumference of under

five children with socioeconomic characteristics. On analysis it was found that

Mid arm circumference was associated with education of father with F value

3.55 and pvalue 0.014 which is statistically significant at 0.05 level.

119

Table 4..4.8. Association of Mid arm circumference of under five


N=1000 Environment and

epidemiological characteristics Mean SD N Test

statistics P


13.0 13.0

1.0 1.1

360 640

t 0.07 0.942


13.0 13.1

1.1 1.0

966 34

t 0.35 0.725


13.0 13.1

1.0 1.1

858 142

t 1.67 0.094


No over crowding CI<1 Crowding CI 1.1 – 4

13.0 13.0

1.1 1.0

523 477

t 0.7 0.483


Dumping Others

13.0 13.2

1.0 1.1

830 170

t 2.17* 0.030



13.0 13.0

1.1 1.0

703 297

t 0.55 0.584

Seeking care for Diarrheal diseases

Yes No

13.0 13.0

1.0 1.1

629 371

t 0.56 0.573



13.0 13.0 13.1

1.1 1.0 1.1

560 399 41

F 0.14

0.865


Yes No

13.0 13.0

1.0 1.1

641 359

t 0.08 0.934



13.0 13.1

1.0 1.1

777 223

t 0.87

0.386


Yes Sometimes

13.0 13.0

1.0 1.0

808 139

t 0.07 0.947


Table 4.4.8 shows Association of Mid arm circumference of under five

children with environment and epidemiological characteristics and on analysis

it was observed that Mid arm circumference of under five children was

associated with method of refuse disposal with a t value 2.17 with p value

0.030 at 0.05 level of significance.

120

Table 4.4.9 Association of Mid arm circumference of under five children

with behavioral and health awareness characteristics

N=1000 Behavioral and awareness characteristics Mean SD N Test statistics P Habits of parents Smoker

Consumption of alcohol Others No bad habits

13.0 13.0 13.1 13.0

1.1 1.1 1.0 1.1

260 398 108 234

F 0.21

0.886



13.0 12.9 13.3

1.1 1.1 1.0

918 37 45

F 1.45

0.235



12.9 13.1 13.1 13.1

1.0 1.1 1.0 1.1

512 49 43 396

F 1.26

0.287


Completely immunized

Partially/No immunized

13.0 13.0

1.0 1.1

860 140

t 0.08

0.940


Yes No

13.0 13.0

1.1 1.0

572 428

t 0.32 0.752



13.0 13.0 13.0

1.0 1.1 1.1

632 265 103

F 0.05

0.952


Table 4.4.9 shows the Association of Mid arm circumference of under five

children with behavioural and health awareness characteristics. It was found

that mid arm circumference was not associated with none of the behavioural

and awareness variables.

121

Table 4.4.10 Association of Mid arm circumference of under five

children with nutritional characteristics N=1000

Nutritional characteristics Mean SD N Test statistics

P


13.0 13.0

1.0 1.1

159 841

t 0.19 0.851



13.0 13.0

1.1 1.0

656 344

t 0.26 0.798


< 1 year >1 year

13.0 13.0

1.0 1.1

343 657

t 0.09

0.932



13.1 13.0

1.1 1.0

403 597

t 1.7

0.089


Table 4.4.10 shows Association of Mid arm circumference of under five

children withtheir nutritional characteristics and on analysis it was found that

MAC was not associated with nutritional variables

122

Section V Association of HB of under five children with demographic

variables.

Table 4.5.1. Association of HB of under five children with their

demographic characteristics. N=1000

Demographic characteristics Mean SD N Test statistics p Age


12.3 11.7 11.9 12.1

1.9 1.1 1.4 1.3

207 232 298 263

F 6.6**

0.000

Gender Male Female

12.0 12.0

1.3 1.5

434 566

t 0.6

0.546

Religion


11.9 12.0 12.1

1.5 1.4 1.7

126 788 86

F 0.5

0.605



11.9 12.0 12.1

1.4 1.4 1.4

482 420 98

F 0.59

0.556

Birth weight of child Normal Below normal

12.0 12.1

1.4 1.7

934 66

t 0.83 0.406

Birth order of the child First Second Third/Fourth

12.0 12.0 12.2

1.4 1.5 1.6

500 391 109

F 1.61

0.200



12.0 12.0 12.1

1.6 1.3 1.4

424 427 149

F 0.27

0.762

Primary care taker Mother Father

12.0 11.9

1.5 1.0

956 44

t 0.64 0.520


Table 4.5.1 shows Association of HB of under five children with

demographic characteristics. On analysis HB of under fives was associated

with age of the child with F value 6.6 and p value 0.000 that is highly

significant at 0.01 level

123

Table 4.5.2. Association of HB of under five children with


N=1000 Socioeconomic characteristics Mean SD N Test statistics P Type of family Nuclear

Joint 12.0 12.0

1.5 1.4

539 461

t 0.04 0.969

Education of father


12.1 12.1 11.8 11.8

1.3 1.5 1.6 1.6

388 316 221 75

F 2.21

0.086

Education of Mother


12.1 11.8 12.0 12.0

1.6` 1.2 1.6` 1.1

319 201 143 337

F 1.22

0.302



12.1 12.1 12.0

1.5 1.3 1.5`

99 195 706

F 1.14

0.320


Unemployed Employed

12.0 11.8

1.5 1.1`

911 89

t 1.03 0.301

Total family Income in the family per month in Rupees

>40,000 <40,000

12.0 12.1

1.4 1.6`

872 128

t 0.93

0.355

Place of residence

Urban Rural

12.0 12.0

1.3` 1.5

113 887

t 0.33 0.744


According to table 4.5.2 Association of HB of under five children with

socioeconomic characteristics shows HB of underfive children was not

associated with socioeconomic variables.

124

Table 4.5.3. Association of HB of under five children with environment

and epidemiological characteristics

N=1000 Environment and

epidemiological characteristics Mean SD N Test

statistics p


12.1 12.0

1.4 1.5

360 640

t 1.1 0.270


12.0 12.4

1.4 1.7

966 34

t 1.55 0.121


12.0 12.0

1.4 1.6

858 142

t 0.19 0.851


No over crowding CI<1 Crowding CI 1.1 – 4

12.0 12.0

1.4 1.5

523 477

t 0.93 0.350


Dumping Others

12.0 11.9

1.5 1.4

830 170

t 0.49 0.627



12.1 11.8

1.5 1.3

703 297

t 2.23* 0.026

Seeking care for Diarrheal diseases

Yes No

12.0 12.0

1.5 1.4

629 371

t 0.53 0.598



12.0 12.0 11.8

1.4 1.5 1.2

560 399 41

F 0.69

0.502


Yes No

12.0 12.0

1.5 1.4

641 359

t 0.1 0.922



12.0 12.0

1.5 1.3

777 223

t 0.35

0.725


Yes Sometimes

12.0 12.1

1.4 1.6

808 139

t 1.2 0.230


Table 4.5.3 shows the Association of HB of under five children with

environment and epidemiological characteristics. On analysis it shows that HB

of under five children was associated with frequency of diarrhoea in preceding

2 weeks with t value of 2.23 with p value 0.026 that is statistically significant at

0.05 level.

125

Table 4.5.4: Association of HB of under five children with behavioral

and health awareness characteristics. N=1000

Behavioral and awareness characteristics Mean SD N Test statistics P Habits of parents Smoker

Consumption of alcohol Others No bad habits

11.8 12.1 12.0 12.1

1.4 1.4 1.3 1.6

260 398 108 234

F 2.95*

0.032



12.0 12.1 11.8

1.4 1.5 1.5

918 37 45

F 0.65

0.523



11.9 12.5 12.3 12.0

1.3 2.3 0.8 1.5

512 49 43 396

F 3.54*

0.014



12.0 12.1

1.4 1.6

860 140

t 0.83

0.409


Yes No

12.1 11.8

1.4 1.4

572 428

t 2.76** 0.006



12.0 12.1 11.8

1.4 1.5 1.3

632 265 103

F 1.7

0.184


According to table 4.5.4 Association of HB of under five children with

behavioral and health awareness characteristics, HB of under five children

was found associated with the following: health habits of the care taker of the

child with F value 3.54 and p value 0.014 that is statistically significant at 0.05

level, habits of parents of the children with F value 2.95 and p value 0.032 that

is statistically significant at 0.05 level and previous iron and Vit A therapy with

t value 2.76 and p value 0.006 that is statistically significant at 0.01 level.

126

Table 4.5.5: Association of HB of under five children with their

nutritional characteristics. N=1000

Nutritional characteristics Mean SD N Test statistics

P


11.8 12.0

1.4 1.5

159 841

t 1.97*

0.049



11.9 12.1

1.4 1.5

656 344

t 1.8 0.072


< 1 year >1 year

12.0 12.0

1.5 1.4

343 657

t 0.52

0.604



11.9 12.1

1.4 1.4

403 597

t 1.91

0.056


As per Table 4.5.5 Association between HB of under five children and

nutritional characteristics HB status of the child was significantly associated

with food habits with t value 1.97 and a p value 0.049 at 0.05 level.

Section VI. Association of malnutrition among under five children with


127

4.6.1 Association of stunting ( height for age) of under five children with clinical variables of their mothers (N=1000)

Clinical variables of mother Normal Stunting Odds (95 % CI) χ2 P Age at marriage Below 18 years

18-35 years 24(77.4) 736 (76)

7 (22.6) 233 (24)

1 1.09(0.46 – 2.55)

0.04 0.851

BMI of the mother Normal Abnormal

713(75.8) 47 (79.7)

228 (24.2) 12 (20.3)

1.25 (0.65 – 2.40) 1

0.46

0.497


Pediatrician(pvt) Govt. Hosp / health centre

3 (100) 757(75.9)

0 (0) 240 (24.1)

1 57.14 (0 – 0)

0.95

0.330


52 (75.4) 708 (76)

17 (24.6) 223 (24)

1.04 (0.59 – 1.83) 1

0.02

0.898

Condition of last two children

Normal Low birth weight Not applicable

669(75.5) 20 (62.5) 70 (87.5)

217 (24.5) 12 (37.5) 10 (12.5)

2.274 (1.15–4.48) 4.19 (1.58–11.12) 1

9.13**

0.010

Obstetrics problems

Normal Abnormal

512(73.1) 248(82.7)

188 (26.9) 52 (17.3)

1.75 (1.24 – 2.47) 1

10.44***

0.001


754(76.2) 6 (54.5)

235 (23.8) 5 (45.5)

1 2.67 (0.81 – 8.84)

2.81

0.094


Yes Sometimes No

699(76.8) 36 (70.6) 25 (64.1)

211 (23.2) 15 (29.4) 14 (35.9)

1 1.38 (0.74–25.57) 1.86 (0.95 – 3.63)

4.18

0.124

Whether de worm during pregnancy

Yes No

206(71.5) 545(77.9)

82 (28.5) 155 (22.1)

1.40 (1.03 – 1.91) 1

4.48*

0.034

Medical condition of the mother

Yes No

113(77.9) 647(75.7)

32 (22.1) 208 (24.3)

1 1.14 (0.74 – 1.73)

0.35

0.556

Post natal complications

Normal Abnormal

707(75.5) 53(82.8)

229 (24.5) 11 (17.2)

1.56 (0.80 – 3.04) 1

1.74

0.187


115(72.8) 645(76.6)

43 (27.2) 197 (23.4)

1.22 (0.83 – 1.80) 1

1.06

0.302

Food choice during pregnancy

Yes No

166(66.7) 594 79.1)

83 (33.3) 157 (20.9)

1.89 (1.38 – 2.60) 1

15.83***

0.000

Willingly accepted each pregnancy

Yes No

696 (77) 64 (66.7)

208 (23) 32 (33.3)

1 1.67 (1.07 – 2.63)

5.07* 0.024


Table 4.6.1 shows association of Stunting (height for age) of under five

children with clinical variables of their mothers. On analysis it was observed

that stunting was associated with obstetrical problem with a χ2 value of 10.44

and p value 0.001, food choice during pregnancy with a χ² value of 15.88 and

p value 0.000, Willingly accepted each pregnancy with a χ² value of 5.07 and

p value of 0.024 and conditions of the last two children with a χ² value of 9.13

and p value 0.10 which is statistically significant at 0.05 level.

128

4.6.2 Association of underweight (weight for age) of under five children

with clinical variables of their mothers (N=1000)

Clinical variables of mother Normal Stunting Odds (95 % CI) χ2 pAge at marriage Below 18 years

18-35 years 25(80.6) 726(74.9)

6 (19.4) 243(25.1)

1 1.40(0.57 – 3.44)

0.53

0.468


707(75.1) 44 (74.6)

234(24.9) 15 (25.4)

1 1.03(0.56 – 1.89)

0.01

0.924


Pediatrician (pvt) Govt. Hosp / health centre

3 (100) 748 (75)

0 (0) 249 (25)

1 60.00 (0 – 0)

1

0.318


50 (72.5) 701(75.3)

19 (27.5) 230(24.7)

1.16(0.67 – 2.01) 1

0.28

0.600



674(76.1) 26 (81.3) 50 (62.5)

212(23.9) 6 (18.8) 30 (37.5)

1 0.73(0.30 – 1.81) 1.91(1.18 – 3.08)

7.9*

0.019

Obstetrics problems

Normal Abnormal

524(74.9) 227(75.7)

176(25.1) 73 (24.3)

1.04(0.76 – 1.43) 1

0.07

0.786 0


747(75.5) 4 (36.4)

242(24.5) 7 (63.6)

1 5.40(1.57–18.61)

8.92***

0.003


Yes Sometimes No

685(75.3) 34 (66.7) 32 (82.1)

225(24.7) 17 (33.3) 7 (17.9)

1.50(0.65 – 3.45) 2.29(0.84 – 6.24) 1

2.96

0.227


Yes No

204(70.8) 536(76.6)

84 (29.2) 164(23.4)

1.35(0.99 – 1.83) 1

3.57

0.059


Yes No

99 (68.3) 652(76.3)

46 (31.7) 203(23.7)

1.49(1.02 – 2.19) 1

4.22*

0.040


Normal Abnormal

705(75.3) 46 (71.9)

231(24.7) 18 (28.1)

1 1.19(0.68 – 2.10)

0.38

0.537


113(71.5) 638(75.8)

45 (28.5) 204(24.2)

1.25(0.85 – 1.82) 1

1.29

0.257


Yes No

183(73.5) 568(75.6)

66 (26.5) 183(24.4)

1.12(0.81 – 1.55) 1

0.46

0.499


Yes No

684(75.7) 67 (69.8)

220(24.3) 29 (30.2)

1 1.35(0.85-2.14)

1.6 0.206


Table 4.6.2 shows Association of underweight (weight for age) of under

five children with clinical variables of their mothers. On analysis, maternal

variables like condition of last two children with a χ² value of 7.9 and p value

0.019, Medical condition of the mother Odds (95 % CI)1.49 (1.02 – 2.19) with

a χ² value 4.22 and p value 0.040 that is statistically significant 0.05 level and

antenatal check up with a χ² value 8.93 and a p value of 0.003 which is

statistically significant at 0.01 level

129

4.6.3. Association of wasting ( weight for length/height) of under five children with clinical variables of their mothers

N=1000 Clinical variables of mother Normal Stunted /

severely stunted

Over weight/ Obese

χ2 P

Age at marriage Below 18 years 18-35 years

15 (48.4) 496(51.2)

10 (32.3) 360(37.2)

6 (19.4) 113 (11.7)

1.73

0.420


486 (51.6) 25 (42.4)

344(36.6) 26 (44.1)

111 (11.8) 8 (13.6)

1.93

0.382


Pediatrician (private) Govt.Hosp/health centre

1 (33.3) 510(51.2)

1 (33.3) 369 (37)

1 (33.3) 118 (11.8)

1.36

0.507


33 (47.8) 478(51.3)

29 (42) 341(36.6)

7 (10.1) 112 (12)

0.85

0.652



451(50.9) 20 (62.5) 38 (47.5)

326 36.8) 8 (25) 36 (45)

109 (12.3) 4 (12.5) 6 (7.5)

5.08

0.279

Obstetrics problems Normal Abnormal

357 (51) 154(51.3)

249(35.6) 121(40.3)

94 (13.4) 25 (8.3)

5.87

0.053


504 (51) 7 (63.6)

366 (37) 4 (36.4)

119(12) 0 (0)

1.67

0.435


Yes Sometimes No

462(50.8) 23 (45.1) 26 (66.7)

342 (37.6) 22 (43.1) 6 (15.4)

106 (11.6) 6 (11.8) 7 (17.9)

9

0.061


Yes No

138(47.9) 366(52.3)

113(39.2) 254(36.3)

37 (12.8) 80 (11.4)

1.59

0.452


Yes No

76 (52.4) 435(50.9)

57 (39.3) 313(36.6)

12 (8.3) 107 (12.5)

2.17

0.337


Normal Abnormal

476(50.9) 35 (54.7)

346 (37) 24 (37.5)

114 (12.2) 5 (7.8)

1.14

0.566


85 (53.8) 426(50.6)

58 (36.7) 312(37.1)

15 (9.5) 104 (12.4)

1.18

0.553


Yes No

133(53.4) 378(50.3)

78 (31.3) 292(38.9)

38 (15.3) 81 (10.8)

6.38*

0.041


Yes No

463(51.2) 48 (50)

336(37.2) 34 (35.4)

105 (11.6) 14 (14.6)

0.74

0.691


According to the above table 4.6.3 shows Association of wasting (weight-

for-length/height ) of under five children with clinical variables of their

mothers, underweight of the children were associated with food choice of the

mother during pregnancy with a χ2 value 6.38 and p value 0.041 that is

statistically significant at 0.05 level

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Section VII The overall contributing factors for malnutrition among

underfive children.

Table 4.7.1. Contributing factors for malnutrition among underfive

children based on demographic determinants. N=1000

Sl No.

Contributing factors Stunting Underweight Wasting χ2 p χ2 p χ2 P

I Demographic Characteristics Spacing between children 7.47* 0.024 Primary care taker 9.28** 0.002 4.64* 0.031 Age (0-1 year) 48.44*** 0.000 19.29** 0.004 Gender Male 4.86* 0.028

II Socio-economic Characteristics Occupation of father 18.53*** 0.000

Total family income in the family per year

8.32** 0.016

III Environment and Epidemiological Characteristics Water supply 3.91* 0.048 8.87** 0.012

Frequency of diarrhoea in preceding 2 weeks

9.2** 0.002

Type of house 13.77*** 0.000 Toilet facilities 9.39** 0.009 IV Behavioural and awareness Characteristics

Decision maker to use money in the family

8.1* 0.017

Health Habits of care taker 10.04** 0.018

V Nutritional Characteristics

Breast feed duration 5.98** 0.014 12.11*** 0.001


4.65* 0.031 6.16** 0.013

Food habits 7.19** 0.007


The above table depicts that factors like spacing between children (for

one year spacing), primary care taker (mother), occupation of father, water

supply (Tap water), frequency of diarrhea in preceding 2 years, decision

maker in the family (Mother), health habits of the care taker (hand washing

practice after use of latrine), duration of breast feed (<1 year), age at which

131

weaning started (< 6months) were associated with stunting among underfive

children.

The factors like age (0-1 Year), gender (male), type of house (Kuchha),

food habits (vegetarian), how long the children got breast feed (<1 year), the

age at which weaning started were associated with under weight of children.

The factors like age (0-1 year), toilet factilities, total family income (>Rs.

40,000/ year), water supply (tap water) influenced wasting among under five

children.

Table 4.7.2. Contributing factors based on maternal determinants

N=1000

Sl No.

Contributing factors Stunting Underweight Wasting χ2 p χ2 p χ2 P

VI Maternal factors Condition of last two children

9.13** 0.010 7.9* 0.019

Antenatal check up 8.92** 0.003 Whether deworm during pregnancy

4.48* 0.034


4.22* 0.040

Obstetrics problems 10.44*** 0.001 Food choice during

pregnancy 15.83*** 0.000 6.38* 0.041


5.07* 0.024


Table 4.7.2 shows maternal factors contributing to malnutrition. With

regards to stunting, conditions of the last two children (χ2 9.13 with p value

0.010), deworming during pregnancy (χ2 4.48 with p value 0.034) and

acceptance of each pregnancy willingly (χ2 5.07 with p value 0.024) were

associated at 0.05 level of significance, obstetrical problems. (χ2 10.44 with p

132

value 0.001 ) and food choice during pregnancy(χ2 15.83 with p value 0.000)

were associated at 0.001 level, that is highly significant.

With regards to underweight, conditions of the last two children (χ2 7.9

with p value 0.019) and medical condition of the mother (χ2 4.22 with p value

0.040) were associated at 0.05 level of significance. However antenatal check

up (χ2 8.92 with p value 0.003) were associated at 0.01 level that is

moderately significant and food choice during pregnancy was found

contributing factor for wasting (χ2 6.38 with p value 0.041) shows a low

significance at 0.05 level

Table 4.7.3 Association of Anthropometric measurements

(BMI and MAC) and Haemoglobin with demographic characteristics.

N=1000 Sl No.

Contributing factors χ2 P χ2 p

VIIA Anthropometric measurements(BMI) Age (0-1 year) 30.58*** 0.000 Total family income 9.94** 0.007 Type of house 9.06** 0.011 Water supply 11.54** 0.003 Toilet facilities 11.62** 0.003 Frequency of diarrhoea in preceding 2weeks

6.25* 0.044

VII B

MAC ‘t’ value P

Age (0-1 year) 3.12* 0.025 Education of father 3.55* 0.014 Method of refuse disposal 2.17* 0.030

VIII Haemoglobin F value P ‘t” value Age 6.6*** 0.000

Habits of parents (t value) 2,95* 0.032 Health habits of care taker 3.54* 0.014 Food habits 1.97* 0.049 Previous iron or vitamin therapy

2.76** 0.006

Frequency of diarrhoea in2 preceding weeks

2.23* 0.023

133

Table 4.7.3 shows over all association of anthropometric measurements

(BMI and MAC) and Haemoglobin with demographic characteristics. The

study observed that age (χ2 30.58 with p value 0.000) was highly associated

with BMI at 0.001 level of significance. Total family income (χ2 9.94 with p

value 0.007), type of house (χ2 9.06 with p value 0.011), water supply

(χ2 11.54 with p value 0.003) and toilet facilities (χ2 11.62 with p value 0.003)

were moderately associated at 0.01 level of significance. However Frequency

of diarrhoea in preceding 2weeks (χ2 6.25 with p value 0.044) was associated

at 0.05 level of significance.

With regards to association of MAC with demographic variables found

that age 0-1 year (‘t’ value 3.12 with p value 0.025), education of father (t’

value 3.55 with p value 0.014),) and method of refuse disposal (t’ value 2.17

with p value 0.030,) were significantly associated at 0.05 level.

With regards to association of Haemoglobin status with demographic

variables, the study observed that age was highly associated with HB

(t’ value 6.6 with p value 0.000,) at 0.001 level, previous iron or vitamin

therapy (F value 2.76 with p value 0.006) were moderately significant at 0.01

level. However habits of parents (t’ value 2.95 with p value 0.032), health

habits of care taker (t’ value 3.54 with p value 0.014), food habits (F value

1.97 with p value 0.049) and frequency of diarrhoea in preceding 2 weeks

(F value 2.23 with p value 0.023) were significantly associated at 0.05 level.

134

SUMMARY

This chapter dealt with the analysis of the data collected from 1000

under five children. Both descriptive and inferential statistics were used to

analyze the data. Findings were presented in tables, graph and diagrams.

Next chapter will deal with discussion, summary, conclusion,

implications and limitations.

135

CHAPTER V

DISCUSSION, SUMMARY, CONCLUSION,

RECOMMENDATIONS, IMPLICATIONS AND LIMITATIONS

DISCUSSION

The present study was carried out to assess the prevalence and factors

influencing malnutrition among children below five years of age at Trivandrum

district, Kerala state. This chapter attempted to discuss the findings of the

study as per the objectives, and hypothesis. The data were grouped,

organized and analyzed from 1000 underfive children by using descriptive and

inferential statistics and presented in the form of tables and diagrams. Where

ever the literature comparison was not possible, researcher made inference

based on her personal and professional life experience.

Out of the 1000 subjects studied the majority 566 (56.6%) of the children

were female, In terms of religion, majority of the children 788 (78.8%)

belonged to Christian community, remaining 126 (12.6%) and 86 (8.6%) of

them belonged to Hindu and Muslim community respectively. With reference

to the birth weight of child most 934 (93.4%) of the children were found

normal. Majority 427 (42.7%) of the family were having two year spacing

between children. Most of them 993 (99.3%) lived with their father and mother

and rest of them 7(0.7%), were separated. With regards to age group of under

five children majority 298 (29.8%) were in the age group of 2.1 - 3 years and

the least number 60 (6.0%) of children were between the age group of 4.1 -

<5 years.

136

Regarding percentage distribution of age and gender among under five

children majority were female in all age group except in the age group of 4.1

- <5 years, 32 (53.3%) were male children. The majority 125 (60.4%) females

were below the age group 0-1 year. With regards to number of under five

children in the family majority 482 (48.2%) of families had only one child below

5 years of age in the family. Majority 500 (50%) of the children were in the

first birth order in the family and few 9 (0.9%) number of under five children

belonged to fourth order of birth. The majority 960 (96 %) of the primary care

taker of the children were mothers

The researcher has discussed the findings according to the objectives of

the study

Objective : 1 Prevalence of malnutrition among under five children It is

discussed under stunting, under weight and wasting.

Stunting: With regards to stunting, 760 (76%) of them were normal and

remaining 240 (24%) were stunted/severely stunted among the 1000 children

studied at 95% CI with a mean height/length of 21.4 - 26.6. Analyzing BMI-for-

age 467 (46.7%) were on normal weight, whereas 384 (38.4%) of them were

under weight /severely under weight and 149 (14.9%) of them had over

weight/obese at 95% CI with a mean weight 35.4 – 41.4.

Underweight: With regards to Underweight, the minimum weight of under five

children was 22.2 and maximum weight was 27.6 at 95% CI in which three

fourth of the subjects 751 (75.1%) were having normal weight and a quarter of

them 249 (24.9%) had underweight /severely under weight.

137

Wasting: At 95% CI, the wasting of children of under five ranged from 34 to

40. % . 511 (51.1%) children had normal weight, 370 (37%) of them had

wasting and 119 (11.9%) of them were overweight/obese.

The findings are consistent with a study by Philomena Ochurus (2007)

who conducted a cross-sectional descriptive study at Namibia and assessed

the prevalence of malnutrition among children between the age of one to five

years and correlated possible causes, with nutritional status. The study

observed wasting rate, 19.7%, caused by chronic malnutrition. Stunting was

28.8% and underweight 35.7%.

Prevalence of malnutrition among under five children with regards to

age and gender

Stunting

Majority 25 (30.5%) stunting was observed in male children among 0-1 year

group.The same percentage with meager difference was observed in 1-3 year

male children as 29.9% and 29.8% respectively .In female majority 35(28%)

stunting was observed in 1-2 year age group followed by 7 (25%) among 4 -

<5year age group

Underweight

On analysis it was observed that in both gender underweight was

observed more or less equal that is 41.5% in male and 41.6% in female as

majority among 0 -1 year aged children. Underweight was found in decreasing

order of percentage in both male and female children from 1 - <5 years

138

Wasting

Regarding distribution of wasting based on age and gender, In male

children wasting was found 39 (47.6%) among 0-1 year and 36 ( 40.4%)

among 3-4 years Whereas in female children 57 (45.6%) as majority in 0-1

year age group compared to 66 (37.9%) in 2-3 year age group. The above

findings are consistent with Poonam.P.Dhatric (2013) who in their study

observed that Malnutrition was prevalent in 56 (58.95%) males and 39

(41.05%) females. Malnutrition was highest amongst infants 26 (27.37%) and

lowest 14 (14.74%) in 37-48 months age group.

Objective -2 Association of malnutrition among under five children with

their demographic variables

The researcher analyzed the contributing factors under demographic

factors, socioeconomic factors, environmental and epidemiological factors,

behavirol and health awareness factors and nutritional factors.

1. Demographic factors :With regards to association of stunting in under

five children with their demographic factors, it was observed that stunting

was associated with primary care taker (mother) at Odds (95 % CI) 2.53

(1.37 - 4.68) with a χ² of 9.26, which is moderately significant at 0.01 level.

Stunting also associated with spacing between children ( for one year

spacing) at Odds (95 % CI) 1.5 (0.96 - 2.35) with a χ² value of 7.47 which is

low significance at 0.05 level.

With reference to association of underweight in under five children with

their demographic analysis showed that underweight was associated with age

139

(0-1Year) Odds (95 % CI) 3.35 (2.2 - 5.11) with a χ² value of 48.44 and p value

of 0.000 which is highly significant at p < 0.001 level. Underweight was also

associated with gender (male) Odds (95 % CI) 1.38 (1.04 - 1.84) with a χ² value

4.86 and p value of 0.028 which shows a low significance at 0.05 level and

primary care taker (father) Odds (95 % CI) 1.96 (1.05 - 3.67) with a χ² value of

4.64 and p value of 0.031 which shows a low significance at 0.05 level.

Referring to association of wasting in under five children with their

demographic variables the study observed that underweight was associated

with age 0-1 year with a χ² value 19.29** with a p value of 0.004 which is

statistically significant at 0.01 level.

2. Socioeconomic factors

On analyzing the association of stunting in under five children with socio

economic factors, the study found that occupation of father (unemployed) at

Odds (95 % CI) 1.15 (0.72 - 1.83) with a χ² of 18.53 associated significantly

at 0.01 level. However underweight was not associated with socioeconomic

factors.

With reference to wasting it was observed that wasting was associated

with total family Income in the family per month in Rupees (>40,000 Rupees)

with a value χ² 8.32 and p value 0.016 at.05 level which shows low

significance.

The findings of the study showed that there is an influence of

demographic and socio economic factors on malnutrition with children

140

belonged lower socioeconomic status, low birth weight and lived in rural

area.

3. Environmental and epidemiological factors

With regards to association of stunting in under five children with

environmental and epidemiological factors the study observed that stunting was

associated with water supply (Tap water supply) at Odds (95 % CI) 2.02 (0.99 -

4.09) with a χ² value of 3.91and p value of 0.048 which low significance at

0.05 level. Stunting was also associated with frequency of diarrhoea at Odds (95 %

CI) 1.6 (1.18 - 2.18) with a χ² of 9.2 and p value of 0.002 which is moderately

significant at 0.01 level.

On analysis it was observed that underweight was associated with type

of house (Kuchha) Odds (95 % CI) 1.73 (1.29 - 2.32) with a χ² value13.77 and

p value of 0.000 which shows a moderate significance at 0.01 level.

On analysis it was observed that wasting was associated water supply χ²

value 8.87 and p value 0.012 at.05 level of significance and toilet facilities with

a χ² value 9.39 and p value 0.009.

4. Behavioural and health awareness factors

On analysis it was observed that stunting was associated use with decision

maker to money in the family (mother) Odds (95 % CI) 2.54 (1.3 - 4.95) with a χ²

value of 8.1 and p value of 0.017 which low significance at 0.05 level.

Stunting also found associated with health habits of the care taker (Hand

washing practice after use of latrine) Odds (95 % CI.. 1.18 (0.87 - 1.6) with a

χ² value of 10.04 and p value of 0.018 which low significance at 0.05 level.

141

However under weight and wasting was not associated with any of the

behavioral and awareness factors.

The above findings are supported by Alom J, Quddus M A and Islam M A

(2012) carried out a study to assess the nutritional status and economic

condition of under-five children in Bangladesh. The analyses showed that 16%

of the children were severely stunted and 25% were moderately stunted, 3%

were severely wasted and 14% were moderately wasted. 11% of the children

were severely underweight and 28% were moderately underweight. The study

revealed the main contributing factors influencing for under-five children’s

malnutrition were the child's age, mother's education, father's education,

father's occupation, family wealth index, currently breast-feeding, and place of

delivery.

5. Nutritional factors

With reference to association of stunting in under five children with

nutritional factors, it was found that stunting was associated with how long the

child got breast feed (<one year)at Odds (95 % CI 1.45 (1.08 - 1.96) with a

χ² value of 5.98 and p value of 0.014 which shows low significance at 0.05

level.

Stunting also associated with age at which weaning started (<6 months)

at Odds (95 % CI 1.38 (1.03 - 1.85) with a χ² value of 4.65 and a p value of

0.031 which shows low significance at 0.05 level

However, underweight was associated with food habits(vegetarian)

Odds (95 % CI )1.65 (1.14 - 2.37) with a χ² value7.19 and p value of 0.007

142

which shows a moderate significance at 0.01 level There was a significant

association observed in underweight with how long the children breast fed

(<1 year) Odds (95 % CI) 1.68 (1.25 - 2.26) with a χ² value 12.11 and p value

0.001 showed high significance .Further underweight was associated with the

age at which weaning started (<6 months) Odds 5 % CI )1.44 (1.08 - 1.92)

with a χ² value 6.16and p value 0.013 which shows a low significance.

However wasting was not associated with nutritional characteristics.

The findings are supported by Mulugeta A.et al (2010) who carried out a

study on Child malnutrition in Tigray-Northern Ethiopia. The aim of the study

was to assess prevalence of malnutrition and identify factors influencing to

child malnutrition in Tigray among under five aged children. The study

revealed that child age, maternal anthropometric characteristics, inadequate

complementary foods, the use of prelacteal feeds and area of residence was

the main contributing factors to child undernutrition.

Therefore the Hypothesis stated earlier RH1 that there will be a

significant association of malnutrition score among under five children with

their demographic, socioeconomic, environmental and epidemiological,

behavioral and health awareness and nutritional factors at p<0.05 level is

accepted for the variables like primary care taker, spacing between children,

age of the child, occupation of father, family income, water supply, frequency

of diarrhoea, type of house, water supply, decision maker to use money in the

family, health habits of the care taker how long the child breast fed, age at

143

which weaning started, food habits of mother, how long the children got breast

feed, age at which weaning started and for other variables rejected.

Objective 3 To determine the association of malnutrition among under

five children with anthropometric measurements

The researcher analyzed the anthropometric measurements like BMI and mid

arm circumference (MAC) with demographic factors, socioeconomic factors,

Environmental and epidemiological factors, Behavirol and health awareness

factors and Nutritional factors

With regards to demographic factors on analysis it was observed that

BMI for age was associated with χ² value 30.58 and p value 0.000 at.0.01 level

of significance. However MAC was associated with age at t value 3.12 and p

value 0.025.

With regards to socioeconomic factors the study observed that BMI for

age was associated with total family Income in the family per month in Rupees

with χ² value 9.94 and p value 0.007 at.0.01 level of significance. However,

MAC was associated with education of father with F value 3.55 and p value

0.014 which is statistically significant at 0.05 level.

With regards to epidemiological and environmental factors on analysis it

was observed that B M I for age was associated with type of house with χ²

value 9.06 and p value 0.001 level, toilet facilities with χ² value 11.62 and p

value at.0.01 level of significance, water supply (public tap) with χ² value 11.54

and p value 0.003 at.0.01 level of significance and frequency of diarrhoea in

preceding 2 weeks with χ² value 6.25 and p value 0.044 at 0.05 level of

144

significance, whereas that MAC was associated with method of refuse

disposal with a t value 2.17 with p value 0.030 at 0.05 level of significance.

However, BMI for age and MAC was not associated with any of the

behavioral, health awareness and nutritional factors.

Therefore the Hypothesis stated earlier RH2 There will be a significant

association of malnutrition score among under five children with their

anthropometric measurement at p<0.05 level is accepted for the variables like

age of the child, total family Income in the family per month in rupees,

education of father, type of house, toilet facilities, water supply, frequency of

diarrhoea in preceding 2 weeks and method of refuse disposal

The above findings are supported by Solomon Demissie, (2013) carried

out a community based, cross-sectional survey to determine magnitude and

factors influencing malnutrition among children. The study revealed that the

prevalence of malnutrition was 42.3% for wasting 34.4% for stunting and

47.7% for underweight. Wasting, stunting and underweight was more

prevalent among boys than girls. Prevalence of wasting was higher among

young children while stunting and underweight were observed in older

children. The analysis showed that the significant determinants of malnutrition

were gender and age of child, marital status, maternal education, monthly HH

income, decision making, having of livestock, presence of ARI, total number of

children born, health status during pregnancy, pre-lactation practice, mode of

feeding, access to clean water and type of floor in the households.

145

Objective 4.To determine association of malnutrition among under five

children with their hemoglobin status

On analysis HB of under fives the study found that Malnutrition was

associated with age of the child with F value 6.6 and p value 0.000 that is

highly significant at 0.01 level.

However there was no association of HB with Socio economic factors

With reference to environment and epidemiological factors, analysis

showed that HB of under five children was associated with frequency of

diarrhoea in preceding 2 weeks with t value of 2.23 with p value 0.026 that is

statistically significant at 0.05 level.

With reference to behavioral and health awareness, health habits of the

care taker of the child with F value 3.54 and p value 0.014 was statistically

significant at 0.05 level. It was also observed that habits of parents of the

children with F value 2.95 and p value 0.032 was statistically significant at

0.05 level and previous iron and Vit A therapy with t value 2.76 and p value

0.006 that is statistically significant at 0.01 level.

With reference to nutritional factors, HB status of the child was

significantly associated with food habits with t value 1.97 and a p value 0.049

at 0.05 level.

Therefore the Hypothesis stated earlier RH3 that there will be a significant

association of malnutrition score among under five children with their

hemoglobin measurement at p<0.05 level is accepted for the variables like

age of the child, frequency of diarrhoea in preceding 2 weeks, health habits of

146

the care taker, habits of parents of the children,previous iron and Vit A therapy

and food habits and others were rejected.

Objective 5 To determine association of malnutrition among under five

children with their clinical variables of mother.

Stunting of the children were significantly associated with obstetrical

problem Odds (95 % CI) 1.75 (1.24 – 2.47) with a χ² value of 10.44 and p

value 0.001 that is statistically significant at 0.001 level. Stunting of the

children were significantly associated with Food choice during pregnancy

Odds (95 % CI) 1.89 (1.38 – 2.60) with a χ² value of 15.88 and p value 0.000

that is statistically significant at 0.001 level.

Stunting of the children are significantly associated with willingly

accepted each pregnancy with a χ² value of5.07 and p value of 0.024 that is

statistically significant at 0.05 level, conditions of the last two children Odds

(95 % CI) 2.274 (1.15 – 4.48) with a χ² value of 9.13 and p value 0.10 which

is statistically significanr at 0.05 level and deworming during pregnancy Odds

(95 % CI) 1.40 (1.03 – 1.91) with a χ² value of 4.48 and p value 0.034.

With reference to underweight on analysis underweight was associated

with maternal variables like condition of last two children with a χ² value of

7.9 and p value 0.019 which is statistically significant at 0.05 level, Antenatal

check up with a χ² value 8.92 and a p value of 0.003 which is statistically

significant at 0.01 level and Medical condition of the mother Odds (95 % CI)

147

1.49 (1.02 – 2.19) with a χ² value 4.22 and p value 0.040 that is statistically

significant at 0.05 level

With regards to wasting under five children were found associated with

food choice of the mother during pregnancy with a χ² value 6.38 and p value

0.041 that is statistically significant at 0.05 level

The above findings are consistent with Michelle Bellessa F et al (2005)

who studied ‘maternal education and child nutritional status in Bolivia’

observed that maternal education and child nutritional status, attitude about

health care. Health care knowledge, with autonomy and reproductive

behaviors, had an impact on nutritional status of under five children.

Hence the Hypothesis stated earlier RH4 “There will be a significant

association of malnutrition score among under five children with Maternal

factors at p<0.05 level” is accepted for, the variables like obstetrical problem

willingly accepted each pregnancy , conditions of the last two children,

Antenatal check up, medical conditions of the mother, whether deworming

during pregnancy and others were rejected.

SUMMARY

The investigator carried out descriptive study with the aim to assess the

prevalence and contributing factors of malnutrition among under five children

The conceptual framework used in this study was based on UNICEF’S

Malnutrition model.

The data was collected from 02.01.2015 to 15.12.2015. After obtaining

the formal permission from the Panchayat presidents and consent from

148

mothers of under five of selected Panchayats, Thiruvananthapuram, the

investigator proceeded to collect the data. Subjects were made seated

comfortably and in a relaxed situation. The researcher developed rapport And

explained the information regarding the present study establish co-operation.

General information regarding socio demographic factors was asked and

responses were recorded as per structured interview schedule.

Anthropometric measurements were taken .Hemoglobin was checked and

recorded. Maternal factors were assessed through a structured questionnaire

and recorded.

Major findings of the study

• The researcher analyzed the prevalence of malnutrition under 3 indices

i.e. stunting, under weight and wasting. The present study observed

stunting 24% and underweight 24.9% comparing national statistics 35%

and 36% respectively however wasting among under five of the present

study was 37% that is higher than the national statistics (8%) (Unicef

2014)

• Prevalence of malnutrition was the highest among the age group of 0-1

year in both male and female infants.

• Prevalence of malnutrition is more observed in male children.

• The study investigated various contributing factors those have impact on

malnutrition such as demographic, socioeconomic, environmental and

epidemiological behavioral and health-awareness including nutritional

factors on the malnutrition status among under-five children.

149

• Spacing between children ( < 1 year), water supply (Tap water), age

(<1 year), Weaning started (< 1 year), Primary care taker, frequency of

diarrhea in preceding 2 years, decision maker in the family (Mother),

duration of breast feed, health habits and occupation of father were

associated with stunting.

• Primary care taker, gender (male), age at weaning, food habits

(vegetarian) age of the child (<1 year), type of house and duration of

breast fed were associated with under weight of children.

• Age (< 1 year), total family income (>40,000 year), water supply

(tap water) and toilet facilities were the factors influenced wasting among

under five children

• Stunting of children were influenced by Maternal factors They were

deworming during pregnancy and acceptance of each pregnancy

willingly, obstetrical problems, conditions of last two children and food

choice during pregnancy. With regards to underweight conditions of the

last two children, medical condition of the mother and antenatal checkup

were associated. However, Food choice during pregnancy was found

contributing factor for wasting among under five children.

• The study analyzed the association of Anthropometric measurements

(BMI, MAC) and hemoglobin. With demographic characteristics the

factors like age, total family income, type of house (Kutcha), water

supply, toilet facilities, frequency of diarrhoea in preceding 2 weeks were

associated with BMI.

150

• With regards to association of MAC with demographic variables found

that age 0-1 year, education of father and method of refuse disposal were

significantly associated.

• With regards to association of Hemoglobin status with demographic

variables, the study observed that age, previous iron or vitamin therapy,

habits of parents hand washing, health habits of care taker, food habits

and frequency of diarrhoea in preceding 2 weeks were significantly

associated at 0.05 level.

• Stunting of children were influenced by Maternal factors They were deworming

during pregnancy and acceptance of each pregnancy willingly, obstetrical

problems, conditions of last two children and food choice during pregnancy.

With regards to underweight conditions of the last two children, medical

condition of the mother and Antenatal checkup were associated. However, food

choice during pregnancy was found contributing factor for wasting among under

five children.

CONCLUSION

The study concluded that :

The prevalence of stunting was 24%, underweight 24.9% and wasting

37% among under five children. Malnutrition was affected by 0-1 year age

group and was prevalent more among male children than female.

The various demographic, socioeconomic, environmental and

epidemiological, behavioral and health-awareness including nutritional factors

influencing malnutrion among under-five children were age, gender, type of

house, spacing between children ( < 1 year), toilet facilities, weaning started

151

(< 1 year), frequency of diarrhoea in preceding 2 years, decision maker in the

family (mother), occupation of father, primary care taker, gender (male), food

habits (vegetarian), duration of breast feeding, total family income (>40,000

year), water supply (tap water), health habits, type of house, food habits.

Maternal factors influencing malnutrition were, deworming during

pregnancy and acceptance of each pregnancy willingly , obstetrical problems

and food choice during pregnancy condition of the last two children, medical

condition of the mother, antenatal checkup and food choice during pregnancy

were found contributing factors among under five children.

BMI, was influenced by age, total family income, type of house (kutcha)

water supply, toilet facilities, frequency of diarrhoea in preceding 2 weeks.

With regards to association of MAC was influenced by age 0-1 year, education

of father and method of refuse disposal.

Hemoglobin status was influenced by age, previous iron or vitamin

therapy, habits of parents hand washing, health habits of care taker, food

habits and frequency of diarrhoea in preceding 2 weeks.

IMPLICATIONS

Nursing Practice

The findings of the study has implications for nursing specifically for pediatric

nursing, maternal nursing and community health nursing These findings will

help nurses to understand the magnitude of the problem of malnutrition and

factors influencing malnutrition .Nurses can plan and implement health

education program for mothers regarding importance of antenatal nutrition,

152

spacing between births, initiation of breast feeding within one hour of birth,

exclusive breast feeding for minimum six months, initiating complementary

feed and weaning. Community health nurses can stress the need for

environmental sanitation in each household. Growth monitoring is an

important aspect of child growth and development. The pediatric nurses and

Anganwadi workers can emphasis monitoring growth of infants and toddlers,

immunization, personal hygiene and other factors influencing malnutrition

such as demographic, socio, socio economic, environmental, epidemiological

nutritional and maternal determinants and preventive measures by IEC

strategies. This will help to improve the nutrition of their children which in turn

will reduce morbidity and mortality among under five children

The role of community health nurse is expanding and extending. The

community-based screening of malnutrition approach is one of the activities of

a public health nurse that aims at timely detection of malnutrition of under

fives in the community and provision of treatment for those without medical

complications with ready-to-use therapeutic foods or other nutrient-dense

foods prepared at home.

• Nurses should conduct high coverage of screening of malnutrition in

under five clinics, balwadis and community at all times and perform active

case finding

• Nurses are usually responsible for completing a nutritional screening

tool in hospital because screening is often part of the admission assessment.

153

However, simply completing a screening tool and recording a risk score will

not be enough to manage a patient’s poor nutritional state.

Pediatric nurses need to be confident to screen children suffering from

malnutrition and they can safely implement a series of actions at ward level

that will benefit children before referring them to specialized health

professionals. Implementing nutritional action plans early in under five

children’s admissions means corrective measures can begin promptly.

There is a scope for nurse epidemiologist to participate in community nutrition

activities

Nursing education

Nursing curriculum should include the contents on the major determinants of

malnutrition among under five children. Growth monitoring should be

strengthened in clinical experience of nursing students.

Curriculum for nurses should include research-based content about

screening protocol and protocol for preventive strategies of malnutrition for

children Nurses should learn and incorporate specific diet conducive to

under five children and mothers including the guidelines by ICMR Hyderabad

on nutrition

• All nurses who directly involved in caring for children in hospital or

community must be given orientation training who can support for community

health workers, multipurpose health workers, Anganwadi teachers. /

workers to identify children with severe acute malnutrition who need urgent

treatment and referral services. Establish adequate referral arrangements for

154

children suffering from complicated forms of severe acute malnutrition so they

can receive adequate inpatient treatment to .prevent further deterioration of

the condition.

Administration

• Adequate funding to be provided for nursing service department for

continuous in-service education for nurses and the resource materials to teach

families.

• Providing the resources needed for management of severe acute

malnutrition,

• Ensuring funding to provide free treatment of severe acute malnutrition

because affected families are often among the poorest .Integrating the

management of severe acute malnutrition with other health activities, such as:

Preventive nutrition initiatives, including promotion of breastfeeding and

appropriate complementary feeding, and provision of relevant information,

education and communication (IEC) materials.

• Mobilize resources for nutrition screening and provision of food

• Nurse should be aware of nutritional policies and national protocol for

prevention malnutrition among under fives through planned in-service

education program

Research

• The study findings will help nurses to do determinant research and

intervention research on malnutrition

155

• Conducting determinant researches to refine protocols of community-

based screening of malnutrition among under five children and preventive

management for malnutrition.

• This study laid the foundation to appraise the various risk factors and

prevalence among under five children can in turn result in mortality if not

attended.

• Practicing nurses and post graduate students may utilize the findings for

validating the need for comprehensive nursing care in community and

hospital settings.

• Research studies of this kind will provide evidence based information and

can help nurses to identify the existing knowledge gap and prevalence of

risk factors of malnutrition in under five children nursing care.

Recommendations

The study recommends the following

• Screening of malnutrition should routinely be performed to identify the risk

group, with different degree of malnutrition so that proper intervention can

be taken in the management by following WHO regimen in order to

reduce mortality due to malnutrition.

• A large multi setting study should be undertaken to assess the

magnitude of malnutrition in Kerala and speculate its risk factors will help

to provide proper measures how malnutrition can be prevented.

• This study was a community based cross sectional study. It can be

conducted in hospital setting specially in pediatric units.

156

• Since maternal factors influence malnutrition, study could be undertaken

on maternal knowledge and practice to prevent malnutrition among

infants.

LIMITATIONS

• Other predictors of morbidity like serum protein could not be studied due

to financial constraints

• The study would have been better if urban and rural differences in

malnutrition was undertaken

157

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LETTER REQUESTING PERMISSION FOR STUDY SETTING

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To

Respected Sir,

Sub: Mrs. Suja Baby Y V – Ph. D Scholar – requesting permission to

conduct study on under five (0-5 yrs) in Trivandrum district- Reg

I am a Ph D scholar of VMACON, as a partial fulfilment of Ph. D degree,

I am conducting a study to assess the Prevalence and Contributing Factors of

Malnutrition among Children below under five at Trivandrum district, for which

I am to collect data from five panchayats of each block under Trivandrum

district. The probable period of data collection will be in the year 2015

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I also assure that the information collected will be kept confidential and I

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content validity of tools – regarding:

I, Mrs. Suja Baby Y V, Ph D Scholar of Vinayaka Missions University

Salem, under Dr. Mrs. A.V .Raman and have selected the following topic as

mentioned below for the award of Ph. D degree in Nursing

Topic: A study to assess the Prevalence And the Contributing Factors of

Malnutrition Among Children Below Under Five at Trivandrum, Kerala State.

The objectives of the study are:

1. To assess the prevalence of malnutrition among under five children



viii


with anthropometric measurements


hemoglobin status.


their clinical variables of mother.

I request you Sir/ Madam to give your expert opinions and suggestions

on the appropriateness of items which need to be modified or deleted.

Kindly sign the certificate of validation stating that you have validated

and approved the tool at the earliest, I will be grateful to you

Thanking you,

Yours faithfully,

[Mrs. Suja Baby Y V]

Enclosures:

1. Objectives of the study

2. Tools developed by the researcher with evaluation criteria

3. Self addressed envelope

ix

ANNEXURE – G

LIST OF EXPERTS

1. Dr.Judie A

Dean, SRM College of Nursing,

SRM University, SRM Nagar,

Katankulathur-603203

Tamil Nadu

2. Dr. S. Valliammal

Lecturer,

NIMHANS College of Nursing

Bangalore – 29

3. Dr. Premalatha

Associate Professor,

Govt. College of Nursing,

Trivandrum

4. Dr. Beena M R


Govt. College of Nursing,

Alappuzha

5. Dr. Blessed Singh

Professor and HOD,

Department of Community Medicine

Karakonam, Kerala

x

6. Dr. Subha

Professor,


Karakonam, Kerala

7. Dr. Manish



Karakonam, Kerala

8. Dr. Soumya

Assistant Professor,


Karakonam, Kerala

9. Dr. Baburaj S

Professor and HOD

Department of Paediatrics

Karakonam, Kerala

10. Dr. Oommen Philip

Research Investigator

Population Research Centre

University of Kerala

11. Dr. Pramod

Statistician,

Dr. SMCSI Medical College,

xi

Karakonam, Kerala.

12. Mrs. Rasheeda Begum

Department of Food and Nutrition

Dr. SMCSI Medical College,

Karakonam, Kerala.

xii

ANNEXURE – H

INSTRUMENTS USED IN THE STUDY IN ENGLISH AND MALAYALAM

PART I

SECTION A

STRUCTURED INTERVIEW QUESTIONAIRE TO COLLECT BASELINE

DATA OF THE SAMPLES

The researcher asks the questions to the respondents and places a tick

mark (√) on the answer stated by the respondent for the corresponding

questions.

Subject Code No……………………………….

BACK GROUND INFORMATION OF THE SAMPLE

A. Demographic characteristics (Personal)

1. Age in years

1.1 0 - 1 year

1.2 1.1 - 2 year

1.3 2.1 - 3 year

1.4 3.1 - 4 year

1.5 4.1 - 5 year

2. Gender

2.1 Male

2.2 Female

xiii

3. Religion

3.1 Hindu

3.2 Christian

3.3 Muslim

3.4 Others

4. No. of under five in the family

4.1 One

4.2 Two

4.3 Three

4.4 More than three

5. Birth weight of child

5.1 Normal

5.2 Below normal

6. Birth order of the child

6.1 First

6.2 Second

6.3 Third

6.4 Fourth

7. Spacing between children

7.1 One year

7.2 Two years

7.3 Three years

7.4 More than three years

xiv

8. Who is the primary care taker?

8.1 Mother

8.2 Father

8.3 Siblings

8.4 Any other, specify

9. Parental Divorce

9.1 Yes

9.2 No

B Socio economic characteristics

10. Type of family

10.1 Nuclear

10.2 Joint

11. Education of father

11.1 Illiterate

11.2 Primary education

11.3 Middle

11.4 High School/Metric

11.5 Under graduate

11.6 Graduate /post graduate

11.7 Professional/honor/above PG

12. Education of mother

12.1 Illiterate

12.2 Primary education

xv

12.3 Middle

12.4 High School/Metric

12.5 Under graduate

12.6 Graduate /Post graduate

12.7 Professionals/honors/above PG

13. Occupation of father

13.1 Unemployed

13.2 Skilled worker

13.3 Clerical/shop keeper/farmer

13.4

Professional

14. Occupation of mother

14.1 Unemployed

14.2 Skilled worker

14.3 Clerical/ shop Owner/ farmer

14.4 Professional

15. Total family Income in the family per year in Rupees

15.1 >40.000

15.2 30,000-39,000

15.3 20,000-29,000

15.4 10,000-19,000

15.5 6,000- 9,000

15.6 4000-5900

xvi

15.7 <4000

16 Place of residence

16.1 Urban

16.2 Rural

C. Environment and epidemiological characteristics

17. Type of house

17.1 Kuccha

17.2 Puccha

18. Water supply

18.1 Public tap

18.2 Bore well

18.3 Well

18.4 Any other specify

19 Toilet facilities

19.1 Own toilet facility

19.2 Shared with other families

19.3 Open field

20 Crowdedness

20.1 No overcrowding

20.2 Crowding

20.3 Over crowding

21 Method of refuse disposal

21.1 Dumping

xvii

21.2 Composting

21.3 Incineration/ burning


22 .Frequency of diarrhea in preceding 2 weeks

22.1 No episode

22.2 Three and less

22.3 Four and more

23 Seeking care for Diarrheal diseases

23.1 Yes

23.2 No

24. Frequency of A R I in preceding 2 weeks

24.1 No episode

24.2 Three and less

24.3 Four and more

25. Seeking care for A R I conditions

25.1 Yes

25,2 No

26. Manifestation of parasitic infection during the past 3 months

26.1 No Manifestation

26.2 1-2 manifestations

26.3 3-4 manifestations

27. Regular deworming the child at every 6 months

27.1 Yes

xviii

27.2 Sometimes

27.3 No

D. Behavioral and health awareness characteristics

28. Habits of parents

28.1 Smoker

28.2 Consumption of alcohol

28.3 Drug addiction

28.4 Chewing betel / tobacco

28.5 No bad habits

28.6 Any other specify

29. Decision maker to use money in family

29.1 Father

29.2 Mother

29.3 Both Jointly

30 Health habits of care taker

30.1 Hand washing practice after

use of latrine

30.2 Before food preparation

30.3 After cleaning the child

30.4 All of the above

31 Immunization status of the child

31.1 Completely immunized

31.2 Partially immunized

xix

31.3 Not immunized at all

32. Previous iron or vitamin therapy

32.1 Yes

32.2 No

33. Exposure to information on malnutrition to parents

33.1 Health professionals

33.2 Mass media

33.3 Friends and relatives

33.4 No information

E. Nutritional characteristics

34. Food habits

34.1 Vegetarian

34.2 Non-vegetarian

34.3 Egg- vegetarian

35. Staple food

35.1 Rice

35.2 Wheat

35.3 Maize


36. Number of meals per day

36.1 Two meals

36.2 Three meals


xx

37. How long the children got breast feed

37.1 < 1 year

37.2 1 - 2 year

37.3 2 - 3 year

38. Specify the age at which weaning started

38.1 < 6 months

38.2 6 - 7 months

38.3 > 7 months

Part - II

ANTHROPOMETRIC MEASUREMENTS

Instruction to the parent

Your child's weight, height and mid arm circumference will be

assessed as a part of the study .If you want to know the result

it will be furnished

1 Weight kg

2

Height/ length cm

3

Mid arm circumference cm

xxi

Scoring

Classification of malnutrition for weight for height, height for age

and weight for age based on Z-score.

( Z-score = Measured value – Median of reference population )

Standard deviation of the reference population

Sl

No.

Items Scoring

1 Height for age

-2 < Z-Score < + 2 - Normal

-3 < Z-Score < - 2 - Moderate stunting

Z-Score < - 3 - Severe stunting.

2 Weight for age

-2 < Z-Score < + 2 - Normal

-3 < Z-Score< - 2 - Moderate underweight

Z-Score < - 3 - Severe underweight

3 Weight for height -2 < Z-Score < + 2 - Normal

-3 < Z-Score < - 2 - Moderate wasting

Z-Score < - 3 - Severe wasting

3 Mid arm circumference

(IAP)

<12.5 cm – Severe malnourished

12.5–13.5cm–Mild to Moderate malnourished

> 13.5 cm – Normal.

xxii

PART III

BIOCHEMICAL MEASUREMENT OF HAEMOGLOBIN

Instruction to the parent

Your child’s blood (less than 1ml) will be taken to assess the

hemoglobin level as a part of the study. Please hold the child in your

lap/arm so that he/she will not shake.

1. Haemoglobin

1.1 > 10

1.2 11 - 12

1.3 13 - 14

1.4 > 14

Scoring ( WHO),

>10 gm% : Mild anemia

10gm- 7gm% : Moderate anemia

< 7 gm% : Severe anemia

< 5 gm% : Very severe anemia

xxiii

PART IV

CLINICAL VARIABLE OF MOTHER

The researcher asks the questions to the mother of the child and

places a tick mark (√) on the answer stated by the respondent for the

corresponding questions.

1. Age at Marriage

1.1 Below 18 years

1.2 18 - 35 yrs

1.3 More than 35 yrs

2. BMI of the mother

2.1 Normal

2.2 Above normal

2.3 Below normal

3. At the time of sickness of your child whom do you consult

3.1 Pediatrician ( private)

3.2 Govt. Hosp/ health centre

3.3 Local village doctors

3.4 None

4 Place of Delivery

4.1 Home

4.2 Hospital/ health centre

5 Condition of last two children

5.1 Normal

xxiv

5.2 Low birth weight

5.3 Not applicable

6 Obstetrics problems

6.1 Anemia in pregnancy

6.2 Hyperemesis gravidarium

6.3 Polyhydramnios

6.4 Gestational Diabetes Mellitus

6.5 Abruptio Placenta

6.6 Placenta previa

6.7 Oligohydramnios

6.8 Normal

7 Antenatal check up

7.1 Regular

7.2 Irregular

8 Iron and folic acid tablets taken during pregnancy

8.1 Yes

8.2 Sometimes

8.3 No

9 Whether deworming done during pregnancy

9.1 Yes

9.2 No

10 Medical condition of the mother

10.1 Diabetes

xxv

10.2 Hypertension

10.3 Heart Diseases

10.4 None

11 Post natal complications

11.1 Increased bleeding per vagina

11.2 Breast feeding difficulties due

to inverted or cracked nipple

11.3 C-section wound

11.4 Normal

11.5 Others (specify)

12 Contraceptive use

12.1 Yes

12.2 No

13 Food choice during pregnancy, if any

13.1 Yes

13.2 No

14 Willingly accepted each pregnancy

14.1 Yes

14.2 No

Findings will be calculated by frequency and percentage

xxviii

xxxiii

xxxvii

xxxviii

xxxix

ANNEXURE I

CRITERIA FOR TOOL VALIDITY

Dear sir/ Madam

Kindly go through the tool and the content for its adequacy and give

your opinion in the column given in the criteria table against each item. If the

item is not relevant or needs modification, please give your valuable

suggestions in the column mentioned in the given format

Item No Not relevant

Relevant to certain extent

Relevant Very relevant

Suggestion

PART I BACKGROUND INFORMATION OF THE SAMPLES a. Demographic characteristics (personal) a1

a2

a3

a4

a5

a6

a7

a8

a9

b. Socio economic characteristics

b 10

b 11

xl

b 12

b 13

b 14

b 15

b 16

c. Epidemiological and environmental characteristics

c 17

c 18

c 19

c 20

c 21

c 22

c 23

c 24

c 25

c 26

c 27

d. Behavioral and health awareness

d 28

d 29

d 30

d 31

xli

d 32

d 33

e. Nutritional characteristics

e 34

e 35

e 36

e 37

e 38

PART II ANTHROPOMETRIC MEASUREMENTS

PART IIIBIO CHEMEICAL MEASUREMENT FOR HEMOGLOBIN

PART IV CLINICAL VARIABLE OF THE MOTHER

1

2

3

4

5

6

7

8

9

10

xlii

11

12

13

14

Remarks by the expert........................................................................

Signature of the expert

Date…….

xliii

ANNEXURE - J

CERTIFICATE OF VALIDATION

This is to certify that the tools Constructed by Mrs. Suja Baby Y V,

Ph. D Scholar of Vinayaka Mission University, Salem to be used in her study

titled A study to assess the Prevalence And the Contributing Factors of

Malnutrition Among Children below Five Year at Trivandrum district has been

validated by me and accepted as it is /minor corrections suggested

Signature:

Name:

SEAL Date:

xliv

ANNEXURE – K

INFORMATION SHEET IN ENGLISH AND MALAYALAM

INFORMATION SHEET

You are invited to take part in a research study titled A study to assess the

prevalence and the contributing factors of malnutrition among children below

five year at Trivandrum district, Kerala State. Before you decide whether you

and your child want to take part, it is important for you to understand why the

research is being done, how your information will be used, what the study will

involve, possible benefits, risks and discomforts. Please take time to read the

following information carefully.

PURPOSE AND PROCEDURE OF THE STUDY

To assess the prevalence and contributing factors of malnutrition on your

children by taking height, weight, mid arm circumference and taking a 0.01ml

of blood from your child. It will not be of much pain and also it will not affect

the health of your child.

BENEFITS OF THE STUDY

It will help you to know whether your child is malnourished by taking the

anthropometric measurement, and by blood investigation you will come to

know whether your child is anemic.

ADVERSE REACTIONS TO THE BODY

There are no adverse reactions to the body as it is a non invasive procedure.

xlv

HOW YOUR PERSONAL DATA WILL BE USED

I assure you that the data collected from you or your child will be kept

confidential and no personal reference will be made in the study data.

COST OF TAKING PART IN THE STUDY

I assure you that no cash or other equivalence have to be paid for enrollment

or continuation of study from your side.

RIGHT TO WITHDRAW FROM THE STUDY

You and your child’s participation in the study is voluntary and you are free to

withdraw from the study at anytime, giving any reasons without your medical

care or legal rights being affected.

NAME:

ADDRESS:

PHONE No:

xlviii

ANNEXURE - L

LIST OF BLOCKS IN TRIVANDRUM DISTRICT AND NUMBER OF SAMPLES UNDER EACH PANCHAYAT

Total Blocks - 12

1. Trivandrum rural. 9. Vellanad

2. Kazhakuttaom. 10. Vamanapuram

3. Nemom 11. Parassala

4. Athiyannur 12. Perumkadavila

5. Chirayinkeezh

6. Killimanoor

7. Varkala

8. Nedumangad

xlix

SELECTED PANCHAYATS AND NUMBER OF SAMPLES

4. ATHIYANNUR

i. VENGANNUR

ii. KANJIRAMKULAM

iii. KARUMKULAM

iv. KOTTUKAL

v. VIZHINJAM

vi. ATHIYANNUR (200 SAMPLES)

8. NEDUMANGAD

i. KARAKULAM

ii. ARUVIKKARA (200 SAMPLES)

iii. ANAD

iv. PANAVOOR

v. VEMBAYAM

9. VELLANAD

i. POOVACHAL (200 SAMPLES)

ii. ARYANADU

iii. KUTTICHAL

iv. VITHURA

v. THOLIKKODU

vi. VELLANAD

vii. UZHAMALACKAL

viii. KATTKADA

11. PARASSALA

i. KULATHOOR (200 SAMPLES)

ii. POOVAR

iii. KARODU

iv. THIRUPURAM

l

v. CHENKAL

vi. PARASSALA

12. PERUMKADAVILA

i. ARIYANKODU

ii. KUNNATHUKAL (200 SAMPLES)

iii. AMBOORI

iv. VELLARADA

v. KOLLAYIL

vi. PERUMKADAVILA

vii. OTTASEKHARAMANGALAM

li

ANNEXURE – M

CERTIFICATE OF EDITING

lii

ANNEXURE- N

CERTIFICATE OF TRANSLATION

liii

ANNEXURE- O

A. PROCEDURE OF RECORDING HEIGHT OF THE UNDER FIVE

Above 1 year

1. Remove shoes.

2. Locate crown of the head to the best of your ability.

3. Ask to stand with his/her back and feet against the wall on a flat floor

directly in front of the measuring tape.

4. Mark the floor with masking tape to indicate where the child should

stand. The tape should run directly down the centre of his/ her back.

5. Child should stand with the back as straight as possible. Weight should

be evenly distributed on both feet.

6. Position the child with heels close together, legs straight, arms at sides,

and shoulders relaxed. Buttocks and shoulders should touch the wall.

7. Ask the child inhale deeply and stand fully erect without altering heel

position or allowing heels to rise off the floor.

8. Ask the child look straight ahead with head erect.

9. Place the square flat against the wall. Lower it until it firmly touches the

crown of the head with sufficient pressure to compress the hair.

liv

10. Hold the square steady and have the child move out from under the

square.

11. Read the measurement at eye level where the lower edge of the square

intersects the measuring tape.

Below 1 year of age

1. Place the child straight (supine position) on a Infantometer to touch

head to the head end.

2. The foot board can be moved to touch the foot to measure length while

keeping the leg straight.

B. PROCEDURE OF RECORDING WEIGHT OF THE UNDER FIVE

Above 1 year of age

1. Place scale on solid level floor (hard surface, not carpeting).

2. Balance the scale.

3. Zero the scale before the child steps on the scale.

4. Ask the child remove shoes and bulky clothing (no jackets).

5. Ask the child to stand with back facing with the assistance of mother to

the sliding beam or other readout, both feet on the center of the platform

and not touch other objects or persons.

6. Record the weight.

7. At the end of measuring and recording the weight, return the scale to

the “zero” position to ensure privacy for each child.

lv

Below 1 year of age.

1. Clean weighing pan with a wet duster.

2. Place draw sheet on the pan of the scale in which the infant is to lie.

3. Balance scale.

4. Instruct mother to stand beside scale to undress child before weighing

and to speak to child, so that infant’s attention is diverted.

5. Mummify the infant with same draw sheet and place him on pan.

6. Record the weight.

C. PROCEDURE OF RECORDING MID ARM CIRCUMFERENCE OF THE

UNDER FIVE

1. Locate the lateral tip of the acromion and the most distal point on the

olecranon process.

2. Place an inch tape so that it passes between these two landmarks and

mark the midpoint.

3. Place the inch tape perpendicular to the long axis of the arm at the

marked midpoint and measure the circumference.

D. PROCEDURE FOR RECORDING HAEMOGLOBIN ESTIMATION

1. Explain the procedure to the parent of the child.

2. Assemble the following articles.

3. Wash hands.

Articles

lvi

1. Sahli’s haemoglobinometer

2. 20% HCL

3. Distil.water

4. Sterile needle

5. Cotton swabs

6. Spirit.

Procedure

1. Clean the finger tip with spirit.

2. Press the finger tip and make a gentle prick by the needle at the same

time get ready with the test tube filled with 20 units of HCL.

3. Instill the 2 drops of blood in the test tube by using pipette.

4. Gently mix it, add distil water to get the colour of constant test tube

5. Stop mixing when it reaches constant colour.

6. Read the level in the test tube. Inform to the parent.

welcome to vinayaka missions research ......certificate by the guide i, dr. (mrs.). a. v. raman,...

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