THE ASSOCIATION OF NUTRITIONAL STATUS ON THE

PREVALENCE OF ACUTE RESPIRATORY TRACT INFECTIONS IN

CHILDREN OF 5-12 YRS of AGE AT DISTRICT MANSEHRA, NWFP

Submitted by

DR. Hammad Habib

Roll No. Y-571673;

for MSc Community Health & Nutrition

1

SUPERVISOR’S CERTIFICATE FOR THE SUBMISSION OF SYNOPSIS

This is certified that DR HAMMAD HABIB; Roll #: Y-571673, Registration # 07-

NMA-1164 has worked under my close supervision for development of synopsis for

thesis entitled THE ASSOCIATION OF NUTRITIONAL STATUS ON THE

PREVALENCE OF ACUTE RESPIRATORY TRACT INFECTIONS IN

CHILDREN OF 5-12 YRS of AGE AT DISTRICT MANSEHRA, NWFP. I have

gone through this and find it satisfactory for the conduct of research and further

discussion by the experts.

Dr Arshad Mahmood UppalMBBS (Pb), MCPS (Pak), FACP (USA),

PGD-Nutrition (Pak), MSc (Pak)

Supervisor

Dated: ----------------------------

2

RESEARCHER

Name: Dr. Hammad Habib

Roll No: Y-571673

Registration No: 07-NMA-1164

Address: House No. F/41, Courts Area,

Kutchery Road, Mohallah Nogazi, Mansehra.

Cell phone No: 0345 590 4509

Email: drhammadhabib@yahoo.com

Subject: Thesis (869)

Program: MSc (Community Health and Nutrition)

Department: Home and Health Sciences

University: Allama Iqbal Open University, Islamabad

Qualifications:

Degree/ Diploma Institution Subject

University/

CountryYear

a. MBBS Ayub Medical College, Peshawwar

Medical Peshawar 2004

Experience: -

Designation Institution Period

b. Medical Officer Provincial Health Deparment, NWFP

Oct 2007 till date

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Dr Hammad Habib

SUPERVISOR

Name: Dr Arshad Mahmood Uppal

Designation: Additional Principal Medical Officer

Qualifications: MBBS (Pb), MCPS (Pak), FACP (USA), PGD-Nutrition (Pak), MSc (Pak

Present place of posting: District Headquarters Hospital, Rawalpindi

Mailing address: House No. DK – 61/20, Usman Ghani Lane, Street No. 1, Bilal Colony, Rawalpindi-46300;

Pakistan.

Cell No: 0333 516 5232

Email: amuppal@hotmail.com

Remarks: Acute respiratory infections (ARIs) continue to be the leading cause of acute illnesses worldwide and remain the most important cause of infant and young children mortality. It is responsible for about two million deaths annually and rank first among causes of disability-adjusted life-years (DALYs) lost in developing countries (94.6 millions, 6.3% of total. Very young are the most at risk; WHO, (2009). This is truer in the third world, which was busy with diarrhea/malnutrition and paid little attention to ARI. Recent data suggest that ARI are more important than realized previously. Accurate data on morbidity and mortality due to medical causes are not readily available from most developing nations. There is no difference in the incidence of the disease between developed and the developing world but the child mortality is higher in the later. This is true for Pakistan also (Khan, Madni & Zaidi 2004; Denny & Loda, 1986). Malnutrition does play a role in the morbidity and this why the infectious diseases are more common in this part of the world. This study will home us on the true situation especially in the remote areas of the Pakistan and hence is very important.

Wishing a good luck for my student Dr. Hammad Habib.

Dr Arshad Mahmood Uppal

References:

Denny, F. W., and F. A. Loda, (1986). Am. J. Trop. Med. Hyg., 35(1), 1986, pp. 1-2.

Khan, T. A., S. Madni, & A. K. Zaidi, (2004). Acute respiratory tract infections in Pakistan: Have we made any progress. J Coll Physicians Surg Pak. Jul; 14(7):440-8.

4

WHO, (2009). Acute Respiratory Infections (Update September 2009). http://www.who.int/vaccine_research/diseases/ari/en/index.html.

TITLE:

An association of nutritional status on the prevalence of acute respiratory tract infections

in children of 5-12 yrs of age at district Mansehra.

INTRODUCTION:

Acute respiratory illness is one of the main causes of ill health in children. It includes a

wide range of effects, including viral and bacterial infection of the lungs and respiratory

tracts. These may affect air passages including nasal ones, bronchi and lungs and are

acute infections as pneumonia & bronchitis or chronic like asthma & COPDs. In under

five children lower tract infections are the major contributors of morbidity/mortality and

include bronchitis, bronchiolitis and pneumonia, caused by Streptococcus pneumonia,

Haemophilus influenzae or respiratory syncytial & parainfluenza viruses (WHO, 2009;

Cashat-Cruz, 2005). If not taken care of in this age, these conditions extend in the old age

children like 5-15 years.

Nutrition-related health problems in children are important causes of disability and

premature death worldwide. While under nutrition continues to be a major problem in

many developing countries, the problem of overweight and obesity is also reaching

epidemic proportions globally. It has affected both developed and developing countries

very seriously. So this has created a double-burden of nutrition-related ill health among

the population, including children. (WHO-2009)

The social and economic costs of poor nutrition are huge. Investing in nutrition makes

good economic sense because it reduces health care costs and the burden of non-

communicable diseases. It improves productivity and economic growth and promotes

education, intellectual capacity and social development. No economic analysis can fully

encompass the benefits of sustained mental and physical development from childhood

into adult life. Healthy adults with the physical capacity to maintain high work outputs

are a huge national asset. (The United Nations – 2000)

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The harsh truth is that developing countries now have to deal with a double burden of

infectious disease, childhood mortality and under nutrition. This double burden has very

serious economic and social implications for these countries. Favoring treatment rather

than prevention is a mistake already made in the industrialized world. (The United

Nations – 2000)

Malnutrition and infection are very strongly correlated as better nutrition leads to stronger

immunity and decreased infections. Nutrition disorders can be due to insufficient intake

of macro/micronutrients, inability of the body to absorb them, or by over consumption of

certain foods. These include PEM, vitamin deficiencies leading to anemia/sight problem,

and obesity. These can be particularly serious in children as they interfere with

growth/development and may predispose them to infection and chronic disease (WHO,

2009; Sripaipan, 2002; Pelletier, 1995)

Globally air pollution comes to be the important factor in children ill health. Majority of

this ill health are proved to be due to respiratory infections. Studies conducted in Europe

report that the incidence of acute respiratory infections is up to 50% higher in children

living in the most polluted areas than in those in the least polluted areas. Exposure to

ambient air pollution also causes increases in the incidence of upper and lowers

respiratory symptoms, many of which are symptoms of infection. The long-term effects

of air pollution and other environmental hazards highlight the need to target children not

only to preserve their lives now but also to ensure the future of society by keeping adults

in good health. In children, outdoor air pollution is associated with acute lower

respiratory tract infections, asthma, low birth weight, and impaired lung function. The

most significant health effects of outdoor air pollution are associated with particulate

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matter (PM). This is the major problem in urban areas (Valent, et al. 2004; WHO, 2004;

Tamburlini, 2002)

Undernutrition has been estimated to be an underlying cause in up to half of all under-

five deaths.

Pneumonia kills more children than any other illness – more than AIDS, malaria and

measles combined. Around 2 million children under five die from the disease each year –

around one in five child deaths globally. In addition, up to 1 million more infants perish

from severe infections, including pneumonia, during the neonatal period. (WHO – 2009)

Preventing childhood pneumonia is critical to the MDG target of reducing child deaths.

However, only about one in four caregivers knows the two key symptoms of pneumonia

– fast breathing and difficult breathing – which indicate that a child should be treated

immediately. More than half of under-fives with suspected pneumonia in the developing

world are taken to appropriate health providers, but this proportion has increased little

since 2000. (Unicef – 2009)

STATEMENT OF THE PROBLEM:

ARIs account for about two million deaths each year and ranking first among causes of

disability-adjusted life-years (DALYs) lost in developing countries (94.6 millions, 6.3%

of total. The incidence of ARIs in children aged less than 5 years is estimated to be 0.29

and 0.05 episodes per child-year in developing and industrialized countries, respectively,

which translates into 151 million and 5 million new episodes each year, respectively.

Most cases occur in India (43 million), China (21 million), Pakistan (10 million),

Bangladesh, Indonesia and Nigeria (56 million each). Pneumonia is responsible for about

21% of all deaths in children aged less than 5 years, leading to estimate that of every

1000 children born alive, 12-20 die from pneumonia before their fifth birthday.

Pakistan has total population 163902 thousands in 2007. GNI per capita in 2007 was

US$ 870. Total adult literacy rate is 55% in which males had the literacy rate of 80% and

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females 60% during 2000-2007. Annual number of births in 2007 was 4446 thousands.

Annual number of under-5 deaths in 2004 was 400 thousands. Pakistan ranks

number 43 in the world as for the under five children mortality is concerned. Under

five mortality rate was 90 in 2007, which is less than 1990 i.e. 130. Infant mortality

rate (under 1) was 73 in 2007, which is less 100 in 1990. 19% of infants were born with

low birth weight during 2000-07. 37% of children were exclusively breastfed for < 6

months during 2000-07. 36% of children were breastfed with complementary food

from 6-9 months during 2000-07. 55% of children were still breastfeeding (20-23

months) during 2000-07. 38% of under-fives were underweight (moderate) during

2000-07. 13% of under-fives were underweight (severe) during 2000-07. 13% of under-

fives were wasted (moderate & severe) during 2000-07. 37% of under-fives were

stunted (moderate & severe) during 2000-07. (UNICEF-2009)

Prevalence of ARI <5 years of age is 37% with no gender difference leading to 25000

deaths due to pneumonia per year. This includes 48% in Sind, 35% in NWFP, 30% in

Baluchistan and 29% in Punjab (WHO-2000).

RATIONALE OF THE STUDY

It is a fundamental human right to live a life without malnutrition. The persistence of

malnutrition, especially among children and mothers, in this world of plenty is immoral.

It is the world community’s responsibility to find effective ways and means to invest for

better livelihood and to avoid future unnecessary social and economic burdens (The

United Nations – 2000). Improving the nutritional status of school-age children is an

effective investment for the future generation. This can lead to a very cost-effective

intervention approach for better future health. (WHO-2009)

Most of the studies conducted till time are for the children < 5 years of age, hence there is

dearth of knowledge about ARIs in 5-12 years old children and that especially in children

from the remote areas of developing country like Pakistan. So this Mansehra study will

give an insight into the areas of Pakistan and we will be better prepared to serve this age

group.

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AIMS:

This study is aimed at reduction in morbidity and mortality in 5-12 years old Pakistani

children.

OBJECTIVES:

To know (describe?) the association of nutritional status on prevalence of acute

respiratory diseases in children (5-12 yrs) at district Mansehra.

HYPOTHESIS:

There is no association of nutritional status of children with prevalence of acute

respiratory infections.

LIMITATIONS:

Single researcher, limited time, limited financial and human resources and regional

cultural constrains are some of the major barriers in conducting the research work. Study

type being cross sectional is also a limitation for establishing causality.

DELMITATIONS / STRENGTHS:

Constant expert supervision of the supervisor, cheapness of the study, rely on the local

resources, primary data collection and involving competent statistician are strengths of

the study.

METHODS OF RESEARCH:

Population: Children (5 – 12 yrs age) of union council Sandesar, district Mansehra.

Sample size & sampling technique: 500 children selected through simple random

sampling technique.

Significance level: α ═ 5% at 95 % CI..

Research design:

This is a cross sectional observational study.

9

Research instrument / Pilot testing: A structured questionnaire will be prepared in

English and then translated into Urdu language for convenience. Weight machines,

measuring taps & stationary will be used for data collection. Pilot testing of questionnaire

will be carried out in union council Baffa of Mansehra. Field editing will be done of

questionnaire. Researcher will make sure that the data is collected properly by data

collectors by refilling the 5-10 questionnaires in the field in front of him.

Study location: It will be union council Sandesar at district Mansehra of NWFP.

Mansehra is a very well established, important and well representative district of NWFP.

This is a very beautiful village located very near to the main highway.

Ethical issues: Written approval will be taken from the concerned authorities especially

the EDO / DHO health, Mansehra. Local administrative authorities will also be involved,

so they feel authoritative, responsible and ready to cooperate whole heartedly for the

success of study. Data will be collected after detailed verbal/written consent of the

subjects. Confidentiality of the data will be ensured at all levels.

Exclusion / inclusion criteria: Children aged 5 to 12 years irrespective of their sex

having cough or cold within the last seven days will be included in the study. Children

with long debilitating illness, mental disability and those who do not want to participate

will be excluded.

Permission from the authorities: Due permission will be sought from the authorities

concerned like district health and education authorities. Local set up like UC nazim will

also be involved.

Consent: A written consent will be obtained from the Subjects/their parents.

Research instruments: The instruments will be the questionnaires. This will be pre

tested and amended accordingly. This will constitute the followings:

1. Anthropometric measurements.

2. Dietary assessment.

3. Clinical examination.

4. Biochemical evaluation.

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Questionnaire will be the main tool to gather all sort of information. A specially prepared

and pre tested performa, which will be used. Help has been taken from the national

nutrition survey of Pakistan (NNS 2001-2). This will contain questions/observations to

collect socio-demographic information, anthropometric measurements, dietary

questionnaire; 24 hours recall form and study of clinical signs.

Collection of data: This will be done in about two months starting from Dec 1st, 2009 to

May 31st, 2010. A team of about five to six members will be hired comprising of both

male and female and they will be trained to collect data. Data will be collected on

following questionnaire with the help of female research assistant (nurse, teacher or Lady

Health Worker) on prescribed questionnaires.

Analysis and Interpretation of Data

Data analysis is the art of putting the numbers together into meaningful expressions,

which may lead to valid conclusions.

Analysis will be done using SPSS latest version after data entry into it. Descriptive

statistics such as means, standard deviations, frequencies, rates, and ratios will be

calculated for different variables. Chi square test will be applied to find out the

association. Linear and logistic regression analysis will be done where applicable.

VARIABLES OF INTEREST:

ARI will be defined as the mother's report of cough, fever and running nose for

less than seven days. (WHO)

BMI stands for body mass index, and is a measure of bodily mass in relation to

frame size. Weight (kg)/height (m2) is most often used for adults. (WHO)

For assessment of the nutritional status the demographic profile of these subjects like

height, weight and socio economic status is required. This data will be collected on the

questionnaire as shown in the annexure A.

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To study the clinical signs of micronutrient deficiencies clinical data will be gathered

through studying the clinical features of protein, iron, vitamin A, iron and iodine

deficiency. As for vitamin A deficiency its signs in the eyes will be noted like presence

of Bitot’s spots and xerosis and conjunctival paler for anemia. This data will be gathered

on the questionnaire shown in annexure B.

BMI for age charts will be used separately for both sexes as given at the end and

designed by WHO. Then the grading of the subjects will be carried out accordingly.

REFERENCES:

Acute respiratory infections in children retrieved on Oct 10, 2009 from

http://www.who.int/acute respiratory infections in children/

Bhutta, ZA., Ahmed, T., Black, R. E., Cousens, S., Dewey, K., Giugliani, E, et al.,

(2008). What works? Interventions for maternal and child undernutrition and survival.

Lancet. 371, 417-40.

Black. R. E., Allen. L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., et al.,

(2008). Maternal and child undernutrition: global and regional exposures and health

consequences. Lancet. 371, 243-60.

Cashat-Cruz, M, Morales-Aguirre J. J., & Mendoza-Azpiri, M., (2005). Respiratory tract

infections in children in developing countries. Semin Pediatr Infect Dis. Apr; 16(2):84-92

Fishman, S. M., Caulfield, L.E., de Onis, M., Blossner, M., Hyder, A. A., Mullany, L., et

al. (2004). Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A,

Murray CJL, eds. Comparative quantification of health risks: global and regional burden

of disease attributable to selected major risk factors. Geneva: WHO. 39-161.

Garene, M., Ronsmans, C., & Campbell, H., (1992). The magnitude of mortality from

acute respiratory infections in children under 5 years in developing countries. World

Health Statistical Quarterly. 45, 180±91.

Graham, N. M. H., (1990). The epidemiology of acute respiratory infections in children

and adults: a global perspective. Epidemiol Rev. 12, 149±78

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Nutrition retrieved on Oct 10, 2009 from http://www.who.int/nutrition/ Retrieved on Oct

10, 2009 from http://www tinyurl.com/WHO-BMI

Pelletier, D. L., Frongillo, E. A., Schroeder, D. G., & Habicht, I. P., (1995). The effects

of malnutrition on child mortality in developing countries. Bull World Health Organ. 73,

443-8.

Sripaipan, T., Schroeder, D. G., Marsh, D. R., Pachón, H., Dearden, K. A., Ha, T. T., &

Lang, T. T., (2002). Effect of an integrated nutrition program on child morbidity due to

respiratory infection and diarrhea in northern Viet Nam. Food Nutr Bull. 2002 Dec; 23(4

Suppl):70-7.

Tamburlini, G., et al., eds. (2002). Children’s health and environment: a revi00ew of

evidence: a joint report from the European Environment Agency and the WHO Regional

Office for Europe. Copenhagen, European Environment Agency, 44–47 (Environmental

issue report, No. 29).

The United Nations University, 2000; Food and Nutrition Bulletin, vol. 21, no. 3

(supplement)

Unicef – 2009; retrieved on Oct 10, 2009 from

http://www.unicef.org/infobycountry/stat_popup1.htm

Valent, F., et al., (2004). Burden of disease attributable to selected environmental factors

and injuries among Europe's children and adolescents. WHO Regional Office for

Europe, 2004

WHO – 2009; Nutrition retrieved on Oct 09, 2009 from http://www.who.int/nutrition/

WHO – 2009; Respiratory tract diseases retrieved on Oct 10, 2009 from

http://www.who.int/respiratory tract diseases/

WHO, (2004). The effects of air pollution on children's health and development: a review

of the evidence. Copenhagen, WHO Regional Office for Europe, 2004

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ANNEXURE: A

QUESTIONNAIREDEMOGRAPHIC DATA

Name AgeFather nameCurrent class Sex M FAddressMarrital Status of mother Married Divorced Widowed OtherFather profession Family sizeMother profession Mother ageMother’s education None Primary Middle Metric. FA or moreTotal family income(Per month)

Type of family Nuclear JointType of area Urban RuralType of the house Kacha Paka Living in One room Separate rooms for family

membersSmokers in the house

Yes No

Vaccination status of the child (EPI)

Completed Not completed

Air pollution Yes No Age of the childSex of the child Male FemaleHeight in cmWeight in kg

ARI DATACough Yes No Fever Yes No Sore throat Yes No Ear discharge Yes No Runny nose Yes No wheeze Yes No Difficulty in breathing

Yes No Going to school

Yes No

ARI Yes No Duration in days

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ANNEXURE: B

Food frequency questionnaire for consumption of different food groups

S. No

Name of foodTaken number of times per Portion size

in grams at one timeSeason Month Week Day

1 Vegetables, Fruits

2 Starchy Foods

3 Dairy Products

4 Eggs, Meat, Fish

5 Foods containing Fat and Sugar

6 Iodized salt

The food we eat is available either from a plant or animal source. It is broadly

categorized as vegetarian and non-vegetarian. The five basic food groups include: -

1. Vegetables and Fruits: They provide several vitamins, minerals, fibers and

enzymes and are known for offering a number of health benefits. Green, leafy

vegetables are rich in iron, which is an important constituent of blood.

2. Starchy Foods: Starchy foods such as cereals, maize, bread, pasta, cornbread and

potatoes. They contain simple or complex carbohydrates, which are an important

source of energy.

3. Dairy Products: Dairy products include milk, cheese, cream, butter and yogurt.

They are an excellent source of calcium and proteins. Dairy foods are also rich in

vitamin A, B and D.

4. Eggs, Meat and Fish: They are the most important source of proteins, zinc, iron

and vitamins B. These nutrients are necessary for growth and repair of the body.

5. Foods containing Fat and Sugar: They are the powerful sources of energy and include

butter, cheese, salad dressings and oils. Sweets such as desserts, syrups, jellies, jams,

candies and soft drinks contain high amounts of sugar.

Source: http://www.buzzle.com/articles/five-basic-food-groups.html

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ANNEXURE: C

INSTRUMENT (SCALE) FOR MEASURING OF SOCIOECONOMIC STATUS OF A FAMILY

NB: The present proforma largely includes the family parameters and very few are based on head of the family. It has been developed for all sections of the society.

A FAMILY includes nuclear or joint family. Married couple with unmarried children or without children. Head of the family is either husband or wife. Dependent father/mother/brother/sister does not become head of the family unless he/she is earning and one kitchen with pooled income is managed by him/her (Agarwal, et al. 2005).

Q No.

Question Score Family score

1 Monthly per capita income from all sources (total monthly income/household size)1.1. >50000 71.2. 20000-49999 61.3. 10000-19999 51.4. 5000-9999 41.5. 2500-4999 31.6. 1000-2499 21.7. <1000 1

2

Education of either husband or wife, who is more educated among them. 2.1. Professional qualification with technical degree or diplomas e.g.

Doctor, Engineer, CA, MBA, etc.7

2.2. Post graduation (non-technical including PhD 6 2.3. Graduation 5 2.4. 10th class pass but < graduation 4 2.5. Primary pass but <10th 3 2.6. < than primary but attended school for atleast one year 2 2.7. Just literate but no schooling 1 2.8. Illiterate 0

3 Occupation of husband, otherwise wife3.1. Service in Federal/Provincial/Public undertakings or owner of a

company employing > 20 persons or self employed professionals viz Doctors, Engineers, CA’s etc.

5

3.2. Service in private sector or independent business business employing 2-20 persons

4

3.3. Service at shop, home, transport, own cultivation of land 33.4. Self employed e.g. shops, rahdies or petty businesses with income 5000

2

3.5. Self employed with income < 5000 13.6. None of the family member is employed 0

4 Family possessions 4.1. Refrigerator 1

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4.2. TV 14.3. Radio/transistor/music system 14.4. AC 14.5. Washing machine 14.6. Telephone 14.7. Mobile telephone 14.8. Credit card 14.9. Sanitary latrine 14.10. Any news paper subscribed throughout the month 1

5 Type of the house living in5.1. Own house with ≥ 5 rooms 75.2. Own house with 3-4 rooms 65.3. Rented/Govt house with ≥ 5 rooms 65.4. Own house with 1-2 rooms 55.5. Rented/Govt house with 3-4 rooms 55.6. Rented/Govt house with 1-2 rooms 45.7. Own jhugi 35.8. No place to live, pavement mobile cart 1

6 Possession of a vehicle or equivalent 6.1. ≥ 2 cars/tractors/trucks 46.2. 1 cars/tractors/trucks 36.3. ≥ 1 scooters/bullock cars 26.4. ≥ 1 cycle (not baby cycle) 16.5. None of the above 0

7 Number of earning members in the family (nuclear/joint)7.1. ≥ 3 members earning and income pooled 37.2. 2 or both husband and wife earning 27.3. Only one family member earning 17.4. No earning member 0

8 Number of the children head of the family has8.1. 0-1 58.2. 2 48.3. 3 38.4. 4 28.5. 5 18.6. > 6 0

9 Facility of some essentials in the family9.1. Both tape water supply and electricity 29.2. Only one of the above two is present 19.3. None of the above is present 0

10 Education Of The Children (In Relation To Head Of The Family) Note: Exclude < 5 children for this item. A child applicable here is who is ≥ 5.10.1. All children going/ever gone to school/college 310.2. > 50% of children going/ever gone to school/college 210.3. ≤ 50 % of children going/ever gone to school/college 110.4. No child going/ever gone to school/college 0

11 Employment of domestic servants at home

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11.1. Employed ≥ 2 fulltime servants on salary for domestic work 411.2. Employed only 1 fulltime servants on salary for domestic work 311.3. Employed ≥ 3 part time servants on salary for domestic work 211.4. Employed 1-2 part time servants on salary for domestic work 111.5. Employed no servant for domestic work 0

12 Type of locality the family is residing12.1. Living in urban locality 512.2. Living in rural locality 412.3. Living in resettlement colony 312.4. Living in slums/jhugis 212.5. No fixed living 1

13 Caste of the family13.1. Upper caste 413.2. OBC 313.3. Dalits 213.4. Tribals 1

14 Members of the family gone abroad in last three years (official or personal)14.1. Whole family 314.2. Only husband and wife 214.3. Only one family member 114.4. None 0

15 Possession of agricultural land for cultivation15.1. Own agricultural land > 100 acres 515.2. Own agricultural land 51-100 acres 415.3. Own agricultural land 21-50 acres 315.4. Own agricultural land 6-20 acres 215.5. Own agricultural land 1-5 acres 115.6. No agricultural land 0

16 Possession of non agricultural/and land for housing/other types of land16.1. Own non agricultural/land for housing > 1000 yards2 316.2. Own non agricultural/land for housing 501-1000 yards2 216.3. Own non agricultural/land for housing 25-500 yards2 116.4. Own non agricultural/land for housing < 25 yards2 or none 0

17 Presence of milch cattle’s in the family for business or non business purposes17.1. Own ≥ 4 milch cattle’s 317.2. Own 1-3 milch cattle’s 217.3. Own one milch cattle 117.4. Does not own a milch cattle 0

18 Presence of non milch cattle’s or pet animals in the family18.1. Own ≥ 2 218.2. Own 1 1

19 Beside the house in which the family is living, the family owns other house/shop/shed etc of any size whether given on rent or not19.1. Own ≥ 3 319.2. Own 2 219.3. Own 1 119.4. None 0

18

20 Positions held (besides the positions as employee) by any one member of the family20.1. Holding position of ≥ 3 officials or non official organizations viz

president/chairperson/secretary/treasurer etc4

20.2. Holding position of 1-2 officials or non official organizations viz president/chairperson/secretary/treasurer etc

3

20.3. Holding position as member only of executive or other of official or non official organizations

2

20.4. Does not hold any such position 121 Parental support in the form of non movable property

21.1. > 50 acres of agricultural land/house or plot > 1000 yards2 or both 421.2. 21-50 acres of agricultural land/house or plot of 501-1000 yards2 both

3

21.3. 1-20 acres of agricultural land/house or plot 100-500 yards2 or 221.4. No agricultural land but a house or plot of 25-100 yards2 121.5. No parental property 0

22 Total amount of income tax paid by the family (includes all the earning members IT)22.1. > 10 lacs 722.2. 1-10 lacs 622.3. > 50000 but < 1 lac 522.4. > 20000 but < 50000 422.5. > 1000 but < 20000 322.6. > 5000 but < 10000 222.7. < 5000 122.8. Nil 0

Total 285Scoring system for Socioeconomic status (SES)

1 Upper high ≥ 762 High 61-753 Upper middle 46-604 Lower middle 31-455 Poor 16-306 Very poor or below poverty line ≤ 15

Source: Agarwal, O. P., S. K. Bhasin, A. K. Sharma, P. Chhabra, K. Agarwal and O. P. Rajoura. 2005. A new instrument (scale) for measuring socioeconomic status of a family: premilary study. Indian Journal of Community Medicine, vol 30 (4), pp 111-114.

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ANNEXURE D

QUESTIONNAIRE: 3. CLINICAL EXAMINATION

Clinical features Present Absent Clinical features Present AbsentEYES FACE

Bitot’s spots in eyes Angular stomatitisXerophthalmia Chelosis Night blindness (Inability to see in the night).

NECK

Conjunctival paler Goiter HANDS Goiter if present

its gradeI II

Kilonychia ANKLE EDEMA

20

21

22