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SHORT COMMUNICATION
Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 332-335  

A study on the role of parental involvement in control of nutritional anemia among children of free primary schools in a rural area of West Bengal


1 Assistant Professor, Department of Community Medicine, R G Kar Medical College, Kolkata, India
2 Associate Professor, Department of Community Medicine, Burdwan Medical College, India
3 Assistant Professor, Department of Community Medicine, Burdwan Medical College, India
4 Assistant Professor, Department of Pediatrics, Burdwan Medical College, India
5 Associate Professor, Department of Community Medicine, Medical College, Kolkata, West Bengal, India

Date of Web Publication30-Jan-2012

Correspondence Address:
Dibakar Haldar
Anandapally, Duttapara, Sitko Road, Kolkata - 700144, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.92420

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   Abstract 

An intervention study was conducted among students of three randomly selected free primary schools in rural West Bengal to assess the effect of health-nutrition education for behavior modification of parents on nutritional anemia of children. Clinically anemic students were school-wise randomized into 'groups of two' and intervened with anthelminthic, iron-folic acid (IFA) pediatric tablet and health-nutrition education by reoriented teachers. Parents of study group were involved in behavior change processes. Baseline overall prevalence of anemia was 64.4%. After IFA therapy, prevalence of anemia was not found to differ between two groups (χ2 = 2.68, P > 0.05, RR= 0.48, 95% C.I 0.2 < RR < 1.19) while reducing 52.2% of relative risk. Reassessment after six months showed significantly lower prevalence in study group (χ2 = 18.14, P < 0.05, RR = 0.20, 95% C.I. 0.08 < RR < 0.49). Parental involvement for life style and dietary modification may curb childhood anemia.

Keywords: Nutritional anemia, Parental involvement, Physical and psychological development


How to cite this article:
Haldar D, Chatterjee T, Sarkar AP, Das SK, Mallik S. A study on the role of parental involvement in control of nutritional anemia among children of free primary schools in a rural area of West Bengal. Indian J Public Health 2011;55:332-5

How to cite this URL:
Haldar D, Chatterjee T, Sarkar AP, Das SK, Mallik S. A study on the role of parental involvement in control of nutritional anemia among children of free primary schools in a rural area of West Bengal. Indian J Public Health [serial online] 2011 [cited 2019 Dec 8];55:332-5. Available from: http://www.ijph.in/text.asp?2011/55/4/332/92420

Nutritional anemia is one of the major public health problems in India affecting almost 90% poor children, adolescent girls and women. [1] There is convincing evidence that iron deficiency and anemia causes impaired growth, developmental delay, decreased physical activity, behavioral abnormalities and impairs cognitive function (poorer attention span, memory, concentration and concept acquisition) leading to poor school performance. [1],[2],[3],[4],[5] Nutrition awareness and education are particularly important given children and adolescents' poor knowledge of anemia, diet and health generally and of iron-rich foods specifically. [6] Nutrition education offered to children may not be translated into practice as the decision maker parents have poor knowledge-practice of nutrition. Therefore, parents need appropriate information or guidance as well to improve the diets of their children. [7] Scarcity of study in this field indulged the authors to contemplate a quasi-experimental intervention study from July 2008 to January 2009 in three free primary schools (FPS) namely Kanchgaria Siddheswari, Kulnagar and Kantatria F.P.S selected randomly out of fifteen FPS within Bhatar Gram Panchayat area of Bhatar community development (CD) block of Burdwan District, West Bengal, which is the rural field practice area of the Dept of Community Medicine, Burdwan Medical College (BMC).

The objectives of the study were the following: i) to estimate, clinically, the magnitude of anemia among the free primary school children, ii) to assess the effect of behavior change communication for parental involvement along with other interventions.

The schools were in same geographic location with students of similar socio-cultural background sharing identical dietary habits, life styles and health seeking behavior. Prevalence of anemia was presumed to be 85% (π1) [1],[8] and a minimum 25% reduction was required to detect the change clinically i.e. the prevalence after the intervention would be 60% (π2). The sample size was calculated by the formula:



Assuming 5% drop out, a total sample size of 114 was finalized for the study.

Initial Assessment: With permission from authorities and parental consent, initially thorough clinical examination of the students present on the day of visit to each school was done to assess the magnitude of anemia clinically by two clinicians independently. Students with chronic illness or undergoing treatment for anemia were excluded. Anemia was determined by interobserver agreement (Kappa ratio 0.84). Subjects having clinicians' disagreement were also treated for anemia but not included in study.

Randomization
: Kantaria F.P.S. was considered as one group but Kulnagar and Siddheswari F.P.S were clubbed in another group due to small number of students. By 'group randomization' two groups were allocated into study (Gr 1) and control group (Gr 2). All 56 anemic students of Kulnagar and Siddheswari F.P.S were considered as study subjects. Out of 67 students of Kantaria F.P.S., 56 students were selected randomly, one control for one study subject proportionate to each class and gender. Another two were randomly chosen from the whole of the rest. Thus, 58 were enrolled to fulfill estimated sample size. Logistics were procured and the teachers were provided with an orientation on nutritive values, proper storage of foods, healthy cooking practice, and personal-food-environmental hygiene in three sessions held separately in each school. At the beginning of the study, parents of students of study group were sensitized about purpose and usefulness of the project with the help of panchayat and health workers.

Intervention for both the groups: Single dose of Tablet Albendazole (400mg) [repeated after 14 days] and pediatric IFA (20 mg elemental iron and 100 μg folic acid) [9] tablets were given in the dose of 1 tab. twice daily after food for 50 days. The dose frequency, timing, storage, side-effects and consequences of over dosage were explained to students. The students who were found to lag behind in consumption due to minor side effects were counseled and inspired for regular intake. Health and nutrition education was provided regularly (at least thrice weekly) to all students by trained school teachers, focusing on implications of anemia, importance of regular intake of locally available cheap iron containing foods, personal and food hygiene and environmental cleanliness.

Additional for the study group:
The parents were involved in behavior change process in various ways. Two mothers' meetings were held in each school area in the presence of health workers. Fortnightly house visit was undertaken by the junior doctors led by faculty members and IEC materials were supplied to parents during house visit. The need assessment for the topics of IEC was determined by focused group discussions (FGDs) arranged beforehand. Parents, especially the mothers, were guided in menu planning, proper cooking practices, kitchen gardening, maintenance of good personal-food-environmental hygiene. Emphasis was given on regular intake of locally available low cost iron containing foods; taking lemon with food; consumption of adequate regular freshly cooked meals; avoidance of tea or coffee within 1 h after meal etc. Socio-economic data like occupation of father, literacy of parents etc, were collected by using a predesigned proforma.

Reassessment
was done in the same way by the same clinicians, first after fifteen days of disbursement of last round of 50 days IFA tablet and the second after six months since the beginning. [10] Remaining anemic participants were treated at the end. Results were analyzed by simple proportion, χ2 test, relative risk (RR) and absolute risk (AR) with 95% confidence interval (C.I.) using Epi info 3.4.3 version.

Average age of the participants was 7.8±1.3 (mean ± sd) years. Among them 58.8% were girls; 98.2% Hindu; 28.9, 33.3, 21.1 and 16.7% were in class-I, class-II, class-III and class-IV respectively. The present study observed high compliance to IFA consumption (>97%), so 4.4 and 7.9% participants were not considered during first and final reassessment for absence and or poor compliance to IFA. At the beginning of the study, out of 191 students screened in three selected schools, 123 were clinically anemic with a prevalence of 64.4 % (95% C.I= 57.6.2%-71.2%) as a whole and 70.15% and 48.93 % among the girls and boys respectively. As per clinicians' agreement (kappa ratio 0.82) and considering those with disagreement also as anemic (and retained in the study), 11.3% of the study and 23.2% of the control group were anemic at first reassessment with no statistical difference in between [Table 1]. During the final reassessment (kappa ratio 0.83), it was found that 9.6% and 47.2% of study and control group respectively were anemic with significant difference [Table 2]. Analysis revealed that improvement regarding anemic status among the study group was not affected by gender of the participants, occupation of father (laborer vs others) and literacy of mother (literate vs illiterate) [RR=1.09(0.93-1.29), 1.14 (0.95-1.36) and 0.87 (0.69-1.10) and one tailed 'P' of Fisher exact test= 0.32, 0.17 and 0.19].
Table 1: Distribution of the participants according to clinical anemia evaluated after 50 days of IFA tablet administration (n=109)

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Table 2: Distribution of the participants according to clinical anemia in fi nal assessment (n=105)

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In the present study, IFA administration was stopped after seven weeks which was recommended adequate for correction of clinical anemia, as opined by Shah A. [11] But this short period therapy does not replenish fully the exhausted iron store of anemic victims, which requires five to six months iron therapy. [11] Increased Hb level by IFA therapy hastened the organs' functions which have been caused suboptimal by inadequate O 2 supply and iron deficiency and improved child's activities and psychological wellbeing with boosted appetite. [2],[12] Then attempt was made to improve dietary iron intake to maintain normal Hb level. Analysis of results of first reassessment [Table 1] viz. RR of 0.48, reduced overall prevalence of anemia to 0.17 , 95% C.I. of -25.8% to 2.0% around the difference between the proportions, the AR reduction to 0.12 and RR reduction up to 52.2% led the authors think that the intervention was very effective. However, χ2 value of no significance and 95% CI of RR rose as suspicion that the favorable RR value might be due to chance. This might be due to effect of IFA therapy which reduced the prevalence of anemia drastically in both groups leaving no significant gap in between. The effect of health-nutrition education offered to the parents of study subjects was not evident robustly till then and or might be masked by the action of IFA. In the final reassessment [Table 2], the results were observed in favor of the positive effect of health-nutrition education leading to behavioral modification of parents, without which the gain achieved so far by IFA therapy was proved to be ill sustained (as revealed in the control group). Other studies [7],[13] also recommended parental involvement in nutrition education process for the improvement of the dietary habits of the children.

 
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  [Table 1], [Table 2]


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