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 Uppal

MBBS (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/ University
Diploma / Yea
Institution Subject
Country

a. MBBS Ayub Medical College, Medical Peshawar 200

Peshawwar 4

Experience: -

Designation Institution Period

b. Medical Officer Provincial Health Deparment, NWFP Oct 2007 till date

3
 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)

5
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

6
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

7
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.

11
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

12
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

QUESTIONNAIRE
DEMOGRAPHIC DATA
Name Age
Father name
Current class Sex M F
Address
Marrital Status of mother Married Divorced Widowed Other
Father profession
Family size
Mother profession Mother age
Mother’s education None Primary Middle Metric. FA or more
Total family income
(Per month)
Type of family Nuclear Joint
Type of area Urban Rural
Type of the house Kacha Paka
Living in One room Separate rooms for family
members
Smokers in the Yes No
house
Vaccination status of Completed Not completed
the child (EPI)
Air pollution Yes No
Age of the child
Sex of the child Male Female
Height in cm
Weight in kg
ARI DATA
Cough Yes No Fever Yes No
Sore throat Yes No Ear discharge Yes No
Runny nose Yes No wheeze Yes No
Difficulty in Yes No Going to Yes No
breathing school
ARI Yes No Duration in
days

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ANNEXURE: B

Food frequency questionnaire for consumption of different food groups

Portion
Taken number of times per
S. size in
Name of food
No Season Month Week Day grams at
one time
1 Vegetables, Fruits
2 Starchy Foods
3 Dairy Products
4 Eggs, Meat, Fish
Foods containing
5 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.

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

16
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 Question Scor Family

No. e score
1 Monthly per capita income from all sources (total monthly income/household size)
1.1. >50000 7
1.2. 20000-49999 6
1.3. 10000-19999 5
1.4. 5000-9999 4
1.5. 2500-4999 3
1.6. 1000-2499 2
1.7. <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. 7
Doctor, Engineer, CA, MBA, etc.
2.2. Post graduation (non-technical including PhD 6
2.3. Graduation 5
th
2.4. 10 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 wife
3.1. Service in Federal/Provincial/Public undertakings or owner of a 5
company employing > 20 persons or self employed
professionals viz Doctors, Engineers, CA’s etc.
3.2. Service in private sector or independent business business employing 4
2-20 persons
3.3. Service at shop, home, transport, own cultivation of land 3
3.4. Self employed e.g. shops, rahdies or petty businesses with income > 2
5000
3.5. Self employed with income < 5000 1
3.6. None of the family member is employed 0
4 Family possessions
4.1. Refrigerator 1

17
 4.2. TV 1
4.3. Radio/transistor/music system 1
4.4. AC 1
4.5. Washing machine 1
4.6. Telephone 1
4.7. Mobile telephone 1
4.8. Credit card 1
4.9. Sanitary latrine 1
4.10. Any news paper subscribed throughout the month 1
5 Type of the house living in
5.1. Own house with ≥ 5 rooms 7
5.2. Own house with 3-4 rooms 6
5.3. Rented/Govt house with ≥ 5 rooms 6
5.4. Own house with 1-2 rooms 5
5.5. Rented/Govt house with 3-4 rooms 5
5.6. Rented/Govt house with 1-2 rooms 4
5.7. Own jhugi 3
5.8. No place to live, pavement mobile cart 1
6 Possession of a vehicle or equivalent
6.1. ≥ 2 cars/tractors/trucks 4
6.2. 1 cars/tractors/trucks 3
6.3. ≥ 1 scooters/bullock cars 2
6.4. ≥ 1 cycle (not baby cycle) 1
6.5. None of the above 0
7 Number of earning members in the family (nuclear/joint)
7.1. ≥ 3 members earning and income pooled 3
7.2. 2 or both husband and wife earning 2
7.3. Only one family member earning 1
7.4. No earning member 0
8 Number of the children head of the family has
8.1. 0-1 5
8.2. 2 4
8.3. 3 3
8.4. 4 2
8.5. 5 1
8.6. > 6 0
9 Facility of some essentials in the family
9.1. Both tape water supply and electricity 2
9.2. Only one of the above two is present 1
9.3. 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 3
10.2. > 50% of children going/ever gone to school/college 2
10.3. ≤ 50 % of children going/ever gone to school/college 1
10.4. No child going/ever gone to school/college 0
11 Employment of domestic servants at home

18
 11.1. Employed ≥ 2 fulltime servants on salary for domestic work 4
11.2. Employed only 1 fulltime servants on salary for domestic work 3
11.3. Employed ≥ 3 part time servants on salary for domestic work 2
11.4. Employed 1-2 part time servants on salary for domestic work 1
11.5. Employed no servant for domestic work 0
12 Type of locality the family is residing
12.1. Living in urban locality 5
12.2. Living in rural locality 4
12.3. Living in resettlement colony 3
12.4. Living in slums/jhugis 2
12.5. No fixed living 1
13 Caste of the family
13.1. Upper caste 4
13.2. OBC 3
13.3. Dalits 2
13.4. Tribals 1
14 Members of the family gone abroad in last three years (official or personal)
14.1. Whole family 3
14.2. Only husband and wife 2
14.3. Only one family member 1
14.4. None 0
15 Possession of agricultural land for cultivation
15.1. Own agricultural land > 100 acres 5
15.2. Own agricultural land 51-100 acres 4
15.3. Own agricultural land 21-50 acres 3
15.4. Own agricultural land 6-20 acres 2
15.5. Own agricultural land 1-5 acres 1
15.6. No agricultural land 0
16 Possession of non agricultural/and land for housing/other types of land
16.1. Own non agricultural/land for housing > 1000 yards2 3
16.2. Own non agricultural/land for housing 501-1000 yards2 2
2
16.3. Own non agricultural/land for housing 25-500 yards 1
16.4. 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 purposes
17.1. Own ≥ 4 milch cattle’s 3
17.2. Own 1-3 milch cattle’s 2
17.3. Own one milch cattle 1
17.4. Does not own a milch cattle 0
18 Presence of non milch cattle’s or pet animals in the family
18.1. Own ≥ 2 2
18.2. 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 not
19.1. Own ≥ 3 3
19.2. Own 2 2
19.3. Own 1 1
19.4. None 0

19
20 Positions held (besides the positions as employee) by any one member of the family
20.1. Holding position of ≥ 3 officials or non official organizations viz 4
president/chairperson/secretary/treasurer etc
20.2. Holding position of 1-2 officials or non official organizations viz 3
president/chairperson/secretary/treasurer etc
20.3. Holding position as member only of executive or other committees 2
of official or non official organizations
20.4. Does not hold any such position 1
21 Parental support in the form of non movable property
21.1. > 50 acres of agricultural land/house or plot > 1000 yards2 or both 4
21.2. 21-50 acres of agricultural land/house or plot of 501-1000 yards2 or 3
both
21.3. 1-20 acres of agricultural land/house or plot 100-500 yards2 or both 2
21.4. No agricultural land but a house or plot of 25-100 yards2 1
21.5. No parental property 0
22 Total amount of income tax paid by the family (includes all the earning members IT)
22.1. > 10 lacs 7
22.2. 1-10 lacs 6
22.3. > 50000 but < 1 lac 5
22.4. > 20000 but < 50000 4
22.5. > 1000 but < 20000 3
22.6. > 5000 but < 10000 2
22.7. < 5000 1
22.8. Nil 0
Total 285
Scoring system for Socioeconomic status (SES)
1 Upper high ≥ 76
2 High 61-75
3 Upper middle 46-60
4 Lower middle 31-45
5 Poor 16-30
6 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 Presen Absen Clinical features Present Absent

t t
EYES FACE
Bitot’s spots in eyes Angular stomatitis
Xerophthalmia Chelosis
Night blindness NECK
(Inability to see in the night).
Conjunctival paler Goiter
HANDS Goiter if present
I II
its grade
Kilonychia ANKLE EDEMA

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