Eighty percent of the world's undernourished children live in 20 countries, with India being home to nearly 60 million children who are underweight. (1) The National Family Health Survey (NFHS) in India reported the prevalence of underweight among children younger than 3 years in 2005-2006 to be nearly 46%, a figure representing only a marginal decline from the rates recorded in 1992-1993 (51%) and 1998-1999 (47%). (2-5)
Weight for age is the most widely used index for assessment of undernutrition in clinical practice and the only one used by the Integrated Child Development Services (ICDS) programme in India. The ICDS programme uses its vast network of primary childcare centres and workers--known as anganwadi workers--to monitor children's growth by weighing at monthly intervals. (6) Weight is then plotted for each child on Indian Academy of Paediatrics (IAP) growth charts, which are based on Harvard growth standards. (7)
In April 2006, WHO released new references for assessing growth and development in children from birth to 5 years. These references, known as the WHO Child Growth Standards, replaced the National Center for Health Statistics (NCHS)/WHO international growth reference (hereafter referred to as NCHS standards), which had certain limitations. In February 2007, the Ministry of Women and Child Development (nodal ministry for the ICDS programme) and the Ministry of Health and Family Welfare in India agreed to a changeover from the IAP growth curves in use at the time to WHO child growth curves. It is, therefore, important to assess whether using the latter will lead to changes in the estimated prevalence of underweight and, if so, how much of a change. (8)
In this study, we aim to compare the prevalence of underweight as calculated using IAP standards with the WHO Child Growth Standards and discuss the implications for child health programmes in India.
India has 28 states and nine union territories. Chandigarh is one union territory where health indicators are better than the Indian average. (9) The population of Chandigarh was 900 635 at the time of the 2001 census, with projections from the National Commission on Population suggesting 1.16 million inhabitants by 2007. (10) Children in the 0-6-year age group make up about 12.8% of the total population.
The ICDS programme's central objective is to reduce child mortality and to achieve optimal physical, mental and psychosocial development for India's children. The programme takes a multisectoral approach to child well-being, as it incorporates health, education and nutrition interventions through a network of anganwadi centres at the community level. At these centres, primary childcare workers and their helpers provide eight key services to pregnant women, children aged 0-6 years and lactating mothers.
Supplementary feeding, immunization, health check-ups and referrals, as well as health and nutrition education are offered to women. For children, micronutrient supplementation, growth monitoring, immunization, health check-ups with timely referrals and informal preschool education are provided. (6) In Chandigarh these services are offered through a comprehensive network of three ICDS projects covering 329 primary childcare centres that have been running since 1979.
Study design and sampling
Multistage stratified random sampling was used to select anganwadi centres. We included 15% of all centres from each ICDS project area, with a probability of being selected proportional to the number of centres in three area types--urban, rural and urban slum--that we categorized using the data from the Department of Social Welfare, Chandigarh. Thus, a total of 45 anganwadi centres were selected: eight urban, 16 rural and 21 in urban slums. A cross-sectional household survey was conducted by the six field investigators (who all had graduate-level qualifications and health-related field experience) in the entire catchment area of each primary childcare centre. …