Assessing Malnutrition, Screening children for developmental milestones and the effect of malnutrition on child development in the Juang

tribe in Kendujhar District of Orissa ( INDIA)

By Dr Samrat Kumar School of Public Health SRM University

Centre for Children Studies KSRM, KIIT University Patia, Bhubaneswar

Report On
Assessment of Malnutrition, Child development and the effect of malnutrition on child development in the Juang tribe of Orissa

Submitted to: Centre for Children Studies, KSRM, KIIT University, Bhubaneswar-751031

Submitted by: Dr Samrat Kumar MPH Scholar, School of Public Health, SRM University.

Dedicated to My Parents

Contents
List of Tables and Bar Diagrams: Acknowledgements: Acronyms and Definitions Developmental Milestones: Introduction Indian Context Orissa Context: Rationale of the study: Objectives Review of literature Methodology Data collection Results and Discussion Conclusions Recommendations Annexure 5 6 7 7 8 10 11 18 19 20 23 24 25 35 36 37

List of Tables and Bar Diagrams:

Tables
Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Bar Diagrams Bar Diagram 1 Bar Diagram 2 Bar Diagram 3 Bar Diagram 4 Bar Diagram 5 Bar Diagram 6 Bar Diagram 7 Bar Diagram 8 Bar Diagram 9 Bar Diagram 10 Bar Diagram 11 Bar Diagram 12 Bar Diagram 13 Nutritional status of children (India) Fertility rate and wealth Children receiving Anganwadi services Trends in children nutritional Status Anemia among women and children Nutritional status of children( Juang Tribe) Weight for age status Weight for height status Height for age status Status of milestones achieved Weight for age and milestones Status Weight for height and milestones Status Height for age status and milestones 11 12 13 14 15 26 26 28 29 30 31 32 33 Adivasi Child Mortality Nutritional Status Children under 6 years Population of Orissa ST population Orissa Kendujhar Sub-division Population Socio-demographic Details Chi Square Analysis WHO guidelines on prevalence of malnutrition 10 15 15 21 21 25 26 34

Figure Analytical Framework 22

Acknowledgements:
I take this opportunity to thank Centre for children studies (CCS), KIIT School of Rural Management, KIIT University, Bhubaneswar and State Office of UNICEF Orissa, for allowing me to be a part of the internship programme. I have taken efforts in this project. However, it would not have been possible without the kind support and help of many individuals and organizations. I would like to extend my sincere thanks to all of them. I am highly indebted to Mrs Nandini Sen, Mrs Kalika Mahaptra, Mr Nihar Singh, Dr Unmesh Patnaik and Prof. L K Vaswani for their guidance and constant supervision as well as for providing necessary information regarding the project & also for their support in completing the project. I would like to express my gratitude towards Dr Vishal, Fatma Alam, Bikash, my parents and my brother for their kind co-operation and encouragement which help me in completion of this project. Sincere thanks to Mr Trinath, Mr Dilip and all the Anganwadi workers and helpers in the Banspal area for giving me such attention and time while data collection which made the fieldwork a valuable learning experience. My thanks and appreciations also go to my mentor Dr Rajan R Patil , Dr Anil I Krishna, Ms Geetha and my colleague Emmanuel O Salawu for the help in developing the project and people who have willingly helped me out with their abilities. Finally, special thanks to CCS coordinator Mr Onkar Nath Tripathi who helped me at every stage from beginning till the end. I extend my gratitude for his unrelenting support, inspirational guidance, lighthearted humour and his concern for humanity. More than just a coordinator, he has been a mentor and guide to me during the entire study period.

Acronyms and Definitions

AWC AWW ICDS WHO W/A W/H H/A NFHS Anganwadi Centre Anganwadi Worker Integrated Child Development Scheme World Health Organization Weight for age Weight for Height Height for Age National Family Health Survey

Developmental Milestones: Skills such as taking a first step, smiling for the first time, and waving "bye bye" are called developmental milestones. Children reach milestones in how they play, learn, speak, behave, and move (crawling, walking, etc.). (CDC National Center on Birth Defects and Developmental Disabilities, Atlanta,US).

Introduction As children are the future of every country, their situation is always of concern to policy makers, their parents and the general public. Ensuring children's health is a universally supported goal of development. In developing countries, children and adults are vulnerable to malnutrition because of low dietary intakes, infectious diseases, lack of appropriate care, and inequitable distribution of food within the households(1). Malnutrition has long been recognized as a consequence of poverty. It is widely accepted that higher rates of malnutrition will be found in areas with chronic widespread poverty. Malnutrition is the result of marginal dietary intake compounded by infection. In turn, marginal dietary intake is caused by household food insecurity, lack of clean water, lack of knowledge on good sanitation, and lack of alternative sources of income. It is also compounded by, inadequate care, gender inequality, poor health services, and poor environment. While income is not the sum of total of people's lives, health status as reflects by level of malnutrition is. Because having good health condition is important precondition for escaping poverty and because improved health and sanitation contribute to growth, investment in people's health and nutritional status is fundamental to improving a countrys general welfare, promoting economic growth, and reducing poverty(2). Meeting primary health care needs and the nutritional requirements of children are fundamental to the achievement of sustainable development. In the United Kingdom and a number of Western European countries about half their economic growth achieved between 1790 and 1980 has been attributed to better nutrition and improved health and sanitation conditions (3). Malnutrition in childhood is known to have important long-term effects on the work capacity and intellectual performance of adults. Health consequences of inadequate nutrition are enormous. It was estimated that nearly 30% of infants, children, adolescents, adults and elderly in the developing world are suffering from one or more of the multiple forms of malnutrition, 49% of the 10 million deaths among children less than 5 years old each year in the developing world are associated with malnutrition, another 51% of them associated with infections and other causes(4). Recent studies have also pointed out those women who were malnourished as children are more likely to give birth to low birth-weight children and thus there is an intergenerational effect of child malnutrition. A practical advantage of using child malnutrition as a poverty indicator over income level is that this measure does not have to be adjusted for inflation and would not be constrained by any inadequacy of price data. Measures of child nutritional status can help capture aspects of welfare, such as distribution within the household which are not adequately reflected in other indicators. Child malnutrition standards are applicable across cultures and ethnicities. Evaluation of nutritional status is based on the rationale that in a well-nourished population, there is a statistically predictable distribution of children of a given age with respect to height and weight. In any large population, there is variation in height and weight; this variation approximates a normal distribution. Use of a standard reference population as a point of comparison facilitates the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. The use of a reference population is based on the empirical finding that well-nourished children in all population groups for which data exist follow very similar growth patterns before puberty. Adequate

nutrition is critical to child development. The period from birth to two years of age is important for optimal growth, health, and development. At this age, children are particularly vulnerable to growth retardation, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute respiratory infections (ARI).

THE MAGNITUDE OF MALNUTRITION AND DIARRHEA Global mortality among children under the age of 5 years approximates 9.710.6 million deaths each year (or 26,00029,000 children each day), of whom 18% (i.e., 1.9 million per year or over 5000 per day) die due to diarrhea(5). Moreover, fully 53% (5.6 million) of these deaths are associated with malnutrition. Furthermore, it is estimated that maternal and childhood under nutrition is the underlying cause of 3.5 million deaths and 35% of the disease burden in children younger than 5 years, accounting for fully 11% of the total global DALYs (disability adjusted life years)(5).We suggest that a substantial proportion of global malnutrition is due to impaired intestinal absorptive function resulting from multiple and repeated enteric infections. These include recurrent acute infections as well as persistent infections, even those without overt liquid diarrhea. Furthermore, impaired innate and adaptive host immune responses and disrupted intestinal barrier function due to malnutrition and diarrheal illnesses likely combine to render weaning children susceptible to repeated bouts of enteric infections leading to intestinal injury and, consequently, nutrient malabsorption during the developmentally critical first 2 years of life. Evidence from the existing literature suggest that the impact of heavy diarrheal burdens and multiple enteric infections in the early formative years of childhood extends long beyond the infection itself and affects both growth and cognitive development in affected children(5). Malnutrition during childhood can also affect growth potential and risk of morbidity and mortality in later years of life. Malnourished children are more likely to grow into malnourished adults who face heightened risks of disease and death. Poor nutritional status of women has been associated with a higher age at menarche(6) and a lower age at secondary sterility(6).

Indian Context Almost half of children under five years of age (48 percent) are stunted and 43 percent are underweight. The proportion of children who are severely undernourished (more than three standard deviations below the median of the reference population) is also notable24 percent according to height-for-age and 16 percent according to weight-for-age. Wasting is also quite a serious problem in India, affecting 20 percent of children under five years of age. Very few children under five years of age are overweight. Less than 2 percent have a weight-for-height estimate more than two standard deviations above the median for the reference population and less than 1 percent are more than two standard deviations above the median on the weight-for-age indicator(1). Under nutrition is substantially higher in rural areas than in urban areas. Even in urban areas, however, 40 percent of children are stunted and 33 percent are underweight. Children who are judged by their mother to have been small or very small at the time of birth are more likely to be undernourished than those who were average size or larger. Under nutrition has a strong negative relationship with the mothers education. The percentage of children who are severely underweight is almost five times as high for children whose mothers have no education as for children whose mothers have 12 or more years of education. Children from households with a low standard of living are twice as likely to be undernourished as children from households with a high standard of living. Inadequate nutrition is a problem throughout India, but the situation is considerably better in some states than in others. Even in these states, however, levels of under nutrition are unacceptably high. ST children in India: 53.9% stunted, 24.7 are wasted and 54.5% are underweight(1). Table 1

The mortality in the tribal children had been found to be more in relation to their share of the total population in rural areas. The table above describes the situation in different communities as per NFHS 2005 data.

Bar Diagram 1

Percent of children under 3 years of age , India

60

51
50 40 30

45

43

40

20
20 10 0

23

NFHS 2 NFHS 3

stunted

wasted

underweight

The proportion of children under three years of age who are underweight decreased from 43 percent in NFHS-2 to 40 percent in NFHS-3(1), and the proportion severely underweight decreased from 18 percent to 16 percent. Stunting decreased by a larger margin, from 51 percent to 45 percent. Severe stunting also decreased, from 28 percent to 22 percent.

Orissa Context:
All but 3 percent of households in Orissa have household heads who are Hindu. One percent of households have Muslim heads and 1 percent had Christian heads. One-fifth of households belong to a scheduled caste, 23 percent belong to a scheduled tribe, and 27 percent belong to Other Backward Classes (OBC). Thirty percent of Orissas households do not belong to scheduled castes, scheduled tribes, or other backward classes. Compared to the national average, Orissas population is poor as 40 percent of Orissa's population is in the lowest wealth quintile, compared to 20 percent of India's population. Fortytwo percent of Orissas households (48% in rural areas and 13 percent in urban areas) are in the lowest wealth quintile and only 21 percent are in the two highest wealth quintiles combined (1).

Bar Diagram 2

The average size of the family is high among the low income families, as shown above; it affects the nutritional status of the child in the low income families. Source: NFHS-3(1) The infant mortality rate in NFHS-3 is estimated at 65 deaths before the age of one year per 1,000 live births, down from the estimate of 81 in NHFS-2 and 112 in NFHS-1. The under-five mortality rate is 91 deaths per 1,000 live births. Infant and child mortality rates in Orissa are higher than the national estimates. The higher rates of infant and child mortality in Orissa imply that, despite declines in mortality, 1 in 15 children still die within the first year of life, and 1 in 11 die before reaching age five. The ICDS programme provides nutrition and health services for children under age six years and pregnant or breastfeeding women, as well as preschool activities for children age 3-5 years. These services are provided through community-based anganwadi centres. Among the 80 percent of children under six years in Orissa who are in areas covered by an anganwadi centre, two-thirds (66%) receive services of some kind from a centre. The most common services children receive are growth monitoring (56% of children age 0-59 months), supplementary food (53% of children under six years of age), health check-ups and immunizations (42-43% of children under six years of age). Twenty-eight percent of children ages 3-5 years receive early childhood care or preschool services. Thirty percent of mothers of children who were weighed at an anganwadi centre received counseling from an anganwadi worker after the child was weighed

Bar Diagram 3

Children of mothers with less education and mothers in the lowest wealth quintile are most likely and children of mothers who have completed high school or who are in the highest wealth quintile are least likely to take advantage of the services offered at anganwadi centres. Children from scheduled castes and scheduled tribes are more likely to receive services from an anganwadi centre than children from other groups. Infant feeding Although breastfeeding is nearly universal in Orissa, only 51 percent of children under 6 months are exclusively breastfed, as the World Health Organization recommends(4). Eighty-two percent are put to the breast within the first day of life, including 55 percent who started breastfeeding in the first hour of life, which means that the majority of infants in Orissa received the highly nutritious first milk (colostrums) and the antibodies it contains. Mothers in Orissa breastfeed for an average of 34 months, which is almost a year longer than the minimum of 24 months recommended by WHO for most children. It is recommended that nothing be given to children other than breast milk in the first three days when the milk has not begun to flow regularly. However, 42 percent of children are given something other than breast milk during that period. Childrens nutritional status Forty-five percent of children under age five are stunted, or too short for their age, which indicates that they have been undernourished for some time. Twenty percent are wasted, or too thin for their height, which may result from inadequate recent food intake or a recent illness. Forty-one percent are underweight, which takes into account both chronic and acute.

Bar Diagram 4

undernutrition. Even during the first six months of life, when most babies are breastfed, 26 percent of children are stunted, 28 percent are wasted, and 36 percent are underweight. Children in rural areas are more likely to be undernourished, but even in urban areas, more than one-third of children (35%) suffer from chronic undernutrition. The majority of scheduled-tribe children are stunted (57%) or underweight (54%). Girls and boys are about equally likely to be undernourished. Childrens nutritional status in Orissa has improved since NFHS-2 by all three standard measures of nutrition. Both chronic and acute undernutrition was less widespread in Orissa at the time of NFHS-3 than they were seven years earlier. Anaemia: Sixty-one percent of women in Orissa have anaemia, including 45 percent with mild anaemia, 15 percent with moderate anaemia, and 2 percent with severe anaemia. Two-thirds of women who are pregnant (69%) and who are breastfeeding (65%) are anaemic. The prevalence of anaemia is lower among the more educated and among those who are in the higher wealth quintiles; however, in every other group more than half of women are anaemic.

Bar Diagram 5

Anaemia among children age 6-35 months was slightly higher in NFHS-3 than it was seven years earlier at the time of NFHS-2. Around 71% of Schedule Tribe people have the lowest quintile in the wealth index as per NFHS-3. The Birth order of 4+ is 36.7% in ST Population, 30.7% in the lowest wealth quintile, 33.5 % among the illiterate mothers. Table 2 Children under 6 years (% age) Nutritional Status:
Height/ Age Weight/Height Weight/Age

< -3sd ST 28.4

< -2sd 57.2

Mean Z score -2.1

< -3sd 8.2

< -2sd 27.6

Mean Z score -1.3

< -3sd 22.9

< -2sd 54.4

Mean Z score -1.9

Source: NFHS-3

Table 3 Population of Orissa: 1. Child Population (0-6 years): 2. Child sex ratio(0-6 years): 3. Literacy rate: Kendujhar District: 1. Population: 2. Child sex ratio(0-6yrs): 3. Child population(0-6yrs):
Source: Census of India-2011

41,947,358 5,035,650 934 females/1000 male children 73.45% Male: 82.4% Female: 64.36% 1,802,777 (4.3% of Population of Orissa) 957 females/1000 males 253,418

57% stunted and 54.4 % are underweight among the Schedule Tribe children of Orissa.

JUANG The Juangs are mostly concentrated in Banspal, Telkoi and Harichandanpur Blocks. They claim themselves to be the autochthons of the area from where they have migrated to other parts of the state. They classify themselves into two sections, viz. the Thaniya (those who dwell in their original habitation) and the Bhagudiya (those who have moved away to other places). The Juangs believe that in ancient times their tribe emerged from earth on the hills of Gonasika where the river Baitarani has its source, not far from the village Honda in Keonjhar. In their language the word "Juang" means man. In other words, man emerged from the earth at the same place where the river Baitarani emerged. The Juang also refer to themselves as patra-savaras (patra means leaf). By this they mean that they are that branch of the Savara tribe whose members used to dress themselves in leaves. They have got their own dialect which has been described by Col. Dalten as Kolarian. They have acquired many Oriya words by coming in contact with the Oriya speaking people. Most of them know and speak Oriya. In the Juang society, the village is the largest corporate group with formally recognized territory. Within the delineated land boundaries they possess their land both for settled and shifting cultivation and the village forests for exploitation. They shift their village sites frequently as they consider it inauspicious to live at a particular place for a longer period. Each Juang village is marked by the presence of a dormitory known as Majang where their traditional dance takes place and the village panchayat sits. It also serves as a guest-house for the visitors to the village. The Pradhan who is the secular headman and the Nagam or Boita or Dehuri, the village priest constitute the traditional village panchayat of the tribe. A group of neighbouring villages constitute a pirh which is headed by a Sardar who decides inter-village disputes. The Juangs are patrilineal and their society is marked by the existence of totemistic clans which are divided into two distinct groups known as "Bandhu clans" and "Kutumba clans". The totem is never destroyed or injured by its members. The clans are exogamous and marriage within the same clan is considered incestuous. Monogamy is commonly prevalent while polygamy is not ruled out . Levirate and sororate type of marriage is prevalent on the Juang society. A Juang husband generally worships the "Sajana"(drum stick) tree if his wife turns out barren and gives her a paste made of "Sajana" flowers and seeds to eat or he ties a sevenfold cotton string with seven knots round his wife's neck, believing this to be a kind of talisman which will cause conception. The Juangs do not allow their pregnant women to go to "Devisthan". She must not tie up anything, must not weave mat or plaster a house with mud. The Juang cremate their dead. The corpse is laid on the pyre with the head to the south . The ashes may be left on the spot of cremation, or alternatively they may be thrown into stream. For their livelihood they depend mainly on primitive shifting cultivation and collection of minor forest produce. The Juang life is marked by the celebration of a number of religious festivals in honour of their gods and goddesses. For them Dharam Devta and Basumata are the supreme deities. The former is identified with Sun God and the latter with Earth Goddess. Gramashree is the presiding deity of the village. There are also a number of hill, forest and river deities in the Juang pantheon. They believe in the existence of spirits and ghosts. They observe Pusha Purnima as a mark of the beginning of the agricultural cycle, Amba Nuakhia as the first eating of mango fruits, Akhaya Trutiya as the ceremonial sowing of paddy, Asarhi, marking the beginning of transplanting and weeding, Pirha Puja for the protection of crops, Gahma for the welfare of domestic cattle and other auspicious days for the ceremonial eating of new rice harvested from different types of lands . All these occasions are marked by dancing and singing. They use a kind of drum known as changu at the time of dancing. For the socio-economic development of the Juangs a micro-project has been established in the Juangpirh at Gonasika. The project has assumed the responsibility for various development activities of the Juang.

Gradually the Juangs have started settled cultivation with modern technology. The podu ravaged areas are being covered with trees of different species. They have also started subsidiary occupation like tasar cultivation, tasar reeling, weaving, tailoring etc. Different infrastructural developments like communication, village electrification, social forestry, and drinking water supply are being implemented for their benefit. Under social activities, education, health care and preservation of the human values existing in them are being taken care of. (http://kendujhar.nic.in)

Rationale of the study: The evaluation will show the magnitude of child malnutrition in the primitive Tribe ( Juang) of Orissa. Empirical studies show that child malnutrition is closely linked to income level and the socio-economic status. A study also shows that child malnutrition is reflective and indicative of other desirable development outcomes i.e. gender equality, intra-household distribution, and health environment quality. That the relationship between child malnutrition and poverty is most sensitive at the lower end of the income range makes child malnutrition a good indicator for development intervention projects and programs, which generally target this section of the population. While child malnutrition could not universally be adopted as a poverty indicator at this point of time due to lack of universally available data, it's strength and relevance as a poverty indicator, particularly for monitoring poverty impacts on the low income population, is gradually being recognized by governments and international agencies around the globe. The Food and Agriculture Organization of the United Nation (FAO) and the International Funds for Agriculture and Development has recently included child malnutrition as one of the indicators to be assessed in their projects and programs. India is experiencing a rapid economic boom due in part to the opening of its markets in the 1990s and the emergence of a knowledge-based economy. However, this prosperity has not translated into well-being among the countrys young children. The prevalence of underweight (a widely used indicator of undernutrition) among children under age five in India is one of the highest in the world 43% in 2006 surpassed only by Bangladesh, Yemen and Timor(7). India is home to 55 million of the worlds underweight children under age five about one third of the global burden of underweight in this age group. During the prosperous 1990s, the average rate of decline in prevalence of underweight has been around 0.9% per year among Indian children aged below five years, whereas in China, another Asian country with a rapidly growing economy, it declined by approximately 5% per year. The nutritional status of young children is an important indicator of health and developmentit is not only a reflection of past health insults but an important indicator of future health trajectories. Children under age three are particularly vulnerable to undernutrition, and because the growth rate in this period is greater than any other age period, it increases the risk of growth retardation. Furthermore, undernutrition among young children captures the extent of development in a society and is thus a marker for the overall well being of a population. With this study, we are analysing the extent of malnutrition and its impact on child development in the Juang tribe in rural areas of Orissa. We have screened the children for the developmental milestones for the different age groups less than 3 years. The various intervention programs like ICDS, MDM and SNP are working to lower down the malnutrition among preschool children. ICDS is also contributing for the adequate child development by providing preschool education at the Anganwadi centers, which includes the social, emotional, cognitive and motor skills in the children. This study is an attempt to understand the level of malnutrition existing in the Juang Tribe, which is a primitive tribe of Orissa, and as such there is no such nutritional data available specifically for the Juang tribe. We are trying to find out the malnutrition and its coexistence with the poor performance in respect of the Child development milestones. As studies have shown the nutrient deficiencies affect the normal development of the child like cognition, motor skills and also the other skills like social and emotional

which are related with the social and cultural environment. The various background characteristics of the population affect the nutrition of the child as it is an environmental factor and similarly the child development. The study will reveal the situation of the children in the Juang community, the prevalence of malnutrition i.e. Underweight, Stunted and Wasted Children, the achievement of developmental milestones and various factors associated with nutritional status of the children less than 3 years of age.

Objectives

To assess the status of Malnutrition in children less than 3 years of age in the Juang tribe in kendujhar district of Orissa. To assess the level of Development in children less than 3 years of age in juang tribe.

To determine the impact of malnutrition on children development in the juang tribe.

Review of literature The various studies conducted to assess the nutritional status of the children explain about the various underlying factors responsible for malnutrition. Harishanker et al (8) found that the maximum overall prevalence of malnutrition was recorded in the age group 13-24 months, prevalence of malnutrition was 56.63% in Schedule Cast population, low educational status of parents, low socioeconomic status and large family size are the probable precipitating factors. Poverty, illiteracy and ignorance are the main reasons which lead to malnutrition. ICMR Bulletin 2003, A study carried out recently by RMRC, Bhubaneswar amongst four primitive tribes of Orissa, revealed an infant mortality rate (per 1000 live birth) of 139.5 in Bondo, 131.6 in Didayi, 132.4 in Juanga and 128.7 in Kondha (Kutia); a maternal mortality rate (per 1000 female population) of 12 in Bondo, 10.9 in Didayi, 11.4 in Juanga and 11.2 in Kondha tribe. The wide spread poverty, illiteracy, malnutrition, absence of safe drinking water and sanitary conditions, poor maternal and child health services, ineffective coverage of national health and nutritional services, etc. have been found, as possible contributing factors of dismal health condition prevailing amongst the primitive tribal communities of the country Guerrant et al.2008,(5) Global mortality among children under the age of 5 years approximates 9.710.6 million deaths each year (or 26,00029,000 children each day), of whom 18% (i.e., 1.9 million per year or over 5000 per day) die due to diarrhea. Moreover, fully 53% (5.6 million) of these deaths are associated with malnutrition. Diarrhea and enteric infections impair weight and height gains, physical and cognitive development. The longterm impact of malnutrition on economic productivity has recently been documented by followup studies of 12-year-old male children treated with nutrient-dense atole in Guatemala between 1962 and 1977; the individuals now earn 46% more than their peers at ages 2542 years. Further intervention studies are needed to document the relevance of these mechanisms and, most importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their full potential. Subramanyam et al. 2010,(9) Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children. The nutritional status of young children is an important indicator of health and developmentit is not only a reflection of past health insults but an important indicator of future health trajectories. Children under age three are particularly vulnerable to undernutrition, and because the growth rate in this period is greater than any other age period, it increases the risk of growth retardation. Furthermore, undernutrition among young children captures the extent of development in a society and is thus a marker for the overall well being of a population. Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children.

Study Area: Orissa is regarded as the Homeland of Adivasis. More than 7 million tribal live in Orissa. They cover 22.21% of the total population of orrisa. It is 11% of the total tribal population of the country. Out of the 62 tribal communities in Orissa, 13 are the most primitive from cultural and technological point stand. The State of Orissa occupies an important place in the country having a high concentration of Scheduled Tribe and Scheduled Caste population. In terms of ST population, it is the second biggest in the country. Both Scheduled Tribe and Scheduled Caste constitute nearly 38.66% of the total State Population (S.Ts 22.13% and S.Cs 16.53% as per 2001 Census). The population of the members of the Scheduled Tribes and Scheduled Castes, as per 2001 Census(10) is as follows: Table 4
TOTAL POPULATION OF THE STATE SCHEDULED TRIBES (S.T.) POPULATION PERCENTAGE OF S.T. POPULATION TO TOTAL POPULATION S.T. COMMUNITIES 36804660 8145081 22.13 62

Source: ST & SC Development Department, Government of Orissa

Percent of population of Kendujhar which comes under ST. Kendujhar Total 44.50% Kendujhar Rural 47.81% Kendujhar Urban 23.56%

As per 1991 census there were 46 Scheduled Tribes in the district. Out of these the principal tribes were Bathudi, Bhuyan, Bhumij, Gond, HO, Juang, Kharwar, Kisan, Kolha, Kora, Munda, Oraon, Santal, Saora, Sabar and Sounti. These sixteen tribes constituted 96.12 % of the total tribal population of the district. The concentration of Scheduled Tribes is the highest in Keonjhar and lowest in the Anandapur Sub-Division. The study has been conducted in the Banspal Block in Kendujhar District of Orissa (India).The Juang villages are surveyed for the data collection in the Banspal block. The majority of Juang population is located in the Banspal block, and random selection of children under 3 years of age was done. Table 5
KEONJHAR SUB-DIVISION POPULATION RURAL 01. Keonjhar Sadar 58,036 02. Patna 41,972 03. Saharpada 39,732 04. Harichandanpur 54,340 05. Ghatagaon 55,122 06. Banspal 56,013 07. Telkoi 37,915 URBAN 01. Daitary Census Town 1,566 TOTAL :3,55,088

The total population of Juangs in Kyunjhar district is about 20000. It is supposed to be one of the main poverty pocket of Orissa, just as kalahandi-naupada districts are considered to be the poverty sricken pockets of the whole world.The juang inhabited panchayats are ravanapalsi, Badapalspal, Pithagoda,Hunda, Janghira,Badagoara, Gonasika, Kodiposa and Banspal. The deaths due to hunger occur regularly in these areas.

RESEARCH DESIGN: Cross-sectional Study, Descriptive Study (Prevalence Study) Research Framework: Child Malnutrition Child Development

Minimum Sample Size: 105 Sampling Method adopted: Multistage sampling protocol was adopted. It was such that 6 villages were selected randomly, then random sampling would be done within each cluster

Methods of Assessing Child Malnutrition: (WHO Standards for Children) Height for age (H/A) Weight for age (W/A) Weight for height (W/H)

Method of Assessing Child Development: Assessing the child development on the basis of developmental milestones achieved by the child in the particular age group. (National Institute of public cooperation and child development, New Delhi)

Tools: Questionnaire as well as physical anthropometric assessment Statistical Analyses: Descriptive Statistics (with emphases on Proportions); Inferential Statistics (with emphases on Comparing 2 Population Proportions)

Prevalence of Malnutrition in children less than 3 years of age in Juang community

Know whether malnutrition has significant effect on child development

Screen the children for Developmental milestones less than 3 years of age inJuanga tribe Odisha

To understand the social and demographic details of the target population.

If yes, then to what extent?

Will describe the nutritional status of the children in the Juang tribe and the status of child development .

Outcome that this study would produce

Methodology
The random selection of the children is done from the 7 Juang dominated villages in the Banspal block. There are around 47 villages of Juangs in the Banspal block. We have randomly selected around 7 villages and covered the households with at least one child under 3 years of age. The total of 105 children under 3 years of age are observed for the milestones of development and the physical anthropometric measurements were recorded as per the standard procedures. Supine measurements for length are taken for the children under 2 years. The international System of units is followed. Measuring Malnutrition in the targeted Children Anthropometry: The measurements of weight and height of the children is done as per the guidelines given by CDC, USA. The weight in Kilograms and height in Centimeters is recorded for all the children. The most standardized indicators of malnutrition in children were used in this study. These indicators are based on measurements of the body to know if growth pattern is normal and adequate.

Height for age (H/A), is an indicator of chronic malnutrition. A child exposed to inadequate nutrition for a long period of time will have a reduced growth - and therefore a lower height compared to other children of the same age (stunting). Weight for age (W/A), is a composite indicator of both long-term malnutrition (deficit in height/"stunting") and current malnutrition (deficit in weight/ "wasting"). Weight for height (W/H), is an indicator of acute malnutrition that tells us if a child is too thin for a given height (wasting).

In each of the 3 indicators (W/H, W/A, H/A), A comparison of the individual measurements to international reference values for a healthy population (NCHS/WHO/CDC reference values) is done and the cases with the values less than the -2SD from the median of the reference population of WHO are categorized as malnourished. The cases with measured values less than -3sd are categorized as Severely Malnourished.

Measuring the Level of Development in the targeted Children Child development was assessed as per the status of developmental milestones achieved. The details of the milestones achieved age wise as illustrated by the National Institute of Public cooperation and child development, New Delhi. A structured format for collecting the information on background characteristics of the household is used along with anthropometric records of the child. Checklist of developmental milestones was used to screen the child and observations for individual child are recorded in the response sheet.

Data collection
This cross-sectional study was undertaken in Kendujhar district of Orissa in June 2011. The study was intended to assess the nutritional status of children under 3 years of age and associated factors. A sample size of 98 was required assuming a 60% prevalence of malnutrition, margin of error of 10% and a 20% contingency for non response. A structured format for collecting the information on background characteristics of the household is used along with anthropometric records of the child. Checklist of developmental milestones was used to screen the child and observations for individual child are recorded in the response sheet. The questionnaire comprised three different parts: socio demographic, anthropometrics measurement together with the screening of the child for developmental milestones. The data were collected with the help of a translator who were trained for two days. The data were checked every day by the investigator who stayed with data collectors for the duration of the survey, which was 10 days. Measurements on weight and height were taken from children under 36 months. The socio-demographic characteristics included in the questionnaire were: sex, caste, ownership of land, educational status of the mothers, and household income. Digital weight scale was used for weighing the under three children while height measure for older children above two years of age, and length of the young children and infants below two years of age were measured by recumbence scale. The nutritional status of the study children was assessed using the indicators weight-forage, weight-for-height, and height-for-age, according to the NCHS (4;11)reference standard taking 2.S.D as the cut-off point indicating malnutrition (under weight, stunting, and wasting).Verbal consent was obtained from heads of households.

Results and Discussion The study included a total 105 children out of which 55(52.3%) were males and 50(47.6%) were female. The number of children in the age group of 12-35 months constituted more than 67% of the study population. The socio-demographic characteristics of the study subjects are shown in Table 6. Table 6 Sociodemographic Characteristics Age in months 9-11 12-17 % No % No % Total 18-23 No % 24-35 No % No %

1-2 No %

3-5 No %

6-8 No

Sex Male Female 0 2 0 1.9 7 5 6.6 4.7 5 4 4.7 3.8 7 4 6.6 3.8 14 10 13.3 9.5 7 9 6.6 8.5 15 16 14.2 15.2 55 50 52.3 47.6

Education of mother Illiterate 1 Literate 1 Birth order 1 2 3 or more

0.95 0.95

11 1

10.4 0.95

9 0

8.5 0

9 2

8.5 1.9

21 3

20.0 2.8

14 2

13.3 1.9

31 0

29.5 0

96 9

91.4 8.57

2 0 0

1.9 0 0

2 5 5

1.9 4.7 4.7

3 2 4

2.8 1.9 3.8

1 3 7

0.95 2.8 6.6

13 3 8

12.3 2.8 7.6

2 4 10

1.9 3.8 9.5

2 6 23

1.9 5.7 21.9

25 23 57

23.8 21.9 54.2

Monthly income <2000 1 >2000 1 Economic status BPL 2 Total 2

0.95 0.95

6 6

5.7 5.7

2 7

1.9 6.6

6 5

5.7 4.7

12 11

11.2 10.4

11 5

10.4 4.7

11 19

10.4 18.0

49 54

47.5 52.4

1.9 1.9

12 12

11.42 11.42

9 9

8.5 8.5

11 11

10.4 10.4

24 24

22.8 22.8

16 16

15.2 15.2

31 31

29.5 29.5

105 105

100 100

According to the NCHS reference standard taking 2.S.D as cutoff point, the study children who fell below 2 S.D. of the indicators (Underweight, Stunted, and Wasted) were computed as 92.3%, 45.8% and 94.3%, respectively. In this study, there were no cases of over nutrition. In order to investigate the association of selected demographic and socio-economic variables with the anthropometric results, Chi square test of association was used. However, there was no statistically significant association with sex, maternal education, birth order and monthly income (Table 7).

Table 7 Chi square Analysis: Variable Variable Chi square value ( Calculated) <0.05 considered significant 0.837 0.165 0.751 0.220 interpretation

Malnutrition Malnutrition Malnutrition Malnutrition

Sex of child Mothers education Monthly income Birth order

Independent Independent Independent independent

Nutritional Status of Juang Tribe of Orissa ( (Children< 3 years): Bar Diagram 6

68.60%
70.00%

59%
60.00% 50.00% 40.00% 30.00% 20.00%

54.30%

33.30% 24.80% 25.70%

Nomal Moderate Severe

21% 5.70%

7.60%
10.00% 0.00%

WFA(Underweight)

WFH(wasted)

HFA(Stunted)

The status of children less than 3 years in the Juang community calculated as per WHO standards Z scores for reference population has been depicted (Bar Diagram 6). It revealed that 33% children were res moderately underweight, 59% severely underweight and only 7.6% were found to be in normal weight category. But in case of wasting which is an indicator for current malnutrition, 54% of the children were indicator normal, 24.8% moderately wasted and only 21% were severely wasted. The third indicator of 21% malnutrition is stunting, there were 68.6% of children who fall into the severely stunted category, 25.7% are moderately stunted and only 5.7% of children observed were in the normal category.

Bar Diagram 7

Weight for Age Status

88.9 90 80 70 60 50 50 50 40 30 20 10 0 0 1-2 months 3-5 months 6-8 months 9-11 months 12-17 months 18-23 months 24-35 35 months 0 0 0 0 16.7 11.1 27.3 29.2 18.8 22.6 9.7 41.7 41.7 Normal moderate severe 72.7 70.8 81.3 67.7

The status of children in their respective age groups showing the underweight percentage It was observed percentage. that the peak prevalence of underweight children is between the age groups 6 months to 35 months, as nearly 90% of children in age group 6 months, 72% in 9-11 months, 70.8% in 12 6-8 11 12-17 months, 81% in 18-23 months, 68% in 24-35 months were severely underweight. It was observed that with the increasing 35 age of the child the proportion of malnourished children increased as depicted in the Bar Diagram 7. chi

Weight for Height Status (Children< 3 years): Bar Diagram 8

100 90 80 70 60 50 40 30 20 10 0 1-2 months 3-5 months 6-8 months 9-11 months 12-17 months 18-23 months 24-35 months 50 66.7 63.6 45.8 37.5 48.4 Normal Moderate Severe

91.7

The weight for height which indicates the wasting percentage among the children observed, reveals that majority of the children in each age group are under the normal category. The highest percentage of wasted children was observed in the age group 18-23 months. 18

Height for Age Status (Children<3 years): Bar Diagram 9

88.9

90
81.3

80 70 60
50 50

72.7

70.8

67.7

50
41.7 41.7 Normal moderate 27.3 16.7 11.1 29.2 22.6 18.8 9.7 0 0 0 severe

40 30 20 10
0 0

0 1-2 3-5 6-8 9-11 12-17 18-23 24-35 months months months months months months months

Height for age status of the children according to the age group of the child showed that peak prevalence of malnutrition was observed in the 6 8 months and till 35 months. This indicator had shown the level of 6-8 chronic malnutrition prevalent in the community, as around 90% of children in the age group 6-8 months, the 6 73% in the age group 9-11 months, 71% in age group 12-17 months, 81% in the age group 18 11 12 17 18-23 months and 68% in the age group 24-35 months were severely stunted. The increased stunting prevalence with 35 prev increased age of the child depicts the trend of higher chronic malnutrition in the higher age groups.

Developmental Milestones Status (%): Bar Diagram 10

100 100 90 80 70 60 50 40 30 20 10 0 0 1-2 months 3-5 months 6-8 months 9-11 months 12-17 months 18-23 months 24-35 35 months 0 25 12.5 55.6 44.4 36.4 25.8 achieved developing 75 63.6 87.5 74.2 100

The developmental milestones status of the children in their particular age group had been observed and the children who had achieved all the milestones as given in the guidelines of NIPCCD, New Delhi was placed in the achieved category and the children who could not achieve all the milestones as given in the guidelines were put in the category of developing. The poor performance of the children in respect of the achievement of the milestones indicated the developmental level of the children whether they were normally developing or not. The diagram described that with the advancing age the developmental deficit is also increasing.

Weight for age and milestones status (%): Bar Diagram 11

80 70 60 50 40 30 20 10 0 Normal Moderate Severe 34 27 50 50 66

73

Achieved Developing

The coexistence of underweight and developmental deficit had been shown here in bar diagram 11. It reveals that among the normal weight children around 50% were still developing, in moderately mod underweight children 66% were still developing and in severely underweight children 73 of the children 6% underweight 73% had yet to achieve the developmental milestones. The diagram shows the trend that as we move from evelopmental moderate to severe underweight category, the proportion of children who were developmentally children compromised had increased considerably.

Weight for height and milestones (%): Bar Diagram 12

80 70 60 50 40 30 20 10 0 Normal 35 27 65

73

73

achieved 27.3 Developing

Moderate

Severe

The comparative study of the status of wasting and the milestones achieved showed that among the normal children around 65% have not achieved the milestones yet. The similar trend had been observed here as well that with the increasing level of malnutrition the developmental deficit was also rising, as 73% of children in the severe wasted category had yet to achieve the milestones.

Height for Age and milestones (%): Bar Diagram 13

80 70 60 50 40

75

55.6
50

50
44.4 achieved developing

30 20 10 0 normal moderate

25

severe

The 75% of the severely stunted children also failed to achieve all the milestones which indicated that there existed a considerable developmental deficit. And this deficit was increasing with the rising malnutrition level, as 55.6% of the ch children in the moderate malnutrition category had yet to achieve the milestones corresponding to their age group.

Key Findings: The peak in prevalence of malnutrition is found in children between 6 months and 35 months which indicate that with the advancing age and as soon as the breast feeding is stopped, the children suffer from malnutrition because there is no replacement for the mother milk in the juang community. They dont use cow milk for feeding children. The developmental delays are most prominent in between 18 to 35 months. The delays in development were also related with the advancing age of the children as it was observed that the prevalence of malnutrition also increases with age as detailed above. The developmental delays are mostly prevalent in the children in the severe malnutrition category, due to the reason that malnutrition is impacting the growth and development in the juang community. There was no significant gender difference in the prevalence of malnutrition. The study has found that malnutrition has no relationship with the sex of the child. 92.5% of children are underweight, which is a composite indicator of both chronic and current malnutrition. The achievement of milestones is delayed with the increase in prevalence of malnutrition. Extremely high malnutrition prevalence in comparison to the normal population of Orissa as per the data available from NFHS 3 for Orissa.

According to WHO guidelines for assessing the severity of malnutrition in a community:

Table 8

Indicator

Severity of malnutrition by prevalence ranges (%) medium high 30-39 20-29 10-14 Very high >40 >30 >15

Findings of study

Stunting Underweight wasting

20-29 10-19 5-9

94.3 92.3 45.8

Conclusions

Extremely high prevalence of malnutrition among the Juang tribe Children (<3 years) of Orissa. About 68% of children have yet to achieve the milestones corresponding to their age group. The nutritional status of children was also having considerable effect on the development of the children. It is evident from the study that the monthly family income of the households is quite low which has become a major predisposing factor for the malnutrition in the community. The high prevalence of stunting in the children had indicated the chronic malnutrition. It is the result of widespread poverty and hunger in these tribal communities. The feeding habits of the community also predispose the children for malnutrition as they interfere with the availability of the macro and micro nutrients specifically in these primitive tribes. Stunting could result in slowing in the age related development and higher order cognitive processes and may also result in long lasting cognitive impairments.

Recommendations

For nutritional interventions, Catch the children young before 3 years before malnutrition sets in and before the child gets compromised regarding the overall growth and development. Detection of malnutrition at an early stage, so that moderate cases may not progress to severe form of malnutrition. Providing nutritional education to mothers regarding low cost, highly nutritive food stuffs. The high prevalence of malnutrition is also related to the purchasing power of the community, so effort should be made to increase the income of the tribal families by various ways. Special attention is needed for the primitive tribes like Juanga. The Tribal development is very much dependent on the status of the children, so we really need look into the grave situation of the tribal children in particular, which is big hurdle to save the primitive tribes from the danger of extinction.

Annexure
Structured format for collecting Anthropometric measurement to assess nutritional status along with checklist for the milestones of development for assessing the child development for different age groups for the children between 0 to 3 years of age in the JUANG tribal community in KENDUJHAR district of the state of Orissa, India
Sir/madam, I am an Intern from Centre for children studies, KSRM, KIIT university is conducting a study to assess nutritional status and child development in children under 3 years of age in the JUANG tribal community. The purpose to conduct the study is to fulfill the academic requirement, to understand the level of malnutrition and the status of child development; and to assess if there is any relationship between developmental delays and malnutrition in children less than 3 years of age.

Date..

Time .

Sr. No..

SOCIO-DEMOGRAPHIC DETAILS: 1. District 2. Block 3. Village House Hold factors: 4. Fathers name 5. Education of father 6. Occupation of father 7. Mothers name 8. Mothers education 9. Cast 1. General

2. SC

3. ST

4. OBC

10. Name of tribe. 11. Name of the child. 12. Date of Birth. 13. Sex of the child.1)Male 2) Female

14. Total no. of children.. 15. Birth order of child.. 16. Provided with nutritional Information during pregnancy 17. No. of family meals per day 18. Family status: BPL, APL..

19. Family income from Agriculture, Job., Labour, Land holdings., any other source 20. Expenditure Food, education, Health.., Clothing, Festival., Travel.., Other factors: 21. Distance of Anganwadi centre 22. AWC details:. 23. AWC/ICDS services availed......

Anthropometric Measurements
Sr No. 1 Birth Weight ( W) Age of the child (A) Present Weight Weight(Kg) (W) Height(cm) (H)

One month before

3 4

Two months before Three months before

Developmental milestones status: Age Group 1 month 3 months 6 months 9 months 12 months 18 months 24 months 36 months Codes of the Milestones achieved 1.1 3.1 6.1 9.1 12.1 18.1 24.1 36.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9

Check list for the Developmental milestones: Yes.1 No..2

Age group (1) One month

Milestones of Development 1.1 Cries in hunger or discomfort 1.2 Turns his head towards a hand that is stroking the childs cheek or mouth 1.3 Brings both hands towards her/his mouth 1.4 turns towards familiar voices and sounds 1.5 suckles the breast and touches it with her/his hand

YES

NO

Age group (3) Three month

Milestones of Development 3.1 Smiles 3.2 Begins to make cooing sounds like OOH and AAH 3.3 Turns head towards bright colours and lights 3.4 Holds head erect and reaches for an object 3.5 Recognizes mother & members of the family 3.6 Makes fists with both hands 3.7 Wiggles and kicks with legs and arms

YES

NO

Age group (6) Six month

Milestones of Development 6.1 Holds head steady when held upright 6.2 Raises the head and chest when lying on her/his stomach 6.3 Reaches out for dangling/swinging objects 6.4 Turns to a sound/voice 6.5 Grasps and shakes objects 6.6 Rolls both ways 6.7 Sits with support 6.8 Responds to her /his own name and to familiar faces 6.9 Explores objects with hands and mouth

YES

NO

Age group (9) Nine months

Milestones of Development 9.1 Sits up from lying position 9.2 Picks up with thumb and finger 9.3 Sits without support 9.4 Crawls on hands and knees

YES

NO

Age group (12) One Year ( 12 months)

Milestones of Development

YES

NO

12.1 Stands without support 12.2 Tries to imitate words and sounds 12.3 Waves Bye -Bye 12.4 Enjoys playing and clapping 12.5 Says Papa & Mama

12.6 Starts holding objects such as a spoon or a cup and attempts self feeding

Age group(18) Eighteen months

Milestones of Development

YES

NO

18.1 Walks well 18.2 Expresses wants 18.3 Stands one foot with help 18.4 Points to objects or pictures when they are named ( e.g. eyes, rose) 18.5 Starts saying names of objects

18.6 Puts pebbles in a cup

Age group(24) Two Years

Milestones of Development 24.1 24.2 24.3 24.4 24.5 Walks, climbs and runs Says several words together Follows simple instructions Scribbles if given a pencil or crayon Enjoys simple stories and songs

YES

NO

24.6

Imitates the behavior of others on household work

24.7

Begins to eat by herself or himself

Age group (36) Three Years

Milestones of Development

YES

NO

36.1 36.2

Walks, runs, climbs, kicks and jumps easily Recognizes and identifies common objects and pictures by pointing Makes sentences of two or three words Says his/her own name and age Can name colours Can understand numbers Uses make-believe objects in play Expresses affection Feeds herself or himself

36.3 36.4 36.5 36.6 36.7 36.8 36.9

REFERENCE LIST

(1) GHOSH S. NATIONAL FAMILY HEALTH SURVEY-3 (2007). INDIAN PEDIATRICS 2007;44(8):619. (2) WORLD B. WORLD DEVELOPMENT REPORT 1993. INVESTING IN HEALTH: WORLD DEVELOPMENT INDICATORS. OXFORD UNIVERSITY PRESS; 1993. (3) SETBOONSARNG S. CHILD MALNUTRITION AS A POVERTY INDICATOR: AN EVALUATION IN THE CONTEXT OF DIFFERENT DEVELOPMENT INTERVENTIONS IN INDONESIA. ASIAN DEVELOPMENT BANK (ADB) INSTITUTE DISCUSSION PAPER 2005. (4) DE ONIS M, BLSSNER M. THE WORLD HEALTH ORGANIZATION GLOBAL DATABASE ON CHILD GROWTH AND MALNUTRITION: METHODOLOGY AND APPLICATIONS. INTERNATIONAL JOURNAL OF EPIDEMIOLOGY 2003;32(4):518. (5) GUERRANT RL, ORI RB, MOORE SR, ORI MOB, LIMA AAM. MALNUTRITION AS AN ENTERIC INFECTIOUS DISEASE WITH LONG-TERM EFFECTS ON CHILD DEVELOPMENT. NUTRITION REVIEWS 2008;66(9):487. (6) HOSSAIN MDG, ISLAM S, AIK S, ZAMAN TK, LESTREL PE. AGE AT MENARCHE OF UNIVERSITY STUDENTS IN BANGLADESH: SECULAR TRENDS AND ASSOCIATION WITH ADULT ANTHROPOMETRIC MEASURES AND SOCIO-DEMOGRAPHIC FACTORS. JOURNAL OF BIOSOCIAL SCIENCE 2010;42(5):677. (7) MISHRA VK, LAHIRI S, LUTHER NY. CHILD NUTRITION IN INDIA. 1999. (8) HARISHANKAR1 SD, DABRAL SB, WALIA DK. NUTRITIONAL STATUS OF CHILDREN UNDER 6 YEARS OF AGE. (9) SUBRAMANYAM MA, KAWACHI I, BERKMAN LF, SUBRAMANIAN SV. SOCIOECONOMIC INEQUALITIES IN CHILDHOOD UNDERNUTRITION IN INDIA: ANALYZING TRENDS BETWEEN 1992 AND 2005. PLOS ONE 2010;5(6):E11392. (10) GENERAL R. CENSUS COMMISSIONER. CENSUS OF INDIA 2001;2001. (11) GRAITCER PL, GENTRY EM. MEASURING CHILDREN: ONE REFERENCE FOR ALL. THE LANCET 1981;318(8241):297-9. Websites: http://www.adbi.org/discussionpaper/2005/01/14/869.malnutrition.poverty.indonesia/measuring.malnutrition/ http://www.who.int/en/ http://www.cdc.gov/ http://www.nfhsindia.org/ http://www.unicef.org/india/state_profiles_4346.htm

SC/ST development, minorities & backward classes welfare Department, Govt. Of Orissa. http://censusindia.gov.in/ www.kendujhar.nic.in/ www.google.com www.youtube.com http://www.rchiips.org/ http://nipccd.nic.in/