|Year : 2022 | Volume
| Issue : 2 | Page : 159-165
Impact of intervention on nutritional status of under-fives in tribal blocks of Palghar District in Maharashtra, India
Suchitra Surve1, Ragini Kulkarni2, Sagar Patil3, Lalit Sankhe4, ICMR Co-ordinating group5
1 Scientist C, Department of Clinical Research, National Institute for Research in Reproductive Health, Indian Council of Medical Research, Mumbai, Maharashtra, India
2 Scientist E, Department of Operational Research, National Institute for Research in Reproductive Health, Indian Council of Medical Research, Mumbai, Maharashtra, India
3 Assistant District Health Officer, Zilla Parishad, Palghar, Public Health Department, Government of Maharashtra, Mumbai, Maharashtra, India
4 Associate Professor, Department of Community Medicine, Grant Medical College and Sir JJ Hospital, Mumbai, Maharashtra, India
|Date of Submission||09-Sep-2021|
|Date of Decision||18-Nov-2021|
|Date of Acceptance||25-Jan-2022|
|Date of Web Publication||12-Jul-2022|
Department of Operational Research, National Institute for Research in Reproductive Health, Indian Council of Medical Research, Jm Street, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There is a need to improve their nutritional status of under-five children through specific targeted interventions. The present study discusses the impact of intervention on nutritional status among under-five children in Palghar district from Maharashtra. Objective: The objective is to improve the nutritional status of under-five children by implementing multi-component health and nutrition education intervention, focusing on dietary counseling and modification keeping in view the cultural and socio-economic status of population. Methods: A prospective pre- and post-intervention study was conducted in two tribal blocks. Total 480 under-five children were included in pre- and post-intervention survey each. Results: Exclusive breastfeeding rates improved from 48.9% to 50.5% and initiation of complementary feeding at 6 months improved from 48.3% to 72.5% in post intervention survey as compared to preintervention survey. Among other Infant and Young Child Feeding indicators, Minimum Meal Frequency increased significantly to 67.03% from 5.91% and minimum acceptable diet improved from 5.37% to 47.2% in post intervention survey. The prevalence of Severe Acute Malnutrition (SAM) reduced from 5.4% to nil whereas severe stunting and underweight significantly decreased by 17% and 8% respectively in post intervention survey. Severe anemia decreased from 16.24% to nil post intervention. Conclusion: The study reveals a substantial improvement in timely initiation of complementary feeds, nil cases of SAM, stunting, and underweight along with severe anemia in postintervention phase. This highlights the impact of multicomponent health and nutrition education interventions which may be adapted at a programmatic level to reduce child mortality and morbidity in India.
Keywords: feeding practices, malnutrition, under-five children, undernutrition
|How to cite this article:|
Surve S, Kulkarni R, Patil S, Sankhe L, Io. Impact of intervention on nutritional status of under-fives in tribal blocks of Palghar District in Maharashtra, India. Indian J Public Health 2022;66:159-65
|How to cite this URL:|
Surve S, Kulkarni R, Patil S, Sankhe L, Io. Impact of intervention on nutritional status of under-fives in tribal blocks of Palghar District in Maharashtra, India. Indian J Public Health [serial online] 2022 [cited 2022 Dec 3];66:159-65. Available from: https://www.ijph.in/text.asp?2022/66/2/159/350657
ICMR Co-ordinating group
Dr. Priyanka Gupta - Bansal, PhD5
5Scientist C Division of Nutrition Indian Council of Medical Research (ICMR)
V. Ramalingaswami Bhawan, P.O. Box No. 4911 Ansari Nagar, New Delhi
Dr. Zaozianlungliu Gonmei, Ph.D.6
6Scientist B Division of Nutrition Indian Council of Medical Research (ICMR)
V. Ramalingaswami Bhawan, P.O. Box No. 4911 Ansari Nagar, New Delhi - 110029
Dr. Gurudayal Toteja, PhD 7, 8, 9, 10, 11
7Formerly, Additional Director General (Scientist H), ICMR, New Delhi
8 Director, ICMR-National Institute for Implementation Research on Non Communicable Diseases (NIIR-NCD), Jodhpur
9Head, Division of Nutrition, ICMR, New Delhi
10Head, Center For Promotion of Nutrition Research & Training.(ICMR), New Delhi
11In charge, Model Rural Research Unit, DHR, Bhanpur Kalan, Jaipur
| Introduction|| |
Undernutrition among children is a major public health problem as it jeopardizes children's survival, health, growth, and development, and slows national progress towards development goals. Currently, nearly 90% of the developing world's chronically undernourished (stunted) children belong to Asia and Africa. Nearly more than two-thirds of under-five children in Asia are wasted and more than half are stunted children.
In India, under-five children contribute to the most vulnerable segment and the prevalence of undernutrition is nearly double that of Sub-Saharan Africa. National Family Health Survey (NFHS)-4 data revealed that underweight is 35.7%, wasting is 21%, and stunting 38.4% in India. It contributes for 68·2% of the total under-5 deaths. Several studies done so far in Indian population have shown that inappropriate infant and young child feeding practices (IYCF) and undernutrition are higher among tribal population.,, Tribal population are particularly vulnerable to undernutrition, because of their geographical isolation, socio-economic disadvantage and inadequate health facilities. Appropriate (IYCF) is crucial to achieve optimal nutrition outcomes among children. Suboptimal child feeding practices including inappropriate breastfeeding and complementary feeding practices are leading causes of undernutrition and mortality during the first 2 years of life. Anemia in young children is also a serious concern. It is an important public health burden as it prevails in 59% of children in India which is maximum as compared to other southeast Asian countries (Bangladesh – 56%, Bhutan - 55%, Nepal - 51%, and Srilanka - 36%).
Despite significant initiatives by the Government of India to improve the nutritional status of under-five children, a large proportion of them are still malnourished and there is a need improve their nutritional status through specific targeted interventions. The present study is a part of the multicenter study conducted by (the Indian Council of Medical Research) to improve nutritional status of vulnerable segments of population such as pregnant women, adolescent girls, and under-five children. The present paper pertains to findings of the study among under-five children in Palghar district from the state of Maharashtra in India. The findings of pre- and post-intervention survey among under-five children and multicomponent health intervention model are discussed in this paper.
| Materials and Methods|| |
A prospective pre- and post-intervention study was conducted in ten villages of two tribal blocks, of Palghar district in Maharashtra, India. Institutional ethical clearance was obtained before the initiation of the study. Within the district, two blocks were selected randomly and from each block, five villages were selected by the Probability Proportion to Size sampling method. Each village was divided into three to four zones to ensure representation. The study participants were under-five children in these two blocks. Assuming the prevalence of undernutrition as 40% in the selected state and anticipated reduction to be 10% in 18 months period, the sample for under-five children was calculated with 95% confidence interval, 80% of power, and a design effect of two. The sample required was 376, however, considering expected loss to follow up of 20%, a sample size of 480 was calculated. Hence, a total 480 children (48 children from each village) were recruited during the study period after obtaining written informed consent from one of the parents. From each zone of the village, households were selected serially until the required numbers of study participants were enrolled. From each household, one under-5 year's child was selected until the desired sample size was met.
Preintervention survey was conducted from July 2015 to August 2016. Demographic, Household Information; information on feeding practices, immunization was collected using a pretested and validated questionnaire. The height was measured using stadiometer (nearest 0.1 cm) and weight (nearest 0.5 kg) was measured using a portable weighing machine. The equipment were standardized before use. Nutritional status was assessed using anthropometric measurements and the child was classified into Moderate Acute Malnutrition (MAM) (weight-for-height/length Z-score below-2 standard deviation [SD] of the median) and Severe Acute Malnutrition-(SAM) (weight-for-height/length Z-score below-3 SD of the median, or a mid-upper arm circumference < 115 mm, or by the presence of nutritional edema) as per the WHO growth standards. Stunting was defined as children having low height-for-age (z-scores < ‒2.00) and underweight was defined as low weight-for-age (z-scores < ‒2.00). The feeding practices were assessed based on the eight-core indicators of infant and young child practices (IYCF) by UNICEF, i.e., early initiation of breastfeeding, exclusive breastfeeding for 6 months, continued breastfeeding at 1 year, introduction of solid, semi-solid or soft foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich or iron-fortified foods. However, analysis of five out of nine indicators namely, exclusive breastfeeding for 6 months, introduction of solid, semi-solid or soft foods, MMF, MDD, and MAD was within the scope of the study as per objectives. To assess anemia, capillary blood was collected by skin prick method, transferred to the filter paper and hemoglobin was estimated in the laboratory for estimation of hemoglobin by cynmethomoglobin method. The anemia in child was classified as mild corresponding to Hb of 10.0–10.9 g/dl; moderate to a level of 7.0–9.9 g/dl, while severe anemia to a level <7.0 g/dl.
After the conduction of preintervention survey, gaps in the implementation of nutritional programs in the study area were identified. It was observed that none of the under-five children had received Iron/Folic Acid (IFA) syrups under Iron plus initiative, a program of Government of India. It was observed that nutritious diet to MAM children was not given at the Village Child Development Centre located at some of the anganwadis due to unavailability of funds from state government. Funds were provided temporarily through the district tribal welfare funds and nutritional diet was given to the MAM children as per the (Integrated Child Development Services) guidelines.
An interventional module was prepared based on the findings of the preintervention survey and gaps identified in the implementation of the programs [Figure 1]. Intervention was implemented via household visits, sending mobile short message service in local language, and mass approach for 18 months (September 2016-February 2018).
|Figure 1: Intervention Plan for Implementation in the selected study area.|
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Three rounds of household visits were completed in selected villages in each house of village with under-fives. Mobile messages were sent to the beneficiaries (Parents of under-five children) in villages.
Mass approach covered activities including group discussion with mothers of under-fives. It mainly covered the importance of iron-rich food in diet, IFA consumption, advantages of exclusive breastfeeding lectures on IYCF practices, initiation of weaning, and types of complementary feeds through role play. Discussion meetings were conducted about the usage of Take Home Ration by mothers of under-fives. Special nutrition sessions were conducted to demonstrate low-cost nutritional recipes to Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and mothers of under-fives. Locally available foods such as drumstick leaves, pumpkin, ragi flour, banana, yellow lentils (moong dal), and dried fish were used and easy weaning recipes with ARF (Amylase Rich Flour) were demonstrated with help of AWWs.
Advice was also given to the lactating mothers regarding the importance of consumption of iron and calcium-rich food and taking Iron and FA and calcium tablets regularly through household visits and mass approach.
The multicomponent health education activities were systematically planned so that mass approaches were covered six times in form of group discussions, lectures, community activities in a defined manner as per intervention module. Household visits were conducted thrice and messages in local language through mobile phones were also sent thrice over a period of 18 months.
The postintervention survey was conducted in the same ten villages as preintervention survey and included almost 70% of the beneficiaries. The remaining could not be included in the postintervention survey due to reasons such as the child in baseline being above 5 years, migration, etc., The postintervention survey was conducted on similar lines as the preintervention survey and included 480 children. The feeding practices, nutritional and status of anemia were compared to preintervention phase.
The categorical data were presented as frequencies and percentages. The impact of intervention was assessed by comparing important indicators in pre and postintervention survey. To understand differences in outcomes of pre intervention and post intervention, the Pearson's Chi-square or Fisher's exact test was performed, as appropriate. A two-sided P < 0·05 was considered statistically significant. Statistical analysis was performed using IBM SPSS Statistics Base version 26·0 (SPSS South Asia Pvt. Ltd, Bengaluru, Karnataka, India).
| Results|| |
The mean age of under-five children was 25.43 (±16.8) months in preintervention and 38.9 (±12) months in postintervention survey. In preintervention, out of 480 children, 51% (n = 245) were males and 49% (n = 235) were females whereas in postintervention, 50.83% (n = 244) were males and 49.16% (n = 236) were females. The majority of the participants belonged to the scheduled tribe. Majority of children belonged to Warali, Katkari, and Malhar Koli tribes. During preintervention phase, hygiene practices, feeding practices and nutritional status of children were assessed and were compared in post intervention phase.
Hygiene practices of mothers of children 6–24 months indicated that 22.08% (n = 106) mothers were washing hands with soap before feeding the child during preintervention which improved significantly to 82.7% (n = 397) in post intervention phase (P ≤ 0.00001). Around 93.1% (n = 447) mothers were washing hands with soap after defecation which significantly increased to 98.1% (n = 471) in postintervention phase (P = 0.000284).
Baselines dietary habits (consumption of different food groups) were assessed in preintervention phase [Figure 2]. Most commonly consumed food groups were cereals, millets (34.58%), and pulses (32.92%) followed by green leafy vegetables, other vegetables, roots and tubers, fruits, milk and milk products, egg, meat, fish, chicken, fats, oils, salt, jaggery.
Out of 480 children, exclusive breast feeding for 6 months was practiced by 48.5% (n = 233) mothers in preintervention phase and 50.8% (n = 244) mothers in post intervention phase. Complementary feeding was initiated between 6 and 8 months by 48.5% (n = 232) mothers in preintervention phase which significantly increased to 72.2% (n = 346) in post intervention phase (P ≤ 0.00001).
Among infants in preintervention phase, early initiation of breastfeeding within 1 h was practiced by 82.7% (78/92) which showed significant improvement (P = 0.008) to 98.2% (55/56) in post intervention phase.
The pre and post intervention analysis of five of nine IYCF indicators, i.e., exclusive breastfeeding for 6 months, introduction of solid, semi-solid or soft foods, MMF, MDD, MAD in children aged 6 months-24 months revealed the following results as shown in [Table 1].
Introduction of complementary foods showed significant improvement in post intervention as compared to preintervention phase (P = 0.00002). MDD was 67.2% (n = 125) which was 58.24% (n = 53) in postintervention phase. Minimum meal frequency, two for 6–8 months, three for 9–23 months, four for 6–23 months) was increased significantly to 67.03% (n = 61) from 5.91% (n = 5). The MAD was practiced by 5.37% (n = 5) in preintervention phase which improved significantly to 47.2% (n = 43) in postintervention phase.
Nutritional status of participants
As shown in [Table 2], it was observed that proportion of children having Moderate Acute Malnutrition (MAM) decreased significantly in postintervention phase to 10% (n = 47) whereas 5.4% (n = 25) of SAM in preintervention decreased to “zero” cases of SAM in postintervention phase. Nearly 15% (n = 72) children were moderately underweight whereas 32.9% children were severely underweight in preintervention phase. Moderate stunting prevailed in 11.87% (n = 57) children and severe stunting in 42.29% (n = 203) children. Moderate stunting decreased by 9% whereas severe stunting significantly decreased by 17% in postintervention phase. It was observed children having normal weight for age and normal height for age increased by 10% and 22% respectively in postintervention.
Similarly, severe anemia was reported in 16.24% (n = 76) children and none of the children had severe anemia in postintervention. It was seen that, children having mild anemia increased significantly by 6.09% and proportion of children with moderate anemia increased significantly by 7.5%.
| Discussion|| |
The study discusses the impact of implementation of multi-component health and nutrition education intervention model focusing on dietary counseling considering the cultural and socio-economic status of the population. It indicates that there was a significant improvement in nutritional status of the under-five children in postintervention survey as compared to the preintervention survey. The study depicted that nearly 93% of the mothers practiced hand washing after defecation similar to studies from West Bengal, Tripura, and Andhra Pradesh., Furthermore, there was significant improvement in hygiene practices of mothers in terms of washing hands before feeding and importantly after defecation. This could be one important contributing factor leading to improved nutritional status of children.
It was observed that nearly 50% of mothers reported Exclusive Breast Feeding (EBF) up to 6 months which is better than in Melghat study reporting EBF by 36% of children. However, it is less than studies reported by Dave and Chaudhary in Sabarkantha. and study from eastern India reporting exclusive breastfeeding among 78% of infants. Similarly, timely initiation of complementary feeding is important to meet nutritional requirement of growing child. The findings showed that complementary feeding was initiated by only 48.3% of mothers in the preintervention phase similar to studies reported in tribal groups. It is lesser than study reported by Sinhababu et al. in West Bengal showing initiation of complementary feeding by 55.8% of mothers. However, it increased to 72.5% in the post intervention survey, which indicated the successful implementation of the intervention model. It was possible to assess MMF, MDD, and MAD in pre and post intervention phase. Baseline findings suggested that 68% of children achieved MDD. However, minimal meal frequency was only up to 6% and minimal acceptable diet was practiced in nearly 5% of children. This is significantly lower than earlier reported studies reporting 88.2% of MDD, 10.7% of MMF, and 17.3% MAD. Despite, the higher prevalence of MDD observed in this study, MMF and MAD were not optimal contributing to inadequate feeding practices. This findings align with the fact that very low proportion of children aged 6–23 months in India received adequate complementary foods as measured by the WHO indicators. The nutrition education intervention focusing on importance of EBF, weaning, inclusion of various food groups and calcium and iron-rich food through locally available foods contributed in adapting desired nutrition practices. Engagement of ASHAs and Anganwadi workers in these awareness activities, distribution of iron/folic acid through PHCs helped in the sustainability of intervention yielding promising results in terms of improved MMF and MAD by 50% in postintervention phase. Importantly, significant improvement in timely initiation of complementary feeds by almost 25% in postintervention phase was characteristic.
The study revealed 5.4% of SAM and 21.6% of MAM in under-five children which is significantly lower than studies from central and eastern India reporting 11% of SAM in children, and more than study from northern India reporting 2.2% of SAM cases. These findings echo with a study reported from Vikramgadh block of Palghar district which showed 4% prevalence of SAM and 20% prevalence of MAM in 375 children aging 1–6 years. However, our study characteristically covered Palghar and Dahanu blocks of Palghar endorsing and representing a substantial prevalence of Malnutrition in Palghar district. Our study also differs with respect to larger number of under-five children as compared to earlier reported study and also discusses impact of intervention on the status of Malnutrition. Similarly, it was seen that nearly 30%–40% children were either severely underweight or stunted which is higher that the studies reported. Undernutrition was observed in lesser percentage compared to widespread prevalence of undernutrition among the children of Dhodia, Kinnaura, and Bhil tribal communities reporting maximum wasting (85.3%), stunting (86.6%) and underweight (93.3%) in Kinnaura girls belonging to Himalayan ecology. It was also less compared to study from tribal Maharashtra reporting nearly 60% of underweight and stunting and 30% of wasting. However, a significant reduction in stunting, underweight, and SAM was observed in postintervention phase unlike a study reported from Tribal parts of Nashik and Palghar districts in Maharashtra which looked at the impact of provision of nutritious meals through centralized kitchens. This is possibly because of integrated research by inclusion of multicomponent health intervention having wider impact on feeding practices leading to favorable outcomes.
The implementation of multicomponent intervention led to improved nutrition status of under-five children and also anemia. This is reflected by zero cases of SAM in post intervention phase and also reduction in MAM cases.
Comparison of post intervention findings of our study with NFHS-5 data revealed the prevalence of stunting was slightly higher (36% vs. 33%); underweight was almost similar (37.7% vs. 37.1%); and wasting was quite less (10% vs. 23.9%). However, there were no underfives with severe wasting as per post-intervention findings in our study as compared to NFHS V (10.5%). It is also intriguing to note that no case of severe anemia was reported in under-five children. The increase in mild and moderate status of anemia also points toward conversion of severe to moderate and moderate to mild cases in post intervention phase. Although few studies have discussed the impact of nutrition education on nutrition status before, this is probably the largest study reported so far with unique multicomponent intervention model.
| Conclusion|| |
The present study highlights impact of structured multicomponent health and nutrition education emphasizing consumption of local nutritious food by means of household visits and mass approach. The sustainability of this model at primary health care level can improve nutritional status of under-five children through the involvement of community health workers. The critical window of opportunity to prevent undernutrition through ground-level health workers should be explored with a focus to improve IYCF practices for optimal growth and development. The results would pave further path to plan for better design and implementation of nutritional interventions at programmatic level to reduce child mortality and morbidity in globally.
The post intervention survey could not cover all the 100% beneficiaries included in the pre intervention phase due to reasons such as the child in baseline being above 5 years, migration, etc., However, it included almost 70% of the beneficiaries from the preintervention phase. Despite approaching all eligible children in post intervention phase, the number of infants and young children (<24 months) were proportionately less in post intervention and not uniform in pre and post intervention phase.
Financial support and sponsorship
This study was supported by the Department of Health Research.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]