|Year : 2013 | Volume
| Issue : 4 | Page : 260-267
Dimensions of nutritional vulnerability: Assessment of women and children in Sahariya tribal community of Madhya Pradesh in India
Suparna Ghosh-Jerath1, Anita Singh2, Aruna Bhattacharya1, Shomik Ray1, Shariqua Yunus3, Sanjay P Zodpey4
1 Associate Professor, Indian Institute of Public Health-Delhi, New Delhi, India
2 Intern, Indian Institute of Public Health-Delhi, New Delhi, India
3 Program Officer, World Food Program, New Delhi, India
4 Director, Indian Institute of Public Health-Delhi, New Delhi, India
|Date of Web Publication||18-Dec-2013|
Associate Professor, Indian Institute of Public Health-Delhi, Plot No. 34, Sector 44, Institutional Area, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Tribal communities are "at risk" of undernutrition due to geographical isolation and suboptimal utilization of health services. Objectives: The objective of this study was to assess the nutritional status of Sahariya tribes of Madhya Pradesh (MP), India. Materials and Methods: A cross-sectional study was conducted in villages inhabited by Sahariya tribal community (specifically women in reproductive age group and children under 5 years) in three districts of MP. Dietary surveys, anthropometric and biochemical assessments were carried out and descriptive statistics on the socio-economic and nutritional profile were reported. Association between household (HH) food security and nutritional status of children was carried out using the logistic regression. Strength of effects were summarized by odd's ratio. Results: Chronic energy deficiency and anemia was observed in 42.4% and 90.1% of women respectively. Underweight, stunting and wasting among under five children were 59.1%, 57.3% and 27.7% respectively. Low food security was found in 90% of HHs and the odds of children being underweight and stunted when belonging to HHs with low and very low food security was found to be significant (P = 0.01 and 0.04 respectively). Calorie, fat, vitamin A, riboflavin, vitamin C and folic acid intake among women was lower than recommended dietary allowance. Infant and young child feeding practices were suboptimal. Awareness on nutritional disorders and utilization of nutrition and health services was poor. Conclusion: A high prevalence of undernutrition and dietary deficiency exists among Sahariyas. System strengthening, community empowerment and nutrition education may play a pivotal role in addressing this.
Keywords: Anemia, Nutritional status, Sahariya tribes, Undernutrition in women and children
|How to cite this article:|
Ghosh-Jerath S, Singh A, Bhattacharya A, Ray S, Yunus S, Zodpey SP. Dimensions of nutritional vulnerability: Assessment of women and children in Sahariya tribal community of Madhya Pradesh in India. Indian J Public Health 2013;57:260-7
|How to cite this URL:|
Ghosh-Jerath S, Singh A, Bhattacharya A, Ray S, Yunus S, Zodpey SP. Dimensions of nutritional vulnerability: Assessment of women and children in Sahariya tribal community of Madhya Pradesh in India. Indian J Public Health [serial online] 2013 [cited 2019 Jan 16];57:260-7. Available from: http://www.ijph.in/text.asp?2013/57/4/260/123268
| Introduction|| |
Madhya Pradesh (MP) is one of the socio-economically and demographically backward states of India with a poverty rate of 32.4% as estimated by National Sample Survey 2004-2005. , The National Family Health Surveys-3 data from MP on chronic energy deficiency (CED) in rural women (15-49 years) shows prevalence of 44.9%; second highest in India. Furthermore, 61% of these women are anemic. Prevalence of wasting and underweight in children under 5 years (U5) in the state is 35% and 60% respectively. More than one in every four children is severely underweight.  Scheduled tribes and Scheduled castes constitute a significant portion of state's population. Due to different linguistic, cultural and geographical environment and its peculiar complications, the diverse tribal world of MP has been largely cut-off from the mainstream of development.  Sahariyas in Chambal division, which constitutes 2.7% of total tribal population in MP, is one of the primitive tribes. Tribal groups are known to have low food security and are undernourished population groups. Some common diseases among all primitive tribes include acute respiratory infections, sexually transmitted diseases, diarrheal diseases and nutritional disorders. 
The present study was a part of an in-depth situational analysis and a baseline assessment of status of Sahariya tribal community of MP. The situational analysis aimed at exploring operational planning for a village level "atta" (wheat flour) fortification program with iron and folic acid (IFA) targeted toward this tribal community living in three districts of MP. Assessing improvement in anemia status of Sahariya women was the primary outcome for this planned nutrition intervention. This study reports nutritional status of women in reproductive age group and under five children studied as part of this situational analysis. Specific objectives of this study were to assess nutritional status and socio-demographic profile of Sahariya tribal community, to assess their awareness regarding nutritional disorders and study their dietary practices and lastly to assess their awareness and utilization of health and nutrition services.
| Materials and Methods|| |
The present study was conducted among selected villages of three districts of MP namely Sheopur, Shivpuri and Guna. All these districts have pockets with high Sahariya population.
Cross-sectional, observational study.
Duration of study
This study was conducted between March 2010 and June 2010.
Sample size calculation
Since this study was part of a situational analysis for village level flour fortification with IFA, the primary outcome of the study was to assess the prevalence of anemia in women of reproductive age group. Considering the prevalence of anemia among women (15-49 years) in MP as 61%,  a sample size of 575 women was arrived at to obtain the prevalence estimates with absolute precision of 0.05 and type 1 error of 5%, adjusted for a design effect of 1.5 and a non-response rate of 5%. Assuming that each household (HH) had a woman in the reproductive age group (15-49 years), 575 HHs were surveyed. For the purpose of assessing anemia status, one woman per HH was recruited. Further as a secondary outcome, the nutritional status using the anthropometric measurements of all the women and children present in the HH during the data collection was assessed. This was an exploratory component of this pilot study.
After procuring a list of villages inhabited by Sahariyas in the three districts, study villages were selected using probability proportional to size sampling.  Based on the distribution of Sahariya population in the three districts which was in the ratio of 1:2:3 in Guna, Sheopur and Shivpuri respectively, three villages were selected from Guna, six villages from Sheopur and nine villages from Shivpuri. A sample of 32 HHs was selected from each village of the 18 selected villages in order to attain a total of 575 HHs (details of sampling framework is provided in [Figure 1]). Depending upon the number of HHs present in each Saharana (villages inhabited by Sahariyas), only 30% of total HHs were covered. In case a Saharana had more than 90 HHs, all 32 HHs were selected from the same Saharana. In case a Saharana had less than 90 HHs, then next adjacent Saharana was covered to reach the adequate sample size.
This study was conducted according to guidelines laid down in declaration of Helsinki and all procedures involving human subjects were approved by Institutional Ethics Committee. Witnessed verbal informed consent was obtained from all participants.
Socio-economic profile, HH information and information on Infant and Young Child Feeding (IYCF) practices were collected at HH level from all selected HHs consenting for survey using an interviewer administered questionnaire. All women and under five children present at the HH during the time of the survey were assessed for nutritional status using the anthropometric measurements. Height/length and weight were taken on children (0-5 years) and women (15-49 years). Mid-upper arm circumference (MUAC) was measured in children between (6 months and 5 years). Standard techniques were used to assess height/length, weight and MUAC. , Stature was assessed using anthropometric rod/infantometer (in case of infants) and weight was taken using electronic bathroom scale. MUAC was assessed by using a fiber reinforced measuring tape. Percent distribution of children according to weight for age, height/length for age weight for height/length and MUAC for age as per the standard deviation (SD) classification by World Health Organization (WHO), 2006 was carried out.  Lower and upper SD levels were considered to be flag limits for extreme or potentially implausible Z score values; weight for age Z score (WAZ) (< −6 or > +5), height/length for age Z score (HAZ) (< −6 or > +6) and weight for height Z scores (WHZ) (< −5 or > +5). All flagged Z scores were rechecked for data entry errors after which they were excluded from the final analysis. Body mass index (BMI) was calculated and compared with standards in women to assess the nutritional status. ,,, At 24 h dietary recall on a sub sample of 205 women (15-49 years); one women per HH was also carried out. Hemoglobin estimation was carried out on one female member per HH (n = 533), participants were classified using WHO classification for anemia and categorized as mild/moderate/severe anemia. , Hemoglobin was estimated using cyanmethaemoglobin method. At the HH level, a standard six items HH food security scale adapted in Hindi was used to assess HH food security status. ,
Statistical analysis was carried out using SPSS windows version 16 and STATA 12.0 Descriptive statistics regarding HH socio-economic profile were reported. The anthropometric data on children (0-5 years) were analyzed using WHO Anthro software. Daily intakes of nutrients as obtained from 24 h dietary recall were calculated using food composition tables  and compared with the recommended dietary allowances (RDA).  The clustering of anthropometric indicators in children, anthropometric indicators and hemoglobin status in women and food security scores at the village and district level was quantified by intra-cluster correlation coefficient (ICC). Association between food security score and nutritional status of children and women was carried out using the logistic regression using svy prefix in STATA 12.0. The strength of effects was summarized by odds ratio.
| Results|| |
HH and socio-economic profile
The study sample consisted a total of 576 Sahariya HHs with 750 women in the reproductive age group and 630 U5 children with 318 males and 312 females. [Figure 2] provides a summary of recruitment.
|Figure 2: Summary of recruitment of study participants for anthropometric assessment|
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A majority of the HHs (98.4%) were Hindus, 80.4% families were nuclear and the average size of HH was 4.6. Most of the Sahariyas (96.5%) lived in kaccha houses. Hand pump was the source of drinking water for most (69.7%) and in the absence of toilets (90%), most of them reported to defecate in open. About 55.4% were engaged as daily wage laborers in non-agricultural areas while 38.7% were agricultural daily wage earners. Average monthly per capita income of HHs was INR 4391. Most of their income was spent on procuring food items and cooking. Almost 84.5% reported to migrate every year for work during Chait (62.8%) and Baishakh (12.9%) of the Hindu calendar months. Majority (93.1%) had Antyodaya Card (under the public distribution system [PDS], a system to provide highly subsidized grains to poorest of the poor citizens of the country) and 6.6% had the Below Poverty Line(BPL) card. Most HHs (90.1%) reported that the grain provided from PDS was less than the entitled amount.
Access to health and nutritional services
Almost 60% of HHs reported availability of supplementary nutrition services at village level from Anganwadi Center (AWC) (Community based centers for mother and child care). Among these HHs, actual utilization of services was reported by 62.7%. Some of these HHs availed supplementary food daily (30%) while others availed 2-3 times a week (25.5%). Most of the HHs availed this service for children (45%) while only 9.7% reported availing the service for both children and entitled women. Health-care seeking behavior showed a preference towards private practitioners. About 54% of HHs preferred going to private doctors/private health facilities for any ailments. For ante natal care services, 51.6% reported availing Iron and Folic Acid (IFA) tablets, out of which 52.4% procured the tablets from government health facilities. IFA tablets for adolescents were availed by only 26.7%. Only 22% HHs reported procuring de-worming medicines for children from government facilities.
Thus irrespective of presence of health and nutrition services in the community, the utilization was sub-optimal. Lack of awareness about the entitlement and/or lack of quality services could be the possible reasons for underutilization. Possible reasons for sub-optimal utilization were not investigated as it was beyond the scope of the present study.
Knowledge and awareness on anemia and malnutrition
General awareness about health and nutrition were found to be poor. Majority, 85.4% and 89% HHs were not aware about symptoms of anemia and malnutrition respectively. Among the aware, 10% cited "weakness" as one of the symptoms of anemia and 6.6% cited lack of balanced diet as the cause of malnutrition. As for the remedial measures, very few knew about IFA tablets (8.7%) and green leafy vegetables (5.9%) and their benefits in preventing or correcting anemia. The source of information on anemia and malnutrition was reported as AWC (9% and 6.6% respectively) or doctors (5% and 2% respectively).
Women in the reproductive age group
Underweight in women Although 750 women constituted the study sample, BMI was calculated in 606 women who were present in the HH at the time of survey. About 42.4% of women were found to have various degrees of CED; 7.4% (95% confidence interval [CI] 4.92-11.05) were found to suffer from CED Grade III (<16.0, severe), 10.9% (95% CI 8.55-13.78) from CED Grade II (16-17 moderate) and 24.1 (95% CI 19.85-28.91) from CED Grade I (17-18.5 mild). The mean BMI among women was 19.23 kg/m 2 .
Anemia in women Overall prevalence of anemia in these women (n = 533) was found to be 90.1%. Almost half of these women (48%) had moderate anemia while 2.8% had severe anemia.
Children (0-5 years)
Though a total of 630 U5 children constituted the study sample, only 488 children were present in the HH during the time of survey. All these children were assessed for height/length and weight; children between 6 months and 5 years (n = 593) and (425, present in HH at the time of survey) were assessed for MUAC.
[Table 1] shows anthropometric data of these children according to Standard Deviation SD classification.  High prevalence of undernutrition in terms of underweight (WAZ ≤−2 SD) (59.2%), stunting (HAZ ≤−2 SD) (57.3%) and wasting (WHZ ≤−2 SD) (27.7%) was observed. The study revealed severe degree (Z score below-3 SD) for underweight, stunting and wasting in 32.7%, 40% and 11.1% children, respectively.
|Table 1: Anthropometric indicators of children (<5 years) in the tribal population of Sahariya|
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About 38.6% of U5 children were severely malnourished (Z score below-3 SD) based on MUAC for age SD classification. 
Nutrient intake in Sahariya women A 24 h dietary recall was conducted on a sub-sample of 209 women. Mean calorie intake was lower than RDA  for women with moderate activity level. Intake of protein, iron, thiamin and niacin was comparable to RDA, while that of total fat, energy, vitamin A, riboflavin, vitamin C and free folic acid were below the RDA [Table 2]. Extent of deficit was maximum with respect to vitamin C (80%) followed by vitamin A (77%) free folic acid (72.4%), riboflavin (55.4%), total fat (26.3%) and energy (33.8%). Though protein intake seemed to be adequate, but since major part of it was met from cereals, its quality was sub-optimal. Milk intake was very low. Intake of fruit and flesh food during the past 24 h was reported by only 12.9% and 4.3% respectively. Though iron intake was comparable to RDA, its bioavailability in diets could be low because of limited promoters and higher amount of inhibitors in the diet.
|Table 2: Comparison of the nutrient intake of Sahariya women (15-49 years) with Indian RDA (n = 209)|
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Only 18.6% of HHs reported to initiate breast feeding within 1 hour of birth. The rest introduced breast milk either after 1 hour (33.6%) or during the next day (18.1%) or after 1-3 days (29.8%) of birth. Almost half (53.5%) reported not to give pre-lacteals to neonates. Exclusive breast feeding until 6 months was reported by 41.3% and 21.8% reported the practice until 1 year. Majority (61.4%) reported introducing complementary feeding after 6 months, while 27.1% reported the practice beyond 1 year of age.
HH food security and its association with undernutrition in U5 children and CED in women
Majority i.e., 90.1% (n = 519) of HHs had low or very low food security (12.8% and 77.3% respectively). [Table 3] shows association of nutritional status of children and women with various levels of food security. The odds of children being underweight and stunted when belonging to HHs with low and very low food security was found to be significant (P = 0.01 and 0.04 respectively). However, such association was not found in case of wasting in children and CED in women. This suggests that children living in HHs with poor food security were at higher risks for poor nutritional status. Clustering of WHZ, HAZ and WAZ score quantified by ICC within HH was 0.23, 0.40 and 0.36 respectively.
|Table 3: Association between food security score and malnutrition status of under five children at individual level|
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| Discussion|| |
The HH and socio-economic profile of Sahariyas indicated a high level of income poverty and poor living conditions. There was a high rate of undernutrition with severe underweight, stunting and wasting afflicting 32.7%, 40% and 11.1% of U5 children, respectively and CED afflicting 45.7% of women. Prevalence of stunting in U5 children was found to be higher than state prevalence.  The present study findings are also comparable with prevalence data of child under nutrtion reported by a recent study conducted by National Institute of Nutrition (NIN) in 50 districts of MP. In the district of Sheopur, the NIN study reported rate of underweight, stunting and wasting as 52.3%, 64.6% and 17.9% respectively, for Guna, the prevalence were 50%, 48.4% and 25.3% respectively and for Shivpuri the prevalence were 55%, 62% and 25.7% respectively.  The district wise prevalence of severe underweight, stunting and wasting in the districts of Shivpuri and Guna were higher compared with the Hunger and Malnutrition Survey 2011.  The prevalence of CED among women in the study was higher than state prevalence of CED in women.  Micronutrient deficiency was evident from a very high prevalence of anemia (90.1%) among women. This is a real cause of concern and needs urgent attention.
The dietary intake data of the women elicited a poor quality diet with a low intake of macro and micronutrients. The IYCF practices in present study were comparable with the NIN study  and practices like delayed introduction of complementary feeding may further accentuate the poor nutritional status of children.
With regards to access to health and nutrition services by women and children, there was a gap between availability and utilization. The utilization of services that may have an impact on nutritional status was found to be sub optimal.
Although schemes and programs like the Antyodaya Ann Yojana under PDS and supplementary feeding under Integrated Child Development Services exist, their utilization, which was found to be dictated by awareness and perception of quality was far from satisfactory. General awareness about nutritional problem was poor, which indicated a lack of awareness generation activities regarding some crucial nutritional problems in the community.
Food security aspect of this population needs special attention. There was significant association between undernutrition i.e., underweight and stunting in children with HH food security status. This tribal group had low food security and unless there is enough food in the HH, any specific program may not be able to bring about substantial improvement in the nutritional status.
| Conclusion|| |
This study on women and children of Sahariya community indicates various facets of nutritional vulnerability. On one hand, malnutrition based on anthropometric indices is rampant in this community and on the other hand, they have poor dietary practices and nutrient intake. In addition to this, poor uptake of various government programs to address malnutrition in the community especially on the grounds of quality and coverage is worsening the scenario. Paradoxically, in spite of the PDS distributing highly subsidized food grain to this community, there is a co-existence of low food security. Nutrition intervention programs coupled with awareness generation, sensitization among the health and nutrition service providers and other supportive strategies like accompanying public health measures are vital in uplifting the nutritional status of this nutritionally vulnerable community of Sahariya tribes. A new scheme under the Government of MP, the Atal Bal Arogya Evam Poshan Mission encompasses better implementation of the childhood nutrition and health interventions. In that context, the present study provides a valuable insight on certain core issues like awareness and sensitization of the community that can play a crucial role in making such noble initiatives address the much needed and targeted approach to curb this "not so silent" emergency of maternal and child undernutrition.
| Acknowledgments|| |
The authors would like to acknowledge the contribution of Dr. P. K. Tiwari, Professor, School of Studies in Zoology, Co-ordinator, Center for Genomics, Molecular and Human Genetics Jiwaji University, Gwalior for his kind support in facilitating data collection, Dr. Archna Singh for her valuable inputs during the development of tools for data collection and analysis of data. We would also like to acknowledge the contribution of field investigators (FI) who collected the data. The contributions of Ms. Anjna Gupta who helped us in the data entry and Dr. Narendra Salvi who worked with the FIs in facilitating data collection are much appreciated. We would also like to thank Dr. Niveditha Devesenapathy for her valuable inputs in the statistical analysis of the data.
| References|| |
|1.||Census 2011. Provisional Population Totals. New Delhi: Office of the Registrar General of India; 2011. Available from: http://www.censusindia.gov.in/2011-prov-results/prov_results_paper1_india.html. [Last cited on 2013 Mar 23]. |
|2.||National Family Health Survey, 2008. Available from: http://www.nfhsindia.org/nutrition_report_for_website_18sep09.pdf 3. [Last cited on 2012 Jan 14]. |
|3.||Available from: http://en.wikipedia.org/wiki/Madhya_Pradesh.[last cited on 2012 Jan 14]. |
|4.||Chakma T, Rao PV, Meshram PK, Singh SB. Health and Nutrition Profile of Tribals of Madhya Pradesh and Chhattisgarh. Proceeding of National Symposium on Tribal Health, 2006. Available from: http://www.rmrct.org/files_rmrc_web/centre's_publications/NSTH_06/NSTH06_26.T.Chakma.pdf. [Last cited on 2012 Jan 14]. |
|5.||Grinnell RM, Unrau YA. Social work Research and Evaluation: Foundations of Evidence-Based Practice. Oxford: Oxford University Press; 2007. |
|6.||Gibson RS. Principles of Nutritional Assessment. New York: Oxford University Press; 2005. |
|7.||Jelliffe DB, Jelliffe EF, Zerfas A, Neumann CG. Community Nutritional Assessment. Oxford: Oxford University Press; 1989. |
|8.||WHO. Child Growth Standards, 2007. Available from: http://www.who.int/childgrowth/standards/en/. [Last cited on 2012 Jan 14]. |
|9.||James WP, Ferro-Luzzi A, Waterlow JC. Definition of chronic energy deficiency in adults. Report of a working party of the International Dietary Energy Consultative Group. Eur J Clin Nutr 1988;42:969-81. |
|10.||WHO. Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. WHO Technical Report Series 854. Geneva: World Health Organization; 1995. |
|11.||WHO. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation. WHO Technical Report Series 894. Geneva: World Health Organization; 2000. |
|12.||WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63. |
|13.||WHO. Report Iron Deficiency Anaemia: Preventing and Controlling Iron Deficiency Anaemia through Primary Health Care. Geneva: World Health Organization; 1989. |
|14.||Sari M, de Pee S, Martini E, Herman S, Sugiatmi, Bloem MW, et al. Estimating the prevalence of anaemia: A comparison of three methods. Bull World Health Organ 2001;79:506-11. |
|15.||Blumberg SJ, Bialostosky K, Hamilton WL, Briefel RR. The effectiveness of a short form of the Household Food Security Scale. Am J Public Health 1999;89:1231-4. |
|16.||Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security: Revised 2000. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; 2000. |
|17.||Gopalan C, Rama Sastri BV, Subramanian SC. Nutritive Value of Indian Foods. National Institute of Nutrition, Indian Council of Medical Research; 1989. |
|18.||Indian Council of Medical Research: Nutrient Requirement and Recommended Dietary Allowances for Indians. A Report of the Expert Group of the ICMR 2010. Hyderabad, India: NIN; 2010. |
|19.||NFHS 3 Madhya Pradesh, 2008. Available from: http://www.mp.gov.in/health/survey/nfhs-3-%20MP%202005-06.pdf. [Last cited on 2012 Jan 14]. |
|20.||Government of Madhya Pradesh. Women and Child Development and Social Justice Department, National Institute of Nutrition Document, 2013. Available from: http://www.mpwcd.nic.in/vibhagiyaprakashan.html. [Last cited on 2012 Mar 23]. |
|21.||The Hungama Survey Report. Hunger and Malnutrition Survey, 2011. Available from: http://www.hungamaforchange.org/HungamaBKDec11LR.pdf. [Last cited on 2013 Mar 23]. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]