Nutritional Disparities among Women in Urban India

The paper presents a wealth quartile analysis of the urban subset of the third round of Demographic Health Survey of India to unmask intra-urban nutrition disparities in women. Maternal thinness and moderate/ severe anaemia among women of the poorest urban quartile was 38.5% and 20% respectively and 1.5-1.8 times higher than the rest of urban population. Receipt of pre- and postnatal nutrition and health education and compliance to iron folic acid tablets during pregnancy was low across all quartiles. One-fourth (24.5%) of households in the lowest urban quartile consumed salt with no iodine content, which was 2.8 times higher than rest of the urban population (8.7%). The study highlights the need to use poor-specific urban data for planning and suggests (i) routine field assessment of maternal nutritional status in outreach programmes, (ii) improving access to food subsidies, subsidized adequately-iodized salt and food supplementation programmes, (iii) identifying alternative iron supplementation methods, and (iv) institutionalizing counselling days

Internal validity and reliability of experience-based household food insecurity scales in Indian settings

Background: Experience-based household food insecurity (HFI) scales are not included in large-scale Indian surveys. There is limited evidence on which experience-based HFI scale or questions within a scale are most relevant for India. Between 01 June and 31 August 2015, we reviewed 19 published and unpublished studies, conducted in India between January 2000 and June 2015, which used experience-based HFI scales. As part of this exercise, internal validity and reliability of the scale used in these studies was examined, field experiences of 31 researchers who used experience-based HFI scales in India were gathered and psychometric tests were conducted where raw data were available. Results: Out of the 19 studies reviewed, HFI prevalence varied depending on the type of experience-based HFI scale used. Internal reliability across scales ranged between 0.75 and 0.94; however certain items ('balanced meal', 'preferred food', 'worried food would run out') had poor in-fit and out-fit statistics. To improve this, the following is suggested, based on review and experience of researchers: (1) cognitive testing of quality of diet items; (2) avoiding child-referenced items; (3) rigorous training of enumerators; (4) addition of 'how often' to avoid overestimation of food-insecure conditions; (5) splitting the cut and skip meal item and (6) using a standardized set of questions for aiding comparison of construct validity across scales. Conclusions: An evidence-based policy dialogue is needed in India for contextualizing and harmonizing the experience-based HFI scales across multiple surveys to aid comparability over time, and support policy decision making

Birth Preparedness and Complication Readiness among Slum Women in Indore City, India

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR)=1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR=1.7, CI 1.05-2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries

Human touch to detect hypothermia in neonates in Indian slum dwellings

ABSTRACT Objective. To assess the validity of human touch (HT) method to measure hypothermia compared against axillary digital thermometry (ADT) and study association of hypothermia with poor suckle and underweight status in newborns and environmental temperature in 11 slums of Indore city, India. Methods. Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Underweight status was determined using WHO growth standards. Results. Hypothermia prevalence (axillary temperature <36.5 o C) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%). Conclusions. HT emerged simpler and programmatically feasible. There is a need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness. [Indian J Pediatr 2010; 77 (7) : 759-762] E-mail: [email protected], [email protected] Key words: Urban poor; Newborn; Hypothermia Urban poor constitute one-third of India's urban population. 1 Despite a plethora of health facilities in cities, 56% urban poor newborns are born at home. 2 Among home births, 87% are attended by an unskilled provider resulting in poor intra and postpartum care. 2 These factors contribute to high rates of hypothermia. Hypothermia is an important contributor of neonatal deaths. Hence, its early recognition and prompt management is crucial. Human touch (HT) is one simple programmatically feasible method to detect neonatal hypothermia. However, there is no study that validated HT in Indian slum settings. This study estimated the prevalence of neonatal hypothermia through trained slum-level field workers using HT and axillary digital thermometry (ADT) and assessed diagnostic accuracy of HT. MATERIAL AND METHODS The study was conducted in 11 slums of Indore between December 2004 and February 2006. These slums were among the 79 slums where a health intervention of a nongovernment organization was operational, through a network of slum-based women groups, health volunteers (1/3,000 population) and field extension workers (1/ 15,000 population). A trained Field Extension Worker (FEW) measured body temperature of 152 newborns in day time during field visits, first using HT and then ADT. She used dorsum of her right hand to assess newborn's skin temperature at abdomen (just below the umbilicus) and soles of feet. She classified the newborn as warm, mildly hypothermic and moderately hypothermic if both abdomen and soles were warm, abdomen warm and soles cold, both abdomen and soles were cold, respectively. Based on the condition, FEW counselled the mother on home-based warming measures 3 and danger signs for referral

Birth preparedness and complication readiness among slum women in Indore City, India

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR)=1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR=1.7, CI 1.05-2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries

Right message, right medium, right time: powering counseling to improve maternal, infant, and young child nutrition in South Asia

IntroductionQuality counseling can positively impact maternal, infant and young child nutrition (MIYCN) behaviors linked to poor nutrition outcomes. Global guidance includes 93 recommendations on MIYCN counseling.MethodsA desk review and key informant interviews sought to assess compliance to the recommendations, reach and quality, systemic gaps and opportunities for MIYCN counseling in seven South Asian countries. Ninety-three (93) policies and guidelines, 180 counseling materials and over 50 documents were reviewed; 115 key informant interviews were conducted. Information synthesis captured eight domains. Data from national surveys were analyzed to determine MIYCN counseling reach, quality and association with nutrition behaviors.ResultsResults showed that national guidelines were inconsistent with global recommendations for seven thematic areas. Coverage of contacts points like antenatal and postnatal care (ANC, PNC) with potential to deliver MIYCN counseling was highly variable. Having at least four ANC contacts was significantly associated with consumption of 100+ iron folic acid tablets in all countries. Rates of early initiation of breastfeeding (18% Pakistan to 90% Sri Lanka) were lower than institutional delivery rates, except for Bangladesh and Sri Lanka. PNC contact within 48 h of birth was positively correlated with exclusive breastfeeding in India, Pakistan and Sri Lanka (OR 1.4, 3.1, 3.2). Health worker contacts and wealth status equally influenced child’s dietary diversity in India. MIYCN services were add-on roles for community-based workers, except in India. Supervision mechanisms exist but were not focused on quality of MIYCN services. Counseling resources were predominantly paper based (>70%), had rural-focused messaging on diets and mainly targeted women. Platforms to engage men were largely missing. Health management information systems included indicators on maternal contact points in all countries but not for children. Assessing funding for MIYCN counseling was challenging as costs were subsumed across several budget line-items.DiscussionThe research findings can be used to (1) align country guidance with global recommendations, (2) review workforce responsibilities and capacity building with supervision, (3) assess the need for new counseling materials based on coverage of content, service providers and audience, (4) integrate MIYCN counseling indicators in information systems and (5) include MIYCN counseling services with activities and budget in country plans

Partnering with women collectives for delivering essential women\u2019s nutrition interventions in tribal areas of eastern India: a scoping study

Background: We examined the feasibility of engaging women collectives in delivering a package of women\u2019s nutrition messages/services as a funded stakeholder in three tribal-dominated districts of Odisha, Jharkhand and Chhattisgarh States, in eastern India. These districts have high prevalence of child stunting and poor government service outreach. Methods: Conducted between July 2014 and March 2015, an exploratory mix-methods design was adopted (review of coverage data and government reports, field interviews and focus group discussion with multiple stakeholders and intended communities) to assess coverage of women\u2019s nutrition services. A capacity assessment tool was developed to map all types of community collectives and assess their awareness, institutional and programme capacity as a funded stakeholder for delivering women\u2019s nutrition services/behaviour promotion. Results: Limited targeting of pre-pregnancy period, delays in first trimester registration of pregnant women, and low micronutrient supplementation supply and awareness issues emerged as key bottlenecks in improving women\u2019s nutrition in these districts. Amongst the 18 different types of community collectives mapped, Self Help Groups (SHGs) and their federations (tier 2 and tier 3), with total membership of over 650,000, emerged as the most promising community collective due to their vast network, governance structure, bank linkage, and regular interface. Nearly 400,000 (or 20% of women) in these districts can be reached through the mapped 31,919 SHGs. SHGs with organisational readiness for receiving and managing grants for income generation and community development activities varied from 41 to 94% across study districts. Stakeholders perceived that SHGs federations managing grants from government and be engaged for nutrition promotion and service delivery and SHG weekly meetings can serve as community interface for discussing/resolving local issues impeding access to services. Conclusions: Women SHGs (with tier 2 and tier 3) can become direct grantees for strengthening coverage of women\u2019s nutrition interventions in these tribal districts/pockets, provided they are capacitated, supervised and given safe guards against exploitation and violence

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review.

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia

Research priorities for nutrition of school-aged children and adolescents in low- and middle-income countries.

PURPOSE: A lack of data, intervention studies, policies, and targets for nutrition in school-age children (SAC) and adolescents (5-19 years) is hampering progress towards tackling malnutrition. To stimulate and guide further research, this study generated a list of research priorities. METHODS: Using the Child Health and Nutrition Research Initiative (CHNRI) method, a list of 48 research questions was compiled and questions were scored against defined criteria using a stakeholder survey. Questions covered all forms of malnutrition, including micronutrient deficiencies, thinness, stunting, overweight/obesity, and suboptimal dietary quality. The context was defined as research focused on SAC and adolescents, 5 to 19 years old, in low-and middle-income countries, that could achieve measurable results in reducing the prevalence of malnutrition in the next 10 years. RESULTS: Between 85 and 101 stakeholders responded per question. Respondents covered a broad geographical distribution across 38 countries, with the largest proportion focusing on work in East and Southern Africa. Of the research questions ranked in the top ten, half focused on delivery strategies for reaching adolescents and half on improving existing interventions. There were few differences in the ranked order of questions between age groups but those related to in-school children and adolescents had higher expert agreement than those for out-of-school adolescents. The top ranked research question focused on tailoring antenatal and postnatal care for pregnant adolescent girls. CONCLUSION: Nutrition programmes should incorporate implementation research to inform delivery of effective interventions to this age group, starting in schools. Academic research on the development and tailoring of existing nutrition interventions is also needed; specifically, on how to package multisectoral programmes and how to better reach vulnerable and underserved sub- groups, including those out of school

Are advertising policies affirmative in restricting the marketing of foods high in fat, salt and sugar (HFSS) in India?: Evidence from SWOT Analysis

The regulatory Indian environment for advertising high fat, salt, and sugar (HFSS) foods and non-alcoholic beverages, on various media was reviewed. Identified national-level policies were categorised as mandatory or self-regulatory based on legal content. For each mandatory regulation, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was undertaken to determine how existing policies could be strengthened to safeguard children from unhealthy food advertisements. Thirteen policies (nine mandatory; four self-regulatory) relevant to advertising in India were identified. Of the nine mandatory policies, Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022, is the only policy that restricts HFSS food advertisements to children across all media. There are key shortfalls, including limited scope of ‘child-targeted’ advertisements and lack of criteria to define HFSS foods. A robust regulatory framework is needed to protect children from HFSS food marketing, not just what is ‘directed’ at them, with clear evidence-based food classification criteria.Funding source: The work is supported by the UNICEF India Country Office, New Delhi, India