dissertation submision 03-01-2012

8/3/2019 Dissertation Submision 03-01-2012

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UNIVERSITY OF BEDFORDSHIRE

FACULTY OF PUBLIC HEALTH

MSc. PUBLIC HEALTH

A Dissertation submitted to Bedfordshire University in partial fulfilment for the

Award of MSc Public Health

Title of Work

CHILDHOOD MALNUTRITION IN INDIA- ASYSTEMATIC REVIEW

Unit Lead: SUSAN SAPSED

Unit Code: PUB010 -6

Submitted by: RENJITH S BHADRAN

Student ID: 1031388


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Abstract

Childhood is a prominent chapter of everyones life and deprivation during this period can lead

to long-term adverse effects on the wellbeing of a child. Reduction in infant and child mortality

rates should be considered as one of the most important goals for a nations prosperity and

success as children represent the building blocks of a nation. The aim of this paper is to examine

the existing picture of childhood malnutrition and prevalence of underweight children in India.

For this purpose data has been collected from seven primary researches which include three

rounds of the National Family Health Survey of India (NFHS). The analysis reveals that there

has not been any improvement in the state of underweight since 1990 in India and trend still

continuous. The effects of under-nutrition are complicated adverse, however, is not

unrecoverable. Treatment of childhood illnesses needs to be improved, as underweight remains

to be a major health problem for many children. Although knowledge about under-nutrition

issues and for the treatment of its consequences, especially weight loss, is well documented,

millions of children are still suffering with chronic illness from deficiency of nutrition. The

results have interesting social and policy implications and indicate several promising lines of

research.

Background: Studies investigating the magnitude of childhood malnutrition and underweight

children of India. Seven major surveys has been carried out from 1990 to 2011 reveals the health

status of every Indian child which is published after the completion of each surveys. Many

researchers began to study on various interested area of malnutrition throughout the country.Although, there are number of studies about the prevalence of underweight and the magnitude of

childhood malnutrition so far, no systematic review has been done on this particular area at

researchers knowledge.

Objective: To systematically review acquainted major studies that have examined malnutrition

effects on Indian children in order to identify underweight prevalence of children aged between 0

and 15.

Search Strategy: The search for appropriate studies included scientific databases like PubMed,

CHINHAL Plus, PsycINFO, as well as those included in the reference and bibliography lists of

all possible identified studies.

Selection criteria: 274 studies published in English between 1990 to till date that examined

childhood malnutrition effects and prevalence of underweight in Indian children.

Data collection and analysis: Data on outcome measures such as underweight prevalence in

Indian children with in age group of between 0 and 15 will be taken for detail analysis.


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Results: Results show a significant number of underweight children in India. It identifies higher

prevalence of underweight condition among female children than the opposite sex. Included

studies showed almost similar higher prevalence of underweight although, it represents various

rage of participants. The most significant effect of under-nutrition contributed India to a higher

ranking country in underweight prevalence.

Authors conclusion: The results of the review identified the significant higher prevalence of

underweight among children in India. The findings from this study give a clear picture of

underweight and nutrition status of Indian children together with a meta-analysis conclusion. The

most important factor was that the prevalence rate is still higher after various stages of primary

researches.


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Authors Declaration

The study was completely undertaken and written by Renjith Seela Bhadran.

The author used his own words or images, and ideas.

After conducting the study, author has formed the results from his work.

This study was not copied from the scripts of other authors or candidates, and no unauthorised

materials were used. No false information has been included.

Name: RENJITH SEELA BHADRAN

Date: 04- 01-2012


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Acknowledgements

Foremost, my sincere gratitude to Almighty God for to give me such a wonderful experience. I

thank god also to making me it possible to achieve all success throughout the course. I thank

you Dr.Chris Papadopoulos, his support and strong vision to lead his students in to higher

success. I respect and proud of Susan Sapsed, a wonderful person and a great course leader.

I respect the great efforts of Dr.R.V Nair and Dr.Bhagyalekshmi (Father in Law & Mother in

Law) for their good support and guidance. I respect my mother and father for their blessings and

prayers. Finally, my loving wife Ambika, thank you for your good support. Thank you everyone

those help me and encourage me, without you, the study would not have been possible.

TABLE OF CONTENTES


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Chapter 1: Introduction..................................................................................................9

1.1 Aims and Objectives............................................................................................11

Chapter 2: Literature Review.........................................................................................12

2.1. The concepts of under-nutrition and under-weight.......................................................12

2.2 Consequences of childhood under-nutrition................................................................14

2.3. Prevalence of Under-weight children- A global perspective...........................................17

2.4. Demographic profile and nutritional status of India.....................................................19

2.5. Prevalence of Underweight children in India.............................................................22

Chapter 3: Methodology...............................................................................................23

3.1. Study Design....................................................................................................23

3.2. Rationale for the method of study chosen.................................................................263.3. Inclusion or Exclusion Criteria for selecting Literature.................................................26

3.4. Search strategy..................................................................................................27

3.5. Screening Strategy:.............................................................................................27

3.6. Quality Assessment............................................................................................27

3.7. Data extraction..................................................................................................29

3.8. Ethical Considerations.........................................................................................30

3.9. Data Analysis....................................................................................................30

4.1. STUDY SELECTION.........................................................................................31

4.2. Description of Evidence:......................................................................................33

4.3. Key Findings of the Seven Primary Researches Analysed for Study.................................41

4.4. META ANALYSIS...............................................................................................43

Chapter 5: Discussion..................................................................................................48

Chapter 6 Conclusion...................................................................................................52

Chapter 7 Dissemination...............................................................................................54

Assignment Top sheet..............................................................................................57

Extension deadline................................................................................................58

Extension deadline


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List of Figures

Fig 2.1: A pictorial framework showcasing the causes of Malnutrition.....................................................12

Fig 2.2: Global Distribution of cause specific mortality among children under five...............................17

Fig 2.4 : Early Childhood Mortality Rates.................................................................................................22Fig: 3.1 . An example of a flow chart which illustrates the literature identification process......................26

Figure 4.1 Mapping OF Search Strategy With Literature Evidence...........................................................34

Fig 4.2: key finding on prevalence of underweight....................................................................................44

Fig: 4.3. Key finding on prevalence of underweight among male children................................................45

Fig: 4.3 Key finding on prevalence of underweight among female children.............................................45

Fig:4.4 Forest plot 1 Over all Prevalence of underweight among children from included studies for

meta-analysis.............................................................................................................................................49


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Fig:4.5 Forest plot 2 Over all Prevalence of underweight among female children from included studies

for meta-analysis............................................................................................................................. ..........50

Fig:4.6 Forest plot 3 Over all Prevalence of underweight among male children from included studies for

meta-analysis.............................................................................................................................................51

Fig: 4.6 Forest plot 3 Over all Prevalence of underweight among male children from included

studies for meta-analysis

List of Tables

Table 1.1 Weight Statuses for Body Mass Index (BMI)..........................................................................15

Table 2.1 Description of Evidence on Demographic Information of India and a Comparison with USA &

UK.............................................................................................................................................................21

Table 3.1 The data extraction matrix used in this study.............................................................................31

TABLE 4.1 Evidence of Screening :( Studies screened at first stage of the study)....................................32

Table 4.2 : Description of evidence of results identified from National Family Health Survey -1............36

Table 4.3: Description of evidence of result identified from National Family Health Survey -2..............36

Table 4.4: Description of evidence of result identified from National Family Health Survey -3..............38


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Table 4.5 : Description of evidence of result identified from Kumar et.al. (1996)....................................38

Table 4.6: Description of evidence of result identified from Bisai et.al (2010)........................................39

Table 4.7 : Description of evidence of result identified from Bisai et.al (2011).......................................41

Table 4.8 : Description of evidence of result identified from Biswas et.al (2011).....................................42

Table 4.9 : Qualitative Analysis of the included studies............................................................................43

Table 4.10 Evidence from primary research to the Meta analysis..............................................................46Table 4.11: Figures of the Different NFHS Studies between states...........................................................52

Table 4.11: Figures of the Different NFHS Studies between states

Chapter 1: Introduction

Malnutrition remains unacceptably high in most of the developing nations. Food and Agriculture

Organization of the United Nations found one child dies every five seconds as a result of direct or

indirect cause of malnutrition worldwide (FAO, 2004). The word malnutrition is derived from Malus, a

latin word (Morris, 1992). Malus means not correctly nourished. Malnutrition essentially means bad

nourishment (WHO, 2011).Although, malnutrition refers both to under nutrition and over-

nutrition (McGuire & Beerman, 2011, p.35) this study focuses on under nutrition and its effects

on children. According to the statistics, Under-nutrition affected nearly one billion people around

the world (Bogden & Louria, 2010, p.568). Furthermore UNICEF (2011)states that, more than

400 million children under the age of five are malnourished in the world. Under-nutrition is not a

state of disease which affects only for children. According to Collins et al. (2005) Malnutrition

may affect every group in the community in different levels; however, childhood malnutrition is

considered predominant among them due to several reasons.

According to UNICEF (1998) Malnutrition is largely a silent and invisible emergency, exacting a

terrible toll on children and their families. It is a state of nutrition deficiency due to many reasons. In

developing countries, malnutrition is mostly associated with reduced calorie intake or imbalanced diets


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(UNICEF, 1998). UNICEF reveals that, out of 12 million child death across developing countries, the

majority of cases were due to the deficiency of nutrition in children (UNICEF, 1998). Malnutrition

collapses intellectual property in to a non-productive condition and disturbs society into a low standard of

living (The World Bank, 2011). The impact of nutritional deficiency among children makes them non-

productive due to many illnesses. It may affect their schooling, personal improvement in various skills

and technology, and also physical, social, mental limitations (World Bank, 2011). It has been directlylinked with family expenses for medical cost and in low standard of living as many reports proved. For

example, TheMalawi Demographic and Health Survey conducted in Africa (DHS, 2004) revealed that

malnutrition is associated with diarrhea, malaria, measles, acute respiratory infections and other infectious

diseases which is a direct reason for nonproductive community and their low standard of living. Aside

from physical illness, some other factors are contributing towards mental retardation and resistance loss

for children. Inaccurate Vitamin A supplementation and the inadequate iodization in salt are some of the

concerns (ICCIDD, 2011). As vitamin A deficiency is a direct cause of anemia as well as Iodine

deficiency which is the primary cause of preventable mental retardation and brain damage in children.

Malnutrition is not only a cause for any disease but also it works as a cycle in the community (Li, 2006).

In order to break the cycle, each issue associating to it should be closely monitored. Similarly, to identify

the magnitude of malnutrition effects, studies should be conducted in different forms. Community basedprograms including motherhood (women) participation is proven to be a best example for this. Good

nutrition should not be an inaccessible right for a child. International law for children significantly points

out the accessibility of every child to a good nutrition (Nathan, 2008). To protect their rights, society has

the obligation to take this issue as a public health priority.

Studies relating to malnutrition has been carried out across the world especially Asian and subSaharan region. For example World Food Programme (WFP, 2011) found that 70% ofunderweight children in the world reside in just ten countries. Out of these ten countries, 8countries are located in South Asian region (UNICEF, 2006). Among these, India is consideredas one of the largest malnutrition affected countries .According to UNICEF (2006), theprevalence of underweight children in India was the top most among all other countries in thesouth Asian community. It was estimated that half of the total population of Indian children wereeither severe or moderately underweight (UNICEF, 2006). Under- nutritional effects are heavilyaffected in people who are not accessible to the health services in India (IIPS & MI, 2007).Imbalance diet together with low standard of living creates disorder in nutritional life and leadsto many infectious diseases. Poverty and unfavorable environmental conditions built vulnerablesituations in social life. Basic needs of people such as food, drinking water; housing, health careservices are closely related to peoples standard of living and hygiene. Infectious diseases arecaused by how the people they live. According to Global Health Council (GHC, 2011), it hasbeen identified that infectious diseases are the major cause for the hike in the mortality rate of

children around the world. Malnutrition can be argued to be both a cause and consequences ofmany other important social phenomena (Keusch, 2003). Malnutrition increases economic andsocial burden but at the same time it is also an outcome of economic and social issues such as poverty, overpopulation, environmental factors and quality of health care services (Keusch,2003). In one hand, malnutrition works as the reason for economic and social burden in a societybut at the same time it is also an outcome from those determinants as a cycle. Overall,malnutrition is an enormous public health concern which increases the morbidity and mortality


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rates of effected community.Hence, breaking the malnutrition cycle in order to reduce theimpacts of malnutrition in children should be considered a prime goal for research in India.

1.1 Aims and Objectives

The objective of this research is to increase our knowledge and understanding about the currentpicture of underweight children in India. More specifically, it aims to:

Systematically review existing primary researches to establish the overall prevalence ofunderweight among children in India aged between 0 and 15.

Systematically review existing primary researches to establish whether the prevalence ofunderweight differs across gender among children in India aged between 0 and 15.

The rationale for this study is associated with the issues related to the magnitude of childhood

under-nutrition among children in India. It is also associated with the higher prevalence of

underweight children in India as compared to any other developing country in the world. As

world health organization referred India as a home for 60 million underweight children in the

world (prinja, 2009), the scope for this study increases and so does the importance of educating

the public about the effects and causes of underweight. During a survey conducted by the Indian

government, called National Family Health Survey (IIPS & MI, 2007), it has been found that

India is highest in severe childhood under-nutrition issues among 16 different countries, in a

cross country comparison (IIPS & MI, 2007). According toDepartment of Economic and social

affairs, India is a country with one of the youngest populations in the world (Ivanov, 2011). In

order to protect the health of next generation, proper health settings should be done at right time.

As of now there have been plenty of researches that have been conducted on this same issue,

however; the prevalence rate of underweight published by various agencies reminds the lack of

clarity about the issue in the public. Most of the researches indicate underweight as a major

concern for under nutrition among Indian children (The World Bank, 2005). Hence, in order to

make the concerned issue as well as finding the prevalence rate of underweight children would

be a prime motive for this research. The research will be evaluating the prevalence rate of

underweight children from primary researches in order to make an analysis of overall prevalence.

Study will be evaluating prevalence of underweight across gender to find the causes of

discrimination of health care among children in India. Many researches have been undertaken

using various methods to find the result however, it is been considered in this study that a

systematic review would be more applicable to suit the purpose of this research.


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Chapter 2: Literature Review.

2.1. The concepts of under-nutrition and under-weight.

2.1.1. Under-nutrition.

Under-nutrition is a state of body affected by deficiency of nutrients such as

protein, energy, minerals, vitamins etc. (RCPL, 2002, p.5). Under nutrition occurs in people, if

their diet does not provide adequate calories and protein for growth and maintenance or they are

unable to fully unitize the food they eat due to illness (WHO, 2001). Under nutrition is caused

by several reasons. The mismanagement in political resources, unfavourable economic structure

of a society, political and ideological superstructure in a community, ineffectiveness of formal

and non-formal institutions working for the public, inadequate education among general public,inadequate care for children and mothers from the health services (WHO, 2001). These factors in

turn lead to inadequate access to food or insufficient health services and unhealthy environment

in the society which are immediate reason for diseases and inadequate dietary intakes. As

mentioned in the earlier part of this report, under-nutrition is a state of nutrition deficiency in the

body and many studies have proved that inadequate dietary intakes and diseases are the cause of

malnutrition and thereby death [Please see Figure 2.1]. Malnourishment is a global concern as

well as a social burden which affects not only the children but also their family and the entire

development of the nation. One of the reasons behind under nutrition is poverty (Misselhorn,

2007, p.4). Not only has under nutrition affects the economic status of a nation but also it

increases the health care costs as well (Misselhorn, 2007, p.4). Under-nutrition contributes toinfectious diseases which in turn leads a larger number of child deaths and other vulnerable

conditions (Calder & Jackson, 2000).

Fig 2.1: A pictorial framework showcasing the causes of Malnutrition.


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Conceptual framework of the causes of under- nutrition. Adopted from UNICEF conceptual framework (1990).

2.1.2. Under-Weight:

According to Tulchinsky and Varavikova (2009, p.303) Underweight is a state ofnutritional deficiency resulting from either inadequate energy or protein intake and manifestingin either marasmus or kwashiorkor. Low weight in proportion to height and later proposition toage are main features of Underweight in children and results in body wasting, stunt and failure tothrive (Fishman et al., 2011). It is believed that, under-nutrition especially protein energymalnutrition is the cause of underweight among children. It has been measured in different scalesworldwide. According to CDC (2011) for American children, underweight is defined amongchildren who are below 5 percentile of BMI. In India, most of the studies followed NationalCentre for Health Statistics/ World Health Organization reference median (NCHS/WHO).According to NCHS/WHO underweight in children is measured according to their weight forage below -2 standard deviations( SDs) (weight-for-age


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2.2 Consequences of childhood under-nutrition.

Malnutrition is the reason behind 5 million deaths globally every year (UNICEF, 2007). It is

considered as a major burden for the affected societies.Nutritional deficiencies among children

such as protein energy malnutrition, deficiencies of micronutrients, Iron deficiency, vitamin A

deficiency and iodine deficiency diversely affects the development of children physically,

socially and mentally. World health organization (Ustan & Jacob, 2005) defines health as "a stateof complete physical, mental, and social well-being and not merely the absence of disease or

infirmity." According to this definition, childhood under nutrition is a major public health issue

to be tackled as such for the physical, mental and social wellbeing of a child.

2.2.1 Protein Energy Malnutrition (PEM):PEM is one of the major reasons which contributetowards malnutrition in children (Mesham & Chatterji, 1999, p.10). Severe PEM can also resulthigher mortality rates in the not so privileged communities of the society. Malnutrition in theearly stages of a child can severely affect a childs growth. The consequences of protein energymalnutrition in children usually results in underweight (less weight in proportion to age),stunting (less height for age), and body wasting (less weight for height). According to WHO

Global Database on Child Growth (Onis et al, 1992), which covers 87% of the total population ofunder-5-year olds in developing countries, Asia was the highest ranking in under nutritionaffected region. According to this study Asia has 42.0% of underweight, 47.1% of Stunting,10.8% of wasting children, which shows the consequences of protein energy malnutrition in thatregion.

2.2.2. Iron Deficiency:It is one of the primary reasons for nutritional deficiency. Iron deficiencycan lead to iron deficiency anaemia (Bowden & Greenburg, 2010). It normally affects childrenand women before their menopausal stage of life. According to WHO (2001) the report revealedfrom the studies of children below age 4 years suggest ,On anaemia prevalence (1990-95),industrialized countries had 20.1% and non-industrialized countries 39.0% as well.

2.2.3. Vitamin A Deficiency: As the name suggests is a condition where humans lack Vitamin A

in their body (Anderson, 2007). It is rarely reported in developed countries but widely recordedin developing nations of the world. Vitamin A can lead to night blindness (Anderson, 2007). Italso affects immunity of a human being to fight infections. According to WHO (1995),approximately one third of the worlds pre-school population have vitamin A deficiencies and ofthat less than 1 % are prone to night blindness.

2.2.4.IodineDeficiency Disorders (IDD):

Iodine deficiency can lead to brain damage and mental ill-health and can be a cause for a range of

problems like goitre and other physical ailments (Preedy, 2009, p.461). These dis orders caused by the

lack of iodine in body due to the deficiency of the same in cultivated food items, is referred to as Iodine

Deficiency Disorders(IDD) (Preedy, 2009, p.461).). In fact under-nutrition contributes many deadly

diseases such as marasmus, kwashiorkor, anaemia, goitre, hypernatremia, hypokalaemia, vitamin Adeficiency etc.

2.2.5. Marasmus: It is a disease that is caused by the deficiency, in fact chronic deficiency ofproteins and calories in the body and is one of the most common diseases caused by malnutritionin children and hence can lead to general lack of energy in them (Koukul, 1991, p.123). Itaffects normally infants under the age of one. Edema, skin problems like dry and scaly skin orloose skin can also be caused by Marasmus (Whitney et al., 2010, p.127).


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2.2.6. Kwashiorkor: Kwashiorkor is one of the most acute protein malnutrition diseases in the

world (Whitney et al., 2010, p.127).It is similar to Marasmus but what makes it different is the

presence of Edema in feet. It can also lead to distended abdomen, swollen liver, thinning of hair

which is normally coarse in texture, teeth lose, skin depigmentation, and dermatitis. Children

affected by Kwashiorkor also show signs of irritability and anaemia.

2.2.7 Anaemia: It is regarded as one of commonly reported malnutrition ailment around the

world. It can be caused due to many reasons but the primary being the lack of iron and Vitamin

B12 in the diet and has been generally reported in pregnant women (DeBruyne et al., 2008).

People who are anaemic also show signs of tiredness, loss of breath and have pallor skin which is

caused due to the lack of haemoglobin in their blood (DeBruyne et al., 2008).

2.2.8 Goitre:This is caused due to the lack of iodine content in food and can lead to swelling of

thyroid gland around the neck. Lethargy, weakness, low metabolic rate and increased

susceptibility to cold are other signs of lack of iodine in the diet (Ottoboni & Ottoboni, 2002,

p.153).

2.2.9 Hypernatremia: Hypernatremia is a condition that is caused due to deficiency of sodium in

the blood and diet. This is a serious type of electrolyte disturbance that is normally seen in

people who have high levels of antidiuretic hormone. In this disease, the concentration of sodium

in the plasma is less than 135mEq/L (Lagua & Claudio, 1996, p.76). This condition is often seen

as a result of a complication of some other serious medical illness, like diarrhoea, excessive

vomiting, polydipsia, etc. Typical symptoms include nausea, vomiting, headache, etc. If the

symptoms are not treated in time and worsen further, there may even be mental clouding,

confusion, convulsions, stupor and the person may even eventually go into coma (Lagua &Claudio, 1996, p.76). The treatment for this disease depends on the underlying cause. In cases of

severe volume depletion, there may be need of intravenous administration of saline. Serious

symptoms like seizures normally require treatment using hypertonic saline.

2.2.10. Hypokalaemia: It is a condition which results from the lack of potassium in the diet. A

person suffering from this disorder may lack potassium in his or her body (Teitelbaum et al.,

2007, p.189). Dehydration or diarrhoea and malnutrition can all lead to this disorder.

Hypokalaemia is followed by symptoms like myalgia, muscle cramps, tetany, slight change in

blood pressure, constipation, etc. Respiratory depression and cardiac arrhythmias can be the

extreme cases of hypokalaemia (Teitelbaum et al., 2007, p.189).

2.2.11. Vitamin Deficiency: Vitamin deficiency can also be a consequence of under-nutrition. The

following is a list of those vitamins and the condition they lead to due to their lack of it: Vitamin

A: Vitamin B1: Vitamin B2: Vitamin B3: Vitamin B12: Vitamin C: Vitamin D:

As can be seen in figure 2.2, approximately 50% of total deaths in children less than 5 years of

age are because of various infectious diseases in the world (UNICEF, 2008). The reason behind


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these diseases is found to be under-nutrition. They key factors from this study as per figure 2,

neonatal period is claimed to be more dangerous period exposed to under-nutrition.

Approximately 40 % of child death are reported in this study is at neonatal period. It includes

19% of children affected by pneumonia, 17% from diarrheal diseases, 10% from severe

infectious diseases etc.

Fig 2.2: Global Distribution of cause specific mortality among children under five

Source: UNICEF,The State of the Worlds Children Report 2008,New York, December 2007.

The problems relating to under-nutrition among Indian children is relatively very high.

According to NFHS-3(IIPS & MI, 2007), Under-nutrition contributes 22% of Indias burden of

disease. It includes iron deficiency, anaemia among preschool children as 75%, vitamin A

deficiency as 57%, and iodine deficiency as 85 % of districts, etc. Similarly protein energy

malnutrition contributed to higher prevalence of underweight, stunted, wasted children in India

as compared to any other Asian region. NFHS-3 (IIPS & MI, 2007) also states that, under-

nutrition contributes either directly or indirectly, in half of the total child death below age of 5

years across the country.

2.3. Prevalence of Under-weight children- A global perspective.

The effects of under-nutrition in children in different places are varied. World agencies such as WHO,

UNICEF etc. conducted many studies to find the real causes and its effect on children in various terms.

According to the World Health Organisation Global Database (2011) on children growth and


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malnutrition, they have succeeded in finding out the decreasing stage of it or some of its effect in some

regions, especially, the prevalence of underweight which was recognized as one of the major

consequences of under-nutrition (WHO, 1997). A major study which carried out 419 nationally

representative surveys on 31 million children from both developing and developed countries, revealed the

changes in prevalence of underweight since 1990. It found that the trend in the prevalence of underweight

children in the study area was slowly decreasing compared to the earlier phase (Onis et al., 2004). It wasreported that during 1990s the prevalence of underweight was 26.5% and it slowly showing a trend of

decrease by 2000 and is projected to be at 17.6% by 2015 (Onis et al., 2004). Furthermore, the prevalence

rate of underweight children in developed countries was estimated to decrease from 1.6% to 0.9% (Onis

et al., 2004). It was more specific in the case of developing countries with an estimated decline from 30.2

% to 19.3 % during the same time period (Onis et al., 2004). The study identified some regions such as

Africa and southern Asia still maintain higher prevalence rate among underweight children. It was found

that the prevalence of underweight in Africa has increased from 24.0 % to 26.8 % since 1990. Asia in

total, there are positive trends towards underweight prevalence as reported same as in any other region

stated here .Asia has a prevalence in underweight children of 18.5 percentages which was 35.1

percentages in 1990 (Onis et al., 2004).. According to this study the total number of underweight children

in the world was 163.8 million in 1990. Study concludes, the number of underweight children in theworld will decrease from 163.8 million to 113.4 by 2015 (Onis et al., 2004). Some south Asian regions

such as India, Bangladesh and Nepal still have higher prevalence rate which is said to be higher than any

other countries even double than sub Saharan countries. NFHS-3 study conducted in India supported this

findings of WHO. During a study of underweight children in India, NFHS -3 compared the prevalence

status of India with other 16 regions and found that India was the most affected country than any other

region [Please see Figure 2.3].

Fig 2.3 The percentages of children with under nutrition are aged five years or under among selected countries based

NFHS -3:

For this study it is considered to be as much important to analyse the status of china and sub

Saharan countries about the same issue. According to the State Statistical Bureau study (Chang, 1996)

with the representation of 26 states in 1992, China has a prevalence of underweight children below age 5

recorded as 17.9%. During the same study, it was also reported that chronic malnutrition among children

was 34.7% and wasting by 4.7%. Study observes the wide difference of prevalence in underweight

children from rural and urban areas of china. According to Svedberg (2007), through the comparison of

various past surveys, with consistent economic development together with conducting malnutrition

programs throughout the region will help in decreasing the intensity of malnutrition issues among

children at least half with in ten years. It was reported that since 1990, sub Saharan region shows adramatic increase in the rate in childhood malnutrition as 20% (Schulz ,1999, p.66). It was claimed that

two hundred million people on the continent, both children and adults, were undernourished (FAO, 2003).

More than one third of children below age five are undergoing chronic malnutrition in most of the sub

Saharan regions. According to the study, more than 28% of deaths among children below age five are

associated with under nutritional issues. Apart from mortality rate and association of nutritional

deficiency, study finds almost 30% of burden of diseases are caused by malnutrition among children.


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2.4. Demographic profile and nutritional status of India

India is one of the 10 fastest growing economies in the world having a total population of1.21

billion people according to 2011 census report (Census India, 2011). It includes623.7 million

males and 586.5 million females. The total population of India is estimated to account for17.31% of the world population. India is believed to have the youngest population in the world

by having 50% of total population representing people below age of 25. According to 2011

census, the life expectancy in India at birth was estimated as 66.8. It has counted for males as

65.77and females 67.95. The life expectancy in India is reported as below average of world

estimation. There is a huge difference in percentage of life expectancy when we compare Indian

life expectancy with the United Kingdom and the United States of America.

According to National Health Service (2011), life expectancy of British people had risen from 72

to 80 within the last three decades. In UK the average life expectancy of male population is 78 as

compared to the opposite sex of 82. According to the United States census Bureau (2011), the

life expectancy of American people was estimated as 77.8, males 75.3 and females 80.3. Infant

mortality rate in India is also extremely high compared to the United Kingdom and the USA.

According to CIA World Fact Book (2011) Infant mortality rate (IMR) of India per 1000 live

births is estimated to be 47.57. It is far lesser in the case of the UK and the US as 4.62, 6.06

respectively (CIA, 2011). In 2009 India had a mortality rate of 65.6/1000 for children under the

age of 5. That means 65.6 out of every 1000 children died before reaching the age of 5 years

(CIA, 2011). WHO Mortality country fact sheet displays the mortality rate of Indian children

aged below 5 years as 85(Male 81, Female 89) at every 1000 live births (WHO, 2006). Mortality

rate of British children below the age of five was estimated 6 for male child and 5 for the

opposite sex, a total of 6 for every 1000 live births (WHO, 2006). Mortality rate of American

children below the age of five was estimated at 8 and 7 for male and female counterparts, a total

of 8 for every 1000 live births (WHO, 2006). The other important area to be overviewed is

maternal mortality rate in India. According to CIA World Fact Book (2011), it was recorded that

UK has a maternal mortality rate of 11 per100000 live births. USA showed 14 per 100000.As in

the case of India it was 540 per 100000live births.

Table 2.1 Description of Evidence on Demographic Information of India and a Comparison with USA &

UK.

Highlighted

Information on :

UK USA INDIA

Total Population 62.3 million 3,12.68 million 1.21 Billion

Life expectancy 80 (M 82, F 78) 77.8 (M 75.3, F 80.3) 66.8 (M 65.77 , F

67.95)


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(Years)

Infant Mortality Rate

(1000 Live Birth)

4.62 6.06 47.57

Child Mortality below

age 5 (1000 Live

Birth)

6 ( M 6, F 5) 8 ( M 8 , F 7) 85 (M 81, F 89)

Maternal Mortality

Rate ( 100000 Live

Birth)

11 14 540

As per the stated information and comparison of some key areas in demographic profile of India

with the UK and the US, it has been found that the infant mortality rate and child mortality under

age 5 in India is significantly high. The life expectancy rate in India is very low and even lower

than the global average. The maternal mortality is found to be another issue as statistics prove,

which is directly affecting child nutrition and breast feeding. Apart from this report, a large scale

national survey conducted in 2005, called National Family Health Survey, which gives overall

information surrounded nutritional life of an Indian children.

Under-nutrition is related to various environmental factors which directly or indirectly affects a

childs life since its birth. It is claimed important to observe all these factors to evaluate thechances of under-nutrition from various perspectives. NFHS (IIPS &MI, 2007) provided wide

information about the matter which showed the real picture of Health status of India. It is also

very important to mention that, the methodology (see page no: 35) used by NFHS to update the

statistics was predominantly successful. It covers the total population of India and the

representation from each group from the community. According to NFHS-3 report, the primary

health distribution was not as effective according to its mission. This study is evaluating some

key information from NFHS-3 to analyse the factors governing health of children in India. It

found that only 24.9% children received a vitamin A dose in their last 6 months (12-35 months

children).It describes about the inaccessibility of health services for a child. According to NFHS-

3 (IIPS & MI, 2007) 26% of Children below age 3 been found with diarrhoea and have notreceived ORS for two weeks. NFHS also found the breastfeeding practices of mothers. Study

claims that only 46.3% mothers breastfed their child during their first 5 months of age. It has

been also noted that the prevalence of anaemia in children aged 6- 35 months were 78.9%.

Further figures as per the NFHS study reveal that children aged between 12-35 months who

received a Vitamin A dose in last 6 months amounted to 24.9 per cent (IIPS & MI, 2007). The

results show the children less than 3 years who received ORS in the previous 2 weeks amounted

to 26.2 per cent and those who were taken to health institution were recorded to be 61.5 per cent


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whereas the children with acute respiratory infection or fever in the last 2 weeks taken to a

healthy facility is around 70.5 per cent.

Child feeding practices and nutritional status of children showed the following figures. Children

less than 3 years who were breastfed with the first hour of birth amounted to 23.4 per cent where

46.3 per cent of children were breastfed between 0 to 5 months of their birth (IIPS & MI, 2007).Children aged between 6 and 9 months who received solid or semi-solid food and breastfed were

recorded to be 55.8 per cent but the figures for children aged between 6 to 35 months who were

anaemic were 78.9 per cent. These figures depict the state of health service distribution and

hence directly points to the status of under-nutrition among Indian children hence been portrayed

here as part of the research study conducted here. One of the sources to reflect the under nutrition

status among children could be linked to the mortality rate of the land. This is emphasised using

major surveys as below.

Three major surveys conducted in India since 1990, found that the mortality rate in Indian

children is very high (IIPS & MI, 2007). Study revealed more than half (54%) of every death in

Indian children before age five years are due to various effects of under-nutrition. As the results

show from three surveys, the mortality rate was gradually decreasing, however, it still stands as

high among all other developing countries.

Fig 2.4: Early Childhood Mortality Rates

In India, approximately 1.72 million children die each year before reaching their first birthday

(WHO, 2007). Infant mortality has declined significantly in India from 129 in 1970 to 68 in the

year 2000 Fig.3. Though, the Infant Mortality Rate (IMR) is decreasing at an annual rate of 2.11

per cent from the early seventies, the decadal rate (compounded annually) is decreasing at a

slower rate when compared between 1981-91 and 1991- 2001. The slow pace of education in the


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IMR is a major worry for the countrys development. To that extent its performance when

compared to other Southeast and East Asian countries is poor. While the expected fall in IMR is

at 47 based on the current rate, it is still above the millennium development goal of 28 per 1000

live births by 2015.

2.5. Prevalence of Underweight children in IndiaThe prevalence of underweight children in India was very high over the decades (IIPS & MI,

2007). NFHS surveys conducted three times since 1990 show the magnitude of underweight

issues among Indian children. As underweight is the consequence of under-nutrition, it shows the

magnitude of nutritional deficiency in a community (Mesham & Chatterji, 1999, p.10). As far as

India, a land of diversity, with having more than 30 states, different religions, castes, sub-castes,

tribes, the social strata is varied from one to another (Duiker &Spielvogel, 2006, p.38). India has

a wide rural population as same as the urban one with vast difference of socio economic

infrastructure. The discrimination among children according to the gender also plays a part

nutritional disorder in Indian community (IIPS & MI, 2007). Hence, the higher prevalence of

unweight children in India is due to many reason. The first ever in Indian history, a studyconducted with the total representation of people from each groups in the community was

National Family Health Survey in 1992. It has gone through each level of analysis to determine

the nutritional deficiency problems and underweight prevalence among children in India. It

found that, the prevalence of underweight among children in India is amongst the highest in the

world, and nearly doubles that of Sub-Saharan Africa (IIPS, 1995). Studies show nearly half of

children with in the age group of 0-5 are chronically malnourished. Further, many studies have

undertaken from various dimensions by both Indian and foreign agencies since first NFHS. Each

study found the alarming situation of under-nutrition, especially the higher prevalence rate of

underweight children in India. Organizations like WHO, UNICEF, WORLD BANK have

focused their attention to promote large scale of further studies and health programs in order tomake improvement of health services to tackle this issue. Following this, two other NFHS

studies have been accomplished with higher intentions, and it has been also evaluated the same

issue in each level. The third NFHS carried out in 2005 attempted to compare the prevalence rate

of underweight children in India with 40 other countries. Precisely, it was the highest most

prevalence rate of underweight children among 40 countries considered for the study (IIPS &

MI, 2007).

The prevalence rate of underweight children in the world is in decaling state. However, most of

the studies conducted in India shows, prevalence rate of underweight children is almost same as

since 1990. Although, India has achieved many improvements in distribution of health services,

there arises a question about the improvement of prevalence rate of underweight children in the

country. Underweight is a consequence from under nutrition as early stated, it can be taken as

one of the measurement to evaluate the nutritional status of children in India. Every study should

have to be initiated with a common interest to make people aware about the concerned issue. In

order to make them understand, the transparency and clarity in results is much needed. A review

of primary researches updated the prevalence of underweight children in India can offer more

clear picture about the seriousness of the issue.


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Chapter 3: Methodology

This chapter describes how the research will be undertaken as per the chosen area of

study. The chapter also explains the method of study undertaken with full description of data

collection, extraction and analysis.

3.1. Study Design

Systematic review aims to review all selected literature in a systematic fashion in identifying the

relevant studies necessary within the given review. It is claimed that, a systematic review

establishes consistent findings which can be generalised across populations and settings of

interest (Mulrow1994).

Primary research involves qualitative, quantitative or a combination of both methods.

Systematic review is a method of reviewing and synthesising primary research in order toproduce findings which accurately represent all of the studies that have been reviewed (Mulrow

1994). More specifically, it consists of identifying, screening, appraising, and synthesising

evidences. Part of the systematic review process involves setting objectives, searching relevant

literature through the use of a search strategy with key words and electronic search engines

(Mulrow1994). Once literature has been identified, a set of predefined inclusion and exclusion

criteria is applied (e.g. of a considered criteria includes Work published in the English language

only). A data extraction process involves a quality appraisal of the identified literature. A flow

chart is often produced in order to concisely illustrate the stages of the literature identification

process (see figure 3.1). The quality appraisal process is important as it involves assessing the

quality of identified literature as well as the level of bias and error that could be inherent in eachstudy. The final stage involves synthesising relevant extracted data from the identified literature

in order to produce evidences that address the research question(s). Synthesising can be done

through meta-analysis and using narrative method. Narrative method can be described as

findings summarised and explained in words. It refers to the approach adapted in bringing

together the findings from studies included in a systematic review. It is not similar to meta-

analysis but can be an alternative to the same. The statistical approach in bringing together the

findings from each study considered would be most appropriate for a valid result in this study.

Meta- analysis is a statistical method of summarising results from each study in to a single

conclusion.


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Fig: 3.1. An example of a flow chart which illustrates the literature identification process

Systematic review has its own advantages over primary research studies. For example,

systematic review can systematically and comprehensively review primary research literature it

can produce findings which is arguable, more reliable and less at risk of bias and error than

single primary research studies (Holly et al., 2011, p.201). Another advantage is that a systematic

review provides readers with more data of interest in one document compared to potentiallymany documents that a reader would have to hunt for themselves. One of the main advantages is

that a meta- analysis can be produced in a systematic review. Meta- analysis is considered to be

the gold standard of research (Holly et al., 2011, p.199).

The need for a systematic review occurs in many situations. If there is much information about a

particular topic and the need of synthesised decision making emerges, a systematic review would

be adopted (Holly et al., 2011, p.199). Systematic review has other advantageous such as they


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can be an ideal stepping stone for a research as they offer researchers a range of comprehensive

literature available in one document. It could also be argued that a systematic review can be

more appropriate when researches have less time and resources available to them (Brown, 2006,

p.503).

3.2. Rationale for the method of study chosenIt is an ideal method for synthesising consolidated prevalence of data from lots of available

research material. A systematic review has never done in India in this context before, to find the

overall prevalence of underweight among Indian children. It would be more appropriate to

combine the results and to evaluate by means of undertaking a meta-analysis and is highly

appropriate in the present scenario (NLM, 2009). Another reason for choosing a systematic

review for this research is that many practical reasons limit researchers ability to conduct his

own prevalence study in India, particularly because a researcher normally prefers to have a

representative prevalence statistic. This would make a primary research even more difficult and

complicated. Also in this research, researcher would want to limit the bias and error that comes

from a solitary study. Avoiding bias and errors gives more generalizability, validity and clarity tothe research.

3.3. Inclusion or Exclusion Criteria for selecting Literature.

Setting Inclusion and Exclusion criteria consists of careful thinking and frame work in every

systematic review. As Inclusion and exclusion criteria have an enormous role in the

generalizability of research findings, it is claimed to be a very important part in setting the

selection criteria cleverly at the beginning of every systematic review. The inclusion criteria

specifies which study is to be included in the review. Similarly exclusion criteria defines

literature those to be excluded from the review. Hence selecting both criteria cleverly helps in

finding the most suitable literature for the study.

The following inclusion criteria were applied: Literature published in 1990 or after; literature

published in English. Literature representing children of the age of 15 and below were also

considered. Literatures representing both male and female children residing in India and born in

India were also included in the inclusion criteria. Literature which studies prevalence of

underweight among Indian children was another inclusion criterion.

The following exclusion criteria were applied: Literature published prior to 1990; literature

published in any language other than English. Literatures with the age limit of study participants

above 15 were excluded. Literatures that do not represent both genders were avoided. Literature,

which is not studied about prevalence of underweight were also part of the exclusion criteria.

Inclusion and exclusions consist of rules that mainly relied upon the selected population, ageranges, gender, risk status, presents of co-morbidities, and range of severity. This study focusedin national level of population in India. This research particularly focuses on underweightproblem in children in order to find the frequency of childhood malnutrition in India. Due tothe difficulties that may arrive in the translation of non-English articles, this study consideredthe articles only published in English language between the year of 1990 and till date. Thesearch of journals will be limited to the area of medical, nursing, human resource, mental health


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etc. to assure the clarity and authenticity of findings of the articles. In order to avoid anypublication bias, researchers and research institutes will be contacted with respect to accessunpublished works for the reference.

3.4. Search strategy.

The search strategy is the method to identify the literature to be selected. The search strategy acts

as a filter based on the specific keywords that relate to the predetermined inclusions and

exclusion criteria. Finding literature is often conducted using a range of relevant electronic

databases. In this study, the following electronic databases will be included:

MEDLINE (a general medical database), PsycINFO (international database for

psychology, behavioural and social sciences), CINAHL (Database for nursing and allied

health disciplines) and PubMed. The study will also search for literature through handpicking

of journals, internet sources and from the reference list of identified published primary research

literatures from the list. The searching strategy that will be applied as follows:

The search will be conducted using the following key words and combination of keywords:underweight OR under-weight OR weight OR BMI OR body mass index OR nutrition OR,

malnutrition OR prevalen* AND child* OR India* OR infant OR baby OR babies OR

adolescen* OR neonatal OR malnourished OR malnourishment.

A search diary will be maintained detailing the names of the databases searched, the keywordsused and the search results. Titles and abstracts of studies to be considered for retrieval will berecorded on an Endnote database, along with the details of where the references have beenfound. Inclusion/exclusion decisions will be recorded in the same database. Retrieved studieswill be filed according to inclusion/exclusion decisions.

3.5. Screening Strategy:

An effective screening strategy based on pre-defined inclusion and exclusion criteria is the keymethod towards filtering out ineligible literature and identifying the most relevant studies foranalysis. The screening process involves three stages. During the first stage retrieved literature isscreened against the study titles and abstracts. In second stage, the full texts of the studies whichcannot be included or excluded during the first screening stage (due to uncertainty) are accessedand again screened using the inclusion of exclusion criteria.

3.6. Quality Assessment.

Every systematic review requires quality assessment as it is considered to be one of the mainingredients of such a system of reviewing of literature (Gilbody & Bower, 2011, p.44). A quality

assessment helps in finding variations or deviations in quality from the chosen literature or

studies considered in a systematic review and Meta-analysis (Littell, 2008, p.66). Every review

process should consider highest standards in determining the quality of study or literatures

selected .It holds true for a systematic review as well. Moreover, it is essential that the process

involved in ensuring quality of the studies should be explicit, well documented, unbiased and

reliable (Aparasu, 2011, p.136). It is also considered important that the systematic review and


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meta-analysis report clarifies on the quality of the data and studies considered for these reviews

and analysis (Aparasu, 2011, p.136).

A close monitoring of the participants, study design, aims and objectives of the study, sample

size of the study, applied methodology, intervention of interest, data analysis, instruments,

description of findings, validity of outcomes, would be applied during the assessment. It consistsof 10 questions which will apply on each primary research to evaluate the quality of the studies.

Each question contains three answers (Y (yes), N (no), and C (not clear). Following are the

questions used in this process.

1. Is the hypothesis aim objective of the study clearly described? : It will examine the

description of research aim, hypothesis and objective clearly stated. It assures the quality

of literatures fulfils the basic standards.

2. Appropriate Method: It will assure whether the study followed appropriate methods in

order to find the study interest. It also examines the study bias as well.

3. Are the main outcomes to be measured clearly described in the Introduction or Methods

section? : The clarity of information from the studies will be analysed.

4. Are the interventions of interest clearly described? It would be evaluated whether the

studies clearly mentioned the interventions of interest in the methodology.

5. Are the main findings of the study clearly described? It will examine the transparency of

description of findings in the study. It will help to find the study bias by evaluating this.

6. Were the participants representing the entire population from which they were

recruited? : It evaluates the generalizability of the study findings.

7. Were the statistical tests used to assess the main outcomes appropriate? : It reveals the

authenticity of research findings.

8. Were the main outcome measures used, accurate (i.e., valid and reliable)? : It will

compare the description of methodology its application in outcome measures.

9. Can the result be applied to every child population? : It reveals the generalizability of the

research findings.

10. Do results fit with other available evidence? It produces the comparability and standard

of evidence.

3.7. Data extraction

The data extraction process consists of identifying pre-specified data elements from eligibleliteratures retrieved from screening. It describes the what, who, and how the included studiesare coded. Data extraction is usually performed by designing a table or a database in whichimportant data from the literatures is extracted into. The term data reflects any relevantinformation derived from the literatures such as participates, methodology, intervention,outcome, results, limitations, researchers identity and publications. For this study, anextraction matrix in Microsoft Excel was created. The specific kind of extracted data is


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included in the source of the study, eligibility, participants, methods, and results (see table 3.1) .Sources include study ID as well as author information. The participants column contains totalnumber of participants, setting, diagnostic criteria, age and sex of participants. The columnmethods have been used to record data about study designs of each literatures, sequencegeneration, allocation sequence concealment etc. Results column have been used for recordingsample size of each study, missing participants information if any, summary data about theinterventions. Some missing data from the literatures have been requested to the authors bysending email to them with specific pointed questions. It has been also decided; make email tothe authors without overwhelming them by asking too many questions.

Table 3.1 The data extraction matrix used in this study

Sl.No:

Author

Paper

title Aims Method

Instrume

nts Weight

Male

weight

Female

weight

Sample

ages

Any other

malnutrition

Limitation

s

The columns of the data extraction matrix could be explained as follows. The SL No represents

the number of primary researches that will be included in this research as part of the evaluation

of the condition of childhood malnutrition in Indian children. Each serial number will correspond

to the primary research being included and analysed. The author column will represent the name

of the person or persons who conducted such a research or contributed towards it. The next

column named Paper title will refer to the name of the research paper under study. It will also

give a glimpse into what the study was about. Aim will mention or refer to the main of the

research being discussed as part of this study. Each primary research or study being discussedhere will have chosen a method of study to undertake the research. This section will discuss the

methodology adopted by the researcher in conducting the primary research, for example, clinical

trials, surveys, experiments conducted during the research for results, interviews conducted while

gathering data, etc. The instruments used or utilized during the research process will be

mentioned in the next column. The next column is about the data relating to the weight of the

children under study during the research. Weight related data emerged through reviews will be

segregated according to weight of each male population under study will go into the next

column. Weight related data emerged through reviews will be

segregated according to weight of each female population will follow in the next column. The

next column is about the sample ages considered during the study. This area will cover all otherissues related to research question from primary researches. Limitations and scope of each study

will be extracted and noted in the final column of the matrix table.

3.8. Ethical Considerations

As this study is a systematic review of primary research, there are few ethical considerations to

be concerned. Primary researches with ethical insufficiency will be avoided in this research. All

non-ethical research data will be avoided for the review in this paper. The conflict of interest


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reports and financial data will be respected in this research. As far as confidentiality is concerned

it will be highly respected and the primary research information will be protected in this study.

As a whole no such issues come in this systematic review in concern with ethical consideration.

3.9. Data Analysis

Results included in each study relating to the underweight of Indian children will be describedand critically evaluated. All comparable prevalence data will be entered in to stata (version 11)

and Meta analysed in order to calculate an overall pooled estimate (with 95% confidence

intervals) of the prevalence of underweight among children living in India. Data synthesis

provides researchers with the result of the systematic review (Filipe et al., 2006, pp.129). Data

analysis of these 7 primary researches will go a long way in conducting a study of childhood

malnutrition of children in India. The results of the data analysis will be discussed in detail in the

results section of this final report and will be mentioned later in this paper.

Chapter 4 Results

Seven eligible studies were found as applicable for the review (Please see Figure 4.1). The

research papers accessed through the search strategy were studied for the under nutrition and

underweight of Indian children below age of 15. Studies were accessed mainly from four

research databases: Medline, Ebsco Host and CHINAL, PubMed. Literatures have been retrieved

from these databases include studies conducted since 1990 to till date. A total of274 studies

been found in first screening as either matching its title or abstract with the subject of interest for

this research. From this, 194 were from PubMed, 36 from Ebsco Host, 22 from Medline and 21

from CHINAL (Table 4.1). Furthermore 1 literature was screened out from reference lists .

TABLE 4.1 Evidence of Screening :( Studies screened at first stage of the study)

Name of the Databases No: Studies accessed Total

PubMed 194

Ebsco Host 36


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Medline 22

CHINAL 21

Study retrieved from the

reference list

1

Studies from hand searching 0

Total studies 0 274

4.1. STUDY SELECTION

The method of selection of studies after the first screening were precisely been accomplished.

Please see Figure 2, for mapping search strategy. During the second stage of screening, each

literature had been taken for the detail analysis to find whether the full text fulfils all inclusions

and exclusions. During the second stage 192 studies has been excluded due to the fact that the

content does not support the study interest. The excluded studies mainly focus the other age

groups or other study interest apart from underweight. One important study has been accessed

from the reference list during the second stage of screening. At the third stage of the screening

which included 82 remaining studies, 7 studies has been taken for the final literature.


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Figure 4.1 Mapping OF Search Strategy with Literature Evidence

4.2. Description of Evidence:

The study assessed seven literatures after the selection process of finding literature papers.According to this process study retrieved most appropriate literatures which are able to answerthe research question. The seven studies are titled as : NFHS-1 , NFHS-2, NFHS-3,Nutritional Status of children: Validity of mid-upper arm circumference for screening under-

Electronic Search

Key Words

Under- nutrition,

Underweight, Prevalence,

Malnourishment, Indian,

Children, Infants,

Adolescents, BMI

Data Bases

Medline, CHINAL

Ebsco Host, Pubmed.

Stage 1: Titles and

Abstracts accessed

from databases search

Inclusion

Criteria

Studies Published

from 1990

English

Publication

Age group 0-15

Prevalence of

Under-Weight

Indian based

Exclusion

Criteria

Studies published

before 1990

Non English

Publication

Age group above 15

Not relevant to the

study

Stage 2: Excluded studies= 192

Full copies accessed for Inclusion

Stage 3: Studies

considered for

Review

Studies= 7Studies not

considered= 4


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nutrition, Prevalence of underweight, stunting and wasting among urban poor children aged 1- 5years of West Bengal, India, Prevalence of under-nutrition among Kora-Mudi children aged 2-13 years in Paschim Medinipur District, West Bengal, India, and Assessment of Health,Nutrition and Immunisation status amongst under -5 children in migratory brick klin populationof periurban Kolkata, India. In these research studies, NFHS studies focused on national dataof prevalence of underweight children whereas the rest of the studies focused on different statesaccording to the research interest. The summery of each studies and table of evidence will nowbe described.

4.2.1: IIPS, 1995 (National Family Health Survey-1): The first National Family Health Survey was conducted in 1992-93 with a nationally representativesample from each group. Total 89,777 married women within age group of 13-49 were interviewed from24 states in different stages (IIPS, 1995). NFHS-1 coordinated with International Institute of PopulationScience (IIPS) with the support of 18 populations research centres in India. The main objective ofthe study was to identify up-to-date information about fertility, family planning, mortality and maternaland child death (IIPS, 1995). Data collection for this study was conducted under three phases since April

1992 to September 1993. The survey used uniform questionnaires, sample designs, and field

procedures to facilitate comparability of the data and to achieve a high level of data quality.Survey has been found as a source of vast knowledge about each population in India, mainly women andchildren and their nutrition status. It followed NCHS/ WHO growth standard [please see page no: 14] todefine underweight among Indian children. According to this standard, the prevalence of underweightchildren less than three years was estimated as 51.5 % (IIPS, 1995). NFHS -1 was the first study beenheld with the total participation of total population groups (IIPS, 1995). It was a milestone for thedevelopment of demographic database as well as a platform for the next survey conducted in 1998.

Table 4.2: Description of evidence of results identified from National Family Health Survey -1

Reference Study Design Study

Sample Size

Input

variables

Output

Variable

Results

International

Institute of

Population

Science (IIPS,

1995)

Survey

performed

interviews and

questionnaires

among study

population

Total 89,777

married

women within

age group of

13-49 were

interviewed

from 24 states

in different

stages

Child Health

Child

Mortality

Prevalence of

Underweight

Mortality and

Health

Underweight

Prevalence:

Total= 51.5 %

(Urban= 44% , Rural

55%, Female= 52%

Male = 53% )


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4.2.2 IIPS& ORCM, 2000 (National Family Health Survey-2): The second National Family Health

Survey was conducted in 1998-99. It was focused to strengthen the demographic database which formed

through NFHS-1 as well as monitor the health status of each population. It was aimed at to provide state

base and national base estimates of health status in each group of total population. It was conducted by

IIPS with technical support from ORC Macro (USA) and funded by the United States agency for

international development (USAID). It covered 90,000 women as a sample compromising for the entire

total population of India (IIPS, 2000). Data collection was in the form of interview and identical

questioners. NFHS-2 also followed NCHS/WHO child growth standard to define underweight NFHS-2

finds the prevalence of underweight children less than age three was 47 percentages (IIPS & ORCM,

2000). Among them 49% of children was belong to female group and 45% from male. Similarly it also

finds 19.7 percentages of children were wasted (low weight proportionate to height) as well. Study found

the prevalence of underweight children in urban areas as 38% whereas in rural area showed to be 50%.

Comparing with NFHS-1, the prevalence of underweight among children less than the age of three

declined from 51.5 to 47 % during the year of 1998 (IIPS & ORCM, 2000).

Table 4.3: Description of evidence of result identified from National Family Health Survey -2

Reference Study Design Study Sample Size Input

variables

Output

Variable

Results

International

Institute of

Population

Science andORC Macro

(IIPS &

ORCM,

2000)

Survey

followed by

interviews and

questionnaires

among study

population

Total 90000

married women

with in age group of

1549 wereinterviewed from 26

states in different

stages.

Child

Health

Child

Mortality

Prevalence

of

Underweigh

t

Nutrition

and Health

Underweight

Prevalence:

Total= 47%

(Wasted children

19.7%, Urban= 38

Rural= 50

Female= 49%, M

= 45%)

4.2.3 IIPS & MI, 2007 (National Family Health Survey-3): The third National Family Health

Survey was conducted by IIPS with the technical support of MACO International (USA) in 2005-2006. It

has revealed enormous facts and figures about the health status of Indian population including some not


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so pleasant information about childhood malnutrition. It was carried out with the participation of each

population representation from 29 states in India. A nationally collected sample of 124,385 women within

the age group of 15- 49 and 74,369 men within age group of 15-54 from 109,041 households been taken

under this massive study (IIPS & MI, 2007). NFHS-3 was supported by 18 research centres including 5

population research centres (PRCs). It was funded by various organisations such as the United States

Agency for International Development (USAID), The United Kingdom aid for the Department ForInternational Development (DFID), the Bill and Melinda Gates Foundation, United Nation International

Children Emergency Fund (UNICEF), United Nation Fund for Population Activities (UNFPA), and

Ministry of Health and Family Welfare Government of India (MOHFW). According to NFHS -3, nearly

half of children within age group of 0 to 5 were under chronic malnutrition. Study defines underweight

according to NCHS/ WHO international growth standard as well as newly accomplished WHO child

growth standard. However, here the study only focused on NCHS/WHO standard as same as all other

litterateurs defined underweight. This is focused to perform a meta-analysis to find overall prevalence of

underweight. According to NCHS/ WHO standard, the prevalence of underweight children was 48 per

cent (IIPS & MI, 2007). (Newly established WHO standard finds 43 per cent in prevalence of

underweight among Indian children which is same to the NCHS/ WHO 48%, which is not taken for this

review as early mentioned). Prevalence rate across gender was estimated as female 43.1% and for themale counterpart as 41.9%. Also study describes the rural and urban prevalence such as 43.7% and 30.1%

respectively (IIPS & MI, 2007).

Table 4.4: Description of evidence of result identified from National Family Health Survey -3


variables

Output

Variable

Results

(International

Institute

Population

Science and

MACRO

International,

IIPS & MI

2007)

Survey

followed by

interviews and

questionnaires

among study

population

Nationally collected

sample of 124,385

women within the agegroup of 15- 49 and

74,369 men within

age group of 15-54

from 109,041

households

Child

Health

Child

Mortality

Prevalence

of

Underweigh

t

Nutrition

and Child

Health

Underweight

Prevalence:

Total = 48

(NCHS/ WH

International Grow

Standard)

(Urban= 30.1% ,

Rural=

43.7% ,Femal43.1% , Male

41.9% )


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4.2.4. Kumar R, et al. (1996).

Kumar et al. (1996) aimed at determining the nutritional status and validity of mid upper armcircumference (MAC) in diagnosing malnutrition among preschool children. It conducted crosssectional household surveys with 3747 children below six years at 47 villages in Ambala, adistrict of Haryana. Trained field workers have been used to identify the data for this research.Study reported 49.6% of total underweight prevalence in children whereas 48.8 were stunted(low height for weight) and 9.1% of children wasted in its results (Kumar et al., 1996).According to this study the prevalence of underweight across gender classified as 47.4% of malechildren and 52% of female children. Study concluded with an assumption of almost everysecond child in this study was undernourished.

Table 4.5: Description of evidence of result identified from Kumar et.al. (1996)

Reference Study Design Study Sample Size Inputvariables

OutputVariable

Results

Kumar

et.al , (1996)

Cross-

sectional

household

survey(Train

ed fieldworkers

recorded

age, weight,

length/

height and

MAC of

children)

3747 children

aged less than six

years

nutritional

status and

validity of

mid upper

arm

circumference

(MAC)

malnutrition

among

preschool

children

Prevalence

of

Underweight

Underweight

Prevalence:

Total = 49.6%

( Female= 52%

Male = 47.4% )

4.2.5. Bisai et al. (2010).

The purpose of the study was to assess the nutritional status among urban poor children aged

between 1 and 5 years in 3 municipal wards of 24-parganas district of west Bengal, India. A total

of 899 children (boys=517; girls=382) were selected for the study. The study followed a cross

sectional survey with having a questionnaire and simple random sampling method. According to

the results of the study, the underweight prevalence of children among urban poor children

within a selected community was 63.6 % (Bisai et al., 2010). It also reports 5.7% of stunted and


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22.0% of wasted children. The underweight prevalence of male children was 65.5% whereas

as female population being 60.9%. Also study found the percentage of underweight among

Tribal, Muslim, Hindu children as 71.5%, 67.2% and 57.6% respectively. Study concluded with

an assumption that selected group of children found higher prevalence of underweight and noted

that it is a critical situation among that classification of children (Bisai et al., 2010).

Table 4.6: Description of evidence of result identified from Bisai et al. (2010)

Reference Study

Design

Study Sample Size Input

variables

Output

Variable

Results

Bisai et. al,

(2010)

cross

sectional

study

[age, sex,

religion,

caste, weight

and height

were

collected

from each

subject

through

questionnaire

Following

simple

Total 899 children

(boys=517;

girls=382) aged 1-5

years.

Urban,

Poor

children,

Underweight

,

Stunting,

Wasting.

Hindu,

Muslim,

Tribal.

Prevalence

of

Underweight

prevalence

of stunting

and wasting

Underweight

Prevalence:

Total = 63.6 %,

(Female= 60.9 % ,

Male = 65.5% ,

Wasted = 22.0 %

Stunted = 5.7 %

Tribal (71.5%

Muslim (67.2%

Hindu (57.6%))


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random

sampling

method.]

4.2.6. Besai et.al (2011).

Besai et al. (2011) aimed at determining the prevalence of underweight, stunting and wasting inKora-Mudi children of Paschim Medinipur, West Bengal, India. It has undertaken a crosssectional survey with participants of 119 children aged between 1and 13 years (59boys & 60girls) from two villages of the Paschim Medinipur District, West Bangal, India. Study found theprevalence of underweight of 52.9% among children (Besai et al. (2011). It also found that thewasting and stunting percentage was 22.7% and 49.6% respectively. The underweight prevalenceof male children was 57.6% and female as 48.3%. Study concluded with indicating thedangerous situation of higher prevalence among children in Kora-Mudi children aged 2-13 years

in Paschim Medinipur District, West Bengal, India.

Table 4.7: Description of evidence of result identified from Bisai et al. (2011)

Reference Study

Design

Study Sample Size Input

variables

Output

Variable

Results


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Bisai et al

(2011)

Cross-

sectional

Study

[a cross

sectional

study was

undertaken

in two

villages of

the

Paschim

Medinipur

District]

119 children aged

2-13 years, 59 boys

and 60 girls

underweight,

stunting and

wasting

weight-for-

age, height-

for-age and

weight-for-

height

Prevalence

of

Underweigh

t

prevalence

of stunting

and wasting

Underweight

Prevalence:

Total = 52.9%

(Female= 48.3%

Male =57.6%, )

Prevalence o

stunting and wasting

was 49.6% and

22.7%

4.2.7. Biswas et al. (2011).

Biswas et al. (2011) aimed at determining health, nutrition and immunization status of childrenunder the age of five among brick kiln internal migrant population of periurban Kolkata, India. Itwas also aimed at finding the different risk factors associating with nutritional status of study population. A cross sectional survey (observational community based) has been undertakenamong brick kilns of periurban Kolkata, along the eastern banks of the river Hooghly, India.Direct interview, clinical examination and anthropometric measurements followed to measurethe prevalence of underweight among children under five among stated population. Researchfound the prevalence of underweight as 64.9% whereas stunting and wasting 64.9% and 20.3%respectively Biswas et al. (2011). The prevalence of underweight among male children wasidentified as 47.9% and female population as 52.1%. Study identifies the risk factors associatedwith under nutrition as Acute Respiratory Infections, Improper immunization, socioeconomicstatus and the lack of proper breast feeding. Study concluded with an emphasis of proper breastfeeding for the improvement of nutritional status of children.


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Table 4.8: Description of evidence of result identified from Biswas et al. (2011)


variables

Output

Variable

Results

Biswas et al

(2011)

Cross-

sectional,

Observational

Community

based study

[House to

house visit,

Clinical

examinationand

Anthropometri

c

measurements

of the under

five children

and interview

of the adult

care-givers

with a pre-

designed pre-

tested

proforma]

74 children aged less

than five years

Migratory,

Brick

Klin,

dissertation submision 03-01-2012

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