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Patra M, Gayen B K, Yasmin S, Sinha N, Baur B. Determinants of Undernutrition among Under-Five Children: A Community-Based Study from Eastern India. JNFS 2024; 9 (3) :439-448
URL: http://jnfs.ssu.ac.ir/article-1-675-en.html
URL: http://jnfs.ssu.ac.ir/article-1-675-en.html
Determinants of Undernutrition among Under-Five Children: A Community-Based Study from Eastern India
Department of Community Medicine, Deben Mahata Government Medical College& Hospital, Purulia, India
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1 Department of Community Medicine, Midnapore Medical College, Midnapore, India; 2 Departments of General Medicine, Midnapore Medical College, Midnapore, India; 3 Department of Community Medicine, Kolkata Medical College, Kolkata, India; 4 Department of Community Medicine, Deben Mahata Government Medical College& Hospital, Purulia, India; 5 Department of Community Medicine, Jagannath Gupta Institute of Medical Sciences & Hospital, Kolkata, India.
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Determinants of Undernutrition among Under-Five Children: A Community-Based Study from Eastern India
Manas Patra; MD1, Biplab Kumar Gayen; MD2, Shamima Yasmin; MD3, Nirmalya Sinha; MD*4
& Baijayanti Baur; MD5
Manas Patra; MD1, Biplab Kumar Gayen; MD2, Shamima Yasmin; MD3, Nirmalya Sinha; MD*4
& Baijayanti Baur; MD5
1 Department of Community Medicine, Midnapore Medical College, Midnapore, India; 2 Departments of General Medicine, Midnapore Medical College, Midnapore, India; 3 Department of Community Medicine, Kolkata Medical College, Kolkata, India; 4 Department of Community Medicine, Deben Mahata Government Medical College& Hospital, Purulia, India; 5 Department of Community Medicine, Jagannath Gupta Institute of Medical Sciences & Hospital, Kolkata, India.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Backgrounds: Children are prone to undernutrition which adversely affects their health status. Nutritional status of under-five children is a sensitive indicator of nutrition and child health. Hence, the present study is undertaken to assess the prevalence and determinants of undernutrition among under-five children in a rural area of West Bengal, India. Methods: A community-based cross-sectional study was conducted among 1680 under-five children who were selected by 30 cluster sampling technique to assess the prevalence and determinants of undernutrition. Nutritional status was assessed by means of weight-for-age, height-for-age, weight-for-height and mid-upper arm circumference-for-age criteria based on World Health Organization’s child growth standards. Results: The prevalence of underweight, stunting, and wasting among under-five children was found to be 33.7%, 34.8%, and 21.6%, respectively. Moreover, 39.4% of the studied children had low mid-upper arm circumference-for-age. After adjustment for possible confounders, maternal illiteracy, lower socio-economic status, presence of anemia and any childhood morbidity were found significant determinants of undernutrition. Conclusions: Widespread prevalence of undernutrition among under-five children with anemia and childhood morbidity as important determinants highlights a need for multi-disciplinary integrated approach towards improving the child health and nutrition. Long term measures like improvement of maternal education and poverty alleviation should also be considered in future plans. Keywords: Under-five children; Undernutrition; Nutritional status; Anthropometry |
|
| Article history: Received:9 Jul 2022 Revised: 7 Dec 2022 Accepted: 30 Dec 2022 |
||
| *Corresponding author: drnirmalya.sinha@rediffmail.com Department of Community Medicine, Deben Mahata Government Medical College& Hospital, Purulia, Pin: 723147, West Bengal, India. Postal code: 723147 Tel: +91 9933887740 |
Introduction
Health and nutrition of under-five children is of paramount importance because the foundation for lifetime, strength, and intellectual vitality is laid during that period. Under-five children are considered as one of the most vulnerable segments of any community. Children in this age group are prone to undernutrition due to various reasons like lack of adequate calories and protein, faulty feeding practices, lack of mothers’ knowledge regarding a balanced diet, impaired utilization of nutrients due to infections, and parasitic infestations (Jood et al., 2000). Apart from under-nutrition, micronutrient deficiencies are very common in this age group, which adversely affect their health status. The vicious cycle of malnutrition and infection also cannot be ignored, and the effects of undernutrition have long-term implications for children’s live who constitute 10.7% of India’s population (Registrar General and Census Commissioner India, 2011).
We are still far from a world without undernutrition. Globally, near 149.2 million under-five children (one in four children) were stunted and over 45.4 million were wasted with a prevalence rate of 22% and 6.7% respectively. In addition, two out of five stunted children live in South Asia (World Health Organization et al., 2021).
In spite of nutritional transition, undernutrition, especially among under-five children, still remains a major public health problem in India. In the state of West Bengal, the prevalence rate of underweight, stunting, and wasting among under-five children was 31.5%, 32.5% and 20.3%, respectively (International Institute for Population Sciences (IIPS), 2017).
Nutritional status of the children is not only a sensitive indicator of nutrition and child health but also reflects the accessibility and utilization of health care services and community health. Considering those facts in mind, the present study was conducted to identify the prevalence and determinants of undernutrition among under-five children in the study area.
Materials and Methods
Study design, study setting and participants
A community based cross-sectional study was carried out among under-five children in Salboni Block of Paschim Medinipur district of West Bengal, India. The total population of the block was 1, 91,705 as per 2011 census(Registrar General and Census Commissioner India, 2011).
The study area was a socially-backward tribal block of West Bengal, India, known as the ‘Jungal Mahal’ due to the presence of a wide range of dense forest. Illiteracy, poverty, and under-nutrition are very common in the area. The present study was conducted in 117 villages out of a total 411 villages in Salboni Block which constitutes the rural field practice area of the Midnapore Medical College, Paschim Medinipur, West Bengal, India. The study was undertaken from May 2019 to November 2020.
Sample size and Sampling technique
The desired sample size with 10% relative permissible error, 95% confidence interval, and design effect of 2 was estimated to be 1674 using the formula: n = Zα2* p * q /l2*design effect (S. K. Lwanga and S Lemeshow, 1991).[where n= desired sample size, p=prevalence, q=1-p, l=permissible error, and Zα= 1.96 where α was 0.05 and the design effect was 2]. The sample size was calculated based on the reported prevalence of 31.5% under-weight under-five children in West Bengal (National Family Health Survey (International Institute for Population Sciences (IIPS), 2017).
The study participants were selected using the 30 cluster sampling technique; the clusters were chosen using the population proportional to the size (PPS) method. In each cluster, 56 under-five children were selected for the study purpose to achieve the desired sample. In case of non-availability of the desired number of under-five children in any cluster, they were chosen from the adjoining village. Thus, all the 1680 under-five children were covered in the present study.
117 villages in the study area (field practice area of the Midnapore Medical College, West Bengal formed the sampling frame. The present study considered villages as the sampling unit in households where any under-five children present as the study unit and under-five children as the study participants.
Data Collection and Measurements
After obtaining informed consents from the respondents, a group of trained medical experts paid house-to-house visits and interviewed the mothers of the under-five children. The study considered only mothers as the sole respondents. Data were collected regarding selected socio-demographic and socio-economic characteristics, birth history, feeding practices, and immunization status of the children, etc., using a pre-designed and pre-tested semi-structured questionnaire. Furthermore, the type of ration card was considered an indicator of socio-economic status. Anemia was detected by means of cyanmethemoglobin method.
Physical examination of the children was also carried out which included anthropometry and clinical examination. In anthropometry, weight, length/height, and mid-upper arm circumference (MUAC) were measured using standard techniques (World Health Organization, 1995).
Nutritional status of under-five children was assessed using weight-for-age, height-for-age, weight-for-height, and MUAC-for-age criteria of the new “Multi-center Growth Reference Standards (MGRS) developed by the World Health Organization (WHO) and expressed in terms of z score (World Health Organization, 2006). Weight-for age, height-for-age, and weight-for-height values with standard deviation below 2 were considered underweight, stunted, and wasted respectively, while standard deviations below 3 were considered severe underweight, severe stunting, and severe wasting. In case of MUAC-for-age, it was considered low (standard deviation below 2) and very low (standard deviation below 3). As an age independent indicator among 12-59 months children, MUAC of more than 13.5 am was considered normal, between 12.5 to 13.5 cm was considered moderately low, and less than 12.5 cm was severely low.
Ethical considerations
The study was approved by Institutional Ethics Committee of Midnapore Medical College, Paschim Medinipur, West Bengal. The purpose, methods, and proposed outcome of the study were explained to either the head of the households or mother of the under-five children, and written informed consent was obtained from each respondent. The severe undernourished children were sent to the nearest ‘Salboni Nutritional Rehabilitation Centre’ for further management.
Data analysis
After a through verification, data were entered and analyzed using the SPSS (Statistical Package for Social Sciences; version 22) software, and ‘Anthro 2005’software was used for analysis and interpretation of anthropometric data (World Health Organization, 2011).The categorical variables were expressed in terms of numbers and percentages. Associations between undernutrition (expressed in terms of underweight, stunting, and wasting) and risk factors were evaluated by calculating crude and adjusted odds ratio (OR) along with their 95% confidence interval by means of multi-variate logistic regression. To calculate OR, the indictors of undernutrition were taken as dependent variables with dichotomous outcome (yes/no), while the children’s age group, sex, caste, and their mothers’ education, and occupation, type of family, socio-economic status, immunization status of the children, presence of anemia, vitamin-A supplementation in the last 6 months, and a history of any morbidity in the last fortnight were taken as independent variables. For all statistical tests,
P-value<0.05 was considered as the level of significance.
Results
Socio-demographic and socio-cultural profile
In the present study, 8.9% of the under-five children were under 6 months of age. Among the studied children, 51.1% were male and the remaining 48.9% were female. Nearly one-fifth of the children belonged to the socially-vulnerable castes (scheduled caste: 20.8% and scheduled tribe: 19.2%). Around half (50.5%) of the mothers had secondary level education while nearly one-third of them (32.7%) were illiterate. The majority of the mothers were homemakers (42.3%), followed by unskilled manual labour (36.8%). Only 7.3% of the mothers were engaged either in service or business. The majority of under-five children belonged to joint family (61.1%). According to socio-economic status, more than one-fourth (28.7%) of the studied children belonged to below poverty line (BPL) family, while the remaining 71.3% were above poverty line (APL, Table 1).
Nutritional status
In the study area, the nutritional status of under-five children by means of various anthropometric indicators was shown in Figure 1. In the present study, the prevalence of wasting, stunting, and underweight among under-five children was estimated as 13.8%, 44.8% and 33.7%, respectively. Also, 39.4% of the children had low MUAC-for-age. 1.7%, 18%, 10.2% and 5.3% of the under-five children were considered severely (<-3SD) wasted, stunted, underweight and with very low MUAC-for-age (<-3 SD), respectively (Figure 1).
MUAC can be used as an age independent indicator of nutritional status among 12-59 months children. Among the 1330 children aged 12-59 months, 58.5% (778/1330) had normal MUAC (>13.5 cm); 29.8% (396/1330) had low MUAC (≤ 13.5 cm), and 11.7% (156/1330) had severely low MUAC (<12.5 cm, Table 2).
We are still far from a world without undernutrition. Globally, near 149.2 million under-five children (one in four children) were stunted and over 45.4 million were wasted with a prevalence rate of 22% and 6.7% respectively. In addition, two out of five stunted children live in South Asia (World Health Organization et al., 2021).
In spite of nutritional transition, undernutrition, especially among under-five children, still remains a major public health problem in India. In the state of West Bengal, the prevalence rate of underweight, stunting, and wasting among under-five children was 31.5%, 32.5% and 20.3%, respectively (International Institute for Population Sciences (IIPS), 2017).
Nutritional status of the children is not only a sensitive indicator of nutrition and child health but also reflects the accessibility and utilization of health care services and community health. Considering those facts in mind, the present study was conducted to identify the prevalence and determinants of undernutrition among under-five children in the study area.
Materials and Methods
Study design, study setting and participants
A community based cross-sectional study was carried out among under-five children in Salboni Block of Paschim Medinipur district of West Bengal, India. The total population of the block was 1, 91,705 as per 2011 census(Registrar General and Census Commissioner India, 2011).
The study area was a socially-backward tribal block of West Bengal, India, known as the ‘Jungal Mahal’ due to the presence of a wide range of dense forest. Illiteracy, poverty, and under-nutrition are very common in the area. The present study was conducted in 117 villages out of a total 411 villages in Salboni Block which constitutes the rural field practice area of the Midnapore Medical College, Paschim Medinipur, West Bengal, India. The study was undertaken from May 2019 to November 2020.
Sample size and Sampling technique
The desired sample size with 10% relative permissible error, 95% confidence interval, and design effect of 2 was estimated to be 1674 using the formula: n = Zα2* p * q /l2*design effect (S. K. Lwanga and S Lemeshow, 1991).[where n= desired sample size, p=prevalence, q=1-p, l=permissible error, and Zα= 1.96 where α was 0.05 and the design effect was 2]. The sample size was calculated based on the reported prevalence of 31.5% under-weight under-five children in West Bengal (National Family Health Survey (International Institute for Population Sciences (IIPS), 2017).
The study participants were selected using the 30 cluster sampling technique; the clusters were chosen using the population proportional to the size (PPS) method. In each cluster, 56 under-five children were selected for the study purpose to achieve the desired sample. In case of non-availability of the desired number of under-five children in any cluster, they were chosen from the adjoining village. Thus, all the 1680 under-five children were covered in the present study.
117 villages in the study area (field practice area of the Midnapore Medical College, West Bengal formed the sampling frame. The present study considered villages as the sampling unit in households where any under-five children present as the study unit and under-five children as the study participants.
Data Collection and Measurements
After obtaining informed consents from the respondents, a group of trained medical experts paid house-to-house visits and interviewed the mothers of the under-five children. The study considered only mothers as the sole respondents. Data were collected regarding selected socio-demographic and socio-economic characteristics, birth history, feeding practices, and immunization status of the children, etc., using a pre-designed and pre-tested semi-structured questionnaire. Furthermore, the type of ration card was considered an indicator of socio-economic status. Anemia was detected by means of cyanmethemoglobin method.
Physical examination of the children was also carried out which included anthropometry and clinical examination. In anthropometry, weight, length/height, and mid-upper arm circumference (MUAC) were measured using standard techniques (World Health Organization, 1995).
Nutritional status of under-five children was assessed using weight-for-age, height-for-age, weight-for-height, and MUAC-for-age criteria of the new “Multi-center Growth Reference Standards (MGRS) developed by the World Health Organization (WHO) and expressed in terms of z score (World Health Organization, 2006). Weight-for age, height-for-age, and weight-for-height values with standard deviation below 2 were considered underweight, stunted, and wasted respectively, while standard deviations below 3 were considered severe underweight, severe stunting, and severe wasting. In case of MUAC-for-age, it was considered low (standard deviation below 2) and very low (standard deviation below 3). As an age independent indicator among 12-59 months children, MUAC of more than 13.5 am was considered normal, between 12.5 to 13.5 cm was considered moderately low, and less than 12.5 cm was severely low.
Ethical considerations
The study was approved by Institutional Ethics Committee of Midnapore Medical College, Paschim Medinipur, West Bengal. The purpose, methods, and proposed outcome of the study were explained to either the head of the households or mother of the under-five children, and written informed consent was obtained from each respondent. The severe undernourished children were sent to the nearest ‘Salboni Nutritional Rehabilitation Centre’ for further management.
Data analysis
After a through verification, data were entered and analyzed using the SPSS (Statistical Package for Social Sciences; version 22) software, and ‘Anthro 2005’software was used for analysis and interpretation of anthropometric data (World Health Organization, 2011).The categorical variables were expressed in terms of numbers and percentages. Associations between undernutrition (expressed in terms of underweight, stunting, and wasting) and risk factors were evaluated by calculating crude and adjusted odds ratio (OR) along with their 95% confidence interval by means of multi-variate logistic regression. To calculate OR, the indictors of undernutrition were taken as dependent variables with dichotomous outcome (yes/no), while the children’s age group, sex, caste, and their mothers’ education, and occupation, type of family, socio-economic status, immunization status of the children, presence of anemia, vitamin-A supplementation in the last 6 months, and a history of any morbidity in the last fortnight were taken as independent variables. For all statistical tests,
P-value<0.05 was considered as the level of significance.
Results
Socio-demographic and socio-cultural profile
In the present study, 8.9% of the under-five children were under 6 months of age. Among the studied children, 51.1% were male and the remaining 48.9% were female. Nearly one-fifth of the children belonged to the socially-vulnerable castes (scheduled caste: 20.8% and scheduled tribe: 19.2%). Around half (50.5%) of the mothers had secondary level education while nearly one-third of them (32.7%) were illiterate. The majority of the mothers were homemakers (42.3%), followed by unskilled manual labour (36.8%). Only 7.3% of the mothers were engaged either in service or business. The majority of under-five children belonged to joint family (61.1%). According to socio-economic status, more than one-fourth (28.7%) of the studied children belonged to below poverty line (BPL) family, while the remaining 71.3% were above poverty line (APL, Table 1).
Nutritional status
In the study area, the nutritional status of under-five children by means of various anthropometric indicators was shown in Figure 1. In the present study, the prevalence of wasting, stunting, and underweight among under-five children was estimated as 13.8%, 44.8% and 33.7%, respectively. Also, 39.4% of the children had low MUAC-for-age. 1.7%, 18%, 10.2% and 5.3% of the under-five children were considered severely (<-3SD) wasted, stunted, underweight and with very low MUAC-for-age (<-3 SD), respectively (Figure 1).
MUAC can be used as an age independent indicator of nutritional status among 12-59 months children. Among the 1330 children aged 12-59 months, 58.5% (778/1330) had normal MUAC (>13.5 cm); 29.8% (396/1330) had low MUAC (≤ 13.5 cm), and 11.7% (156/1330) had severely low MUAC (<12.5 cm, Table 2).
| Table 1. Socio-demographic and socio-economic profile of the study participants (n-1680). | ||
| Variables | Number | % |
| Age groups (month) 0-6 |
149 |
8.9 |
| 7-11 | 201 | 11.9 |
| 12-35 | 679 | 40.4 |
| 36-59 | 651 | 38.8 |
| Gender Boys |
859 |
51.1 |
| Girls | 821 | 48.9 |
| Caste General |
1009 |
60.0 |
| Scheduled caste | 349 | 20.8 |
| Scheduled tribe | 322 | 19.2 |
| Mothers’ education >10th class |
283 |
16.8 |
| 1-10th class | 848 | 50.5 |
| Illiterate | 549 | 32.7 |
| Mothers’ occupation Home maker |
711 |
42.3 |
| Service or business | 122 | 7.3 |
| Unskilled manual labor | 618 | 36.8 |
| Skilled work | 229 | 13.6 |
| Type of family Nuclear |
653 |
38.9 |
| Joint | 1027 | 61.1 |
| Socio-economic status (based on ration card) Above poverty line |
1198 |
71.3 |
| Below poverty line | 482 | 28.7 |
| Table 2. Determinants of undernutrition by logistic regression analysis (n=1680). | ||||
| Variables | Number |
Underweight | Stunting | Wasting |
| OR (95% CI) | OR (95% CI) | OR (95% CI) | ||
| Age groups(years) 0-1 |
350 |
1 |
1 |
1 |
| 1-3 | 679 | 2.1 (1.6-3.4)a | 3.7 (1.8-5.2)a | 1.4 (1.1-2.7)a |
| 3-5 | 651 | 1.9(1.4-3.2)a | 2.7(1.4-4.8)a | 1.1(0.7-1.9) |
| Gender Boys |
821 |
1 |
1 |
1 |
| Girls | 859 | 1.6(1.1-2.8)a | 2.6(1.6-4.1)a | 1.4(1.1-2.6)a |
| Caste General |
1009 |
1 |
1 |
1 |
| Scheduled caste | 349 | 0.9(0.6-1.3) | 1.1(0.7-1.9) | 1.1(0.8-1.9) |
| Scheduled tribe | 322 | 1.2(0.8-2.3) | 1.6 (1.2-2.7)a | 1.2(0.7-2.3) |
| Mothers’ education >10th class |
283 |
1 |
1 |
1 |
| 1-10th class | 848 | 1.2(0.8-2.7) | 1.3(0.7-2.6) | 1.3(0.8-3.5) |
| Illiterate | 549 | 2.7(1.7-3.8)a | 2.1(1.2-3.2)a | 1.6 (1.1-2.6)a |
| Mothers’ occupation Home maker |
711 |
1 |
1 |
1 |
| Service/ business | 122 | 0.9(0.6-1.9) | 0.8(0.5-1.4) | 0.8(0.6-1.6) |
| Unskilled labor | 618 | 1.6(1.1-3.2)a | 1.4(1.1-2.8)a | 1.3(0.8-2.7) |
| Skilled work | 229 | 1.1(0.7-2.1) | 0.9(0.6-1.9) | 0.9(0.5-1.7) |
| Type of family Nuclear |
653 |
1 |
1 |
1 |
| Joint | 1027 | 1.2 (0.7-1.9) | 1.1(0.7-1.8) | 0.9(0.6-1.7) |
| Socio-economic status Above poverty line |
1198 |
1 |
1 |
1 |
| Below poverty line | 482 | 1.7(1.4-3.2)a | 3.1(2.4-6.2)a | 2.8(1.9-4.1)a |
| Immunization status Age appropriate |
1458 |
1 |
1 |
1 |
| Not appropriate | 222 | 1.1(0.7-1.9) | 0.9(0.6-1.8) | 1.2(0.8-2.6) |
| Vitamin A in the last 6 monthsb Received |
1094 |
1 |
1 |
1 |
| Not received | 461 | 0.8(0.6-1.6) | 0.9(0.6-2.1) | 0.8(0.5-1.7) |
| Anemiac No |
609 |
1 |
1 |
1 |
| Yes | 874 | 1.9(1.3-4.3)a | 3.6(1.8-5.2)a | 1.8(1.1-3.9)a |
| History of any morbidityd Present |
718 |
1 |
1 |
1 |
| Absent | 962 | 1.7(1.1-2.8)a | 1.2(0.9-2.6) | 1.6(1.1-2.3)a |
| a: P< 0.05; b: 9-59 months children eligible for vitamin A supplementation; c: Anemia assessed among 6-59 months children only; d Any morbidity during preceding fortnight. | ||||
Determinants of nutritional status
The determinants of nutritional status of under-five children were shown in Table 2. The odds of being underweight, stunting, and wasting were the highest in the age group of 1-3-year-old children followed by 3-5 ones compared with 0-1-year olds. It was 2.1, 3.7, and 1.2 times higher respectively among children aged 1-3 , and1.9, 2.7 and 1.1 times higher respectively among the children aged 3-5. Except for wasting regarding the children aged 3-5, all the indicators of undernutrition were found significantly higher (P<0.05) among children of 1-3 and 3-5 compared with those under 1 year of age. The prevalence of underweight, stunting, and wasting was found significantly higher (P<0.05) among male children compared with female ones. Children belonging to the scheduled caste and tribe were similarly at risk of underweight, stunting, and wasting as that of the children from higher castes such as general and other backward class (OBC) except stunting among the scheduled tribe children which was found significantly higher [OR=1.6 (95% CI= 1.2-2.7); P<0.05] compared with general and OBC children. Children whose mothers were illiterate had significantly higher odds (P<0.05) of being underweight [OR=2.7(95% CI=1.7-3.8)], being stunted [OR=2.1(95% CI=1.2-3.2)] and wasted [OR=1.6(95% CI=1.1-2.6)] compared with children whose parents had more than 10th class education. Similarly, significantly higher relative odds (P<0.05) of underweight [OR=1.7(95% CI=1.4-3.2)], stunting [OR=3.1(95% CI=2.4-6.2)] and wasting [OR= 2.8(95% CI=1.9-4.1)] were observed among children belonging to BPL families compared with that of APL families. No significant association was found between nutritional status of children and the type of family.
Moreover, no significant relationship (P>0.05) was found between nutritional status of under-five children as evidenced by different indictors (underweight, stunting and wasting) and their immunization status as well as the status of vitamin-A supplementations in last 6 months. Children having anemia had significantly higher odds (P<0.05) of being underweight [OR=1.9 (95% CI=1.3-4.3)], stunted [OR=3.6 (95% CI=1.8-5.2)] and wasted [OR=1.8 (95% CI=1.1-3.9)] compared with children who did not have anemia. Similarly, children who suffered any morbidity in 2 weeks preceding the survey were significantly (P<0.05) more underweight [OR=1.7 (95% CI=1.1-2.8)] and wasted [OR=1.6 (95% CI=1.1-2.3)] than children who did not suffer from any morbidity.
Discussion
In the present study, the prevalence of underweight, stunting, and wasting among under-five-children was found to be 33.7%, 34.8% and 21.6%, respectively. In addition, 39.4% of the under-five children had low MUAC-for-age and 41.5% 12-59 months children had low MUAC (≤13.5 cm) in the study area. Similar findings (underweight-31.5%, stunting-32.5% and wasting-20.3%) were reported by the national level survey from West Bengal. At national level, the reported prevalence was found slightly at higher level (underweight-35.7%, stunting-8.4% and wasting-21%) (International Institute for Population Sciences (IIPS), 2017). The findings of the few other Indian studies were not much in line with the findings of the present study (Mandal et al., 2014, Reddy et al., 2016, Senthilkumar et al., 2018). A study from slums area of Kanpur, India reported a 31.3% rate of underweight and a 14.6% rate of wasting among under-five children (Gautam et al., 2018). A multi-center study from 9 states of India among tribal <5 children reported a much higher prevalence of underweight (49%) and stunting (51%) but a similar proportion (22%) of wasting (Meshram et al., 2012). Higher prevalence (underweight-46.6% and stunting-69.8%) was also reported by a study from rural West-Bengal (Ray et al., 2001). Another Indian study reported that the prevalence of underweight, stunting, and wasting among pre-school children was 61.6%, 51.2%, and 32.9% respectively (Rao et al., 2005). A study from West Bengal reported a 41.6% rate of underweight and 80.3% rate of any anthropometric failure among under-five children dwelling in slums (Shit et al., 2012). Few other Indian studies also reported much higher prevalence of undernutrition among under-five children (Manjunath et al., 2014, Purohit et al., 2017). Some studies reported a lower prevalence of undernutrition among under-five children as compared to the findings of this study (Hadju et al., 2017, Radhamani and Rajeev, 2017) .
Very few Indian studies considered MUAC for assessing nutritional status of under-five years children. In the present study, the authors discovered that 29.8% of the children aged 12-59 months had low (≤13.5 cm) MUAC, and another 11.7% had a severely low (<12.5 cm) MUAC. A study from rural West Bengal also reported 18.9% of the children aged 12-49 months had a low MUAC (Ray et al., 2001). Another study from Varanasi suggested that 23.9% children aged 12-59 months had a low MUAC (Mridula et al., 2004). The study by Mandal et al. reported a 20.3% prevalence rate of moderately low MUAC (12.5-13.5 cm) among 1-5-year-old children (Mandal et al., 2014).
The varied prevalence of undernutrition among under-five children as reflected by different nutritional indicators in several studies across India were due to different socio-cultural practices in different study settings, difference in the criteria used for undernutrition and different timing of carrying out the studies, as Onis et al. reported that malnutrition was decreasing in Asia (De Onis et al., 2004 ).
In the present study, undernutrition was significantly more prevalent among the children aged 1-3 year, male children, children whose mothers were illiterate, children from BPL families, those with anemia and any morbidity in the last fortnight preceding the survey. The study also revealed that under-five years children whose mothers were unskilled manual labor were significantly more underweight and stunted. No significant association was found between undernutrition and caste except stunting which was found more prevalent among the scheduled tribes. In the present study, the type of family was not found to be an important determinant of undernutrition. Several studies also reported the highest prevalence of undernutrition among children in the age group of 1-3 (Meshram et al., 2012, Purohit et al., 2017, Swami et al., 2000). In the present study, male children were found significantly more undernourished compared to the female ones. Several other studies reported similar finding (Deshmukh et al., 2013, Hadju et al., 2017, Meshram et al., 2012). Male children need more energy and nutrients for sufficient growth and development compared with females. Thus, availability and accessibility of foods along with the amount of feeding must be higher in case of boys compared with girls. This may be one of the explanations. Opposite findings reported by other studies may be due to gender inequality (Dey and Chaudhuri, 2008, Radhamani and Rajeev, 2017).
The present study revealed that undernutrition among under 5 years children was the most prevalent among illiterate mothers. Most of the studies found similar and significant reciprocal relationship between literacy status of mother and undernourished child (Deshmukh et al., 2013, Hadju et al., 2017, Meshram et al., 2012). A time trend analysis using national level data regarding child undernutrition in India concluded that mother’s educational status was the only variable which influenced child nutrition (Sen et al., 2011).
The present study found children whose mothers were unskilled manual labor were significantly more underweight and stunted. Several studies reported similar positive associations, i.e. undernutrition among under-five years children were found more common among working mothers (Deshmukh et al., 2013, International Institute for Population Sciences (IIPS), 2017, Srivastava et al., 2012). However, some studies also reported that a child’s undernutrition was significantly more prevalent among nonworking mothers (Gautam et al., 2018, Ray et al., 2001, Senthilkumar et al., 2018, Tigga et al., 2015). Children from low socio-economic status (BPL families) were significantly more undernourished in the present study. Several Indian studies also reported similar findings (Mandal et al., 2014, Senthilkumar et al., 2018, Swami et al., 2000).
In the present study, immunization status and vitamin-A supplementation in the last 6 months were not considered important determinants of undernutrition among under-five children. But a study from Bankura,West Bengal demonstrated that unimmunized children were more likely to be undernourished (Shit et al., 2012). Another study in central part of India reported that vitamin-A supplementation in the last 6 months was an important determinant of stunting among under-three children. But, the study also reported that stunting did not differ significantly regarding immunization status which was similar to the findings of this study (Deshmukh et al., 2013). Anemia and any childhood morbidity in the preceding fortnight were found to be significant determinants of undernutrition in this study. Similar associations were reported by other studies. A large scale study involving 9 states of India among tribal under-five children reported that morbidities during preceding fortnight had a 1.3 times higher risk of underweight and wasting (Meshram et al., 2012). The study by Mandal et al. also reported children with any illness in the past 2 weeks were 6.8 times more undernourished (Mandal et al., 2014). A study reported anemic children had 1.9 times higher odds of being stunted than children who were not anemic (Deshmukh et al., 2013).
Community based study setting and large sample size were the main strengths of the present study. Majority of the studies not considered common childhood morbidities and anemia as determinants of under nutrition among under-five children which were considered in the present study. As limitations of study; immunization status assessed based on immunization card, those lost their cards were misclassified. The study also was not taken dietary survey of under-five children.
Conclusions
The present study revealed a widespread prevalence of undernutrition among under-five children in the study area. Illiteracy of the mother and lower socio-economic status were important socio-economic determinants of undernutrition which need long term measures with an inter-sectoral coordinated approach aiming to improve the socio-economic status. Moreover, childhood morbidity and anemia were found to be important determinants of undernutrition among under-five children which highlights a need for an integrated approach towards improving child health and nutrition.
Acknowledgements
The authors would like to thank district health authority and all the mothers of under-five children for their continuous support.
Authors’ contribution
Patra M, Gayen BK, Yasmin S, Sinha N, and Baur B designed the research. Patra M, Yasmin S, and Gayen BK conducted it. Sinha N and Yasmin S analyze the data. Patra M, Gayen BK, Sinha N,Yasmin S, and Baur B wrote the manuscript. Sinha N, Patra M, and Gayen BK had primarily responsible for final content, and all the authors read and approved the final version of the manuscript.
Funding
Logistic and technical support was provided by Midnapore Medical College, West Bengal. This study received no financial support from anywhere for research as well as publication purpose.
Conflict of interest
The authors declared no conflict of interests
References
De Onis M, Blössner M, Borghi E, Frongillo E & Morris R 2004 Estimates of Global Prevalence of Childhood Underweight in 1990 and 2015. JAMA.
Deshmukh PR, Sinha N & Dongre AR 2013. Social determinants of stunting in rural area of Wardha, Central India. Medical journal armed forces India. 69 (3): 213-217.
Dey I & Chaudhuri RN 2008. Gender inequality in nutritional status among under five children in a village in Hooghly district, West Bengal. Indian journal of public health. 52 (4): 218-220.
Gautam S, M V, Barman S & Arya A 2018. Nutrtional status and its corelates in under five slum children of Kanpur Nagar, india. International jounal of contemporary pediatrics. 5 (2): 584-590.
Hadju V, Yunus R, AI A, Salmah A & Wahyu A 2017. Nutritional Status of Infants 0-23 Months of Age and its Relationship with Socioeconomic Factors in Pangkep. Asian journal of clinical nutrition. 9 (2): 71-76.
International Institute for Population Sciences (IIPS) 2017. National Family Health Survey (NFHS-4), 2015 -16. Ministry of Health and Family Welfare (MoHFW): India, Mumbai.
Jood S, Bishnoi S & Sehgal S 2000. Nutritional status of rural pre-school children of Haryana state. Indian journal of pediatrics. 67 (3): 189-196.
Mandal S, Prabhakar RAM, Pal J, Parthasarathi R & Biswas R 2014. An assessment of nutritional status of children aged 0-14 years in a slum area of Kolkata. International journal of medicine and public health. 4 (2): 149.
Manjunath R, Kulkarni P, Begum K & Gangadhar M 2014. Malnutrition among under-five children of kadukuruba tribe: need to reach the unreached. Journal of clinical and diagnostic research. 8 (7): Jc01-04.
Meshram, II, et al. 2012. Trends in the prevalence of undernutrition, nutrient and food intake and predictors of undernutrition among under five year tribal children in India. Asia Pacific journal of clinical nutrition. 21 (4): 568-576.
Mridula D, Mishra C & Srivastava P 2004. Nutritional status of 'At Risk' under-fives of urban slum of Varanasi. Indian journal of preventive and social medicine. 35 (1): 16-30.
Purohit L, Sahu P & Lata B 2017. Nutritional status of under- five children in a city of Maharashtra: a community based study. International journal of community medicine and public health. 4 (4): 1171-1178.
Radhamani K & Rajeev S 2017. A study on nutritional status of Anganwadi children in a rural area of North Kerala. Indian Journal of child health. Indian journal of child health. 4 (3): 348-351.
Rao VG, et al. 2005. Undernutrition & childhood morbidities among tribal preschool children. Indian journal of medical research. 122 (1): 43-47.
Ray SK, Haldar A, Biswas B, Misra R & Kumar S 2001. Epidemiology of undernutrition. Indian journal of pediatrics. 68 (11): 1025-1030.
Reddy VB, Kusuma YS, Pandav CS, Goswami AK & Krishnan A 2016. Prevalence of malnutrition, diarrhea, and acute respiratory infections among under-five children of Sugali tribe of Chittoor district, Andhra Pradesh, India. Journal of natural science, biology and medicine. 7 (2): 155-160.
Registrar General and Census Commissioner India 2011. Census of India 2011. censusindia.
S. K. Lwanga and S Lemeshow 1991. Sample size determination in health studies: A practical manual. World Health Organiztion: Geneva.
Sen P, Bharati S, Som S, Pal M & Bharati P 2011. Growth and nutritional status of preschool children in India: a study of two recent time periods. Food and nutrition bulletin. 32 (2): 84-93.
Senthilkumar S, Chacko T & Kannappan S 2018. Nutritional status assessment of children aged 0-5 years and its determinants in a tribal community of Coimbatore district. International journal of community medicine and public health. 5 (7): 2835.
Shit S, Taraphdar P, Mukhopadhyay DK, Sinhababu A & Biswas AB 2012. Assessment of nutritional status by composite index for anthropometric failure: a study among slum children in Bankura, West Bengal. Indian journal of public health. 56 (4): 305-307.
Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP & Kumar B 2012. Nutritional status of school-age children - A scenario of urban slums in India. Archives of public health. 70 (1): 8.
Swami HM, et al. 2000. National immunization day to assess nutritional status of underfives in Chandigarh. Indian journal of pediatrics. 67 (1): 15-17.
Tigga PL, Sen J & Mondal N 2015. Association of some socio-economic and socio-demographic variables with wasting among pre-school children of North Bengal, India. Ethiopian journal of health sciences. 25 (1): 63-72.
World Health Organization 2011. Child growth standards: WHO Anthro Survey Analyser and other tools. World Health Organization.
World Health Organization 1995. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. In World Health Organ Tech Rep Ser, pp. 424-438: Geneva.
World Health Organization 2006. WHO child growth standards : length/height-for-age, weight-for-age, weight-for-length, weight -for-height and body mass index-for-age : methods and development. World Health Organization: Geneva.
World Health Organization, United Nations Children's Fund & World Bank 2021. Levels and trends in child malnutrition: UNICEF / WHO / The World Bank Group joint child malnutrition estimates: key findings of the 2021 edition. World Health Organization: Geneva.
The determinants of nutritional status of under-five children were shown in Table 2. The odds of being underweight, stunting, and wasting were the highest in the age group of 1-3-year-old children followed by 3-5 ones compared with 0-1-year olds. It was 2.1, 3.7, and 1.2 times higher respectively among children aged 1-3 , and1.9, 2.7 and 1.1 times higher respectively among the children aged 3-5. Except for wasting regarding the children aged 3-5, all the indicators of undernutrition were found significantly higher (P<0.05) among children of 1-3 and 3-5 compared with those under 1 year of age. The prevalence of underweight, stunting, and wasting was found significantly higher (P<0.05) among male children compared with female ones. Children belonging to the scheduled caste and tribe were similarly at risk of underweight, stunting, and wasting as that of the children from higher castes such as general and other backward class (OBC) except stunting among the scheduled tribe children which was found significantly higher [OR=1.6 (95% CI= 1.2-2.7); P<0.05] compared with general and OBC children. Children whose mothers were illiterate had significantly higher odds (P<0.05) of being underweight [OR=2.7(95% CI=1.7-3.8)], being stunted [OR=2.1(95% CI=1.2-3.2)] and wasted [OR=1.6(95% CI=1.1-2.6)] compared with children whose parents had more than 10th class education. Similarly, significantly higher relative odds (P<0.05) of underweight [OR=1.7(95% CI=1.4-3.2)], stunting [OR=3.1(95% CI=2.4-6.2)] and wasting [OR= 2.8(95% CI=1.9-4.1)] were observed among children belonging to BPL families compared with that of APL families. No significant association was found between nutritional status of children and the type of family.
Moreover, no significant relationship (P>0.05) was found between nutritional status of under-five children as evidenced by different indictors (underweight, stunting and wasting) and their immunization status as well as the status of vitamin-A supplementations in last 6 months. Children having anemia had significantly higher odds (P<0.05) of being underweight [OR=1.9 (95% CI=1.3-4.3)], stunted [OR=3.6 (95% CI=1.8-5.2)] and wasted [OR=1.8 (95% CI=1.1-3.9)] compared with children who did not have anemia. Similarly, children who suffered any morbidity in 2 weeks preceding the survey were significantly (P<0.05) more underweight [OR=1.7 (95% CI=1.1-2.8)] and wasted [OR=1.6 (95% CI=1.1-2.3)] than children who did not suffer from any morbidity.
Discussion
In the present study, the prevalence of underweight, stunting, and wasting among under-five-children was found to be 33.7%, 34.8% and 21.6%, respectively. In addition, 39.4% of the under-five children had low MUAC-for-age and 41.5% 12-59 months children had low MUAC (≤13.5 cm) in the study area. Similar findings (underweight-31.5%, stunting-32.5% and wasting-20.3%) were reported by the national level survey from West Bengal. At national level, the reported prevalence was found slightly at higher level (underweight-35.7%, stunting-8.4% and wasting-21%) (International Institute for Population Sciences (IIPS), 2017). The findings of the few other Indian studies were not much in line with the findings of the present study (Mandal et al., 2014, Reddy et al., 2016, Senthilkumar et al., 2018). A study from slums area of Kanpur, India reported a 31.3% rate of underweight and a 14.6% rate of wasting among under-five children (Gautam et al., 2018). A multi-center study from 9 states of India among tribal <5 children reported a much higher prevalence of underweight (49%) and stunting (51%) but a similar proportion (22%) of wasting (Meshram et al., 2012). Higher prevalence (underweight-46.6% and stunting-69.8%) was also reported by a study from rural West-Bengal (Ray et al., 2001). Another Indian study reported that the prevalence of underweight, stunting, and wasting among pre-school children was 61.6%, 51.2%, and 32.9% respectively (Rao et al., 2005). A study from West Bengal reported a 41.6% rate of underweight and 80.3% rate of any anthropometric failure among under-five children dwelling in slums (Shit et al., 2012). Few other Indian studies also reported much higher prevalence of undernutrition among under-five children (Manjunath et al., 2014, Purohit et al., 2017). Some studies reported a lower prevalence of undernutrition among under-five children as compared to the findings of this study (Hadju et al., 2017, Radhamani and Rajeev, 2017) .
Very few Indian studies considered MUAC for assessing nutritional status of under-five years children. In the present study, the authors discovered that 29.8% of the children aged 12-59 months had low (≤13.5 cm) MUAC, and another 11.7% had a severely low (<12.5 cm) MUAC. A study from rural West Bengal also reported 18.9% of the children aged 12-49 months had a low MUAC (Ray et al., 2001). Another study from Varanasi suggested that 23.9% children aged 12-59 months had a low MUAC (Mridula et al., 2004). The study by Mandal et al. reported a 20.3% prevalence rate of moderately low MUAC (12.5-13.5 cm) among 1-5-year-old children (Mandal et al., 2014).
The varied prevalence of undernutrition among under-five children as reflected by different nutritional indicators in several studies across India were due to different socio-cultural practices in different study settings, difference in the criteria used for undernutrition and different timing of carrying out the studies, as Onis et al. reported that malnutrition was decreasing in Asia (De Onis et al., 2004 ).
In the present study, undernutrition was significantly more prevalent among the children aged 1-3 year, male children, children whose mothers were illiterate, children from BPL families, those with anemia and any morbidity in the last fortnight preceding the survey. The study also revealed that under-five years children whose mothers were unskilled manual labor were significantly more underweight and stunted. No significant association was found between undernutrition and caste except stunting which was found more prevalent among the scheduled tribes. In the present study, the type of family was not found to be an important determinant of undernutrition. Several studies also reported the highest prevalence of undernutrition among children in the age group of 1-3 (Meshram et al., 2012, Purohit et al., 2017, Swami et al., 2000). In the present study, male children were found significantly more undernourished compared to the female ones. Several other studies reported similar finding (Deshmukh et al., 2013, Hadju et al., 2017, Meshram et al., 2012). Male children need more energy and nutrients for sufficient growth and development compared with females. Thus, availability and accessibility of foods along with the amount of feeding must be higher in case of boys compared with girls. This may be one of the explanations. Opposite findings reported by other studies may be due to gender inequality (Dey and Chaudhuri, 2008, Radhamani and Rajeev, 2017).
The present study revealed that undernutrition among under 5 years children was the most prevalent among illiterate mothers. Most of the studies found similar and significant reciprocal relationship between literacy status of mother and undernourished child (Deshmukh et al., 2013, Hadju et al., 2017, Meshram et al., 2012). A time trend analysis using national level data regarding child undernutrition in India concluded that mother’s educational status was the only variable which influenced child nutrition (Sen et al., 2011).
The present study found children whose mothers were unskilled manual labor were significantly more underweight and stunted. Several studies reported similar positive associations, i.e. undernutrition among under-five years children were found more common among working mothers (Deshmukh et al., 2013, International Institute for Population Sciences (IIPS), 2017, Srivastava et al., 2012). However, some studies also reported that a child’s undernutrition was significantly more prevalent among nonworking mothers (Gautam et al., 2018, Ray et al., 2001, Senthilkumar et al., 2018, Tigga et al., 2015). Children from low socio-economic status (BPL families) were significantly more undernourished in the present study. Several Indian studies also reported similar findings (Mandal et al., 2014, Senthilkumar et al., 2018, Swami et al., 2000).
In the present study, immunization status and vitamin-A supplementation in the last 6 months were not considered important determinants of undernutrition among under-five children. But a study from Bankura,West Bengal demonstrated that unimmunized children were more likely to be undernourished (Shit et al., 2012). Another study in central part of India reported that vitamin-A supplementation in the last 6 months was an important determinant of stunting among under-three children. But, the study also reported that stunting did not differ significantly regarding immunization status which was similar to the findings of this study (Deshmukh et al., 2013). Anemia and any childhood morbidity in the preceding fortnight were found to be significant determinants of undernutrition in this study. Similar associations were reported by other studies. A large scale study involving 9 states of India among tribal under-five children reported that morbidities during preceding fortnight had a 1.3 times higher risk of underweight and wasting (Meshram et al., 2012). The study by Mandal et al. also reported children with any illness in the past 2 weeks were 6.8 times more undernourished (Mandal et al., 2014). A study reported anemic children had 1.9 times higher odds of being stunted than children who were not anemic (Deshmukh et al., 2013).
Community based study setting and large sample size were the main strengths of the present study. Majority of the studies not considered common childhood morbidities and anemia as determinants of under nutrition among under-five children which were considered in the present study. As limitations of study; immunization status assessed based on immunization card, those lost their cards were misclassified. The study also was not taken dietary survey of under-five children.
Conclusions
The present study revealed a widespread prevalence of undernutrition among under-five children in the study area. Illiteracy of the mother and lower socio-economic status were important socio-economic determinants of undernutrition which need long term measures with an inter-sectoral coordinated approach aiming to improve the socio-economic status. Moreover, childhood morbidity and anemia were found to be important determinants of undernutrition among under-five children which highlights a need for an integrated approach towards improving child health and nutrition.
Acknowledgements
The authors would like to thank district health authority and all the mothers of under-five children for their continuous support.
Authors’ contribution
Patra M, Gayen BK, Yasmin S, Sinha N, and Baur B designed the research. Patra M, Yasmin S, and Gayen BK conducted it. Sinha N and Yasmin S analyze the data. Patra M, Gayen BK, Sinha N,Yasmin S, and Baur B wrote the manuscript. Sinha N, Patra M, and Gayen BK had primarily responsible for final content, and all the authors read and approved the final version of the manuscript.
Funding
Logistic and technical support was provided by Midnapore Medical College, West Bengal. This study received no financial support from anywhere for research as well as publication purpose.
Conflict of interest
The authors declared no conflict of interests
References
De Onis M, Blössner M, Borghi E, Frongillo E & Morris R 2004 Estimates of Global Prevalence of Childhood Underweight in 1990 and 2015. JAMA.
Deshmukh PR, Sinha N & Dongre AR 2013. Social determinants of stunting in rural area of Wardha, Central India. Medical journal armed forces India. 69 (3): 213-217.
Dey I & Chaudhuri RN 2008. Gender inequality in nutritional status among under five children in a village in Hooghly district, West Bengal. Indian journal of public health. 52 (4): 218-220.
Gautam S, M V, Barman S & Arya A 2018. Nutrtional status and its corelates in under five slum children of Kanpur Nagar, india. International jounal of contemporary pediatrics. 5 (2): 584-590.
Hadju V, Yunus R, AI A, Salmah A & Wahyu A 2017. Nutritional Status of Infants 0-23 Months of Age and its Relationship with Socioeconomic Factors in Pangkep. Asian journal of clinical nutrition. 9 (2): 71-76.
International Institute for Population Sciences (IIPS) 2017. National Family Health Survey (NFHS-4), 2015 -16. Ministry of Health and Family Welfare (MoHFW): India, Mumbai.
Jood S, Bishnoi S & Sehgal S 2000. Nutritional status of rural pre-school children of Haryana state. Indian journal of pediatrics. 67 (3): 189-196.
Mandal S, Prabhakar RAM, Pal J, Parthasarathi R & Biswas R 2014. An assessment of nutritional status of children aged 0-14 years in a slum area of Kolkata. International journal of medicine and public health. 4 (2): 149.
Manjunath R, Kulkarni P, Begum K & Gangadhar M 2014. Malnutrition among under-five children of kadukuruba tribe: need to reach the unreached. Journal of clinical and diagnostic research. 8 (7): Jc01-04.
Meshram, II, et al. 2012. Trends in the prevalence of undernutrition, nutrient and food intake and predictors of undernutrition among under five year tribal children in India. Asia Pacific journal of clinical nutrition. 21 (4): 568-576.
Mridula D, Mishra C & Srivastava P 2004. Nutritional status of 'At Risk' under-fives of urban slum of Varanasi. Indian journal of preventive and social medicine. 35 (1): 16-30.
Purohit L, Sahu P & Lata B 2017. Nutritional status of under- five children in a city of Maharashtra: a community based study. International journal of community medicine and public health. 4 (4): 1171-1178.
Radhamani K & Rajeev S 2017. A study on nutritional status of Anganwadi children in a rural area of North Kerala. Indian Journal of child health. Indian journal of child health. 4 (3): 348-351.
Rao VG, et al. 2005. Undernutrition & childhood morbidities among tribal preschool children. Indian journal of medical research. 122 (1): 43-47.
Ray SK, Haldar A, Biswas B, Misra R & Kumar S 2001. Epidemiology of undernutrition. Indian journal of pediatrics. 68 (11): 1025-1030.
Reddy VB, Kusuma YS, Pandav CS, Goswami AK & Krishnan A 2016. Prevalence of malnutrition, diarrhea, and acute respiratory infections among under-five children of Sugali tribe of Chittoor district, Andhra Pradesh, India. Journal of natural science, biology and medicine. 7 (2): 155-160.
Registrar General and Census Commissioner India 2011. Census of India 2011. censusindia.
S. K. Lwanga and S Lemeshow 1991. Sample size determination in health studies: A practical manual. World Health Organiztion: Geneva.
Sen P, Bharati S, Som S, Pal M & Bharati P 2011. Growth and nutritional status of preschool children in India: a study of two recent time periods. Food and nutrition bulletin. 32 (2): 84-93.
Senthilkumar S, Chacko T & Kannappan S 2018. Nutritional status assessment of children aged 0-5 years and its determinants in a tribal community of Coimbatore district. International journal of community medicine and public health. 5 (7): 2835.
Shit S, Taraphdar P, Mukhopadhyay DK, Sinhababu A & Biswas AB 2012. Assessment of nutritional status by composite index for anthropometric failure: a study among slum children in Bankura, West Bengal. Indian journal of public health. 56 (4): 305-307.
Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP & Kumar B 2012. Nutritional status of school-age children - A scenario of urban slums in India. Archives of public health. 70 (1): 8.
Swami HM, et al. 2000. National immunization day to assess nutritional status of underfives in Chandigarh. Indian journal of pediatrics. 67 (1): 15-17.
Tigga PL, Sen J & Mondal N 2015. Association of some socio-economic and socio-demographic variables with wasting among pre-school children of North Bengal, India. Ethiopian journal of health sciences. 25 (1): 63-72.
World Health Organization 2011. Child growth standards: WHO Anthro Survey Analyser and other tools. World Health Organization.
World Health Organization 1995. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. In World Health Organ Tech Rep Ser, pp. 424-438: Geneva.
World Health Organization 2006. WHO child growth standards : length/height-for-age, weight-for-age, weight-for-length, weight -for-height and body mass index-for-age : methods and development. World Health Organization: Geneva.
World Health Organization, United Nations Children's Fund & World Bank 2021. Levels and trends in child malnutrition: UNICEF / WHO / The World Bank Group joint child malnutrition estimates: key findings of the 2021 edition. World Health Organization: Geneva.
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Received: 2022/07/9 | Published: 2024/08/20 | ePublished: 2024/08/20
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