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The effect of income generation through the integrated rural development programme on the nutritional status of children under six years old in India


Namanjeet Ahluwalia, Arvind Wadhwa. and Sushma Sharma

Editor's note

The relationship between poverty and malnutrition is now well established. However, convincing demonstrations that a specific intervention that improves family income and food supply results in a prompt improvement in nutritional status are not common. The following paper reports that the young children of families participating in a rural development assistance programme for a period as short as two years had better anthropometric measurements than children in similar families not participating in the programme.

The validity of the conclusions depends on the comparability of important variables between the two groups before the intervention. In fact, as the reviewers noted, the control group had significantly more families in the lowest caste, a difference which might be expected to have influenced pre-intervention economic and health status. However, within-group comparisons did not find caste to be a significant factor in accounting for within-group differences in nutritional status within this relatively uniformly and severely underprivileged population. Moreover, the differences in child nutrition observed between the two groups can be explained by the specific changes clearly associated with the intervention.

Introduction

India is an agrarian nation with 77% of its population living in rural areas [1]. The Integrated Rural Development Programme (IRDP) is a nationwide anti poverty programme, initiated in 1978-1979, to benefit the "poorest among the poor" in the rural areas. It aims at raising the level of living of the target families above the poverty line* on a lasting basis by providing them with income-generating assets and access to credit and other inputs. The IRDP is implemented in the rural areas through the District Rural Development Agency (DRDA) with the assistance of the block machinery (block development officers and village level workers) [2].

The true success of a national development programme such as the IRDP must be measured in terms of its impact on the quality of human resources-a major determinant of the latter being the health and nutritional status of its people. The purpose of this study was to evaluate the impact of the IRDP on the growth and nutritional status of children under six years of age.

Children under six years old constitute 17% of the Indian population [1]. The latest reports from the National Nutrition Monitoring Bureau show that nearly 85% of the children under five years of age in India are malnourished [3]. As the problem of malnutrition has its roots in poverty, a nationwide antipoverty programme like the IRDP must attack the problem of malnutrition, and its benefits must reach children 0-5 years old, whose growth is most sensitive to and adversely affected by poverty.

This paper presents a descriptive analysis of data that were collected in the study without making any causal claim. The limitation of the study design arising from the fact that pre-IRDP data were not available is recognized.

Materials and methods

The study was conducted in four villages of Alipur block in Delhi, India. The sample consisted of a group of families participating in the Milk Cattle Scheme under the IRDP,* the beneficiary group (B), and a matching group of nonparticipants, the non beneficiary group (NB), from the same villages. The names of the beneficiaries and nonbeneficiaries were obtained from verified official records of the DRDA in Delhi.

By a house-to-house survey in the villages of Delhi, the DRDA made an exhaustive list of individuals whose family income from all sources was below the poverty level. The people in the beneficiary group were ones who belonged to this category and who approached the officials for assistance and received the benefit (milk cattle) through the IRDP. The non beneficiary families were also on the list of those with income below the poverty line but did not get help from the IRDP because of limited quotas. It is important to understand that both the B and the NB families had incomes below the poverty line before the intervention through the IRDP.

The sample comprised those families in the study villages whose names appeared on the lists obtained from the DRDA who had at least one child under six years old-and, in the case of the beneficiary group, who had acquired cattle through the scheme at least two years before the study. The total sample consisted of 78 families with 140 children 0-5 years old-49 families with 91 children in the B group, and 29 families with 49 children in the NB group.

Interview and observation methods were used to collect data. The techniques used in the assessment of nutritional status were dietary survey, anthropometric measurements, and clinical examination. Food intake was determined for two days (one weekday and one weekend day) by a 24-hour dietary recall method using an interview. The mean food intake was converted into nutrient intake using Indian food-composition data [4]. The anthropometric measurements-weight, height, head circumference, chest circumference, and mid-upper arm circumference (MUAC)-were taken following the guidelines given by Jelliffe [5], using a portable (Soehnel) weighing scale and a PVC-coated fibreglass tape. Children were also examined for signs of protein-energy malnutrition (PEM), anaemia, and avitaminosis A. The anthropometric indices used were weight for age and height for age as modified by Shanti Ghosh [6], weight for height (percentage of Harvard standard), Rao and Singh's weight/height2 statistic [7], McLaren and Kanawati's MUAC/head circumference ratio [8], and head/chest circumference ratio.

Results and discussion

The socio-economic characteristics and general information regarding the families studied are presented in table 1. A significant difference in the monthly per capita income (Z score = 5.74, P L .01) was observed, although the range of per capita income (Rs 60-244 in the B group and Rs 45-200 in the NB group) did not show much difference. A Z test was also done to see if the monthly per capita income in the two groups differed significantly after deducting the income due to the milk cattle (obtained through the IRDP) from the total income in the B group. No significant differences were found (Z score = -0.16, P L .05). Average family size was the same in both groups.

The increased total income in the B families after adoption of the milk-cattle scheme resulted in an increased expenditure on food (by 90%), clothing (by 59%), household durable goods such as fans and radios (by 51%), and tobacco (by 57%). Spending on convenience foods like bread and biscuits increased by 80%. A decreased expenditure on fuel was reported by 18% of the beneficiaries because of the use of dung cakes as fuel.

The general profile of the child population is presented in table 2. The percentage of children with a birth weight greater than 2.5 kg was higher in the B group (81%) than the NB group (57%). A clear association between birth weight of below 2.5 kg and birth order was observed: 21%, 39%, and 57% of the children whose birth order was <3, 3-6, and >6 respectively fell into this birth-weight category.

Almost all the children (100% in the B group and 96% in the NB group) were breast-fed. In most cases, colostrum was fed to the infants. Pre-lacteal foods included ghutti, made of sugar and warm water (96%), honey (1%), and cow's milk (3%). Most of the children had been breast-fed up to 12 years old. A clear trend of prolonged breastfeeding was observed in both the groups. However, the introduction of supplementary foods-liquid, soft, and hard in that order-was earlier (around 9 months of age) for the children of the B group than for their NB counterparts. Relatively early weaning of the B-group children might be attributed to the fact that the B mothers had to go out to work (related to the cattle). Further, the increased availability of milk in the B households might have sewed as an incentive to supplement the mothers' breast milk.

TABLE 1. Profile of the study households (N= 78)

 

Non-beneficiary group (NB)

Beneficiary group (B)

No. of households Children 0-5 years old No. of households Children 0-5 years old
All households 29 49 49 91
Family type
Nuclear 21 41 32 59
Joint 8 8 17 32
Caste
Scheduled 12 19 10 18
non-scheduled 17 30 39 73
Mother's education level
Illiterate 20 33 29 50
Pamary 5 8 9 19
Middle 3 6 5 9
>middle 1 2 6 13
Family size (mean SD)

6.0 1.5

6.0 1.8

Average number of cattle owned

0

1

TABLE 2. Profile of the child population

 

Number of children

NB group B group
Age (years)a
< 1 16 30
1-2 17 30
3-5 16 31
Sex    
male 17 51
female 32 40
Birth order
<3 30 55
3-6 15 26
>6 4 10
Birth weight
<2.5 kg 21 17
3 2.5 kg 28 74

a. 1-2 years means 3 12 but <36 months; 3-5 years means 3 36 but <72 months.

The food-consumption pattern of the children was influenced by economic factors, seasonal availability of foods, traditional food habits, and certain beliefs and taboos regarding foods. Wheat was the staple food of the study group. The consumption of milk and pulses was higher among the B children, whereas the NB children had a higher cereal and green leafy vegetable intake. Part of the pulse intake of the B children was contributed by the nutritional supplement component of another national programme, called the Integrated Child Development Services (ICDS), run by the Ministry of Social Welfare of the government of India. It was observed that the B families were more aware of welfare programmes such as ICDS and primary health care services because of their greater interaction with different levels of functionaries at the Block Development Officer's office. This accounted for the greater use of these services by the B than by the NB households.

There was a gross deficit of calories and iron in the diets of the children (table 3). The iron intakes were lower than the recommended dietary intake [9] and not significantly different for B and NB children under one year old and one and two years old. However, the significantly higher iron intake of NB children three to five years old than of their B counterparts may be due to their greater consumption of green leafy vegetables, which are inexpensive and often available free of cost. The protein, vitamin A, and calcium intakes of all the children except the NB children under one year old was higher than the recommended dietary intakes. The inadequate intake of these nutrients by the latter group was due to delayed weaning and to the sole dependence on their mothers' milk for the supply of nutrients. The B children had significantly higher calorie, protein, and retinol intakes than the NB children due to their higher milk and pulse intake. A significant correlation between calorie intake and monthly per capita income was observed for the children under one year old (r = .30, P L .05), one and two years old (r = .29, P L .05), and three to five years old (r = .31, P L .05).

The physical growth pattern of all the children was well below the standard values for well-nourished Indian children [6]. However, inter-group comparisons show that the B children had a better anthropometric profile than their NB counterparts. Among various indices used for detecting malnutrition, MUAC/head circumference ratio was observed to be the most sensitive (table 4). Table 5 shows the assessment of nutritional status of children in different age groups on the basis of this index. It is clear from table 5 that the percentage of malnourished children was much higher in the NB than the B group in all age groups. Thus, the children of the B group were relatively better off in terms of physical growth and prevalence of malnutrition than the NB children.

Among such variables as income, family type, caste, mother's education, and sex, only income was found in this study to be significantly associated with nutritional status (X2 = 8.03, p L 05). There were more nonscheduled caste children and more male children in the B group, but these variables were not statistically associated with nutritional status in our study. Thus, the lower prevalence of malnutrition in the B-group children can be explained on the basis of higher caloric and protein intake due to increased income and other associated benefits of IRDP in the B group. The spin-off benefits of IRDP included increased awareness and better utilization of primary health care services by the B households, and contributed to better immunization status among the B children. Infections, such as coughs, colds, diarrhoea, fever, and eye infections, were common among all the children, but the prevalence of infections was significantly higher among the NB children.

TABLE 3. Daily nutrient intake of children 0-5 years old

 

Intakea

RDIc

Intake as

NB groupb

B groupb

NB B

< 1 year old

Calories* (kcal) 490 212 (340-1,059) 709 328 (345-1,638) 960 51 74
Protein* (g) 10 7 (6-29) 17 11 (6-49) 16 62 106
Carotene (g) 69 163 (0-578) 171 359 (0-1,428) -    
Retinol* (g) 252 73 (125-457) 326 103 (218-697) -    
Total vitamin A (g) 269 72 (203-458) 369 146 (218-836) 350 77 105
Calcium** (g) 0.4 0.3 (0.2-1.2) 0.6 0.5 (0.2-2.2) 0.5-0.6 73 109
Iron (mg) 1 2) (6-10) 2 2 (0-6) 8.5 12 24

1-2 years old

Calories (kcal) 1,120 355 (515-1,723) 1,170 317 (701-1,893) 1,220 92 96
Protein (g) 3612 (15-57) 42 13 (17-68) 22 164 190
Carotene (g) 1,941 2,173 (20-9,252) 1,376 1,056 (4-3,728) -    
Retinol (g) 209 129 (102-663) 265 82 (131-422) -    
Total vitamin A (g) 694 557 (107-2,545) 609 273 (189-1,165) 250 278 244
Calcium.** (g) 0.8 0.4 (0.2-2.2) 1.1 0.4 (0.6-2.2) 0.4-0.5 177 244
Iron (mg) 20 10 (6-42) 19 10 (4-47) 20-25 88 84

3-5 years old

Calories* (kcal) 1,342 254 (893-1,815) 1,569 295 (863-1,976) 1,720 78 91
Protein** (g) 47 9 (27-60) 53 10 (30-68) 29 160 180
Carotene** (g) 3,394 2.118 (152-8.480) 2,175 1.766 (105-7.024) -    
Retinol* (g) 141 64 (5-247) 24568 (111-389) -    
Total vitaminA(g) 989516 (182-2,174) 789454 (199-1,997) 300 330 263
Calcium* (g) 0.8 0.3 (0.2-1.2) 1.2 0.3 (0.6-2.2) 0.4-0.5 178 267
Iron** (mg) 34 8 (20-48) 29 8 (7-43) 20-25 151 128

a. Mean SD. Figures in parentheses indicate range.
b. See table 2 for number of subjects in each age group
c. Recommended dietary intake [9].
*Difference significant at P =<.01
**Difference significant at P =<.05.

TABLE 4. Nutritional status of children on the basis of various anthro-pometric indices

Index and group

Normal

Malnourished

Mild

Moderate

Severe

MUAC/head-circumference ratio
NB 18 (37) 18 (37) 11 (22) 2 (4)
B 43 (47) 31 (34) 15 (17) 2 (2)
Weight for age                
NB 21 (44) 14 (28) 10 (20) 4 (8)
B 45 (50) 29 (32) 13 (14) 4 (4)
Height for age
NB 45 (92) 4 (8) 0   0  
B 84 (92) 7 (8) 0   0  
Weight for height
NB 33 (68) 8 (16) 5 (10) 3 (6)
B 64 (70) 17 (19) 9 (10) 1 (1)
Weight height2
NB 32 (65)     17 (35)    
B 66 (73)     25 (27)    
Head/chest-circumference ratioa
NB 32 (76)     10 (24)    
B 67 (84)     13 (16)    

Principal values are numbers of children. Figures in parentheses indicate percentages.
a. Computed for children above six months of age.

TABLE 5. Nutritional status on the basis of MUAC/head-circumference ratio, by age range

Age and group

Normal

Malnourished

Mild

Moderate

Severe

<1
NB 5 (31) 4 (25) 6 (38) 1 (6)
B 17 (57) 9 (30) 3 (10) 1 (3)
1-2
NB 7 (41) 7 (41) 3 (18) 0  
B 14 (46) 8 (27) 8 (27) 0  
3-5
NB 6 (38) 7 (44) 2 (12) 1 (6)
B 12 (39) 14 (45) 4 (13) 1 (3)

Principal values are numbers of children. Figures in parentheses indicate percentages.

Clinical signs of severe PEM such as dull, thin, dyspigmented hair, pot-belly, oedema, and apathy were seen in 16% of the B and 34% of the NB children. Pale conjunctive was present in 25% and 61% of the B and NB children respectively.

In conclusion, the IRDP Milk Cattle Scheme raised the income level of the selected beneficiaries significantly and achieved the objective of raising the resources and income level of the vulnerable sections of the population by providing them with productive assets and access to credit. Further, participation in the scheme led to improved nutritional status for the children under six years old of the beneficiary group compared to their non-beneficiary counterparts. This was achieved directly as a result of income generation through the scheme and indirectly by increased awareness and utilization of ICDS and primary health care services by the beneficiary group.

References

1. Directorate General of Health Services. Handbook of health statistics of India. New Delhi: Government of India, Sixth Five Year Plan (1980 1985) Planning Commission, 1981.

2. Planning Commission. Evaluation of Integrated Rural Development Programme. New Delhi: PEO, Government of India, 1981.

3. Gopalan C. The child in India: nutrition and health care, problems and policies (a compilation of recent addresses). Special publication series, no. 1. Nutrition Foundation of India, 1985:1-21.

4. Indian Council of Medical Research. Nutritive values for Indian foods. New Delhi, 1981.

5. Jelliffe DB. The assessment of the nutritional status of the community. WHO monograph series, no. 53. Geneva: WHO, 1966.

6 Ghosh S. The feeding and care of infants and children. New Delhi: Voluntary Health Association of India, 1981.

7. Rao KV, Singh D. An evaluation of the relationship between nutritional status and anthropometric measurements. Am J Clin Nutr 1970;28:83-93.

8. McLaren DS, Kanawati AA. Assessment of marginal malnutrition. Nature 1970;228:573-75.

9. Indian Council of Medical Research. Recommended dietary intakes for Indians. New Delhi, 1981.


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