RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. NAME OF THE CANDIDATE ANDADDRESS / DR. ANKEETA MENONA JACOB,
No. 142, TRIVENI LADIES HOSTEL,
M S RAMAIAH MEDICAL COLLEGE,
M S R NAGAR, MSRIT POST,
BANGALORE-560054.
2. NAME OF THE INSTITUTION / M S RAMAIAH MEDICAL COLLEGE AND HOSPITALS, BANGALORE-560054.
3. COURSE OF STUDY AND SUBJECT / MD (COMMUNITY MEDICINE)
4. DATE OF ADMISSION TO COURSE / 10.06.2013
5. TITLE OF THE TOPIC / A COMPARATIVE COMMUNITY BASED COMPARATIVE STUDY OF NUTRITIONAL STATUS OF CHILDREN AGED 5-15YEARS WITH AND WITHOUT DISABILITY.
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION:
Disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being as defined by World Health Organization (WHO 1976).1
The term as per World health Organization (WHO) 2004 -Disability to refer to loss of health, where health is conceptualized in terms of functioning capacity in a set of health domains such as mobility, cognition, hearing and vision.1
According to National Sample Survey Organization (2002), about 8.4% and 6.1% of the total estimated households in rural and urban India, respectively, reported to have at least one disabled person.1
Good nutrition is important to supporting growth and maximizing learning potential. Nutrition is an important factor affecting growth, health and all round development of individuals, mostly children.
It has been established that poor health and malnutrition in early childhood may affect cognitive abilities2. It is recognized that children with disabilities can have a poorer nutritional status than their non-disabled peers. 3
Under-nutrition in children with disabilities can exacerbate the disability.3Studies indicate that disabled individuals especially those neurologically disabled under-nutrition, growth failure, overweight, micronutrient deficiencies, and osteo-penia are nutritional co-morbidities are known to affect the child.2
Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition related morbidity and mortality. 2
6.1 NEED FOR THE STUDY:
Undernourished children show lower levels of exploratory activity and attachment behavior which may affect social–emotional development.4
In India where malnourishment is a problem, disabled children are more likely to be affected than able bodied children.5
Disabled children have the same health, emotional and educational needs as those without disabilities in our country.5
Nutrition and disability are intimately related: both are global development priorities; and for both the elimination of malnutrition and ensuring the health and well-being of children with disabilities can only be addressed by also tackling issues of poverty, ensuring equity and guaranteeing the human rights of at-risk individuals.
1. Mainstreaming (or including) the rights of people with disabilities in the development agenda is a way to achieve equality for people with disabilities.6 Therefore this study aims to assess the nutritional status in individuals with disability compared to the non-disabled peers and its association to the intellect and social interactions in disabled children. To compare the nutritional status in age and sex matched non-disabled peers
2. To evaluate the performance of their respective scholastic performances using augmented intelligence test
6.2 LITERATURE REVIEW:
Tthe National Sample Survey Organization (NSSO) has estimated people with disabilities in India to be 1.8% (49-90 million) of the Indian population (NSSO 2002), and that 75% of persons with disabilities live in rural areas.1, 49% of the disabled population is literate and only 34% are employed (NSSO 2002)
Yousafzai A K et al found that the quality of the diet in low-income communities, with consequent micronutrient deficiencies, may potentially further compromise the nutritional wellbeing of children with disabilities.3
Essien E et al in 2012 concluded that malnutrition was negatively and significantly related with academic performance.7
Marchand V, Motil K J have shown that undernourished children have decreased attention, and academic performance as well as experience more health problems compared to well-nourished children.2
Shore et al have shown that lower scholastic achievement, socially unacceptable behavior, and poorer physical fitness were also attributed to food insufficiency.8
6.3 RESEARCH QUESTION:
What is the nutritional status of children with disability and its association with their intellect & social interaction?
6.4 AIM:
To assess the nutritional status in disabled children as comparcompared with their non-disabled peers and its association to intellect & social interactioned to their non-disabled.
by measure of their respective scholastic performances using augmented intelligence test Chikkaballapur district of Karnataka state
6.5 OBJECTIVES:
1. To assess nutritional status of individuals disabled children and compare it with their non-disabled peers.
2. To assess the association between the nutritional status and intellect & social interaction among the disabled children.
7. MATERIAL AND METHODS
7.1
STUDY SETTING:
Villages under Kaiwara Primary Health Center, Rural field practice area of M S Ramaiah Medical College and hospitals.
7.2 STUDY POPULATION:
Children with disability and their non-disabled peers between age groups of
5-15 years.
7.3 INCLUSION CRITERIA:
Children of age group 5-15 years with various (Locomotor disability/mental/visual and hearing impaired) according to definition as per “The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995”.9
A person with restrictions or lack of abilities to perform an activity in the manner or within the range considered normal for a human being was treated as having disability.
The non-disabled peers will be:
1. Matched class-mates of either the same class/ section as that of the disabled child.
2. Matched group of siblings (if between age group of 5-15 years) or neighbors if the sibling doesn’t fall into the age category (who are not attending formal schooling).
7.4 EXCLUSION CRITERIA:
1. Minor injuries in the past 3 months (minor injury /physical disability lasting for less than 30 days) will be excluded from both the groups. 10
2. Children with disabilities and the non-disabled peers not willing to participate in the study.
7.5 STUDY DESIGN:
Cross-sectional study.
7.6 with internal comparative group.
STUDY INSTRUMENTS:
Questionnaire developed by the Indian Community Based Rehabilitation Forum used for Identification of disabilities will be administered to all care-givers and children from age 5-15years.11
A pre-tested semi-structured questionnaire will be used for obtaining information : such as identification data, family profile, presence of disability, details of disability (origin, duration and severity), the response of the family to the disability, family background, care of children, morbidity pattern for the child since past 1 year, literacy of care-givers, employment status and housing status.
Along with clinical nutritional assessment, dietary assessment using 24 hour recall of food intake, meal patterns and feeding habits among the 2 groups will be collected.
Anthropometric measurements assessed in both the groups will be as follows:
1. Height using stadio-meter with 1mm accuracy,
2. Weight using bathroom weighing scale accurate up to 0.1kg (100g).
3. Long-bone measurement- Humerus, Tibia, Arm-span measurements, Mid-upper arm circumference- This will be done Record analysis, SRS questionnaireusing a non-elastic measuring tape of 1mm accuracy.
For measurement of intellect and social interactions in the disabled children, Vineland Social Maturity Scale will be used.
7.7 .
STUDY PERIOD:
One yearOne year- January 2014 to December 2014.January 2014 – December 2014.
7.8
METHODOLOGY:
Multi pronged approach will be adopted to identify the study participants. Questionnaire developed by the Indian Community Based Rehabilitation Forum used for Identification of disabilities will be administered to all care-givers and children from age 5-15years by complete enumeration of all the houses under Kaiwara PHC to collect data.
A pre-tested semi-structured questionnaire will be developed and data will be collected. The study will be explained to all families willing to participate and informed consent will be taken.
Along with clinical nutritional assessment, dietary assessment 24 hour recall of food intake, meal patterns and feeding habits among the 2 groups will be assessed. Festivals and fasting days will be accounted for when data will be collected before taking 24 hour recall method.
Anthropometric measurements assessed in both the groups:
Weight will be measured to the nearest 100g on standard bathroom weighing scale. If a child is unable to stand due to their age or type of impairment, they will be weighed together with a care-giver/ teacher and then the care-givers/teachers weight will be deducted from the value of the combined weight.
Height is measured to the nearest 1 mm using a stadio-meter. The height measurements for some of the subjects with physical impairments, when inaccurate, Alternative long-bone (Humerus , Tibia) measures will also be taken of all children to predict height from linear regression analysis.3
Arm-span measurements will be measured from the tip of the middle finger of one arm to the tip of the middle finger of the other arm with the arms outstretched at right angles to the body.
Arm-length measurements will be measured from the tip of the Humerus bone to the tip of the middle finger of the left arm. Tibia length will be measured from the knee joint to the ankle joint.5Mid-upper arm circumference measured for individuals of age 5 only, Chest circumference, Abdominal circumference will be measured to the nearest 1 mm
using a non-elastic measuring tape.
INTELLECT AND SOCIAL INTERACTIONS:
Assessment will be done using Vineland Social Maturity Scale. The Vineland Maturity scale was developed by Sparrow; Balla, & Cicchetti, 1984) is an informant-interview technique used for the diagnosis of the degree or level of social competence and intellect in children with disability.
The use of the Vineland has been endorsed as a measure of adaptive behavior by the World Health Organization (1994) and the United Kingdom Royal College of Psychiatrists (2001) in their diagnostic guides. The Vineland has also proved to be popular in legal as well as clinical and research contexts. For purpose of this study Indian adaptation of the same scale modified by Dr Bharath Raj will be used.
7.9 SAMPLE SIZE:
Study done in the slum area of Dharavi Mumbai in the year 1999, where the prevalence of moderate to severe malnutrition was found to be 69% in disabled and 53% height for age which is a parameter for assessment of chronic malnutrition at the precision level of 5%.3
The above data was used to calculate sample size using N-Master software developed by Christian Medical College Vellore.
Expecting the similar results at 95 % confidence level, 5% alpha error and 80 % power, 2 sided tests, a minimum sample size of 145 disabled children and non-disabled children will be required per group.
7.10 SAMPLING TECHNIQUE:
The total population of 5-15year age group expected to have disabilities (5.4% prevalence – as per thesis submitted to Rajiv bout Gandhi University Of health sciences, Bangalore – In the year 2004) is estimated to be 194.12
Since the required minimum sample size is 145 total enumeration of the population under Kaiwara Primary Health Center by multi- pronged approach using the Indian Community Based Rehabilitation Forum Questionnaire used for Identification of disabilities will be used till the required sample size will be attained.
7.11 STATISTICAL ANALYSIS OF DATA:
Descriptive statistics such as age, height, weight, mid upper arm circumference, arm span length among the children with disability and control group will be expressed in terms of such as mean, standard deviation, median and range with 95% confidence intervals.
All qualitative variables such as gender distribution, feeding practices, dietary survey will be expressed in terms of proportions.
Alternative long-bone (Humerus, tibia) measures will also be taken in children with inability to measure height will be used to predict height using linear regression analysis.
The Z scores for weight/age, height/ age, weight/height, mid upper arm circumference will be computed for disabled children and non-disabled peers.
The Z scores would be used to categorize the nutritional status among the disabled children and controls. Chi-square test would be employed to assess the nutritional status between disabled and non-disabled children.
Independent student t test/Mann-Whitney test would be used to compare the Z scores.
Spearman’s correlation would be used to find the correlation between nutritional status and IQ levels and social maturity levels among disabled children. Level of significance will be fixed at 5%.The Vineland maturity scale will be used to assess the Intellectual Quotient and Social age for the disabled.
7.12 Does the study require any investigation or intervention to be conducted on subjects or animals? If so, describe briefly.
No laboratory investigations or interventions will be carried out.
8. REFERENCES:
1. South Asia Network for Chronic Disease. Disability. [Online] Available from: https://sancd.org/uploads/pdf/disability.pdf. [Accessed 1 Sept 2013].
2. Marchand V, Motil K. Nutrition Support for Neurologically Impaired Children: A Clinical Report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology and Nutrition. 2006; 43: 123-135.
3. Yousafzai A, Filteau S, Wirz S. Feeding difficulties in disabled children leads to malnutrition: experience in an Indian slum. British Journal of Nutrition. 2003; 90 (06): 1097--1106.
4. Samson-Fang L, Stevenson R. Identification of malnutrition in children with cerebral palsy: poor performance of weight-for-height centiles. Developmental Medicine & Child Neurology. 2000; 42 (3): 162--168.
5. Krishnaswamy S. Diet for the Disabled. ActionAid Disability News. 1998; Iss. 2: 67-69.
6. Un.org. UN Enable - Mainstreaming disability in the development agenda. [Online] Available from: https://www.un.org/disabilities/default.asp?id=708 [Accessed 15 Oct 2013].
7. Essien E, Haruna M, Emebu P. Prevalence of Malnutrition and its Effects on the Academic Performance of Students in Some Selected Secondary Schools in Sokoto Metropolis. Pakistan Journal of Nutrition. 2012; 11 (7): 511--515.
8. Shore S, Sachs M, Lidicker J, Brett S, Wright A, Libonati J. Decreased scholastic achievement in overweight middle school students. Obesity. 2008; 16 (7): 1535--1538.
9. L V Prasad Eye Institute. The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. [Online] Available from: https://www.lvpei.org/patientcare/vision-rehabilitation/images/disabilities-act1995.pdf. [Accessed 10 Oct 2013].
10. World Health Organization (WHO). GUIDELINES FOR CONDUCTING COMMUNITY SURVEYS ON INJURIES AND VIOLENCE. [Online] Available from: http://whqlibdoc.who.int/publications/2004/9241546484.pdf [Accessed 1 Oct 2013].