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Pulkit Mathur, Sushma Sharma, and Arvind Wadhwa
We developed and tested tools for the rapid appraisal of the health and nutrition profile of adolescent girls (11 14 years). The sample consisted of 80 girls, their mothers (n=61) or married older sisters (n=3), 6 village-level workers, their helpers, and four doctors in Ladosarai village in Delhi, India. Girls carried out rapid assessment exercises for mapping food intake and occurrence of diseases according to season, and actively participated in focus group discussions. They also ranked their families accurately according to relative wealth. There was no significant difference between the mean nutrient intakes obtained by the conventional and modified rapid assessment 24-hour recall (p>.05). The rapid assessment methodology not only helped save survey time but also added depth and gave new insights into the girls' hearth and nutrition problems and perceptions.
Rapid assessment procedures (RAP) are a reality in international health, nutrition, and development planning [1]. Planning and implementing development programmes with people's participation is considered one of the keys to sustainable development [2]. Although RAP are often not explicitly participatory, at least as originally conceived, the participatory approach in the present study was a vital addition to the basic method for better involvement of the target population in the research process.
We explored the potential of using RAP to study the health and nutrition profile of adolescent girls. As future mothers and present caretakers, these girls are recognized as potential human resources and have been brought into the fold of the nationwide network of the Integrated Child Development Services (ICDS) scheme [3]. The study was designed to develop and test tools for the rapid appraisal of the health and nutrition profile of adolescent girls (11 14 years) from a periurban background, with the following objectives:
Design
The design emphasized collection of qualitative data. Quantitative data were collected to assist in amplifying and substantiating the qualitative issues. The study was carried out from October 1992 to January 1993.
Locale
The village of Ladosarai in Mehrauli, Delhi, was chosen as the study locale. Although classified as a village, it is closer to what can be described as periurban, with most of the basic amenities of cities.
Sample
The village has six anganwadi centres (village-level units of the ICDS catering to approximately 1,000 people) and a total of 246 girls in the age group 11 to 14 years (according to a survey conducted by the anganwadi workers in December 1992). Twelve to 15 girls were selected from each anganwadi centre based on their residence in the village for at least two years and willingness to participate. The final sample consisted of 80 girls.
As RAP recommends obtaining the viewpoint of several groups of people concerned with a problem, we included the mothers of these girls (n = 61) or married older sisters (n = 3) for girls who were not staying with their parents. The six anganwadi workers and their helpers were also interviewed, together with four of the most frequently consulted doctors in the village, as key informants.
RAP tools and techniques
The following tools and techniques were selected for the rapid appraisal of the girls' health and nutrition profiles:
The girls in each anganwadi were put in groups of six to eight each. Participatory mapping was used to identify the general pattern of intake and the 24-hour intake (repeated on three days: two school days and one holiday). Pictures of fruits, vegetables, and other commonly consumed food items such as milk, meat, eggs, and bread were glued onto pieces of cardboard, and grains of different cereals and pulses were placed in plastic pouches. The girls were asked to point to the pictures or pouches to indicate what they had eaten the day before. These materials were familiar and culturally acceptable to the girls during pretesting of the tools. Portion sizes were indicated with standardized cups, bowls, glasses, spoons, and circular cardboard cut-outs standing for chapati (flat thin cake of unleavened, whole-meal bread) sizes.
The seasonal variation in the prevalence of diseases was determined in groups of 12 to 15 girls (i.e., all the participants in one anganwadi made up one group). A chart was divided into three sections representing winter, summer, and rainy season. The girls assigned different colours to different ailments. Each girl then used a marker pen to make a coloured square in the season in which she suffered most from each disease. This resulted in a bar diagram showing the time of year when the illness occurred most and the number of girls affected (see FIG. 1. Sketch of the mapping exercise carried out by the girls of one anganwadi. Six commonly occurring diseases are depicted using a symbol for each one. The number of symbols in a column indicates the number of respondents, thereby forming a bar diagram).
These tools are designed to include triangulation, which is the qualitative method of ensuring validity. Triangulation emphasizes the use of several sources and/or several methods to cross-check data and ensure a balanced perspective.
The girls were asked about the economic status of the village and how they would divide the community on the basis of relative wealth. They were then asked to draw or write the criteria on cards and to place a bean in the class in which they thought they belonged.
Conventional tools and techniques
Data collection was repeated using the conventional methodology to compare the two procedures with respect to the quality of data and the time required to collect them. An interview schedule was used to obtain information about the economic profile, morbidity profile, and dietary habits of all 80 girls. As the meal patterns of the girls did not vary much from day to day, only a one-day 24-hour recall was carried out on a subsample of 40 girls selected randomly.
Data processing and statistical treatment
Nutrient intake was calculated using food composition tables [4]. The mean and standard deviation were calculated from the data obtained from the dietary survey. The paired t test was applied to see if there was any significant difference in nutrient intakes by the RAP and conventional methodologies.
Economic profile
The criteria used by the girls to classify their families into different economic classes were determined in a group discussion. The girls divided themselves into three major classes: rich, middle-class, and poor. The principal criterion was the house they lived in. The other criteria had different priorities in different anganwadi centres and were based on ownership of consumer durables and cattle, and the kinds of clothes worn and food eaten. Family incomes were estimated using the conventional interview schedule and comparison was made of the findings by the two tools (table 1) [5]. The estimates made according to the two methodologies matched well, although there was a slight overlap.
TABLE 1. Results of wealth ranking by RAP compared with conventional questionnaire
| Conventional ranking by income class (Rs/yr)a | No. of families in each income class according to RAP | |||
| Poor | Middle-class | Rich | Totals | |
| Lower-lower (up to 12,500) | 10 | 0 | 0 | 10 |
| Lower (12,501-25,000) | 2 | 24 | 0 | 26 |
| Lower-middle (25,001-40,000) | 0 | 15 | 0 | 15 |
| Middle-middle (40,001 -56,000) | 0 | 4 | 1 | 5 |
| Upper-middle and high (>56,000) | 0 | 0 | 8 | 8 |
| Totals | 12 | 43 | 64 | |
The classification of Kaushal and Khanna at 19X9 1990 prices was used to categorize the income estimates obtained by the conventional method. The numbers of girls falling into each category match well with the numbers obtained by the RAP exercise.
a. 1 Rs = US$0.03.
Health profile
The girls' perception of seasonal variation in peak frequency of different diseases was similar to that reported by the doctors. The winter months had the maximum frequency of fevers (75%), coughs (73.5%), and colds (72.5%); the summer months had a high frequency of conjunctivitis (57.5%) and diarrhoea (23.7%); the rainy season saw a peak in skin infections (27.5%) (see FIG. 2. Seasonal variation in peak frequency of common ailments as reported by the girls). The girls associated each ailment with a particular season, except for diarrhoea, which almost half the girls reported as occurring frequently and not specific to any season.
Table 2 gives the winter prevalence of some common ailments. All those with some disorder at the time of the investigation and those who had just recovered in the past seven days were noted. The point to be stressed is that the girls considered these ailments to be major health problems.
TABLE 2. Prevalence of common ailments for 80 girls in winter
| Ailment | No. (%) |
| Common cold | 29 (36) |
| Cough | 12 (15) |
| Fever | 12 (15) |
| Diarrhoea | 11 (14) |
The prevalence rates (per 1,000) of some major diseases in the past year were 12.5 each for tuberculosis, typhoid, measles, mumps, and dysentery, and 62.5 for malaria. Measles is not a very common condition in this age group, and was reported by only one girl. Confirmation was made by recall from the parents and/or a family doctor.
The disability rates for these girls were also very high: 1,630 per 100,000 population just for locomotor disabilities. According to the 1981 national sample survey report [6], the prevalence of locomotor disabilities in girls (rural population) age 5 to 14 years was 515 per 100,000.
Dietary pattern
Depending on family resources, meals were prepared one to three times a day, and the number of meals eaten ranged from two to four each day. The staple cereals were wheat and rice. Twenty (25%) of the girls were non-vegetarian, although only three (3.7%) ate meat regularly (i.e., at least once a week).
Table 3 gives the nutrient intake of the girls as obtained by the two methods. A t test showed no significant difference between the methods (p > .05); thus, for further discussion, the values obtained using RAP are used. Figure 3 (see FIG. 3. Nutrient intakes of the girls obtained by the RAP method as a percentage of the recommended dietary allowances) gives the nutrient intakes as a percentage of the Indian recommended dietary allowances (RDA) [7]. Except for vitamin C, the consumption of all nutrients was below the RDA in all age groups. Table 4 gives the calorie and protein gap at each age. The 14-year-olds had the greatest energy and protein gaps and the 12-year-olds the smallest gaps.
TABLE 3. Mean + SD (range) nutrient intakes according to RAP and conventional methods
| Method | Energy (kcal) | Protein (g) | Calcium (mg) | Iron (mg) | Vitamin C (mg) | Vitamin A (µg) |
| 11-year-old girls | ||||||
| RAP | 1,431 ± 345 | 43 ±12 | 393 ± 230 | 13.3 ±4.4 | 54 ± 33 | 465 ± 364 |
| (n = 24) | (998-2,351) | (26-73) | (182-1,121) | (8.5-21.2) | (13-140) | (91-1,298) |
| Conventional | 1,391 ± 427 | 42 ±14 | 368 ± 260 | 12.3 ±4.5 | 58 ± 41 | 298 ± 301 |
| (n = 12) | (997-2,329) | (26-74) | (160-1,090) | (7.4-12.1) | (14-139) | (91-950) |
| 12-year-old girls | ||||||
| RAP | 1,511 ± 464 | 45 ±16 | 412 ± 234 | 14.2 ±6.0 | 51 ± 29 | 421 ± 408 |
| (n = 24) | (1,014-2,736) | (29-73) | (156-1,126) | (7.4-26.1) | (14-117) | (91-791) |
| Conventional | 1,518 ± 435 | 45 ±17 | 418 ± 264 | 15 ± 6.7 | 55 ± 30 | 438 ± 374 |
| (n = 12) | (990-2,261) | (29-73) | (170-1,121) | (7.4-26.4) | (18-97) | (91-791) |
| 13-year-old girls | ||||||
| RAP | 1,550 ± 569 | 47 ±20 | 391 ± 265 | 15.1 ±8.8 | 64 ± 53 | 507 ± 595 |
| (n = 19) | (996-2,723) | (27 89) | (186-872) | (6.2 39.6) | (14-204) | (74-1,764) |
| Conventional | 1,503 ± 573 | 43 ±26 | 452 ± 327 | 15.3 ± 10 | 64 ± 48 | 541 ± 659 |
| (n = 10) | (1,070-2,793) | (17-85) | (188-1,131) | (6-40.3) | (19 180) | (56-1,352) |
| 14-year-old girls | ||||||
| RAP | 1,419 ± 428 | 41 ±16 | 429 ± 277 | 13.1 ± 6 | 53 ± 26 | 566 ± 449 |
| (n= 13) | (1,015-2,793) | (25-83) | (198-1,179) | (7.6-29.9) | (19-117) | (74-1,423) |
| Conventional | 1,287 ± 252 | 32 ±12 | 344 ± 125 | 11.3 ±3.7 | 63 ± 35 | 534 ± 532 |
| (n = 6) | (976-1,588) | (14-45) | (197-480) | (8.1-16.8) | (33-132) | (120-1,500) |
The RAP tool for the 24-hour food intake was much faster, taking an average of 4.7 minutes to complete, whereas the conventional tool took an average of 10.3 minutes. The entire RAP exercise for one anganwadi centre took about 8 hours, against 15 hours to complete the conventional interview schedule. Thus, the RAP tool was indeed both rapid and reliable.
TABLE 4. Calorie and protein gaps according to age group
| Age (yr) | RDA
for energy (kcal/day) |
Calorie
gap (kcal/day) |
RDA
for protein (g/day) |
Protein
gap (g/day) |
| 11 | 1,970 | 539 | 57 | 14 |
| 12 | 1,970 | 459 | 57 | 12 |
| 13 | 2,060 | 510 | 65 | 18 |
| 14 | 2,060 | 641 | 65 | 24 |
Wealth ranking in a group was advantageous, as who can assess your living standard better than your neighbour! Even if some of these girls were hesitant, their friends made the assessment for them. This also served as a sort of cross-check, so it was less likely that any participant would misinform the researcher without the others correcting her. Thus this RAP exercise had an edge over conventional probing about family income and wealth, estimates of which are not easy to obtain in a community because of the invasiveness of the questions. In poor communities income may come from several sources and may be seasonal, making it all the more difficult to quantify total family income. The RAP was definitely a more respondent-friendly methodology. Furthermore, it highlighted the girls' acute awareness of societal divisions based on wealth. Wealth ranking is increasingly being used by non-governmental organizations in India to identify the poorest and those most at risk [8].
Of energy, protein, calcium, iron, and vitamins A and C, only vitamin C was consumed in excess of the RDA. This was probably because of the inclusion of fresh fruits and vegetables in the daily diets, especially guava, a vitamin C-rich source the girls purchased from vendors outside their schools. The calorie and protein gap was maximum in the 14-year olds (641 kcal, 24 g). This could be related to the fact that the older girls ate with their mothers after the men in the family, and probably inadequate amounts were left for them. As revealed by dietary consumption data of the National Nutrition Monitoring Bureau, girls age 13 to 15 years consume less than two-thirds of the recommended calorie intake and therefore do not achieve their full height and weight potential [9].
The various focus group discussions gave in-depth information about the health problems that would be difficult to obtain by conventional interviews. The girls identified common colds, cough, fever. diarrhoea, conjunctivitis, and skin infections as major health problems that affected their lives more than serious illnesses that health professionals tend to focus on. The high prevalence of locomotor disabilities was a chance finding, the idea for which emerged in one of the focus group discussions. These merit further investigation by medical practitioners to characterize the nature of the disabilities and to see if they could be prevented.
Group activities especially enabled the girls to open up and put forward their views about sensitive and socially taboo topics such as gender bias and menstruation. The use of RAP can thus be suggested for better understanding of community nutrition problems and for greater success in health and nutrition education programmes, especially those for adolescent girls.
The results of the wealth ranking exercise were consistent with estimates of income obtained by conventional interviews. Seasonal variation in frequency of diseases mapped out by the girls was confirmed by the doctors. The locomotor disability rates for the girls were very high in this community.
There was no significant difference between the mean nutrient intakes obtained by the conventional and modified (RAP) 24-hour recall. The consumption of all nutrients except vitamin C was below the RDA. The mapping of food intake using RAP and, indeed, the entire RAP exercise took much less time than conventional interviews. The greatest asset of the method was the allowance it gave for creativity and modification. It was this leverage that ultimately helped to elicit a range and quality of information and insights that were inaccessible with the more conventional methods.
