Academic journal article Bulletin of the World Health Organization

Relationship between Health Services, Socioeconomic Variables and Inadequate Weight Gain among Brazilian Children

Academic journal article Bulletin of the World Health Organization

Relationship between Health Services, Socioeconomic Variables and Inadequate Weight Gain among Brazilian Children

Article excerpt

Voir page 902 le resume en francais. En la pagina 903 figura un resumen en espanol.


Among Brazilian children under 5 years of age, the prevalence of undernutrition has decreased significantly in recent years. Nevertheless, the percentage reduction has been lower for the north-east and north regions compared with the rest of the country (1). The proportion of children with weight-for-age two standard deviations below the median of the NCHS/WHO reference population (2) dropped from 27% in 1975-77 to 12.8% in 1989 in the north-east and from 13.4% to 4.1% in the south-east (1). This persistent inequality may be due to gaps in economic and social development, including differences in income, and access to basic health services, education, water supplies and sanitation (1). Apart from regional differences, variations in the nutritional status of infants and children between municipalities have been reported within the State of Ceara in north-east Brazil (3, 4). Studies of these variations may permit identification of the determinants of child undernutrition that could be addressed by local governments. We report here the results of an ecological study that examined the relative contributions of behavioural, health Services and socioeconomic variables to variations in the prevalence of inadequate weight gain in infants and young children among municipalities in Ceara.


Study site

Ceara is one of nine states in the north-east of Brazil, the poorest region of the country (5). According to the 1991 census, the State of Ceara had a population of 6366 647 inhabitants (34.6% rural), of whom approximately 2.5% were aged [is less than] 1 year (6). The area has a high prevalence of child undernutrition (5): a cross-sectional survey in 1995 revealed that 25% of children aged 0-36 months had a weight-for-age [is less than] 10th percentile of the reference population (4). The prevalence of underweight increased with age, from 8% of infants aged 0-5 months to 31% of children aged 12-17 months (4), and was found to be closely related to poor socioeconomic conditions (5).

Data sources

Data for this study were obtained from the 1991 census of the State of Ceara (6) and the Community Health Workers' Program (PACS) (7), a state government programme of paid community health workers (CHWs) implemented in all 184 municipalities of Ceara. The analyses included only the 140 municipalities that reported complete information on variables of interest every month from January 1994 to June 1996. Data before January 1994 were incomplete for several municipalities.

The CHWs visit the homes of 50-250 assigned families each month to provide health and nutrition education; they also weigh infants and children, and collect information on health indicators (7, 8). Pregnant women and children needing treatment are referred to health units for antenatal care. The health workers report information monthly to a supervisor who aggregates the data at the municipality level (7-9). Municipality-specific data on water supply and sanitation, household income, illiteracy rates, per capita gross product and percentage urbanization were obtained from the 1991 census (6).

Infants and children aged [is less than] 24 months were weighed monthly at home on a portable beam balance scale, using standard techniques (7-9). The weights were recorded on a growth monitoring chart, based on the NCHS/WHO reference growth curves (2). Infants or children were classified as having inadequate weight gain if they failed to gain weight or lost weight between two consecutive measurements. As dependent variables, we used the proportion of infants (0-11 months) and children (12-23 months) with inadequate weight gain. This proportion was calculated by averaging the percentage of infants and children with inadequate weight gain in each municipality for each month over the 30-month study period. …

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