Introduction
India has an enormous burden of undernutrition – a major public health problem that increases premature mortality and morbidity during childhood (UNICEF, 2019). Globally, undernutrition causes about 3.1 million child deaths annually (Black etal., Reference Black, Victora, Walker, Bhutta, Christian and de Onis2013; IFPRI, 2016; Ramesh etal., Reference Ramesh, Sundari and Ramesh2017).
Anthropometry is a reliable, non-invasive, inexpensive and easily measurable method to assess nutritional status in adults and children (Kuczmarski etal., Reference Kuczmarski, Ogden, Guo, Grummer-Strawn, Flegal and Mei2002). The three most conventional anthropometric indicators of undernutrition in children are stunting (low height-for--age), wasting (low weigh-for-height), underweight (low weight-for-age) and thinness (low body mass index [BMI]-for-age) (WHO, 2006). The most recent National Family Health Survey (NFHS-4) reported that in India in 2015–16, 35.7%, 38.4% and 28.5% children were underweight, stunted and wasted, respectively, and that there were 34.0% stunted, 21.6% wasted and 33.6% underweight children under 5 years of age in rural areas of West Bengal (IIPS, 2017). However, these different indicators are considered to represent different aspect of nutritional conditions. Stunting represents the long-term cumulative effect of poor nutrition or infection since birth or during prenatal growth; wasting indicates a combined effect of chronic and acute malnutrition; underweight and low BMI-for-age reflect acute conditions, and are associated with an increased risk of mortality (WHO, 2010). However, estimates of these indicators in a population overlap and thus separate values for each condition cannot give an overall estimate of the undernourished state of children in a population. Besides, it is sometimes difficult to choose one of these as the best indicator. Moreover, these parameters also show different patterns of association with independent factors (Ahmadi etal., Reference Ahmadi, Amarnani, Sen, Ebadi, Cortbaoui and Melgar-Quiñonez2018).
To address these issues, in the year 2000, the Swedish economist Peter Svedberg first suggested an alternative single indicator, namely, the Composite Index of Anthropometric Failure (CIAF), to determine the state of undernutrition, including all three conventional indicators (Svedberg, Reference Svedberg2000; Nandy etal., Reference Nandy, Irving, Gordon, Subramanian and Smith2005). Use of a single criterion, such as wasting, might miss individuals who are also nutritionally vulnerable; CIAF identifies all of them under one umbrella as ‘anthropometric failure’ (AF) and provides an overall estimate of the undernourished state in children. This is why the prevalence rate determined with CIAF is often higher than that obtained using one of the conventional indicators. There have been numerous previous studies, including many recent ones, that has assessed nutritional status among children using the three conventional indices of stunting, wasting and underweight (Sen etal., Reference Sen, Dey and Mondal2011; Ray & Chandra, Reference Ray and Chandra2013; Mandal etal., Reference Mandal, Prabhakar, Pal, Parthasarathi and Biswas2014; Mansur etal., Reference Mansur, Haque, Sharma, Mehta and Shakya2015; Pramanik etal., Reference Pramanik, Bose Banerjee and Dey2015; Chellamma etal., Reference Chellamma, Chandrasekharan Nair, Suresh Lakshmi, Jaleel, Soman Chellappan and Shameena2017; Giri etal., Reference Giri, Biswas and Bose2017; Abbasi etal., Reference Abbasi, Mahmood, Zaman, Farooq, Malik and Saga2018; Elema, Reference Elema2018). Nevertheless, many studies also used CIAF for nutritional assessment among Indian children (Sen etal. Reference Sen, Dey and Mondal2011; Acharya etal., Reference Acharya, Mandal and Bose2013; Ramesh etal., Reference Ramesh, Sundari and Ramesh2017; Roy etal., Reference Roy, Dasgupta, Roychoudhury, Bandyopadhyay, Mandal and Paul2018).
It has long been recognized that socioeconomic factors and living conditions, such as poverty, education, gender inequality, drinking water facility and household sanitation, are important determinants of health outcomes in low-income countries (CSDH, 2018). The nutritional status of children has been shown to be significantly affected by socioeconomic factors, including parental occupation and education, household socioeconomic status, number of people in a household and location of residence (urban/rural) (Sunil etal., Reference Sunil2009; Emina etal., Reference Emina, Kandala, Inungu and Yazoume2011). Poor socioeconomic conditions and other demographic situations have been shown to play a significant role the prevalence of undernutition (Meshram etal., Reference Meshram, Arlappa, Balakrishna, Laxmaiah and Mallikarjun Rao2012; Arora etal., Reference Arora, Datta and Sau2014; Rengma etal., Reference Rengma, Bose and Mondal2016; Sarkar, Reference Sarkar2016; Yadav etal., Reference Yadav, Kotwal, Vaidya and Yadav2016; Ramesh etal., Reference Ramesh, Sundari and Ramesh2017; Pal etal., Reference Pal, Pari, Sinha and Dhara2017). Poor quality of drinking water and adverse hygiene practices also play roles in increasing health risks and may in turn contribute to the burden of undernourished conditions (Teshome etal., Reference Teshome, Kogi-Makau, Getahun and Taye2009), whereas improvement in hygiene practices has been shown to be associated with a reduction of stunting (Fenn etal., Reference Fenn, Bulti, Nduna, Duffield and Watson2012). Dearden etal. (Reference Dearden, Schott, Crookston, Humphries, Penny and Behrman2017), in their study in Ethiopia, found that children with access to improved sanitation, e.g. appropriate toilet facilities, had a lower rate of stunting than those who defecated in the open.
Mother’s education has been found to be closely associated with several factors linked to child health and nutrition (Kraamwinkel etal., Reference Kraamwinkel, Ekbrand, Davia and DaoudI2019; Vikram & Vanneman, Reference Vikram and Vanneman2019). Women are generally the primary care-givers in the home and decision-makers on their children’s health, and generally devote more time to the protection and care of children than men (Caldwell, Reference Caldwell1993; Frost etal., Reference Frost, Forste and Haas2005; Akresh etal., Reference Akresh, Lucchetti and Thirumurthy2012). One of the most commonly explored links between maternal education and child health is socioeconomic status (Owoaje etal., Reference Owoaje, Onifade and Desmennu2014). Women’s education, in particular, may positively influence child health by increasing women’s decision-making power within the family (Shafiq etal., Reference Shafiq, Hussain, Asif, Hwang, Jameel and Kanwel2019). It has been reported in previous studies from different parts of the world that mother’s education has a significant effect on the nutritional status of children (Handa etal., Reference Handa1999; Frost etal., Reference Frost, Forste and Haas2005; Abuya etal., Reference Abuya, Ciera and Kimani-Murage2012).
The use of CIAF to provide a more ‘overall’ estimate of undernourishment, along with its socioeconomic and demographic determinants, has so far not been much studied – especially mother’s educational status (Endris etal. Reference Endris, Asefa and Dube2017). This is particularly the case for populations where children are suffering from a very high prevalence of undernutrition, such as in India. The present study was conducted to assess the effects of these factors in a population of India where variations in socioeconomic factors like parental education, income and occupation are not very high, as is the case in rural areas. The objectives of the study were to assess the prevalence of CIAF among rural children in an East Indian district and the association of CIAF with socioeconomic and demographic characteristics, with special emphasis on mother’s education.
Methods
Subjects and settings
This community-based, cross-sectional study was part of a larger study conducted between December 2014 and April 2016 in an urban industrial area (Haldia) and adjacent rural areas of Purba Medinipur district, West Bengal, India. According to NFHS-4, in Purba Medinipur district 75.2% of women were literate, 66.7% of households had proper sanitary facilities and 6.6% of households used clean fuel for cooking in 2015–16. The survey also reported that 7.1% children were suffering from diarrhoea and 52.6% from symptoms of acute respiratory infections (IIPS, 2017). The present study included rural children belonging to three villages (Kultalia, Sikdarchak and Uttar Amtalia) under the jurisdiction of a bigger administrative unit (Gram Panchayat or GP) called Amtalia, under the developmental block Contai-II. These three closely situated villages were the furthest, and most remote, in the particular rural segment of the Block, situated on the bank of the Rosulpur River, a tributary of the Hoogly River. The villages are inhabited by the Bengalee population who are Hindu by religion and belong to several caste groups. As previous studies have not found any significant differences in the anthropometric characteristics of the different castes of Bengalees, they can be pooled into a single group, namely ‘Bengalee’ (Biswas etal., Reference Biswas, Bose and Koziel2011; Bhadra etal., Reference Bhadra, Mukhopadhyay, Chakraborty, Bose, Koziel and Ulijaszek2013).
Participants were selected through door-to-door visits employing a combination of opportunity and snowball sampling strategies. In each of village, all houses, starting from one end of the village, were approached one after another to find participant children in the target age group (3–12 years). All eligible children present during visits were recruited, after obtaining informed consent from at least one parent. However, in several cases, a second visit was made to a household at a date fixed during the first visit. In this way, a whole village was covered, then the next village was approached.
As is normal in governmental facilities in the region, children start attending care centres for a mid-day meal and preliminary pre-nursery type education at age 3. As the study was aimed at pre-adolescent children, an upper age of 12 years was set – the average age of menarche of Bengalee girls (Bhadra etal., Reference Bhadra, Mukhopadhyay, Chakraborty, Bose, Koziel and Ulijaszek2013). A total of 621 children (308 boys and 313 girls) aged 3–12 years were included from just over 600 households. A child’s age was ascertained from their birth certificate or polio vaccination card. All participants belonged to families of Bengalee-speaking Hindu caste groups. Children who were reported by their parents as having any illness and/or physical deformity were not included in the study. The response rate was slightly over 90%. A pre-structured questionnaire was used to acquire socioeconomic and demographic information. Both parents’ education levels were recorded as the highest standard they passed in school, college or university. Their occupations were also recorded. Total monthly income of the family was recorded in Indian currency. It was also enquired whether a family owned or rented their house. Number of living rooms in the household and total number of family members were also recorded. Three types of toilet facilities/practices (toilet type) were found among village residents: i) typical Indian type with concrete structures, ii) temporary pit type (abandoned when filled up with night soil and a new one dug) and iii) no latrine in household and thus, open air defecation in the riverside fields. For the purpose of analysis, the first type was recorded as a ‘proper’ type and the second and the third types were clubbed together as ‘improper’ types. Cooking fuel was recorded as being either smoke-generating or not. Parents of children were asked if their child had any illness and whether they had experienced any kind of illness in the previous month (child morbidity status). All this information was obtained by interviewing parents.
Anthropometry and nutritional status
One of the researchers (PK) performed the anthropometric measurements. Weight (kg) and height (cm) were measured for each child to the nearest 1 mm and 500 g, respectively, following standard procedures (Lohman etal., Reference Lohman, Roche and Martorell1988). Technical Errors of Measurements (TEM) were computed after Ulijaszek and Kerr (Reference Ulijaszek and Kerr1999) and were found to be well within the reference range of values, and were thus not incorporated in the analyses. Nutritional status was assessed using growth reference value of the National Centers for Health Statistics (NCHS), US. Three types of z-scores were calculated –height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WHZ) – to determine stunting, underweight and wasting, respectively. Age- and sex-specific <–2SD z-scores were considered the cut-off points for underweight, stunting and wasting. The same data were used to calculate the variable CIAF (Nandy etal., Reference Nandy, Irving, Gordon, Subramanian and Smith2005) by classifying children into seven categories (see Table 1). The reason for using NCHS standards was the age range of participants (3–12 years). The construction of CIAF requires HAZ, WAZ and WHZ – all three z-score values. However, other acceptable growth standards, such as the latest WHO standard (WHO, 2006), do not provide reference values of WAZ for age 10–12 years or WHZ for age above 5 years. Moreover, the NCHS cut-offs were used as most of the previously reported studies on CIAF worldwide have used these values. Thus, the appropriateness of comparison of the different components of CIAF of the present study with these earlier investigations was possible using NCHS z-scores.
Table 1. Classification of Composite Index of anthropometric failure (CIAF) a among children
A=no anthropometric failure; B, C, D, E, F and Y=anthropometric failure.
a Following Nandy etal. (Reference Nandy, Irving, Gordon, Subramanian and Smith2005).
Data analyses
Percentage statistics were used to describe the frequencies of participants in each sex and different nutritional categories (stunting, wasting, CIAF etc.). Chi-squared analysis (χ 2) was employed to assess the significance of differences in prevalence of CIAF between the sexes as well as the association between nutritional indicators and socioeconomic parameters in boys and girls. The variables showing a significant association in the χ² tests were further used as independent variables in multiple binary logistic regression (MBLR) analyses to assess their relative impacts on CIAF status (yes/no). Odds ratios (ORs), along with 95% confidence intervals (CIs), were used to assess the risks of AF. The MBLR was performed in two different ways. First, all predictors were put together (method: Enter) at once and the mutual effects were noted. Finally, in the second approach, the forward step wise method was used to identify the most important predictor(s) of AF.
For all these analyses, the outcome/dependent variable (CIAF) was categorized into ‘0’ (indicating ‘No AF’) and ‘1’ (indicating ‘AF’). Parental education was classified into two categories: up to upper primary level and above upper primary level (because a very few parents had education above secondary school level). Other predictor variables included: house ownership (owned vs rented), number of living rooms (1, 2–4 and ≥5), toilet type (proper Indian type toilet vs pit type and/or open air defecation) and type of the cooking fuel used (smokeless vs smoky). For each of these predictors, the superior alternatives (such as, smokeless fuel) were coded ‘0’ and the respective poorer options (such as, smoky fuel) was coded ‘1’. A p-value of <0.05 was considered to be statistically significant. All statistical analyses were performed through SPSS-16 software for Windows.
Results
Table 2 shows the prevalence of undernutrition among the study children. The overall prevalence of CIAF was 59.40% and this was higher than the three conventional indices of stunting (28.34%), wasting (30.76%) and underweight (44.61%). Boys had significantly higher prevalence of underweight (χ 2 = 4.14, p<0.01) compared to girls. The sex differences in prevalence of other indicators of undernourishment, however, were not statistically significant.
Table 2. Prevalence of undernutrition among rural children aged 3–12 years, West Bengal, India
*p<0.05.
The prevalences of anthropometric failure as measured by CIAF by socioeconomic characteristics are shown in Table 3, along with the results of the χ 2 analyses to assess the significance of those differences. Significant associations with the prevalence of CIAF were observed for father’s education (χ 2 = 6.22, p<0.01), mother’s education (χ 2 = 11.84, p<0.001), house ownership status (χ 2 = 8.36, p<0.01), number of living rooms (χ 2 = 5.71, p<0.05), toilet type (χ 2 = 3.76, p<0.05) and fuel type (χ 2 = 4.94, p<0.05). Lower parental education level, rented house (although the sample size was small), fewer living rooms in the house, poor quality of toilet type (pit or open) and use of smoky fuel were all associated with a significantly higher prevalence of CIAF (Table 3). It is worth mentioning that parental occupation and family income and expenditure were not significantly associated with nutritional status.
Table 3. Association of socio-demographic characteristics and reported illness with anthropometric failure as assessed by CIAF among the rural children aged 3–12 years, West Bengal, India
*p<0.05; **p<0.01; ***p<0.001.
Multiple logistic regression analysis was performed on those predictor variables that showed significant associations with CIAF in the χ 2 analyses to assess their relative or mutually exclusive effects on CIAF status, independent of each other. Only maternal educational status showed a significant effect amongst all the other predictors (Wald’s χ 2 = 5.381; p<0.05). A lower maternal educational level (up to upper primary) was associated with a greater risk of AF (OR = 1.63; 95% CI = 1.07–2.47) compared with a higher maternal education level. Finally, forward stepwise logistic regression analysis excluded all other variables from the equation and retained only mother’s education as the only significant predictor (Wald’s χ 2 = 11.67, p<0.01). Maternal educational level up to upper primary gave a greater risk (OR = 1.872; 95% CI = 1.31–2.68) of having a child with CIAF (results not shown in a tabular form).
Discussion
The study results show that the conventional indicators of undernourishment underestimate the prevalence of undernutrition compared with CIAF. While the classical indicators showed the prevalence to be roughly between 28 and 45%, the prevalence of CIAF was calculated to be 59.4%, with boys tending to have a higher prevalence of undernourishment. As CIAF includes the prevalence of stunting, wasting and underweight together to produce an overall estimate of the undernourished state (‘anthropometric failure’, AF), the prevalence is usually higher than that estimated by any one of the conventional indicators. A similar prevalence of CIAF has previously been observed in rural children (50.20%) of the same district, Purba Medinipur (Acharya etal., Reference Acharya, Mandal and Bose2013). A few previous studies have also reported a higher prevalence of CIAF among children of different states of India, including Tamil Nadu (86.6%, Seetharaman etal., Reference Seetharaman, Chacko, Shankar and Mathew2007), Uttar Pradesh (62.8%, Kumar etal., Reference Kumar, Mittal and Sharma2010) and Jammu and Kashmir (73.2%, Dewan etal., Reference Dewan, Gupta and Kumar2015). Studies have also reported different prevalences of CIAF among preschool children from other places within West Bengal state, including Nadia (60.4%, Biswas etal., Reference Biswas, Bose, Mukhopadhyay and Bhadra2009), Midnapore Town (58.2%, Sinha & Maiti, 2012), Singur (32.7%, Dasgupta etal., Reference Dasgupta, Sahoo, Taraphdar, Preeti, Biswas, Kumar and Sarkar2015), South 24 Parganas (61.28%, Biswas etal., Reference Biswas, Giri and Bose2018) and Purba Medinipur (55.3%, Khanra etal., Reference Khanra, Biswas and Bose2019).
Despite the enormous economic progress achieved in the past two to three decades, undernourishment among children in both urban and rural India has claimed many lives due to the immense population size, illiteracy, inadequate access to health facilities and socioeconomic disparities (Pal etal., Reference Pal, Pari, Sinha and Dhara2017). The present study has shown that the nutritional status (measured by CIAF) of children in West Bengal was significantly associated with fathers’ education, mother’s education, house ownership status, number of living rooms, toilet type and cooking fuel type. A higher prevalence of CIAF was associated with lower parental education level, living in a rental house (in contrast to an owned house), having fewer living rooms, having a poor quality toilet (pit or open) and the use of smoky cooking fuel. Lower or poorer levels or qualities of these factors were associated with a higher risk of CIAF than higher levels or better qualities. For instance, CIAF was significantly higher in children whose parents were educated up to upper primary or less, compared with children whose parents were educated above upper primary level. However, in the multivariate analysis, only mother’s education level showed significant inverse relationship with prevalence of undernutrition (AF). Higher maternal education was associated with a lower prevalence of AF. Parental occupation and family income and expenditure were not significantly associated with the nutritional status of children.
Hitherto, different studies have shown that various indicators of socioeconomic status, such as educational level of parents, parental income and family assets, are associated with children’s nutritional status (Victora etal., Reference Victora, Adair, Fall, Hallal, Martorell, Richter and Sachdev2008; Nguyen etal., Reference Nguyen, Eriksson, Petzold, Bondjers, Tran, Nguyen and Ascher2013; Keino etal., Reference Keino, Plasqui, Ettyang and van den Borne2014; Mohammad etal., Reference Mohammad, Kassab, Gamble, Creedy and Foster2014). It has been suggested by many scholars that improvement in socioeconomic conditions, along with parental education and the prevention of infection through personal hygiene, might help to improve the nutritional status of children (Meshram etal., Reference Meshram, Arlappa, Balakrishna, Laxmaiah and Mallikarjun Rao2012; Kavosi etal., Reference Kavosi, Hassanzadeh Rostami, Nasihatkon, Moghadami and Heidari2014; Owoaje etal., Reference Owoaje, Onifade and Desmennu2014; Garcia Cruz etal., Reference Garcia Cruz, González Azpeitia, Reyes Súarez, Santana Rodríguez, Loro Ferrer and Serra-Majem2017; Pal etal., Reference Pal, Pari, Sinha and Dhara2017; Vollmer etal., Reference Vollmer, Harttgen, Kupka and Subramanian2017; Roy etal., Reference Roy, Dasgupta, Roychoudhury, Bandyopadhyay, Mandal and Paul2018). Poor sanitary systems have also been closely linked to diarrhoeal disease, environmental enteropathy and worm infection (Walker etal., Reference Walker, Rudan, Liu, Nair, Theodoratou and Bhutta2013). The present study found a lower prevalence of undernutrition among children belonging to families using smokeless cooking fuel. Previous studies have also showed that use of unclean, smoky cooking fuel has long-lasting effects on the growth, health and nutritional status of children (Mishra & Retherford, Reference Mishra and Retherford2007; Bhagowalia & Gupta, Reference Bhagowalia and Gupta2011).
Mother’s education is very often considered to be the most significant predictor of child undernutrition (Stamenkovic etal., Reference Stamenkovic, Djikanovic, Laaser and Bjegovic-Mikanovic2016). Although low household income is most likely to produce undernourishment in children, education is believed to act as a protective factor, with children whose mothers have a higher level of education being likely to be better nourished (Nguyen etal., Reference Nguyen, Eriksson, Petzold, Bondjers, Tran, Nguyen and Ascher2013; Keino etal., Reference Keino, Plasqui, Ettyang and van den Borne2014; Mohammad etal., Reference Mohammad, Kassab, Gamble, Creedy and Foster2014). Among the children of the present study, mother’s education level was the single most significant factor associated with CIAF, adjusting for the effects of all other factors. The prevalence of CIAF was significantly higher in children whose mothers were educated only up to upper primary level compared with those educated above upper primary level. A study in Ethiopia showed that children over 12 months of age born to uneducated mothers and with poor wealth status had higher odds of being malnourished as assessed by CIAF (Endris etal., Reference Endris, Asefa and Dube2017). Kamiya (Reference Kamiya2011) showed that, in Laos, level of parental education, household assets, hygiene standards and water quality were the most important determinants of nutritional status in children. A recent study revealed that growth in Indonesian school children was directly associated with parental education and that this influence was not via nutrition-mediated pathways (Groth etal., Reference Groth, Scheffler and Hermanussen2019). Another study in Laos found that low maternal education, poor nutrition knowledge and restricted intake of meats were interlinked and considered to be the main contributors to childhood malnutrition (Phengxay etal., Reference Phengxay, Ali, Yagyu, Soulivanh, Kuroiwa and Ushijima2007). Children of educated mothers experience lower mortality as well as lower prevalence of undernourishment than children of uneducated mothers (Gwatkin etal., Reference Gwatkin, Rustein, Johnson, Pande and Wagstaff2000).
Maternal education can exert a crucial effect on the nutritional and health status of children through several mediating mechanisms. It can lead women to greater exposure to, and better understanding of, guidelines and recommendations for better health through mass media and other literary sources. Educated mothers indeed show better knowledge and practice of feeding and health management for their children (Frost etal., Reference Frost, Forste and Haas2005; Makoka & Masibo, Reference Makoka and Masibo2015; Smith etal., Reference Smith, Hourihane, Kenny, Kiely, Leahy-Warren and Murray2016). Additionally, they are better able to read medical instructions for the treatment of childhood illness and apply the treatment, and increased number of years in school makes women more receptive to modern medicine (Glewwe, Reference Glewwe1999). Higher educated mothers have been found to have a better understanding of the causes, means of prevention, recognition and cures for disease, as well as nutritional requirements, than lesser educated women (Kraamwinkel etal., Reference Kraamwinkel, Ekbrand, Davia and DaoudI2019). Several previous studies have clearly indicated that mother’s education is vital for good child health and nutrition (Owoaje etal., Reference Owoaje, Onifade and Desmennu2014; Makoka & Masibo, Reference Makoka and Masibo2015; Garcia Cruz etal., Reference Garcia Cruz, González Azpeitia, Reyes Súarez, Santana Rodríguez, Loro Ferrer and Serra-Majem2017; Vollmer etal., Reference Vollmer, Harttgen, Kupka and Subramanian2017; Roy etal., Reference Roy, Dasgupta, Roychoudhury, Bandyopadhyay, Mandal and Paul2018; Kraamwinkel etal., Reference Kraamwinkel, Ekbrand, Davia and DaoudI2019). Studies have also revealed a strong link between maternal education, socioeconomic status and child nutrition. This is because educated women are more likely to get steady and better paid jobs, or marry men with higher education and higher income, and as a result have a modest living standard, which ultimately have positive effects on child health and survival (Cleland & Van Ginneken, Reference Cleland and Van Ginneken1988; Desai & Alva, Reference Desai and Alva1998). It has often been found in low-resource settings that women are more likely than men to mobilize resources towards the well-being of their children (UNICEF, 2011), and that women with higher decision-making power have fewer undernourished children than women with lesser power (Cumnnigham etal., Reference Cunningham, Ruel, Ferguson and Uauy2015). A higher level of education could make women more capable of exercising decision-making power at the household level (Cheng, Reference Cheng2019). Therefore, although mother’s education does not influence a child’s growth directly, it does so indirectly via other factors that exert an influence on child nutritional status. The tangible improvement of women’s education should be a major goal towards the attainment of sustainable development of child health and development at the community level in India.
In conclusion, this study found that, although the participating rural Bengalee children were beneficiaries of two national nutritional supplementation programmes (MDM and ICDS), they had a very high prevalence of undernutrition (CIAF = 59.4 %). It further showed that, even in a population where women’s educational levels were lower than average, a little variation in this could significantly affect child nutritional condition at the community level. A lower level of maternal education was found to be significantly associated with a higher prevalence of anthropometric failure, as measured by CIAF, and this effect was independent of several other parameters of socioeconomic status. The study also indicated that the health and nutritional status of children is sensitive to mother’s education level, even in a low-resource setting where the education level of mothers is also low, in general, and the range of variation in education level was also minimal.
Funding
This research did not receive any grant from any funding agency, commercial entity or nor-for-profit organization.
Acknowledgments
All participants and their parents are sincerely acknowledged for their kind cooperation. The Block Development Officer and Child Development Programme Officer of Desopran Block are also gratefully acknowledged for providing permissions. The authors are also grateful to the anonymous reviewers for their valuable comments.
Conflicts of Interest
The authors of this paper do not have any conflicts of interest.
Ethical Approval
Necessary approval was obtained from the appropriate administrative offices (BDO, CDPO and Gram Panchayat) before commencement of the study. The relevant institutional committee of Vidyasagar University Midnapore assessed the ethical standards of the research proposal and approved the study. The ethical guidelines as laid down in the World Medical Association Declaration of Helsinki, 1975, as revised in 2008, were strictly followed.
