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The topic for this study was decided in consultation with the Director
of the organization. The topic of my study was " Feasibility of
providing integrated health and nutrition care to preschool children
coming to an Urban Primary Health care institution”. A brief report
of the work done is presented.
FEASIBILITY (PRACTICABILITY) OF
PROVIDING
INTEGRATED (incorporated) HEALTH
AND NUTRITION CARE TO PRESCHOOL
CHILDREN COMING TO AN URBAN
PRIMARY HEALTH CARE INSTITUTION
Background information on health and
nutritional status in infancy and early
childhood
Figure 1: Undernutrition prevalence in South Asian countries is much
higher than in Africa
Preschool children are one of the most nutritionally vulnerable
segments of the population. Nutrition during the first five years has
an impact not only on growth and morbidity during childhood, but
also acts as a determinant of nutritional status in adolescent and
adult life. Global comparative data indicate that contrary to common
perception, prevalence of underweight and stunting is highest in
South Asian children (Figure 1, ). Changes in prevalence of
undernutrition in under five children in different regions/ countries
of the world over the last three decades is shown in Figure 2.
India is home to the largest number of underweight and stunted
children in the world. Projected trends in number of underweight
under five children is given in Figure 3. In South Asia, especially
India there will be a substantial reduction in undernutrition rates;
but Asia and India will continue to have by far the largest number of
underweight children in the world in 2015. Time trends in poverty,
undernutrition and mortality in developing countries is shown in
Figure 3: Current estimates of underweight and projected numbers of underweight children
under age five, 1990–2015 (WHO)
Table 1. Over the last four decades there has been a progressive
reduction in poverty, increase in energy intake and undernutrition
and infant and under five mortality in the developing countries.
1970197519801981198419851987199019931995199619992000200120032005 ARC
IMR (/1000) 108 88 71 67 62 60 -1.8
U5MR
167 133 105 98 91 87 -1.99
(/1000)
Energy
availability 211021462308 2444 2520 2602 2654 0.83
(Kcal)
Underweight
37.6 33.9 30.1 27.3 244 22.7 -2.99
(%)
Stunting
48.6 43.2 37.9 33.5 29.6 26.5 -2.03
(%)
Poverty
headcount 40.4 32.8 28.4 27.9 26.3 22.8 21.8 21.1 -2.45
(%)
50
60
52 53.4
40
percent
30 50 45.5 47 45.9
20
10 38.4
40
percent
0
breastmilk (6-9
Stunting (< 3
Wasting (< 3
Breastfeeding
Underweight
solid food and
solid or semi-
(0-5 months)
(< 3 years)
Exclusive
Receiving
years)
years)
30
19.1
20 17.3
Infant f eeding Prevalence of undernutrition 15.5
practices
10
0
stunted (%) underweight (%) wasted (%)
nti
ve
er
Vitamin A
(2nd soln) (Figure 8). Antenatal steroids
Improvement in IYCF Newborn temperature management
Tetanus toxoid
Measles vaccine
Insecticide-treated materials
Protein (g) 22.8 23.7 20.9 19.5 20.2 30.2 33.9 31.2 28.2 28.7
Energy (Kcal) 834 908 807 729 719 1118 1260 1213 1066 1020
Vitamin A
(µg) 136 117 133 106 126 159 153 205 127 166
Thiamin (mg) 0.5 0.52 0.4 0.4 0.5 0.76 0.83 0.7 0.7 0.7
Riboflavin
(mg) 0.38 0.37 0.4 0.3 0.3 0.48 0.52 0.6 0.6 0.4
Niacin (mg) 5.08 5.56 4.6 5.1 5.2 7.09 8.4 7.4 8.1 7.9
Vitamin C
(mg) 15 14 15 17 17 20 23 25 24 25
%
40
60
Kcals
30 719 1020 1230 1423 1645 50
1913 2000 1389 1566 1630 1738
%
40
20 30
RDA 1240 1690 1950 2190 2450 2640
20
2425 1970 2060 2060 1875
10 10
% RDA 58.0 60.4 63.1 65.0 67.1 72.5
0 82.5 70.5 76.0 79.1 92.7
0
75- 88- 96- 00- 04- 92- 98- 05-
75- 88- 96- 00- 04- 92- 98-
79 90 97 01 05 93 99 79 90 97 01 05 93 99 06
Data from NNMB surveys have shown that over the last three
decades there has been a steep decline in the prevalence of
moderate and severe undernutrition as assessed by weight for age
and height for age. Inspite of the steep decline in the prevalence of
stunting over the last three decades, the change in the mean height
of children is very small. There has been a decline in underweight
children but even now nearly 50% of the children are underweight
as compared to the NCHS norms. There has been some reduction
in stunting rates similar to the reduction in underweight rates.
Wasting rates are much lower than the underweight and stunting
rates. It is noteworthy that there has been no change in wasting
rates over the same period. It is not clear how much of this is
attributable to the fact that Indian children are shorter as compared
to NCHS norms and will therefore weigh less, even though their
body weight is appropriate for their current height (Figure 9 and
10).
HYPOTHESIS
By appropriate modifications and minimal additional resources it is
possible to reorganise the existing out patient services in the
primary health care institutions so that integrated child nutrition
and health care envisaged under NRHM is provided to all children
coming to the hospital .
OBJECTIVES
General-
To assess the feasibility of reorganising the OPD routine in
primary healthcare institution so that all children who enter the
portals of the hospital irrespective of the reason they came to the
hospital get integrated child health and nutrition care .
Specific
Ill children are brought to the OPD and are examined by the
doctor and given appropriate treatment . However the opportunity
of hospital visits is not used to enquire about the infant and young
child feeding practices, immunisation status or assess nutritional
status of the child and give appropriate care and counselling . There
is no system to provide counselling regarding feeding and caring
during illness and convalescence .
EXISTING SYSTEM
Examined by
Get immunization done doctors and Receive no care
appropriate
treatment given
mothers but do not get examined or given any screening or
advise.
The staff in the OPD ensured that the proposed reorganization was
implemented effectively and consistently. They stream lined the
procedures so that neither the children nor the doctors had to spend
more time in the OPD. Even when there were nearly 20 children to be
attended to the whole team was able to cope with work load
In all children (irrespective of the reason they came to the hospital)
information on immunization status, feeding and caring practices were
obtained; assessment of nutritional status was done in all.
When they went to the physicians the physician could look at the
completed proforma and advise the mother taking these into account They
also informed the mother that they should go to the nutrition nterns
and get the benefit of detailed individualized counseling.
The nutrition interns counseled the mothers about immunization , infant
and young child feeding , feeding during illness and convalescence and
how to improve nutritional status of the child within the existing
constraints ; they also answered the queries that the mothers posed
The mother then collected the drugs prescribed by the doctor and went
home
The Performa filling was done when the mothers were waiting to be
called for the consultation / immunization and so did not involve any
additional time spent tin the OPD. They did spend 5 more minutes with
the nutrition interns for counseling but they got excellent advice
REORGANIZED SYSTEM
Mothers waiting for their Waiting for their turn Waiting for their turn
turn for ANC for immunization for monitoring
Socio-demographic Profile
The socioeconomic profile of these children is given in Table .
PARAMETER ACC Immunization Ill child
S.NO Parents N=94 (%) N=55
N=70 (%)
(%)
1 Household Type
a. Joint family 47.14 44.68 69.09
b. Nuclear family 52.86 55.32 30.91
2 Family Members
a. >=3 25.71 24.47 29.09
b. 4-8 57.14 61.70 63.64
c. <8 17.14 13.83 7.27
3. Age
a. 0-3 11.43 36.17 16.36
b. 4-6 2.86 8.51 7.27
c. 7-9 2.86 12.77 10.91
d. 10-12 1.43 3.19 5.45
e. 13-18 8.57 19.15 16.36
f. 19-24 20 3.19 16.36
g. 25-36 20 5.32 14.55
h. 37-48 21.43 6.38 10.91
i. 49-60 11.43 5.32 1.82
4. Sex
a. Male 47.71 43.62 45.45
b. Female 54.29 56.38 54.55
5. Literacy status
(Mother)
a. Illiterate 20 18.09 18.18
b. Upto 5 20 11.70 14.55
c. 5-12 50 57.45 61.82
d. College 10 12.77 5.45
6. Literacy status
(Father)
a. Illiterate 2.86 7.45 10.91
b. Upto 5 14.29 11.70 14.55
c. 5-12 61.43 65.96 52.73
d. College 21.43 14.89 21.82
7. Work status (Father)
a. Not working 5.71 2.13 1.82
b. Unskilled 18.57 12.77 18.18
c. Semi-skilled 34.29 51.06 25.45
d. Clerk 15.71 11.70 20.00
e. Teacher 21.43 12.77 18.18
f. Professional 4.29 9.57 16.36
8. Work status (Mother)
a. Not working 97.14 93.62 94.55
b. Unskilled 2.86 2.13 3.64
c. Semi-skilled
d. Clerk
e. Teacher 1.82
f. Professional 1.06
9. Diet
a. Vegetarian 32.86 34.04 20
b. Non-vegetarian 67.14 65.96 80
10. Monthly income
a. >3000 3.45 1.39 11.11
b. 3000-6000 63.79 70.83 61.11
c. <6000 32.76 27.78 27.78
11. Locality
a. Slum 20 10.64 10.91
b. Developing 80 89.36 89.09
colony
12. Type of house
a. Kuccha 12.86 5.32 14.55
b. Semi-pucca 15.71 18.09 16.36
c. Pucca 71.43 76.60 69.09
13. Ownership
a. Own 44.29 43.62 50.91
b. Rented 55.71 56.38 49.09
14. No. of Rooms
a. One 42.86 46.81 56.36
b. TWO 31.43 24.47 25.45
c. Three 14.29 12.77 10.91
d. More than 3 11.43 15.96 7.27
15. Toilet facility
a. Shared 21.43 20.21 29.09
b. Sulabh 14.29 6.38 7.27
c. Own flush 64.29 73.40 63.64
16. Transport
a. Public 60 47.87 61.82
b. Bicycle 10 24.47 18.18
c. Scooter 25.71 18.09 12.73
d. Car 4.29 9.57 7.27
17. Cooking fuel
a. Kerosene 7.14 4.26 9.09
b. Gas 91.43 94.68 90.91
c. Other 1.43 1.06 0.00
18. Drinking water
a. Public tap 30 27.66 32.73
b. Own 58.57 64.89 61.82
arrangement 11.43 7.45 5.45
c. Tanker
19. Entertainment
a. No 21.42 11.70 20
b. Radio 7.14 2.12 7.27
c. T.v ( b/w) 10 5.31 12.72
d. T.v (colour) 61.42 80.85 60
20. Kitchenware
a. Aluminium 2.85 3.19 3.63
b. Cast iron 1.06
c. Brass/ copper
d. Stainless steel 95.71 95.74 96.36
21. Smoking
a. yes 24.63 21.83 24.07
b. No 75.36 71.86 75.92
Majority of children were from the low or low middle income group
families . There were no significant differences in the profile of the
families to which the children belonged depending on the reason for
their coming to the hospital . From the sociodemographic profile it
is obvious that these children did not come from homes with
severe economic constraints and food insecurity. There were
significant differences in the age profile of children a attending
hospital for different reasons: children who came for immunization
were young infants ; those who accompanied their parents were
older.
AGE (m o nth s )
40
35
P ER C EN T A G E
30
25 A c c p ar ents
20 Immun is ation
15 Ch ild is ill
10
5
0
0 -3 4 -6 7- 9 10 -1 2 1 3 -1 8 19 - 24 2 5- 36 3 7- 48 49- 60
A GE
Immunization rates
IMMUNISATION
100
80
60
PERCENTAGE
40
20
0
BCG DPT POLIO PULSE HEPB MEAS
% 96 92 93 92 79 68
TYPESOFIMMUNISATION
Majority had accessed immunization services during infancy . While
coverage under BCG was nearly universal but only 68% had
measles immunization. Complete immunization ( BCG, 3 doses of
OPV and DPT , measles) before first birth day was reported by
59% only. Reasons for the relatively low complete immunization
rate varied : from non awareness and difficulties in complying
with the suggested schedule . Health education on the importance
of complying with the immunization regimen can make a difference
in complete immunization rates.
Morbidity due to infections
30
25
20
Percentage 15 Diarrhea
Fever
10
RES infection
5
Skin diseases
0
0-6 7-12 13- 19- 25- 31- 37- 43- 49- 55-
18 24 30 36 42 48 54 60
Age groups (months)
REFERENCES
Socio-demographic Profile
* 1. Diluted 2. Undiluted
Supplements Month when initiated How often given Amount /Dose
1 IFA
2 Vitamin A
3 Any other, specify
Immunization
Vaccine Dose/date
BCG Measles
DPT 1 2 3
Polio 0 1 2 3 Pulse
Any
other
Morbidity
Severity:
1. Mild 2. Moderate 3. Severe
Treatment given:
1. Home remedies 2. Home fluids 3. ORS 4. Antibiotics
5. Antipyretics 6. Unknown medicines from quacks 7. Cough syrup
Anthropometric indices
Advice
Feeding practices
Immunization
Physical activity
Health care during illness
Diet during illness and convalescence
Life style
Diet