National Immunization Day to Assess Nutritional Status of Underfives in Chandigarh H.M. Swami, d.S.Thakur, S.P.S. Bhatia, Kamaljit Singh, V.K. Bhan and V. Bhatia
Department of Community Medicine, Government Medical College, Chandigarh N~Iract. National Immunization Days (NIDs) are an additional opportunity to reach a large number of children and can be used to undertake additional activities beside immunization. Thisstudy highlights an attempt to assess nutritional status of under five children by using a NID. Seven thousand four hundred and thirteen underfives were selected randomly from urban, rural and slums areas of Chandigarh. Nutritional status was assessed by using weight for age criteria. Prevalence of protein energy malnutrition (PEM) was found to be about 42% while 22.7%, 14.5%,4. I% and 0.7% children had gmcle I, II, III and IV PEM respectively. The prevalence of PEM was significantly higher among females (47.6%), in I-3 years age group (53.80%), in slum area (67%) and children of labour class (60.5%) (p < 0.001). With increase in family size, the prevalence of malnutrition also significantly increased, and decreased with high literacy rate in parents (p < 0.001). The prevalence of PEM in present study (42%) was comparable to a community based survey (51.6%) among pre-school children of an ICDS block of Chandigarh. National immunization days can be successfully used to assessnutritional status of children. This approach can be used by others for screening common childhood problems, preparing normogram for a region or country, administering Vitamin A and educating mothers. (indianJ Pediatr2000;66 : 15-I7) Key words:National immunization days; Protein energy malnutrition; Prevalence; Occupation.
With the global effort to eradicate polio, National Immunization Days (NIDs) have become an additional opportunity to reach children. In 1997 alone, more than 450 million children-almost two third of the world's children under five years of age were immunized during NIDs 1. In India, the fact that nearly 5 million persons were mobilized to manage 6,50,000 PPI booths (average 8 per booth) and many more to fetch the children to these booths is an indication of the social mobilization success 2. The programme reached about 98% of the target population on either of the days. The fact that only 93.2% in various states and 92.5% in urban poor population had both the doses in 1996-97 indicates that there was a scope to reach all accessed with both doses2. This large cross-section of underfive children with their mothers or relatives available, gave an opportunity not only to study various common childhood health problems but also to educate mothers. WHO also recommends vitamin A supplementation during NIDs as a part of an overall national plan to control vitamin A deficiency (VAD) wherever this problem existsL Using this background, the present study was conducted to use National Immunization Day to assess the nutritional Reprint requests : H,M. Swami, Prof. and Head, Department of Community Medicine, Govt. Medical College, Sarai Building, Sector 32-A,Chandigarh Indian Journal of Pediatrics, 2000; 67 (1) : 15-17
status of underfive children in Chandigarh.
MATERIALS AND METHODS The study was conducted on the National Immunisation Day (Jan 18t 1997) in Chandigarh. Using the simple random sampling method, out of 169 pulse polio immunization centres, ten urban, four rural and four slum polio centres were selected to give proportionate representation and 7413 children upto 5 years of age (4592 urban, 1421 rural and 1400 slum) attending the pulse polio immunization centres were included in the study. A trained team of 5-6 final year MBBS students, one Intern and one Resident or Consultant from the Department of Community Medicine was assigned the duty at each polio centre. Information was collected from mother or the person accompanying the child through a pretested and pre-designed questionnaire. Correct age of the child was determined from the vaccination card, local events calender or other eligible records. The weight of the child, barefooted with minimum clothings (the approximate weight of clothings was also deducted) was taken with MISAKI baby scale (BT-5012) recording maximum weight of 12.0 kg and weight fraction upto 50 g. Children above two years of age were weighed with dial type weighing machine (Adult type). Zero error was adjusted prior to weighing. Both type of the machines were
H.M. Swami et al checked frequendy against known weights. Nutritional status was assessed using weight for age criteria of Indian Academy of Paediatricss. Mothers of malnourished children were given health and nutritional education. Data was entered into a computer and analysis was done using chi-square test.
RESULTS In the present study 7413 (4592 urban, 1421 rural and 1400 slum) preschool children were studied. Of these 41.9% were found malnourished while 22.7%, 14.5%, 4.1% and 0.7% had grade I, II, III and IV malnutrition respectively. Distribution of children with PEM in relation to sex, age, area of residence, origin and occupation is shown in Table 1. The prevalence of PEM was significantly higher among females -1-3 years age group, children of slums and labour class (p < 0.001) It was also observed that with increase in educational
TABLEI. Distribution of Protein Energy Malnutrition in Relation to Sex, Age, Area, Origin and Occupation Variable
Total
PEM
% Age
X2/p Value
37.6 47.6
X2-10.4 P < 0X)01
IIIIIII I
TAsLE2. Protein Energy Malnutrition and Educational Qualification of Parents Education
Total
PEM
% Age
llliterate
2359
1386
58.7
Primary
539
301
55.8
Matric
2331
910
Above matric
2184
511
39.0 P < 0.001 23.4
Total
7413
3108
Mother's education
4193 3220
1575 1533
Age (yrs) 0- I I-3 3-5
1379 2681 3353
357 1442 1309
25.9 53.8 39.0
X2-44.6 P < 0.001
Area Urban Rural Slum
4592 1421 1400
1533 637 938
20.7 44.8 67.0
)(2-10.3 P < 0.001
4102
1393
36.4
X2-270,18
546 2765
224 1491
41.0 53.9
P < 0.001
2072 3143 574
1253 1239 203
60.5 39.4 35.9
770 826
196 196
25.4 23.7
Occupation Labourer Skilled Petty shopkeeper/ cultivator Businessman P1rofessional 16
41.9
Illiterate
1162
75<5 65.1
Primary
546
Matric
2842
308
56.4
Above matric
2863
763
26.6
Total
7413
3108
41.9
X2-84.05
1281 45.1 P < 0.001
TABLE3. Protein Energy Malnuffition in Relation to Birth Order and Family Size Variable
Total
PEM
% Age
X21P Value
Birth order I
3094
1218
39.4
2
2464
987
40.0
X2-7.15
3 >4
1246 609
588 315
47.2 51.7
P > 0.05
Tc~al
7413
3108
41.9
1
1974
700
35.5
2 3 Total
3017 2422 7413
1246 1162 3108
41.3 47.9 41.9
Family size
Origin Punjab, Haryana and Chandigarh Himachal Pradesh Others (Bihar U.P. etc.)
Xa-90.4
Father's educe#on
Sex Male Female
X21p Value
X2-72.8 P < 0.001
X~-70.79 P < 0.0001
status of parents, the prevalence of malnutrition steadily and significandy decreased (p < 0.001) as shown in Table 2. The relation of PEM to birth order and family size is shown in Table 3. Prevalence of PEM increased significantly with increase in family size (p < 0.001) and also with increase in birth order although it was not significant (p > 0.05)
DISCUSSION The present study approach of using children attending PPI campaign to assess their nutritional status was not only found to be feasible but also served as a rapid method for data Indian Journal of Pediatrics, 2000; 67 (1)
National Immunization Day and Nutritional Status collection and an opportunity to educate the mothers. This study can be generalized to a representative community based study because the programme coverage on National Immunization Day was 95.7% for Chandigarh as per national evaluation2 and also because of a proper sample selection process as urban, rural and slum areas were fairly represented giving proportional representation. Moreover, the prevalence of PEM (42%) in this study was comparable to 51.6% observed in a community based survey among unprivileged preschool children of an ICDS block of Chandigarh (Swami et al unpublished data) which confirms the efficiency of the approach. As per W H O , vitamin A delivery and NIDs can be combined because the target population of underfives was the same; nation-wide campaign discovered the "unreached" and those most at risk; limited financial and human resources were used efficiently, and cost effectiveness and impact were increased 1. Same could be true for malnutrition since the distribution of the prevalence of protein energy malnutrition and xerophthalmia in preschool children is similar and almost all cases of keratomalacia had severe PEM 4. The prevalence of PEM is very high in our country among preschool children as reported by various studies5t~ which also justifies its inclusion as supplementary activity to NIDs. Assessment of nutritional status could be easily added to NIDs with minimum of training and equipment. Since no special logistics or formally trained health workers were needed, the cost was also low. It, however, does increase the work load at an immunization post so arrangements must be made to have an extra worker per team to ensure ~mooth flow and avoid delays. Screening of children should be limited to minimum information after the child receives polio drops. A
REFERENCES 1. WHO. Using National Immunization Days to deliver Vitamin A. EPI Update 1998; 33 : 1-4. 2. Evaluation of Pulse Polio. Immunization, National Immunization days, India 1996-97, Ministry of Health and Family Welfare, Govt. of India, 1997. 3. Nutritional sub-Committee of lAP. Report of Convenor, Indian Pediatr 1972; 9 : 360. 4. Vijayaraghavan K. Vitamin A deficiency Consequences and control programmes. In : Sachdev, HPS, Chaudhury Panna (eds). Nutrition in ChildrenDeveloping Country Concern. 1st edn. Delhi Cambridge Press, 1994; 536-44. 5. Kapil U a n d Bali P. Nutritional status of preschool children of urban slum communities in Delhi. Indian Pediatr 1989; 26 : 338-40.
Indian Journal of Pediatrics, 2000; 67 (1)
simple tally sheet should be used to record the information. The supplementary activity to NIDs should not overshadow the primary activity of administering polio drops. Approximately 4.5% children who did not utilize NIDs might not be important statistically since 95.7% children made up the representative sample. Main reasons given for non-immunization on NIDs were (a) not aware of the need for immunization twice (20.3%) (b) not aware of the days (15.2%), and (c) no faith (11.9%) 2 which might not be representing a special category of children but may be due to lack of awareness. Besides assessment of nutritional status, this approach could be used to screen for common childhood health problems for delivering vitamin A I, and educating mothers on health and nutrition. Normogram for a region and even for a country as a whole can be prepared by undertaking a multicentric study on NIDs. Good planning is essential for the successful integration of additional activities in NIDs. The key steps to remember include explaining the importance of additional activity to decision makers, convincing them and getting their agreement, engaging partners if funds needed, informing and educating the public and all levels of staff about its importance, arranging logistics, training health workers and volunteers and finally evaluating success.
CONCLUSION The present strategy to use national immunization day to assess the nutritional status of under five children was found to be feasible, cost effective and a rapid method for data collection. This approach can be used for screening of common childhood problems, preparing normograms for a region or country, administering vitamin A and educating mothers.
6.
Matto GM and Shah GN. Epidemiological correlates of protein energy malnutrition. Indian J Prev Sec Med 1995; 26 (3, 4) : 100-105. 7. Luwang NC. Protein energy malnutrition in pre-school children in a rural community in Manipur. Indian Pediatr 1980; 17 (10) :879-82. 8. Srivastava BK, Srivastava BC, Deoki Nandan and Vidya I~hushan. Protein energy malnutriton among preschool children in rural population of Lucknow. Indian Pediatr 1979; 16 (6) : 507-13. 9. Dwivedi SN, Bannerji N a n d Y a d a v UP. Malnutrition among children in an urban Indian town. Indian J. Mater Child Health 1992; 3 (3) : 79-81. 10. Maya Chowdhary and Rao KV. Nutritional status of preschool children a n d the associated factors. Indian J Nut Diet 1983; 10 9 18-20,
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