It is the cache of ${baseHref}. It is a snapshot of the page. The current page could have changed in the meantime.
Tip: To quickly find your search term on this page, press Ctrl+F or ⌘-F (Mac) and use the find bar.

Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking Deshmukh P R, Dongre A R, Sinha N, Garg B S - Indian J Med Sci
Indian J Med Sci About us | Subscription  |  Top cited articles | Contact Us | Feedback | Login   
Print this page Email this page   Small font size Default font size Increase font size 
 Users Online : 174
Home Current Issue Ahead of print Back Issues  Instructions Search e-Alerts
  Navigate here 
  Search
 
 ¤  Next article
 ¤  Previous article 
 ¤  Table of Contents
  
 Resource links
 ¤   Similar in PUBMED
 ¤  Search Pubmed for
 ¤  Search in Google Scholar for
 ¤Related articles
 ¤   Article in PDF (71 KB)
 ¤   Citation Manager
 ¤   Access Statistics
 ¤   Reader Comments
 ¤   Email Alert *
 ¤   Add to My List *
* Registration required (free)  


  In this article
 ¤  Abstract
 ¤  Introduction
 ¤  Materials and Me...
 ¤  Results
 ¤  Discussion
 ¤  Acknowledgment
 ¤  References
 ¤  Article Tables

 Article Access Statistics
    Viewed 2470    
    Printed 170    
    Emailed 7    
    PDF Downloaded 176    
    Comments  [Add]    
    Cited by others  5    

Recommend this journal

 


 
ORIGINAL ARTICLE
Year : 2009  |  Volume : 63  |  Issue : 8  |  Page : 345-354
 

Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking


Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram, India

Date of Web Publication 18-Sep-2009

Correspondence Address:
P R Deshmukh
Dr Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102
India
Login to access the Email id


DOI: 10.4103/0019-5359.55886

PMID: 19770525

Get Permissions

 ¤ Abstract  

Background: In India, common morbidities among children under 3 years of age are fever, acute respiratory infections, diarrhea. Effective early management at the home level and health care-seeking behavior in case of appearance of danger signs are key strategies to prevent the occurrence of severe and life-threatening complications. Objectives: To find out the prevalence of acute child morbidities, their determinants and health-seeking behavior of the mothers of these children. Setting and Design: The cross-sectional study was carried out in Wardha district of central India. 0 Material and Methods: We interviewed 990 mothers of children below 3 years of age using 30-cluster sampling method. Nutritional status was defined by National Center for Health Statistics (NCHS) reference. Composite index of anthropometric failure (CIAF) was constructed. Hemoglobin concentration in each child was estimated using the 'filter paper cyanm ethemoglobin method.' Using World Health Organization guidelines, anemia was defined as hemoglobin concentration less than 110 g/L. Post-survey focus group discussions (FGDs) were undertaken to bridge gaps in information obtained from the survey. Statistical Analysis: The data was analyzed by using SPSS 12.0.1 software package. Chi-square was used to test the association, while odds ratios were calculated to measure the strength of association. Multiple logistic regression analysis was applied to derive the final model. Results: Anemia was detected in 80.3% of children, and 59.6% of children were undernourished as indicated by CIAF. The overall prevalence of acute morbidity was 59.9%. Children with mild anemia, moderate anemia and severe anemia had 1.52, 1.61 and 9.21 times higher risk of being morbid, respectively. Similarly, children with single, 2 and 3 anthropometric failures had 1.16, 1.29 and 2.27 times higher risk of being morbid, respectively. Out of 594 (60%) children with at least one of the acute morbidities, 520 (87.5%) sought health care, where majority (66.1%) received treatment from private clinics. The final model suggested that anemia and mother's poor educational status are predictors of childhood morbidity. Conclusions: Nutritional anemia and mother's poor educational status are the most important risk factors of acute childhood morbidity. There is need to revitalize existing health care delivery and child health programs in rural India with emphasis on immediate correction of nutritional anemia.


Keywords: Anemia, CIAF, diarrhea, dysentery, fever, malnutrition, pneumonia


How to cite this article:
Deshmukh P R, Dongre A R, Sinha N, Garg B S. Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking. Indian J Med Sci 2009;63:345-54

How to cite this URL:
Deshmukh P R, Dongre A R, Sinha N, Garg B S. Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking. Indian J Med Sci [serial online] 2009 [cited 2014 Mar 5];63:345-54. Available from: http://www.indianjmedsci.org/text.asp?2009/63/8/345/55886



 ¤ Introduction   Top


In India, common morbidities among children under 3 years of age are fever, acute respiratory infections, diarrhea. [1] Many of these children die at home, without access to essential health services that might have saved their lives. Some children succumb to respiratory or diarrheal infections that are no longer threats in industrialized countries. [2],[3] Up to half of deaths of children under the age of 5 years are associated with undernutrition, a condition in which a young child's body and mind are deprived of the nutrients needed for growth and development. United Nations' millennium development goal is committed to reduce two thirds of child mortality by the year 2015. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) also envisions that family and community health practices, especially health care-seeking behaviors, are to be improved to reduce child morbidity and mortality. [4] Effective early management at the home level and health care-seeking behavior in case of appearance of danger signs are key strategies to prevent occurrence of severe and life-threatening childhood illnesses. [5] Understanding the determinants of these morbidities, as well as the health seeking-behavior, may help in planning interventions for controlling childhood morbidity and mortality.

Though the magnitude of childhood morbidities in India is well known, very few studies have focused on their determinants and the health-seeking behavior of the mothers of the ill children. [6],[7],[8] Hence we conducted the present study to find out the prevalence of acute morbidities; their epidemiological determinants; and the health care-seeking behavior of mothers among children below 3 years of age in rural Wardha district.


 ¤ Materials and Methods   Top


Study setting

The present triangulated research study using quantitative (survey) and qualitative (focus group discussions, FGDs) methods was undertaken in 3 primary health centers (PHCs) of Wardha district, namely, Anji, Gaul and Talegaon, with a total population of 88,187. A list of 5067 children was prepared by undertaking house-to-house visits. The study site was located in rural Wardha district, about 758 km east of the Maharashtra state capital, Mumbai. The health care delivery system of the district comprised of state-owned sub-centers (SCs), primary health centers (PHCs) at the primary level; rural hospital (RH) at the secondary level; and district hospital (DH) and 2 private medical colleges at the tertiary level. Apart from this structure, there were private doctors, practicing allopathy and/ or Indian systems of medicine. The study was approved by the institutional ethical committee.

Study design, sampling method and sample size

The present study was conducted in 2 phases. The first phase comprised of quantitative survey. The second phase comprised of post-survey qualitative study (FGDs) to bridge identified gaps in the information obtained from survey. [9] The study was undertaken during the period from January 2005 to December 2005.

Considering the rough estimate of the proportion of children below 3 years of age who could have one or the other acute morbidity under study to be 0.5; 5% alpha error; 10% relative error in the estimated prevalence; and design effect of 2.5, the minimum sample size required was 960 children. [10] The sample was drawn from 3 PHC areas by 30-cluster sampling technique, where the number of clusters was proportional to the population in each of the 3 PHC areas. From each cluster, 33 children below 3 years of age (11 children from each of the following age groups: 0-11 months, 12-23 months and 24-35 months) were chosen by systematic randomization. Thus the total sample studied comprised of 990 children. The study was approved by the institutional ethical committee.

Data collection

After obtaining informed consent, a trained interviewer interviewed 990 mothers of children below 3 years of age using a pre-designed and pre-tested questionnaire by undertaking house-to-house visits. The structured questionnaire covered symptom-specific information on acute child morbidities as perceived by the mother in the 2 weeks preceding the survey, as well as health care-seeking behavior of mothers of these children. Socioeconomic status was assessed by the type of ration card issued to the family of the child by the government of Maharashtra state under its public distribution system. Families below poverty line receive yellow ration cards, while other families receive orange ration cards. Health care seeking was defined as any attempt by the mother to obtain an expert opinion from a biomedical health care provider outside the home during the child's illness.

To assess nutritional status, weight was obtained by Salter scale provided by United Nations Children's Fund (UNICEF) . Height was measured for children between 24 and 35 months, while length was measured for children below 24 months as per the WHO guidelines on anthropometry. [11]

Hemoglobin concentration in children between 6 and 35 months (n= 772) was estimated using 'filter paper cyanmethemoglobin method.' [12] Using WHO guidelines, anemia was defined as hemoglobin concentration less than 110 g/L. [13] Mild anemia was defined as hemoglobin concentration less than 110 g/L but greater than or equal to 100 g/L; moderate anemia, as hemoglobin concentration less than 100 g/L but greater than or equal to 70 g/L; and severe anemia, as hemoglobin concentration less than 70 g/L. [14],[15]

Post-survey qualitative study

Post-survey focus group discussions (FGDs) were undertaken to bridge gaps in the information obtained from the survey. [9] A trained social worker, after obtaining informed consent, facilitated FGDs with the mothers of children below 3 years of age belonging to different socioeconomic groups. The structured guidelines were followed, and a note taker carefully recorded the discussions in the local language, Marathi. A total of 9 FGDs were conducted. The number of FGDs to be undertaken was decided by the saturation point, i.e., the point at which it stopped yielding any new information.

Statistical analysis

The data was analyzed by using SPSS 12.0.1 software package. Nutritional status was defined by NCHS reference (1978) values for 'weight for age,' 'weight for height' and 'height for age.' 'Weight for age,' 'weight for height' and 'height for age' values below 2 standard deviations were considered as underweight, wasted and stunted. [11] For nutritional analysis, epi_info 6.04d was used.

We constructed the composite index of anthropometric failure (CIAF) as explained by Nandy et al.[16] As given by Nandy et al., the anthropometric permutations of the children are as follows: group A- no failure; group B- wasting only; group C- wasting and underweight; group D- wasting, stunting and underweight; group E- stunting and underweight; group F- stunting only; and finally, group Y- underweight only. The sum of the numbers of children in groups B to F provides the CIAF. [16] These were further grouped as having 'no failure,' 'single failure,' i.e., groups B, F and Y; 'two failures,' i.e., groups C and E; and 'three failures,' i.e., group D; for analysis purpose.

Associations between risk factors and morbidity were evaluated by using chi-square tests. To calculate odds ratio (OR), morbidity was taken as a dependent variable with dichotomous outcome (yes, no); while age group (0-11, 12-23, 24-35 months), sex (male, female), caste [(open category and other categories ('other backward castes,' scheduled castes, scheduled tribes)], mother's education (>10 years, 1-10 years, uneducated), family type (joint, nuclear), socioeconomic status (above poverty level, below poverty level), anemia (no anemia, mild anemia, moderate anemia, severe anemia) and CIAF (no failure, single failure, two failures, three failures) were considered independent variables. Independent variables with a P value of .2 and less in bivariate analysis were forced into the final model that was derived by multiple logistic regressions using backward LR method. P< .05 was taken as a cut off value of statistical significance. A content analysis of qualitative data was undertaken.


 ¤ Results   Top


Study population

Out of the 990 children studied, there were 330 children in each of the following age groups: 0-11 months, 12-23 months and 24-35 months; and 55.1% were male. A majority (51.4%) of children were from the 'other backward castes' category, while only 2.9% were from the 'open' caste category. Majority (65.2%) of mothers had 1-10 years of education, while 6.9% of mothers were uneducated. About 57.5% of children were from a joint family, and 19.9% of children were from families below poverty level [Table 1]. About 137 (85.1%) out of 161 children below 6 months were exclusively breastfed during the last 24 hours.

The prevalence of anemia was 80.3%. Mild, moderate and severe anemias were detected in 27.7%, 51.3% and 1.3% of children, respectively. As per composite index of anthropometric failure (CIAF), 59.6% of children were undernourished, where 22.4% of children had only 1 type of anthropometric failure (2.4%- only wasting; 7.4%- only underweight; and 12.6%- only stunting), 32.0% of children had 2 types of anthropometric failures (6.2%- wasting and underweight; and 25.8%- stunting and underweight) and 5.2% of children had 3 types of anthropometric failures (stunting, wasting and underweight) [Table 1].

Acute morbidities

The overall prevalence of acute morbidity was 59.9%, i.e., at least one of the conditions like fever, cough and cold, pneumonia, diarrhea or dysentery was present during the 2 weeks preceding the survey. Most frequently reported symptoms were cough and cold (41%) and fever (34.1%), followed by pneumonia (6.7%), diarrhea (5.7%) and dysentery (0.3%) [Table 2].

The prevalence of morbidity was minimum (54.2%) in the first year of life, while it was maximum (65.8%) in the second year of life. The difference in the prevalence of morbidities among children of different age groups was statistically significant (P< 0.05). It did not differ significantly between male (60.7%) and female (58.9%) children (P> 0.05). It was least (48.3%) among open caste category children and highest (63.0%) among scheduled tribe children, but the difference in the prevalence of morbidities between different caste groups was not statistically significant (P> 0.05). The prevalence of morbidities among children with mothers with education of 10 years or more was 51.8% as compared to 63.4% and 59.4% among children with mothers with less education or no education, respectively (P< 0.05). Acute morbidities were not found to be significantly associated with type of family and socioeconomic status. These were associated significantly with grades of anemia. The maximum (90.9%) prevalence of morbidities was found in children with severe anemia. It was 63.7%, 62.4% and 52.1% among children with moderate, mild and no anemia, respectively (P< 0.05). No significant association was found between the number of anthropometric failures and the morbidities [Table 1].

Some epidemiologic correlates

Children aged 12-23 months were 1.62 times more likely to be morbid as compared with children aged 0-11 months. This risk decreases to 1.25 times in the age group 24-35 months. Similarly, the risk of being morbid was 1.61 and 1.36 times among children with mothers having 1-10 years of education and with mothers having no education, respectively, as compared to that among those children with mothers having more than 10 years of education. Children with mild anemia, moderate anemia and severe anemia had 1.52, 1.61 and 9.21 times higher risk of being morbid, respectively. Similarly, children with single, 2 and 3 anthropometric failures had 1.16, 1.29 and 2.27 times higher risk of being morbid, respectively [Table 2]. On bivariate analysis, statistically significant risk of any morbidity (at least one of the morbidities studied) was associated with child's age being 12-23 months, child having mother who was less educated or uneducated, child being anemic and child having all 3 types of anthropometric failures (stunting, wasting and underweight).

After applying a multiple logistic regression, the final model suggested that significant predictors of morbidity were mother's education and anemia. Children with mothers having 1-10 years of education and children of illiterate mothers were at 1.43 (95% CI: 1.06-1.93) and 1.10 (95% CI: 0.63-1.90) times higher risk of morbidity, respectively, compared with children with mothers having more than 10 years of education. Children with mild anemia, moderate anemia and severe anemia were at 1.56 (95%CI: 1.09-2.23), 1.57 (95%CI: 1.14-2.17) and 8.9 (95%CI: 1.17-70.83) times higher risk of morbidity, respectively, compared with children with normal hemoglobin levels [Table 2].

Health seeking

Out of 594 (60%) children with at least one of the acute morbidities, 520 (87.5%) sought health care, where the majority (66.1%) received treatment from private clinics, followed by rural hospital/ district hospital/ medical college (21%) and sub-center/primary health center (9.2%). Majority (66.7%) of the mothers gave home-based treatment for diarrhea [Table 3]. All the children received home-available fluids, while 61.1% of children with diarrhea received oral re-hydration solution (ORS).

As explored in the post-survey FGDs with the mothers, the major reason for not accessing government health facilities was lack of faith in government health services due to unavailability of doctors at the primary health care level like SCs/ PHCs, poor care by doctors and nurses at the tertiary care level, lack of medicines and equipments and finally no relief with the treatment provided. The paid services of doctors at private clinics were reported to be good as they were available when required; and unlike government health care providers, private providers treated the case in less time period, without further referring the sick child. So rural people preferred to borrow and spend money for the sick child's treatment.


 ¤ Discussion   Top


Children under 3 years of age are very prone to infections and childhood morbidities. Morbidities lead to malnutrition and micro-nutrient deficiencies and vice versa. Acute respiratory infections, primarily pneumonia, are the major cause of illness among children and the leading cause of childhood mortality throughout the world, followed by diarrhea. [15]

In the present study, about 60% of children were reported to have at least one of the acute morbidities like fever, cough and cold, pneumonia, diarrhea and dysentery within the 2 weeks of the survey. Most frequently reported symptoms were cough and cold (41%) and fever (34.1%), followed by pneumonia (6.7%), diarrhea (5.7%) and dysentery (0.3%). Mishra et al. reported that 26.3% of children below the age of 5 years suffered from cough and cold; 22%, from diarrhea; and 3.6%, from pneumonia; in rural Allahabad. [17] Ray et al. reported that 58.2% and 22.2% of children below the age of 5 years suffered from ARI and diarrhea, respectively, in rural West Bengal. [18] Another study from the rural areas of Meerut district of Uttar Pradesh revealed that 42.3% of children below the age of 5 years suffered from ARI. [19] According to National Family Health Survey-III (NFHS-III) in India, 19.2%, 29.5% and 2.6% of mothers of children below the age of 3 years reported that their children suffered from diarrhea, fever and dysentery, respectively. [20]

In the present study, it is noteworthy that 87.5% of children from this rural community received health care, where 66.1% of sick children got treatment from private clinics. Majority of mothers accessed private health care service for all illness symptoms, and it was not restricted to any particular illness symptoms except for diarrhea, where home remedy was sought in the form of home-available fluids and ORS. In NFHS-III, 71% of children with fever were taken to a health facility, and 26% of children with diarrhea received ORS. [20] This information showing interstate variations in child morbidity pattern is crucial for need-based and area-specific prioritization and policy formulation during implementation of child survival program.

Owing to the poor quality of treatment provided by government health care providers, the poor rural mothers preferred to spend out-of-pocket and access private health care services. In order to address resource limitations and management inefficiencies of public health facilities, the government of India has undertaken an ambitious nationwide decentralized National Rural Health Mission (NRHM), which intends to implement Integrated Management of Neonatal and Childhood Illnesses (IMNCI) through training and capacity-building of the existing health care delivery system. [21] Apart from revitalization of public health care systems, NRHM also envisioned public-private partnership for health care delivery. [21] Poor rural people are expected to benefit from these schemes.

In the present study, out of the various risk factors assessed, mother's poor educational status (1-10 years of education) and presence of nutritional anemia were the factors significantly associated with acute morbidities. Basu and Stephenson also reported the importance of maternal education in prevention of childhood morbidity and mortality. [7] It needs long-term intervention to improve the educational status of mothers. Iron deficiency has an adverse effect on the immune system. Reduced capacity of leucocytes to kill ingested microorganisms and decreased ability of lymphocytes to replicate, coupled with the lower concentration of cells responsible for cell-mediated immunity, result in higher morbidity due to infectious diseases. Iron supplementation has demonstrated reduction in morbidities from infectious diseases. [22] This makes a strong case to 'operationalize' programs like National Nutritional Anemia Control Program and the IMNCI program, which focus on prevention and correction of nutritional anemia among children. The correction of nutritional anemia will break the vicious cycle of morbidity leading to malnutrition and vice versa.

Conventionally, malnutrition is assessed by 'weight for age,' i.e., underweight; 'weight for height,' i.e., wasting; and 'height for age,' i.e., stunting; implicating different processes of malnutrition. Each of these indicators gives different values, and there is overlap between them. There is no summary indicator to show how many children in total are affected by malnutrition. Composite index of anthropometric failure (CIAF) overcomes the above-mentioned drawback of conventional indicators and gives a summary measure of undernutrition. It encompasses wasting and/ or stunting and/ or underweight status. [16] CIAF used in combination with these routinely used indicators will present a better picture of malnutrition in the community. [16] Nandy et al. have shown the relationship between the number of anthropometric failures and the morbidities among children. [16] Nandy and Miranda have argued in favor of using the summary measure to track the progress in achievement of millennium development goals. [23] In the present study, significantly higher risk of morbidity was observed in a child who had 3 types of anthropometric failures simultaneously.

To summarize, the study points to a number of constraints in the existing rural health care delivery systems in India and high prevalence of acute childhood morbidities. Nutritional anemia and mother's poor educational status were the most important risk factors of acute childhood morbidity. There is need to revitalize the existing health care delivery systems and child health programs in rural India with emphasis on immediate correction of nutritional anemia. However, the limitation of the study should be kept in mind. The study was carried out in a small geographic area with high female literacy, and the findings should be validated by carrying out studies in larger geographic areas so that the findings can be generalized to larger population groups.


 ¤ Acknowledgment   Top


We acknowledge with thanks the financial assistance received from Aga Khan Foundation and USAID under Child Survival Grant with the cooperative agreement GHS-A-00-03-00015-00.

 
 ¤ References   Top

1. National Family Health Survey-1998-99. International Institute for Population Sciences, Mumbai, 2000. Available from: http://www.nfhsindia.org/data/india/indch6.pdf. [cited on 2006 Dec 10].  Back to cited text no. 1      
2. World Health Organization. World Health Report, 2003. Available from: http://www.who.int/whr/2003/en/whr03_en.pdf. [cited on 2006 Dec 10].  Back to cited text no. 2      
3. United Nations Children Fund. Millennium development goals, 2000. Available from: http://www.unicef.org/mdg/childmortality.html. [cited on 2009 Jul 13].  Back to cited text no. 3      
4. Government of India, Ministry of Health and Family Welfare. Integrated Management of Neonatal and Childhood illness: Training modules for medical officers. New Delhi: 2005. p. 3.  Back to cited text no. 4      
5. Gupta N, Jain SK, Ratnesh, Chawla U, Hossain S, Venkatesh S. An evaluation of diarrheal diseases and acute respiratory infection control programmes in a Delhi slum. Indian J Pediatr 2007;74:471-6.  Back to cited text no. 5      
6. Nayar KR. Social exclusion, caste and health: A review based on the social determinants framework. Indian J Med Res 2007;126:355-63.  Back to cited text no. 6      
7. Basu AM, Stephenson R. Low levels of maternal education and the proximate determinants of childhood mortality: A little learning is not a dangerous thing. Soc Sci Med 2005;60:2011-23.  Back to cited text no. 7      
8. Awasthi S, Agarwal S. Determinants of childhood mortality and morbidity in urban slums in India. Indian Pediatr 2003;40:1145-61.  Back to cited text no. 8      
9. Hudelson PM. Qualitative research for health programmes. Geneva: World Health Organization; 1994.  Back to cited text no. 9      
10. Lwanga SK, Lemeshow S. Sample size determination in health studies: A practical manual. Geneva: World Health Organization; 1991. p.2.  Back to cited text no. 10      
11. World Health Organization. Physical status: the use and interpretation of anthropometry. Geneva: World Health Organization; 1995.  Back to cited text no. 11      
12. Raghuramulu N, Nair MK, Kalyansundaram S, editors. A manual of laboratory techniques. 2 nd ed. National Institute of Nutrition: Hyderabad; 2003. p. 68-9.  Back to cited text no. 12      
13. World Health Organization. Iron deficiency anemia - assessment, prevention and control: A guide for program managers. Geneva: World Health Organization; 2001. p.33.   Back to cited text no. 13      
14. Kapur D, Agarwal KN, Sharma S, Kela K, Kaur I. Iron status of children aged 9-36 months in an urban slum integrated child development services project in Delhi. Indian Pediatr 2002;39:136-44.  Back to cited text no. 14      
15. Murray CJ, Lopez AD. The global burden of disease. Cambridge, Massachusetts: Horward University Press; 1996.  Back to cited text no. 15      
16. Nandy S, Irving M, Gordon D, Subramanian SV, Smith GD. Poverty, child undernutrition and morbidity: New evidence from India. Bull World Health Organ 2005;83:210-6.  Back to cited text no. 16      
17. Mishra PC, Agrawal VK, Baveja R. Immunization status and morbidity pattern of children: A clinical study. Indian Medical Gazette 1998;122:234-6.  Back to cited text no. 17      
18. Ray SK, Haldar A, Biswas B, Misra R, Kumar S. Epidemiology of undernutrition. Indian J Pediatr 2001;68:1025-30.  Back to cited text no. 18      
19. Kaushik PV, Singh JV, Bhatnagar M, Garg SK, Chopra H. Nutritional correlates of acute respiratory infections. Indian J Mat Child Health 1995;6:71-2.  Back to cited text no. 19      
20. National Family Health Survey-2005-06. International Institute for Population Sciences, Mumbai - India and ORC Macro. November 2007. p. 233-40.  Back to cited text no. 20      
21. Ministry of Health and Family Welfare. 2006. National Rural Health Mission document, 2005-2012, New Delhi. Available from: http://mohfw.nic.in/NRHM/Documents/NRHM%20Mission%20Document.pdf. [cited on 2006 Dec 10].  Back to cited text no. 21      
22. World Health Organization. Iron deficiency anemia - assessment, prevention and control: a guide for program managers. Geneva: World Health Organization; 2001. p. 94.  Back to cited text no. 22      
23. Nandy S, Miranda JJ. Overlooking undernutrition? Using a composite index of anthropometric failure to assess how underweight misses and misleads the assessment of undernutrition in young children. Soc Sci Med 2008;66:1963-6.  Back to cited text no. 23      



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Social determinants of stunting in rural area of Wardha, Central India
Pradeep R. Deshmukh,Nirmalya Sinha,Amol R. Dongre
Medical Journal Armed Forces India. 2013; 69(3): 213
[Pubmed]
2 Socio-economic and demographic factors affecting the Composite Index of Anthropometric Failure (CIAF)
Jaydip Sen, Nitish Mondal
Annals of Human Biology. 2012; 39(2): 129
[VIEW]
3 æFirst we go to the small doctoræ: First contact for curative health care sought by rural communities in Andhra Pradesh & Orissa, India
Gautham, M., Binnendijk, E., Koren, R., Dror, D.M.
Indian Journal of Medical Research. 2011; 134(11): 627-638
[Pubmed]
4 Health-promoting school initiative in ashram schools of wardha district
Dongre, A.R., Deshmukh, P.R., Garg, B.S.
National Medical Journal of India. 2011; 24(3): 140-143
[Pubmed]
5 Conventional nutritional indices and Composite Index of anthropometric failure: Which seems more appropriate for assessing under-nutrition among children? A cross-sectional study among school children of the Bengalee Muslim population of North Bengal, India
Sen, J., Dey, S., Mondal, N.
Italian Journal of Public Health. 2011; 8(2): 172-185
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article

    

© 2004 - Indian Journal of Medical Sciences
Published by Medknow
Online since 15th December '04