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Food and Nutrition Policy
Provision of health-nutrition services at the
grass-roots level in the Palghar and Kasa projects and the
possibility of their replication
Comparison of nutriwards and nutrihuts in the Northern Mindanao region (region x) of the Republic of the Philippines
Malnutrition, wealth, and development
Report of the third meeting of the ACC/SCN consultative group on maternal and young child nutrition
Provision of health-nutrition services at the grass-roots level in the Palghar and Kasa projects and the possibility of their replication
P.M. Shah and Kusum P. Shah
Grant Medical College and J. J. Group of Government Hospitals, Bombay, India
Severe malnutrition was the leading cause of death among children one to five years old in a rural population of 52,193 in Palghar, India, during 1965 and was a primary contributor to 31.9 per cent of the age-specific deaths (1). Similarly, low birth-weight was the foremost cause of infant deaths in those villages (2). It was observed during 1964 that none of the children with kwashiorkor who were seen at the weekly paediatric clinic of the Government Health Unit, Palghar, for whom hospitalization had been recommended actually went to the teaching hospital in Bombay, and very few came back to the clinic for a follow-up visit. Hence, an innovation in the system of health-care management was thought to be necessary.
All the mothers of children with kwashiorkor were informed about the cause of the illness and advised to take care of the child at home, feeding an inexpensive, nutritious food modified from the family diet, and were told to increase the frequency of feeding. Any diarrhoea, worm infestation, or mineral and vitamin deficiencies were treated at the Health Unit. The auxiliary nurse midwife (ANM) from the neighbourhood health sub-centre and local persons from the villages were involved in the nutritional care of these children.
During 1965 - 1969, neither a death nor recurrence of kwashiorkor occurred in the series of children who were under domiciliary management (3). These children could match the average weight curve of their healthy counterparts in the villages within one year. Even one to three years after recuperation, the mothers' and the neighbour women's knowledge of nutrition and of how to feed their young children an inexpensive, locally available food was very impressive (4). An analysis of this kind of home-management showed that the cost to family for curing the child and to the Health Unit was 5 and 37 times less, respectively, than when the child was admitted to the teaching hospital in Bombay (3).
It is worth noting that 85.2 per cent of the families who had children with kwashiorkor were nuclear, and 78.8 per cent of the mothers were employed outside the home (5). In 55.6 per cent of the families, children under five years of age were being cared for by mother-substitutes who were themselves children. Before the project began, these needy children were not getting appropriate health and nutrition care, as they could not come to the health centre or contact the personnel there. The awareness by mothers of how to feed their infants was poor, and for 65.6 per cent of these children, solid foods were introduced after they were nine months of age.
THE PALGHAR PROJECT
Given this background, the Palghar Project was started in 1972. One of its objectives was to organize and implement integrated health-nutrition services within a government health infrastructure for children and married women in their own homes, even in the remotest villages, with the help of workers from the local community and with community involvement. Another objective was to study the feasibility of replicating these services elsewhere under the prevailing health-care system. A population of 18,401 in 20 villages in two health sub-centre areas was included in these studies. Three outlying villages 20 to 50 kilometres from Palghar were the controls.
A four-tier system of health-nutrition service delivery was devised. Eight part-time social workers (PTSWs), seven female and one male, formed the first tier of the system, each serving a population of about 2,000 to 3,000 and residing in one of the villages in which she/he worked. The names of these workers were suggested by the members of the local community. Considering that 40 per cent of the total deaths in a community occur in the first six years of life, and that 20 per cent of such deaths are caused by preventable illnesses related to malnutrition, the focus of the project was on elimination of malnutrition. The PTSWs provided health and nutrition care to all children under five years old and to married women, identifying the degree of malnutrition and supplying nutrition supplements to those children who weighed 65 per cent of the reference weight or less. The PTSWs identified "at-risk" children and pregnant women, who were referred to the social workers' immediate supervisors, the ANMs (second tier), to the health supervisors (third tier), or to the medical officers (fourth tier). A job description of each team member and the work plan of the project were prepared (6).
ACCOMPLISHMENTS OF THE PALGHAR PROJECT (7, 8)
The Palghar Project established a new pattern for providing health-nutrition services through a combined domiciliary and clinic outreach involving a new cadre of health workers. The approach ensured broad coverage of the sick, developed nutrition surveillance for all children and women and distributed nutrition supplements to the needy, set up a monthly screening system for at-risk children and pregnant women, and formed a system of special care, including referrals to physicians when necessary (9, 10). The latter ensured the most economical use of the time of the doctors and nurses, who were expected to attend only those who were most in need and who required special or immediate care. Appropriate technology was developed, especially for midwives, and quite a few devices were worked out (11, 12). A system of effective supervision through upgrading the posts of those PTSWs who were found to be most efficient was established one Year after the project began. Community participation was encouraged in terms of involvement in activities, support and management of severe cases of malnutrition, contributions to the resources of the project, and construction of approach roads to clinics and provision of clinic sites.
The fall in infant and neonatal mortality rates was from 57.2 to 46, and 34 to 24, respectively, in the first two years. The birth rate dropped from 24.6 to 20.5 per thousand. There was a favourable change in the nutritional status of the children, particularly among those who initially weighed 65 per cent of the reference weight or less. The project created an awareness of the significance of weight-for-age in the community. The status of immunization of the children and pregnant women improved remarkably. And in general, research was conducted into the factors that impede growth (13 - 18).
GOVERNMENTAL DECISION ON EXTENSION OF THE PROGRAMMES
Within 18 months of the start of the Palghar Project, the governments of India and Maharashtra State, as well as international agencies, became interested in this system of providing health-nutrition care in the home. During early 1974, a team from the Planning Commission of India, visiting Bombay, evinced keen interest in the project and suggested that it might be extended to cover an entire district in order to study its replicability. This led to further operational study of management of home healthcare services in a wider area around the Primary Health Centre at Kasa.
THE KASA PROJECT
The Kasa Primary Health Centre (PHC) was selected because it is approachable from Bombay, has an 88 per cent tribal population, and was already covered by the Government's Supplementary Nutrition Programme. The project was sponsored by the Government of India (60 per cent contribution), the state government of Maharashtra (20 per cent), and CARE-Maharashtra (20 per cent) (19).
The Kasa Project began in 1974 with the objective of studying the feasibility of duplicating this system of providing integrated health and nutrition services to young children and mothers throughout rural India. Existing health-nutrition programmes and personnel were utilized, community support was developed, and persons from the community were used to serve as liaison workers in providing health and nutrition care to all in order to ensure maximum coverage of most health needs in the homes and clinics. The focus of the project was on comprehensive and promotional health care, and timely management of common illnesses in children and mothers (19).
The population in 79 project villages was 74,605, of whom 56,364 lived in the 60 villages of the Supplementary Nutrition Programme. A typical tribal village consists of an average of six hamlets, and each hamlet has clusters of huts. Some villages spread five to six kilometres from one end to the other. Per capita income in the project area was estimated to be as low as Rs 0.72 (US$0.09) per day. The literacy rates for males and females were 17 per cent and 4 per cent, respectively. The area is hilly and covered with forests. The nearest telephone and telegraphic communications are 25 kilometres away. A few houses in ten villages had no electricity. Except for the PHC staff (19), there were no qualified practitioners of allopathic medicine in the area.
The normal staff of the PHC was maintained at Kasa, and no special efforts were made to fill vacancies. For an initial period of 13 months, only one out of two medical officers was available. Eight ANMs, two at headquarters and six in the sub-centres, and four smallpox vaccinators were redesignated as multi-purpose health workers (MHWs). The sanitary inspector became Programme Co-ordinator. The nurse midwife and the sanitary inspector worked as health supervisors of the MHWs. The female (ANM) and male MHWs were immediate supervisors of the PTSWs. The District Health Officer and Block Development Officer (from the Rural Development Department) were assigned as Project Co-ordinators (19). In addition, there were one Programme Officer, one Field Supervisor, three helpers for preparing the packets of nutrition supplements, and three office assistants. Many of these workers helped in the operational research.
Each PTSW covered a population of about 2,000 in an average of two villages and worked four to five hours a day. They were paid US$10 per month. The mean age of 28 PTSWs was 22 years, and they had had an average of seven years of schooling. Sixteen of the 28 PTSWs were male, and 21 were tribal. The MHW was supposed to visit a PTSW's area twice a week to guide and supervise. The frequency of field visits by the health supervisors and medical officers was increased and more referral cases were attended to by the medical officers. Some cases were referred to the Taluka or District hospital. Deliveries were conducted by traditional birth attendants (TBAs). Of 142 TBAs in the project area, 110 were trained and provided with specially devised, tiny delivery kits, whose contents were replenished after each delivery (20, 21).
About 95.4 per cent of 10,152 children under six years of age were covered on the basis of their weight charts. The others in the villages were treated for acute illnesses. Twenty-eight PTSWs who were trained in community diagnosis and management (22) provided health and nutrition services in the homes and at the clinics. A PTSW was equipped with locally prepared electrolyte powders, massive doses of vitamin A, tablets of iron-folic acid, piperazine, aspirin, sulphadiazine, an emulsion of benzyl benzoate, and eye ointment. They used the handbook Timely Health Care of Children and Mothers (23), written in the Marathi language.
These domiciliary services were very helpful for those children whose mothers were employed outside the home. It was observed at the Palghar Project that 91.3 per cent of the mothers of children with kwashiorkor worked away from home. Of children under six whose mothers worked 36.2 per cent were severely malnourished, whereas the community average was 8.5 per cent. Only 12.7 per cent of those from six months to six years old whose mothers worked were normal compared to 57.1 per cent among that age group whose mothers were at home (5). Of the small children of working mothers, 43.5 per cent were looked after by elder sisters and brothers.
Nutrition services. Children who weighed 65 per cent or below of the reference weight received food supplements until they reached, and maintained for six weeks, a weight equal to, or above, that standard. Severely malnourished pregnant women identified as at-risk also received nutrition supplements during the last six weeks of pregnancy and for the first four weeks of lactation (21, 24).
Immunization services. Mass immunization campaigns were organized for 13 days during November-December 1975, and for 12 days in February 1976, in which the district team of BOG vaccinators and staff members of the PHC and PTSWs participated. During May 1976, a follow-up campaign was continued by the MHWs to make sure of complete coverage (21, 24).
The "at-risk" concept of surveillance and referral services. At the Palghar Project, 84 per cent of children under five who died showed one or more of the at-risk indicators (9). It was possible for PTSWs to identify as at-risk in advance of their deaths about 76 per cent of the under-fives who died. Those who were at-risk in this age group represented 2.1 per cent of the total population, yet the deaths among these at-risk children represented 21.5 per cent of the total deaths (9, 10). The at-risk indicators followed at the Kasa Project were based on the two-year study at the Palghar Project (9 - 11).
Those listed as at-risk formed the principal target group for most project programmes and for referrals to the MHWs and medical officers. One-third of the pregnant women and 25.5 per cent of the children under six in the Kasa Project were at-risk in May 1976. The parents in these families were referred to the Block Development Officer to apply for jobs under the Government Employment Guarantee scheme, and they received preferential treatment in obtaining employment.
Family planning services. From the analysis of the households of families with children suffering from kwashiorkor in the villages of the Palghar Project, it was observed that 60.8 per cent of the children in these households were 14 years old or younger, and 32.7 per cent were under age five (5). Family planning was thus of utmost importance for preventing severe malnutrition and for motivating parents to better child care, and family planning was one of the major educational aims of the PTSWs.
Health and nutrition education. The main tools for providing education were the weight chart and mother's card maintained in the home. Healthy, normal children or those who had been malnourished and who had recovered were the models for demonstrations. The PTSWs talked to the mothers and mother-substitutes about health and nutrition.
Environmental sanitation. Every month the PTSWs chlorinated the drinking-water wells in their areas. They also tried to involve the villagers in improving environmental sanitation.
ACCOMPLISHMENTS OF THE KASA PROJECT (20, 21,24)
Increased utility of health services. The services were delivered to the doorstep in all the project villages. Each worker treated 60 to 70 patients every month. Monthly coverage of the children under six years of age and of the married women was 95.4 and 53.6 per cent, respectively, of the total number in the programme villages. The proportion of known infertile women who had undergone sterilization or whose husbands were vasectomized was between 15 and 20 per cent, and they were not registered for services.
Improvement in nutritional status. The nutritional status of the severely malnourished children improved remarkably. In 18 months, 62.9 per cent of the children who weighed 65 per cent or less of the reference weight showed improved nutritional status.
Properly organized distribution of nutrition supplements. Food supplements were restricted to only those who, through surveillance, were identified as needy on the basis of weight. During the difficult months of the monsoon season, 85 per cent of the food-supplement deliveries were made to at-risk beneficiaries in the so-called inaccessible zones. In the summer deliveries of food supplements increased to 98.9 per cent in all of the zones covered by the PTSWs.
Immunization services. Within the first 18 months, the immunization status of 9,560 children in the project villages was upgraded from 1.4 per cent of the total number of children covered to about 65 per cent, for complete immunization against diphtheria, pertussis, tetanus, smallpox, and tuberculosis.
Family planning programmes. It was possible to carry out 770 sterilization operations during the first year, and 1,668 during the second, exceeding the targets and expectations.
Special care for at-risk and referral services. A system of special care for at-risk persons was developed in which the community was involved in management and education. The mortality among 58 marasmic children who were identified as at-risk and cared for at home for one year was as low as 5.3 per cent.
Community involvement. The PTSWs who had been recommended by their community became involved in stimulating more self-help in terms of community participation in the programmer. They met with the villagers and their leaders and informed them of the problems encountered while running the programmer, and many times solutions were suggested by the villagers themselves. The villagers provided the clinic sites and assisted in collecting children and women. In one-third of the villages, someone from a hamlet collected the beneficiaries and made them eat their nutrition supplements in his or her presence. When told of the problem of feeding small infants whose mothers experienced lactation failure, the community provided milk for from 13 to 17 children in the Palghar Project and for three in the Kasa Project area (25, 26).
Sometimes villagers constructed roads to facilitate communication with the PHC. During mass immunization campaigns, the Block Administration allotted Rs 2,500 (US$310), and the Forest Workers' Society and villagers made arrangements to meet the local needs of the teams, serving tea, lunch, and dinner for 36 persons for a total of 25 days. The village leaders talked to the residents about the importance of immunizations and brought children to the centre for their shots. They also helped in environmental sanitation programmes. There was helpful collaboration among the 110 TBAs (dais) and 278 traditional healers (bhagats) of the area.
A system of built-in evaluation was operating that provided overall monthly information about all the registered children and women in the project villages. Nutrition and health education given in the homes and clinics was realistic in relation to the social background of the people involved. An awareness of the significance of weight-for-age was created even in tribal villages. This provided a good base for purposeful implementation of the education.
PROBLEMS ENCOUNTERED AT THE EXTENDED PROJECT, KASA
Although the accomplishments were promising, there were problems that are worth noting.
Unsatisfactory supervision. Supervision was a weak point in the project. The District Health Officer was preoccupied with other projects going on in the district, which is adjacent to Bombay. He could not supervise the Kasa Project to a satisfactory extent. The medical officers made fewer field visits than were scheduled in the project, but even so there were many more visits than in the past. Field visits were mainly by the Programme Co-ordinator. The MHWs did intensify their field schedules to a considerable extent, but one-third of the nurses did not become actively involved.
Vacancies and delays in filling posts. For 4 of the first 17 months of the project, there were only two medical officers at the PHC. As one object of the project was to study the feasibility of replicating it, no pressure to fill the posts was brought to bear at higher administrative levels than the District Health Officer. In Thane District, a medical officer continued to be in service for an average of two years, and started practice in the metropolis of Bombay.
Lack of proper end timely directives. Many times, the District Health Officer did not give prompt, clear-cut instructions to the medical officers at the PHC on matters already decided in administrative meetings, and hence the local staff was not whole-heartedly implementing the decisions made jointly by them and the project staff. Sometimes, the superiors of the District Health Officer had to intervene.
Negative feelings about the Project among PHC staff members. There were at times distinct feelings within the staff that all these services were "project programmes" under operational research and not true PHC services. This was probably because the experiment was being carried out for the first time in the country, and it was directed by a person who belonged to a teaching institute of the Department of Medical Education and Research of the government, not to the Department of Health. However, after frequent discussions, this factor did not seriously impede the project activities.
Other heavy assignments of the PHC staff. Family-planning months with target dates, surveys of smallpox vaccination scars, smallpox-like illnesses, the number of couples eligible for family planning, and other unexpected compulsory, priority-oriented activities all had to be carried out by the PHC staff, leaving little time for the project programmes, as instructions for the other activities came from higher administrators of the state or from the Government of India. During such periods there were discontinuities in the supervision and activities of the medical officers and supervisory staff. Such assignments took the entire time of these team workers for three to four months in a year.
High drop-out rate of PTSWs. The drop-out rate for PTSWs was 60 per cent at the Palghar Project. At Kasa, by the end of 18 months, only 35.8 per cent of the workers who were employed at the very beginning were still in service. The dropout rate was very heavy following the kharif harvest. Some of those who resigned rejoined. The turnover of male workers was greater than that for females. The problem became less severe during the second year, and subsequently diminished considerably.
The reasons for drop-outs included low remuneration, overload of work, long distances to walk daily, finding other jobs with higher salaries, and - for female PTSWs - marriage. Some PTSWs were fired because of their unsatisfactory work performance.
Inadequate Training. Training of the PTSWs was inadequate, largely because of the high drop-out rate PTSWs were appointed at any time, and to train all new workers for the most part one at a time was really time-consuming. There was no separate cadre of trainers.
Other trainees. The numbers of trainees from outside the project as well as visitors impeded smooth implementation. The project at Palghar was widely known, and the number of trainees and visitors increased at both the Palghar and Kasa projects. The Government of India utilized the Kasa Project for training 90 supervisors and project officers from 22 states for the Integrated Child Development Scheme (ICDS) during 1975-1976. Twenty-seven medical officers, nurses, and district health officers attached to the ICDS projects in the states of Gujarat, Maharashtra, and Madhya Pradesh were oriented at the Kasa Project. On average, 121 persons were trained every year, and the staff spent three days a month in training activities. The number of visitors from India and abroad amounted to between 160 and 180 per year. Organizers of community health programmes from various medical schools and national institutes stayed in Kasa from time to time. Every year 10 WHO/UNICEF fellows from developing countries who were senior teachers in child health and 10 to 15 other WHO fellows also utilized the project for their field assignments and stayed there for varying amounts of time. These activities, although welcome, did affect the project's outcome by diverting much of the staff members' time from their project work.
Difficult Project Area
Difficult terrain and poor communications. The project area was in a hilly, forested tribal region. Accessibility to villages and hamlets was difficult. Lack of transportation and the limitations of communication hampered performance.
Tribal population and extreme poverty. There was extreme poverty among the tribes. During the summer, about one fourth of the families had nothing to eat except tuber roots. The literacy rate was 11 per cent. During the initial three to four months of the project, it was a daily occurrence that when any stranger, particularly a medical person, came to a village, all the residents would either run away to the hills or shut their doors. Two PTSWs faced some bad moments because the local people thought they were agents for family planning; they were even manhandled. However, within five to six months of implementation of the services, after much dialogue with the tribal leaders, these problems were resolved.
Problems Occurring When the Project Was Taken Over by the Government
At a meeting called by the Chief Secretary of Maharashtra State on 2 April 1976, 16 months after the project started, and attended by the Secretaries of Health, Finance, and Rural Development and Planning and the Directors of Health and of Medical Education and Research, great appreciation was expressed for the accomplishments of the project, and it was decided to extend such programmes over the entire state (population 55 million). However, it was suggested that, before doing so, a study should be made of the functioning of the project under governmental auspices beginning in April 1977. Accordingly the project came under the complete control of the Director of Health Services. One of the Deputy Directors of Health and the District Health Officer were made responsible for the operations. The Project Director continued as a consultant to the project from April 1977 on.
Problems occurring during the new phase. Problems occurred at the level of the secretariat and top management personnel. The Finance Ministry was not certain about the budget divisions, and the monthly salaries of the PTSWs were not cleared for seven months. Though the cause of the problem was relatively trivial, it required numerous visits by the Deputy Director of Health and the consultant to various government officials to get it cleared up. The PTSWs did not receive their pay and were dissatisfied, Again, because of a delay in approving the budget in various government departments, payment was delayed a second time for four months. The morale of the supervisory staff was low. However, it was amazing that more than half of the PTSWs and MHWs kept working as efficiently as they had the year before; to them, the work itself was satisfying.
During 1978 the Maharashtra government considered introducing a system of MHWs and community health workers (CHWs) all over Thane District, but this did not materialize. This slowed down the operations of the project to a great extent. The nutrition supplements were not purchased, and the supply of drugs was limited. The Deputy Director of Health and the District Health Officer made only infrequent visits to the project area, as they were occupied in planning the proposed whole-district extension that was never accomplished.
LESSONS ON THE REPLICABILITY OF THE PALGHAR AND KASA PROJECTS
The operation of health-nutrition services in special projects differs to a considerable extent from that in a typical government set-up. Project directors often have greater flexibility in decision-making; the management is smoother and more efficient; logistics are simplified and can be modified according to the work plan. In addition, there is the advantage of the personal characteristics of those who work in a project: team members tend to be diligent and sincere and to have a desire to do something that benefits the whole community. Many times it seems that the project is like an inverted pyramid, with the director at the tip.
New alternative approaches to community health services need to be tried out as projects before being established as regular government services. But, to provide a valid trial, it is imperative for the projects to be run under government administration and with government personnel manpower rather than by other agencies. There have been a number of projects which showed outstanding achievements, but when their approaches were put into operation on a large-scale governmental basis, they failed miserably.
The Palghar and Kasa projects were experiments within the governmental milieu. Priorities were chosen according to local problems. The accomplishments were remarkable and promising. The inputs of manpower, material, and finances were scrutinized as part of the research component of the projects. The management study at the Kasa Project indicated that there is a need for separate teams of trainers at the district level, and that supervisors of PTSWs and MHWs should be involved in that training. Frequent reorientations and a built-in training process by means of fortnightly meetings are important. It is equally important to convert uni-purpose health workers into multipurpose workers able to provide various services.
Supervision is equally important for efficient performance and needs to be increased throughout all levels of the government staff. The community can indirectly assist in supervision.
The programme for providing health-nutrition services at grass-root levels envisages that each team member will work as prescribed in the job chart. It is a universal observation that sincerity, hard work, aptitude, interest, and devotion of team members are not uniform, and teams consist of both good and unsatisfactory workers. However, good leadership and supervision are among the deciding factors.
The post of Programme Manager at the PHC, preferably filled by someone of non-medical background, is important. The responsibility of this officer would be to see that the programmes are implemented and that there is co-ordination between all functionaries and outside agencies, and that the whole community is involved. It should be a senior post at a level just below Block Development Officer.
Studies of the economics of an alternative approach at Kasa showed that it will involve a total budget slightly more than three times the present budget - excluding the budget for the supplementary nutrition programme - of Rs 116,100 (US$14,510) for regular and national programmes for a population of about 65,000. About half of the estimated budget, based on 1978 prices, will be for nutrition supplements. Implementation of nutrition services is quite difficult from the point of view of management and logistics. However, the priority of nutrition in the package of services is unquestionable, and until such time as the local community sponsors the nutrition supplementation, government investment is desirable. The additional expenditure also includes provision for a Programme Manager, helpers to prepare nutrition supplements, additional office assistants, petrol, transportation and one more driver, drugs, and vaccines.
The Kasa Project is replicable, although it will test the managerial ability of the government. The problems encountered at the governmental level when the Kasa Project was taken over were "teething pains." However, when there is a whole-hearted commitment, such constraints Hill be minimal. The other problems described and suggestions offered above should be taken into consideration when planning and implementing such services.
1. P.M. Shah and P.M. Udani, "Analysis of the Vital Statistics from the Rural Community, Palghar. III. Pre-School and School Age Mortality," Indian Pediat., 6 (12): 759-767 (1969).
2. P.M. Shah and P.M. Udani, "Analysis of the Vital Statistics from the Rural Community, Palghar. II, Perinatal, Neonatal and Infant Mortalities," Indian Pediat., 6 (10): 651-668 (1969).
3. P.M. Shah, P.M. Udani, and R.V. Aphale, "Domiciliary Management of Kwashiorkor in Rural Set-up: A Longitudinal Study of Clinical, Economic, and Social Aspects," Indian Pediat., 8: 805-813 (1971).
4. P.M. Shah, K.K. Wagh, P.V. Kulkarni, and B. Shah, "The Impact of Nutrition Rehabilitation on the Diet of Children," Trop. & Geogr. Med., 26: 446 - 448 (1974).
5. R.D. Khare, P.M. Shah, and A.R. Junnarkar, "Insight into Etio-Ecological Factors of Kwashiorkor in Rural Communities," Indian Pediat., 13 (6): 405-407 (1976).
6. P.M. Shah, "Domiciliary Treatment of Protein-Calorie Malnutrition: The Project Document" Institute of Child Health, Bombay, 1972).
7. P.M. Shah, and A.R. Junnarkar, "Domiciliary Treatment of Protein-Calorie Malnutrition: First Year Progress Report" (Institute of Child Health, Bombay, 1973).
8. P.M. Shah and A.R, Junnarkar, "Domiciliary Treatment of Protein-Calorie Malnutrition: Second Year Progress Report" (Institute of Child Health, Bombay, 1974).
9. P.M. Shah, A.R. Junnarkar, R.D. Khare, and V.S. Dhole, "Community Surveillance of 'At Risk' Under-Fives in Need of Special Care," J. Trop. Pediat. 22: 103-107 (1976).
10. P.M. Shah and A.R. Junnarkar, "Weightage of the Various 'At Risk' Factors and Practicability of Management," in "At Risk" Factors and Young Child Nutrition, an IUNS Conference organized by D.B. Jelliffe with the Supreme Council on Family Planning and the Medical School of the University of Cairo (Cairo, Egypt, 1975).
11. P.M. Shah and Kusum P. Shah, "Role of Teachers from Medical Colleges in Delivery of Health Care in Rural Areas: Development of Appropriate Technology, Training, and Operational Research," in V. Kumar, ed., Delivery of Health Care in Rural Areas (Chandigarh, India, 1978).
12. Kusum P. Shah, "Appropriate Technology in Primary Health Care for Better Midwifery Services," J. Obstet. Gynaec. (India), Vol. 30 (1980).
13. P.M. Shah, A.R. Junnarkar, D.D. Monteiro, and R.D. Khare, "The Effect of Periodic Deworming on the Nutritional Status of Preschool Community. A Preliminary Communication," Indian Pediat. 12 (10): 1015-1020 (1975).
14. P.M. Shah, A.R. Junnarkar, and R.D. Khare, "Role of Periodic, Deworming of Preschool Community in Nutrition Programmes," Progress in Drug Res., 19: 136 - 146 (1975).
15. S.N. Mudkhedkar and P.M. Shah, "The Effect of Spacing of Children on the Nutrition and Mortality of Under-Fives," Indian J. Med. Res., 64: 453-458 (1976).
16. S.N. Mudkhedkar and P.M. Shah, "The Impact of Family Size on Child Nutrition and Health," Indian Pediat., 12 (11): 1073-1077 (1975).
17. P.M. Shah, "Main Nutrition Problems during the Weaning Period and Their Solution," papter presented at the XI International Congress of Nutrition, Rio de Janeiro, 1978 (proceedings in press, Plenum Publishing Co., New York).
18. P.M. Shah, "Non-nutritional Constraints in Fulfilling Nutritional Targets: Problems and Solution," in Proceedings of the Diamond Jubilee Celebrations Conference, National Institute of Nutrition (Hyderabad, India, 1979).
19. P.M. Shah and CARE-Maharashtra, "The Project Document: The Kasa Model Integrated Mother-Child Health-Nutrition Project" (Institute of Child Health, Bombay, 1974).
20. P.M. Shah and CARE-Maharashtra, "The Kasa Model Integrated Mother-Child Health-Nutrition Project: First Progress Report" (Institute of Child Health, Bombay, 1975).
21. P.M. Shah and D. Corra, "The Kasa Model Integrated Mother-Child Health-Nutrition Project: Second Progress Report" (Institute of Child Health, Bombay, 1976).
22. P.M. Shah and Kusum P. Shah, "Community Diagnosis and Management of Malnutrition," Food and Nutr. (FAO), 4 (3,4): 2-7 (1978).
23. P.M. Shah and Kusum P. Shah, Timely Health Care of Children and Mothers (first ed., Popular Prakashan, Bombay, 1978).
24. P.M. Shah and CARE-Maharashtra, "The Kasa Model Integrated Mother-Child Health-Nutrition Project: Third Progress Report" (Institute of Child Health, Bombay, 1977).
25. P.M. Shah, S.R. Walimbe, and V.S. Dhole, "Wage-Earning Mothers, Mother-Substitutes, and Care of the Young Children in Rural Maharashtra," Indian Pediat, 16 (2): 167-173 (1979).
26. P.M. Shah, "Community Participation and Nutrition. The Kasa Project in India," Assignment Children (UNICEF), 35: 53-72 (1976).
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