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Indian Journal of Community Medicine

Nutritional Status of Adolescent Girls of Urban Slums and the Impact of IEC on their Nutritional Knowlege and Practices

Author(s): A. Saibaba, M. Mohan Ram, G.V. Ramana Rao, Uma Devi, T.S. Syamala

Vol. 27, No. 4 (2002-10 - 2002-12)

Abstract:

Research question: What is the nutritional status of adolescent girls living in urban slums and methods to improve their nutritional knowledge and practices through Information, Education and Communication (IEC).

Objective: To assess the nutritional status and dietary intake of adolescent girls and study the impact of IEC programme on their nutritional knowledge and practices.

Study design: After collection of the baseline data, IEC intervention was carried out for six months and its impact was studied.

Setting and participants: 2500 adolescent girls from urban registered slums located in twin cities of Hyderabad and Secunderabad, Andhra Pradesh, India.

Statistical analysis: Proportions, Z test.

Results: Though the pattern of growth in adolescent girls was similar to that of NCHS standards, their heights and weights at any given age were far below the standards and deficit increased with age. Iron deficiency anaemia was found to be the most common nutritional problem observed in them. After IEC intervention significant proportion of girls could correctly identify the foods rich in various important nutrients. A marked increase in the intake of finger millet or 'Ragi' was observed, which is a very rich source of calcium as well as iron.

Conclusions: The IEC intervention resulted in improvement of nutritional knowledge of adolescent girls as well as behavioural pattern as envisaged by better cooking methods and increase in the consumption of nutrient rich foods.

Keywords : Adolescent girls, Nutritional status, Nutrient intake, IEC intervention, Link volunteers

Introduction:

The period of adolescence comprises nearly half of the growing period. Besides the obvious changes in physical size and shape associated with adolescent growth and the onset of puberty, there are social and psychological changes that are equally transformative in magnitude. With the profound growth, comes increased demand for nutrients like proteins, energy, vitamins and minerals. Since majority of the adolescent girls especially representing the lower segments of society are undernourished with associated social maladies like son preference, incidence of early marriage and high rates of maternal mortality, a strong focus on improvement in nutritional status of adolescent girls through IEC is warranted. Several studies reported earlier also confirm the need for special attention to improve the health and nutritional status of the adolescents1-8.

Material and Methods:

The study was conducted in the registered slums under India Population Project-VIII, MCH, located in twin cities of Hyderabad and Secunderabad, Andhra Pradesh - India. Girls between 10 and 19 years of age were covered in the study. One hundred slums were selected based on criteria like availability of (a) an active NGO, (b) Urban heath post (UHP) (c) link volunteer scheme etc. These slums are being covered by 8 urban health posts and 3 NGOs. Link volunteer scheme is also in operation. Availability of adolescent girls was ascertained through household enumeration survey. In each of 100 slums, a quota of 25 adolescent girls or a total of 2500 respondents were covered, which accounts for 63% of all adolescent girls available in the study areas. A combination of anthropometry, biochemical, dietary assessment and interview schedule method was used for assessing the nutritional status and nutritional knowledge of adolescent girls. The study was conducted in three stages. In the first stage, baseline data were collected using a specially designed pretested interview schedule. Four female trained investigators with home science background collected data/samples pertaining to KAP, nutritional status (height and weight), dietary intake (24 hours recall oral questionnaire method, using standard cups)9. Finger prick samples of blood (20 ul) were collected from subjects using standardized pipettes on 'Whatman# 1 filter paper'. After recording identification particulars on each filter paper, these were dried and placed in individual envelops. Haemoglobin levels were estimated at National Institute of Nutrition (NIN), Hyderabad by cyanmethaemoglobin method, within seven days10. The diet surveys were carried out on randomly selected sub-sample of 125 families from all UHP centres.

In the second stage an intensive IEC intervention was carried out for a period of 6 months mainly through Inter Personal Communication (IPC) techniques. The IEC tools used included cooking demonstrations, posters, information booklet, innovative games and nutrition melas. Cooking demonstrations were held in all the intervention areas. They were organized in collaboration with Food and Nutrition Extension Board, Govt. of India. Adolescent girls were taught to prepare simple iron, calcium and energy rich recipes. They were also provided information on nutritive values of some commonly consumed food articles, right cooking methods and some tips to preserve nutrients while cooking. As a part of IEC intervention, some innovative participatory learning activities in the form of games were used. The approach used in these games is called 'experiential learning'. It helped girls to learn from their own experiences, with facilitator-trainer as a guide. Situations and problems were presented, discussed and analyzed. Problem-solving is emphasized. The experimental games were conducted by the project investigators, with the help of facilitator's guide, which were intended to motivate young girls to change undesirable behaviours and adopt new behaviours, promote participation in the learning process. The informative booklet on adolescent health and nutrition, four multicoloured posters on education, nutrition, health and hygiene and age at marriage were used to evoke positive response among subjects. All the respondents were given information pertaining to their heights and weights, haemoglobin status etc. As a part of nutrition melas, poster exhibition on nutrition was also held. Services of Gynaecologist, Pediatrician, Public Health Specialist, Nutrition and Communication experts were utilized during the melas. Counselling sessions were held and many doubts with regard to nutrition, healthy cooking practices and menstruation were clarified by concerned specialists. Adolescent girls themselves presented some cultural items like songs, street plays etc.

In the third stage, a repeat survey was conducted to find out the impact of IEC intervention in terms of improvement in knowledge scores. The data were computerized and analysis was done with SPSS package. Per cent frequency of each of the responses for various individual aspects/questions included in the schedule was calculated. The proportions Z test was applied to measure the impact of IEC intervention.

Results:

The socio-economic profile:

Table I: Socio-economic profile of respondents - (n=2500).

  No. Percent/ Mean± SD
Age in years
  14.3+3.4
Marital status
Unmarried 2460 98.4
Married 40 1.6
Education (years of schooling)
Illiterate 330 13.2
1-6th class 948 37.9
7-10th class 1105 44.2
>10th class 117 4.7
Schooling in years   7.0±2.7
Caste/Religion
Hindu-Upper caste 178 7.1
Hindu-Backward caste 821 32.8
Hindu-Scheduled caste 708 28.3
Hindu-Scheduled tribe 32 1.3
Muslims 704 28.2
Christians 57 2.3
Type of family
Nuclear 2070 82.8
Joint 430 17.2
Current status
Studying 1430 57.2
Working 195 7.8
Helping in household activities 875 35.0

The mean age of the adolescent girls was 14.3 years. Majority of respondents were unmarried (98.4%). The educational levels of the adolescent girls revealed that 13.2% of them were illiterates, around 38% of them had primary education and 44% of them had high school (7-10 years) education. Only a very small proportion of the girls studied upto 10th standard and above. The mean years of schooling among the sample population was 7 years. Distribution of the respondents according to religion showed that the majority of them were Hindus (69.5%) with greater proportion representing either backward castes (32.8%) or scheduled castes (28.3%). About one third of the subjects were Muslims. Majority of respondents (82.8%) belonged to nuclear family. Out of the total 2500 girls, 57.2% were studying, 7.8% of them were working and 35% were engaged in household activities (Table I).

Nutritional status:

The mean height of subjects was 147.1 cms and their mean weight was 38.7 kg. The pattern of growth was similar to that of NCHS standards. However, the heights and weights of study subjects at any given age were far below the NCHS standards and the deficit increased with age. The maximum increase in the height and weight was observed between 10 and 14 years of age and later it got stabilized. According to height for age SD classification of NCHS revealed that 7.2% were categorized as severely malnourished, 27.9% as moderately malnourished, 43% were mildly malnourised and 21.9% were classified as normal11,12.

Iron deficiency anaemia was found to be the most common nutritional problem encountered by respondents. About 88% of subjects were anaemic using WHO classification13. Mild, moderate and severe anaemia was observed in 49.0%, 31.3% and 7.9% of respondents respectively. Only 12.0% of respondents were found to be having normal haemoglobin levels of >12 g/dl.

Nutrient intake:

Table II: Mean intake of nutrients (per day) by adolescent girls (10-17 years) - (n=163).

Nutrient Mean± SD RDA
Proteins (gms) 39± 17.28 57-63
Fat (gms) 20± 13.33 22
Energy (kcal) 1600± 531.12 1970-2060
Calcium (gms) 324± 634.46 600
Phosphorous (mg) 839± 354.36 500-600
Iron (mg) 20±34.37 19-30
Vitamin A (g) 428± 2176.87 600
Thiamin (mg) 07±0.41 1.0
Riboflavin (mg) 07± 0.58 1.2
Niacin (mg) 10± 4.53 13-14
Vitamin C (mg) 51± 160.55 40
Folic acid (g) 137±272.79 70-100

Barring the intake of vitamin C (51 mg), folic acid (137 ug) and to some extent fat (20 gms), recommended dietary allowances for adolescents as suggested by ICMR, in respect of major nutrients like proteins, energy, calcium, iron, vitamin A etc., were not met (Table II).

Impact of IEC intervention: Following IEC intervention, the knowledge about physical changes improved significantly. About 70% of the subjects for the first time received information on growth and development during IEC intervention. Though they were not aware earlier, after IEC intervention, 77.6% of girls could correctly identify the foods rich in iron, 55.2% could recall calcium rich foods and 62% could list the energy and protein rich recipes/food articles.

Table III: Consumption of food items* - (n=2500).

  Pre IEC intervention* Post IEC intervention* Proportions Z value
Cereals 98.8 99.7 3.70**
Millets (Ragi) 3.5 97.9 66.80**
Pulses 63.5 72.0 6.43**
Fats/oils 92.7 96.6 6.12**
Oil-seeds 8.7 9.2 0.62
Meat 27.3 27.0 0.23
Eggs 12.7 16.5 3.81**
Milk and milk products 24.5 19.6 4.18**
Vegetables 73.6 82.8 7.88**
Fruits 30.6 36.0 0.46
Rice flakes 1.6 2.8 2.89**
Condiments/spices 9.7 10.5 0.94

*Precentage of study subjects consumed the food items on previous day; **Significant at p<0.001

Barring oil-seeds, fruits, meat and condiments, the consumption of all other food articles was found to be significantly higher (p<0.001) than the pre IEC intervention stage. A striking difference was noticed in the consumption of millets like ragi which is especially rich in iron and calcium following intervention (Table III).

Table IV: Cooking methods - (n=2500).

No. of times cleaning rice in water Pre IEC intervention (%) Post IEC intervention (%) Proportions Z value
1.1 Once 1.8 2.2 1.01
1.2 Twice 38.5 49.4 7.77*
1.3 More than or equal to thrice 59.7 48.4 4.95*
Discarding Kanji 83.4 28.9 7.22*
Discarding excess water after cooking dal/vegetables 7.7 4.9 4.07*
Aware of nutrient losses due to discarding water after cooking 48.2 74.2 18.86*
Washing the vegetables before cutting 70.2 84.8 12.36*
Germination/fermentation will promote the nutrient quality of food 22.1 38.8 12.83*

*Significant at p<0.001.

Around 60% of respondents were found to be washing rice thrice or more than that before cooking. Majority of them (83.4%) were also discarding kanji and excess water after cooking. A small proportion of the families (7.7%) was even discarding excess water after cooking dal/vegetables. The awareness regarding the nutrient loss due to discarding water was also not very high. Only 48.2% of the girls knew that there would be a loss of nutrients if they remove water. The nutrition education intervention has not only helped in increasing the knowledge significantly (p<0.001) among adolescent girls with respect to right cooking methods (for example the per cent figures of awareness regarding nutrients loss due to discarding water was only 48.2 in baseline and 74.2 in follow up), it also helped them to translate the knowledge in improving their cooking practices (Table IV).

Local media channels/sources like posters and innovative games used during intervention reached around 45% of the study population. More than 30% of the subjects were exposed to cooking demonstrations and one fifth attended nutrition melas. Almost all respondents received information pertaining to their heights and weights and haemoglobin status. With regard to mass media during pre as well as post intervention period, only about 1/3rd of the respondents received nutrition related information through television and around 2% of the subjects through Radio. A small percentage of respondents (4%) stated that they had received nutrition related information through Newspapers and Magazines.

Discussion:

The hallmark of adolescent years is change. This is a period when a child catches up with an adult at a fast forward pace. The most revealing part of the present study pertains to the socio-economic profile of the study subjects. Barring a negligible few, all the girls were still unmarried despite the attainment of menarche. Secondly, a very large segment of the subjects were educated at least up to high school. These two findings surely point towards the changing values of the community. In addition, most of the girls belonged to nuclear families and were also inclined to update their nutrition knowledge through Inter Personal Communication or Media.

There exists a general feeling in the society that adolescent years are normally free from major health problems. On the contrary, it is crucial period, because adolescent girl is still a developing child. The present study also reveled some shortcomings in this regard. There was a failure to capitalize on the growth spurt as the gain in height and weight of the subjects was seen to stabilize too soon as compared to their American counterparts. Similar results were also found in earlier studies14-16. This fact calls for urgent measures to aid their proper growth. Right type of nutrition and health education and dietary supplementation could help achieve this.

A sizeable number of these girls were also seen to compromise on linear growth, a good number of them lighter in weight and were found to be either mildly or moderately malnourished as per the height for age SD classification using NCHS standards. Studies by Srikantia (1989) and Govt. of Maharashtra/ UNICEF/WHO (1991) also revealed deficit in growth of adolescent girls4,17. These results clearly indicate that 10-16 years age group is more critical in terms of malnutrition, hence all efforts should be made to provide adequate nutrition to these age groups. Anaemia was found to be widely prevalent among study subjects which will adversely affect their functional capacity. Data from surveys conducted by Indian Council of Medical Research (1989) and National Institute of Nutrition (2000) confirm the high prevalence of anaemia among adolescent girls18,19. According to Second National Family Health Survey in Andhra Pradesh, the prevalence of anaemia was 54.9% among adolescent girls in the age group of 15-19 years20. A recent survey conducted by National Institute of Nutrition in Mehabubnagar district of Andhra Pradesh also revealed high prevalence of anaemia (91.8%) among adolescent girls indicating the gravity of the problem of anaemia among this group and need to tackle it through appropriate strategies21. With regard to intake of nutrients, there were gaps to be filled in respect of some major nutrients like proteins, energy, calcium and iron. Reddy RR and Chendralekha K (1989) also concluded that adolescent diet is deficient in proteins, minerals and vitamins22.

The most vital aspect of the study was the use of interpersonal channels of education. The use of a package of education aids like cooking demonstration, booklets, innovative games and nutrition melas had positive effect on the nutritional knowledge, which may ultimately improve their nutritional status. It also revealed that adolescent girls need more exposure with respect to certain cooking habits which will minimize the nutritional loss in the food items. Most of the subjects learnt the importance of preserving kanji while cooking rice. They gained knowledge regarding techniques pertaining to preserving the nutrients and about healthy cooking practices. The results obtained following intervention suggest an improvement in the practice of right cooking methods. Nutrition melas, in particular could attract the attention of study subjects, their parents and also even adolescent girls belonging to neighbouring slums (non-study subjects). They evinced keen interest in the educational activities. The nature and complexities of changes occurring during adolescence were not fully known to girls before the start of the programme. But, IEC interventions brought about a positive change in the understanding of the physical changes taking place in the individual. This again confirms the cultural practices in the society especially parents usually have inhibitions in talking to adolescents regarding their natural development.

The IEC intervention, therefore, brought about significant improvements in not only in nutritional knowledge of adolescent girls but also translated some of them into action.

Acknowledgements:

The authors thank the Joint Director and Staff of IPP-VIII, Municipal Corporation of Hyderabad, Andhra Pradesh for providing the financial support. The Co-operation extended by the Director and her colleagues of National Institute of Nutrition in measurement of Haemoglobin levels in the study sample by HiCN method is acknowledged. Thanks are also due to all the project investigators, NGO representatives, Medical Officers of UHPs, Link Volunteers, all the adolescent girls, their parents and the community members for their participation during various stages of the project, specially in all IEC related activities.

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A. Saibaba: Deptt. of Communication

M. Mohan Ram: Director

G.V. Ramana Rao: Deptt. of Epidemiology

Uma Devi, T.S. Syamala: Deptt. of Demography

Indian Institute of Health and Family Welfare, Vengalrao Nagar, Hyderabad - 500 038 (A.P.)

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