Rajiv Gandhi University of Health Sciences s90

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and address RAMESH JEVUR (in block letters) I YEAR M. Sc. NURSING INDIRA NURSING COLLEGE FALNIR MANGALORE - 575002

2. Name of the Institution INDIRA NURSING COLLEGE FALNIR MANGALORE - 575002

3. Course of Study and Subject M. Sc. NURSING PAEDIATRIC NURSING

4. Date of Admission to the Course 15.07.2011

5. Title of the study

A COMPARATIVE STUDY TO ASSESS THE IMPACT OF MID-

DAY MEAL (MDM) PROGRAM ON NUTRITIONAL STATUS

OF SCHOOL CHILDREN IN SELECTED SCHOOLS AT

MANGALORE.

6. Brief resume of the intended work

1 6.1 Introduction

“A Healthy child is an assert to the society”

“Today’s children are tomorrow’s citizens”. Children are considered to be the back bone of the nation. India has one of the largest populations of school going children. The children belonging to different socio-economic strata constitute around 40% of its population. A majority of them share the socio-economic deprivation of their parents, and do not have access to essential requirements of nutrition, health care and learning opportunities.

Nature has provided a variety of foods for man to consume and be healthy. We consume food for maintenance of health, growth and to develop greater resistance against infections. Food contains substances called nutrients in varying proportions which are needed for proper growth and maintenance of life processes. Good nutrition is the basis of good health. A balanced diet is of utmost importance in achieving normal growth and development. Nutritional status is nothing but ‘a condition of intake and utilization of nutrients which is manifested in good or bad health.

B. T. Basavanthappa reported that Nutrition is a significant factor in the growth, development and overall functioning of a child. Meeting nutritional requirements throughout childhood is essential for the development. An inadequate or imbalanced nutritional intake may not only affect growth and development in childhood but may also have its impact on health problems, such as heart disease later in life.1

Children aged between 7 to 10 years require 80 calories per kilogram of body weight and essential nutrients. Studies in India on nutritional status of school children are shown that nutritional disorders are more in children. The deficiencies are related to protein, carbohydrates, fats, vitamins and minerals. Most of the children from low socio-economic status in the society are suffering from nutritional disorders. A healthy child can be expected to take full advantage of schooling. The diet of the school children should, therefore receive first attention. The diet should contain all the nutrients in proper proportion, adequate for the maintenance of optimum health.1

Indian Government is providing many welfare programs for the children through Applied Nutrition Program, Balwadi Program, Vitamin -A Prophylaxis Program, Mid- day- meal Program etc. In spite of implementation of all these programs the prevalence of

2 malnutrition among school children is high.

One of the pioneers of the scheme is the MID DAY MEAL (MDM) program, which is one of the universally accepted program for children to improve their nutritional status.

Mid Day Meal in schools has had a long history in India. On 15th August 1995 Government of India launched the National Program for Nutritional support to Primary Education (NP-NSPE). The Program was introduced for disadvantaged children in Madras Municipal Corporation, with a view to enhance enrollment, retention and attendance and simultaneously improve the nutritional levels among children. As per this Program, each child was provided with 3 kgs of rice per month for 10 months in a year, initially in 2408 blocks in the country.5

The objectives of mid-day meal scheme are: - Improving the nutritional status of school children in classes I-VIII in government, local body and government aided schools, and EGS, and AIE centres, providing nutritional support to the children of primary stage in drought-affected areas during summer vacation.6

In Karnataka, the Akshaya Patra Foundation was by then successfully implementing its own feeding program in Karnataka. The Karnataka government began its mid-day meals scheme in June 2002. Initially, the program was limited to seven backward districts of the state. Later, in 2003 under the ambitious "Akshara Dasoha" program, the remaining 22 districts were also included in the scheme. In 2007 the government of Karnataka has extended the scheme of providing hot cooked meal to the children of VI & X standards of Government and Government aided school out of its own resources.7

According to Department of School Education and Literacy, India:

During 2009-10 total 11.04 crore children were covered under mid day meal program. During 2010-11 total 11.36 crore children i.e., 7.97 crore of primary and 3.39 crore children in upper primary are expected to be covered in 12.63 lakh schools.8 Mid day meal program is one of the universal program for children to improve nutritional status all around the world with the help of NGOs all over the India.8

6.2 Need for the study

Jean Dreze says “Nutritious Mid-day meal needs to be recognized as an integral part

3 of a healthy school environment and this recognition needs to be reflected in permanent legal entitlements as well as in political priorities and financial allocations”.

The main purposes of the study are; The mid-day meal could have a major impact on nutritional status of school children. The study helps to compare the nutritional status of children between public and private primary schools.

The study also helps to identify the various nutritional deficiencies such as anaemia, vitamin-A deficiencies’ and vitamin-B deficiencies etc. between public and private schools.

There are three commonly used indicators of poor nutrition among children which are stunting (low height for age), thinness (low body mass index for age) and under weight (low weight for age). There are fewer studies related to the anthropometric measurements of school going children, utility of anthropometric measurements as indicators for the screening and evaluation of the health and nutritional status of the children of school going ages, and the value of changes in anthropometric measurements in the assessment of progress in meeting healthy, equity and social goals.

The World Bank estimates (2009) reported that India is ranked 2nd in the world of the number of children suffering from malnutrition & the most growth retardation occurs by the age of two, and most damage is irreversible. The prevalence of underweight in rural areas 50% versus 38% in urban area and higher among girls (48.9%) than boys (45.5%).9

According to the world food program and the M S Swaminathan research foundation (MSSRF); over the past decade there has been a decrease in stunting among children in India. Today child malnutrition is 43% in India.10

A study done by experts from food and nutrition department Maharaja Sayajirao University (MSU) Baroda, at Vadodara district found that there was a big divide in the children aged 6 to 14 years from the urban and rural areas. The study used anthropometrical surveys and focusing on the Body mass index (BMI) as the main indicator of nutrition. The

study found that 75% of 30,000 children in the rural areas of this district were malnourished, whereas 15% of the 23,000 children in urban areas were overweight.11

4 A comparative study was conducted to assess the impact of wholesome MDM program run by NGOs on nutritional status and growth of the primary school students in rural area of Mathura district U.P. Six primary schools in which in which nutritionally balanced MDM provided by an NGO were selected as intervention group. Eight schools which received locally prepared MDM by village Panchayat were selected as control group. During the study the food was provided for 221 days in one year. Using Generalized Estimating Equation (GEE), within both intervention and control groups, the result showed that the height and weight had significantly increased (p<0.05). There was no change in prevalence of malnutrition in either of the groups. Reduction in Vitamin A deficiency signs was 38% more in intervention group (<0.001). Prevalence of Vitamin D deficiency was reduced by 50% more in intervention group. The study concluded MDM provided by NGO has no better impact on growth of primary school children except improvement in Vitamin A and Vitamin D deficiency.12

A study was conducted to determine the effectiveness of school feeding program in improving physical and psycho-social health for disadvantaged children by using the method of randomized controlled trials (RCTs). Non-randomized controlled clinical trials (CCTS), controlled before and after studies (CBAs). The result showed that experimental group children gained an average of 0.39 kg (95% C I: 0.11 to 0.67) over an average of 19 months and 0.71 kg (95% C I 0.48 to 0.95) over 11.3 months respectively. Small improvements in some cognitive tasks were found. The author concluded that school meals may have some small benefits for disadvantaged children and they recommend further well designed studies on the effectiveness of school meals be undertaken.13

Many studies have shown that, because of mid-day meal program the school enrollment has improved, and some studies also show that mid-day meal program facilitates the healthy growth of the children. So in this study the researcher wants to test the effectiveness of mid-day meal program on nutritional status of primary school children.

6.3 Review of literature

Related research and non research literature was reviewed to broader the understanding and to gain insight into the selected area under study. The reviews are under

5 the following headings.

 Nutritional status of School Children.

 Impact of mid-day meal program on nutritional status of primary school children were measured for the height, weight and clinical examination.

I. Review of literature related to the nutritional status of school children

The descriptive study was conducted to assess the nutritional status and morbidity pattern of primary school children. The methods used in this study are descriptive, cross sectional study was administered in the five governmental schools the schools were selected using simple random sampling technique. From these selected schools, a total number of 818 students studying from class I to V were enumerated in the study using census survey method. The results are revealed that, among 818 students, 61% of the students were found to be malnourished. The students were more stunted (21.5%) than wasted (10.4%). Only 5.4 % of the students were found to be both wasted and stunted. The collected blood and stool samples from the students revealed parasitic infestation of 65.8% and anaemia of 58%. The most common diseases in those schools were: skin diseases (20%), dental caries (19.8%), and lymphodenopathy (10.5. The study result revealed the urgent need for initiation of school health program with specific emphasis on prevention of diseases, improvement of personal hygiene and nutritional status with the collaboration of governmental and nongovernmental institutions.14

A study was conducted on the nutritional status of 8 to 12 years old school children in an urban area of Sri Lanka. Seven schools situated in the city of Colombo were randomly selected as sample. Anthropometric data of 1224 children (48% boys) and feeding practices and behaviour pattern data of 1102 children (44% boys) were analyzed. The result showed obesity prevalence among boys (4.3%) was higher than in girls (3.1%). The prevalence of thinness was 24.7% in boys and 23.1% in girls. 5.1% boys and 5.2% of girls were stunted.

7.0% of boys and 6.8% of girls were underweight. 66% of obese children and 43.5% of overweight children belongs to the high income category. The study concluded obesity and overweight in older children are some emerging nutritional problems and diet in response to social and cultural changes.15

6 A study was conducted on nutritional status of primary school children in Townsville. The setting was based in three Northern Queensland Health regions (pre) primary schools with high proportion of Indigenous children. The result of the study showed that more number of children were overweight to obese than underweight children. There was no significant difference in Body Mass index (BMI) between indigenous and non- indigenous children. Indigenous children were shown to consume lees vegetables and dairy products and were significantly more likely to suffer from anaemia and eosinophilia than non-indigenous children. The study concluded the health status of indigenous is poorer than of non-indigenous children and they demonstrate an immediate need to implement appropriate nutritional programs within the school environment to improve dietary habits and overall health.16

The study was conducted to assess the growth and nutritional status of school age children (6-14 years) of tea garden workers of Assam. Compared to NCHS standard and affluent Indian children, the mean height and weight of tea garden children was inferior at all ages. Assessment of nutritional status using WHO recommended anthropometric indicators revealed a high prevalence of malnutrition among tea garden school age children and malnutrition was both chronic and recent in nature. Prevalence of wasting, stunting and underweight was 21.2%, 47.4% and 51.7% respectively among the children in the age group of 6-8 years. Prevalence of stunting and thinness was 53.6% and 53.9% respectively among the children in the age group of 9-14 years age group.17

Conducted a cross-sectional study to assess the nutritional status of adolescents of Indian origin living in India and United Arab Emirates (UAE). A total 2459 adolescent boys and girls between the age of 10 to 16 years old were selected as samples. The result showed, regardless of gender, the rate of stunting was higher in Indian adolescents from India (25.5%-51%) compared with Indian adolescents in UAE (3.1%-21%). The thinness was also more in India (42%-75.4%) when compared to adolescents living in UAE (4.5%-14.4%).

The study concluded improved economic conditions favours better expression of genetic potential for physical growth.18

II. Review of literature related to the impact of mid-day meal programme on nutritional status of school children

7 The study was conducted on the impact of mid day meal program on educational and nutritional status of school children in Andhra Pradesh. A total of 83 schools from 3 districts were selected. Among these, 45 schools had MDM program and 38 schools did not have MDM program. The result of the study indicated improved attendance, increased retention rate with reduced dropout rates. The nutritional component revealed better growth performance among the regular beneficiaries of the program.19

The study was conducted to assess the effect of the Mid Day Meal (MDM) Program on enrolment, attendance, dropout rate and retention rate in the schools and its impact on nutritional status as well as on school performance. The design of this study was comparison by multistage random sampling. The main subject included in this study was primary school children, who are attending the school in the MDM and non-MDM areas. The results in this study are a total of 2,694 children (MDM: 1361; Non-MDM: 1333) from 60 schools were covered in the study. Results of the study indicated better enrolment (p <0.05) and attendance (p <0.001), higher retention rate with reduced dropout rate (p <0.001) a marginally higher scholastic performance and marginally higher growth performance of MDM children. After we conclude that the MDM program is associated with a better educational and nutritional status of school children in Karnataka.20

The comparative study was conducted on the impact of nutritional support to primary education program of MDM on growth of enrollment, attendance and nutritional status on primary school children. The study reveals that between the pre-MDM period(1989-90 to 1994-95) and post MDM period (1995-96 to 1998-99), there was n improvement in average annual growth rate of enrollment and attendance and decline in dropout rate in the post- MDM period in Orissa compared to Tamil Nadu. The study concluded that pre-school and post-school nutritional programs are to continue as separate programs for the benefit of children.21

A study was conducted on The meals provided to children have been found to be deficient in terms of nutritive content. The caloric and protein content of the school meal were calculated. The samples collected from 63 schools in Madhya Pradesh. He found that variety in meals served the purpose of meeting the requirement of recommended daily allowance rather than serving the same menu on all days. A program which serves a varied menu was found to meet 22 percent of the daily recommended allowance for children,

8 whereas wheat porridge (the same menu every day) met only 11 percent of the daily recommended allowance of energy intake. One common problem with meeting the nutritional requirements of children was found to be the substitute nature of the meal. Most studies reported that the MDM actually serves as a substitute for home food rather than a supplement.22

6.4 Statement of the problem

A comparative study to assess the impact of Mid-day meal (MDM) Program on Nutritional status of School Children in selected Schools at Mangalore.

6.5 Objectives of the study

 To assess the nutritional status of children in mid-day meal schools.

 To assess the nutritional status of children in non mid-day meal schools.

 To compare the nutritional status of the children of both mid-day meal and non mid- day meal schools.

 To ascertain the nutritional status of children aged 9-12 years at Mangalore.

 To find the impact of mid day meal on the nutritional status of school going children.

6.6 Operational definitions

Compare: Evaluate the similarity between the level of nutritional status which is measured through the anthropometric measurement among the Mid-day meal and Non Mid-day meal school children.

Impact: Effect of mid day meal on nutritional status of school children.

Mid-day meal program: It is the nutritional supplementation program to improve the nutritional status and educational status of school children.

Nutritional status: The nutritional status of the individual refers to adequacy of the food intake which indicates the adequate health status, growth and development. It measured through the anthropometric measurements and compared with WHO growth standard.

School Children: The children’s those who are studying in the primary school and

9 falls in the age between 9 to 12 years

Primary school: It is an institution where the primary education takes place from 1st to 5th class in governmental and nongovernmental sectors in rural / urban areas.

6.7 Assumptions

 There will be a great impact of Mid-day meal Program on Nutritional status of School Children.

6.8 Delimitations

 The study is limited only in the primary schools in Mangalore.

 The study is limited in Mangalore only.

 The study is limited to the both sets of schools belongs to same geographical area with essentially similar socio-economic background.

6.9 Hypotheses

The hypotheses will be tested at 0.05 level of significance.

H0: There is no significant difference in nutritional status of children between mid-day- meal and non mid-day meal primary schools.

H1: There is a significant difference in nutritional status of children between mid-day meal and non mid-day meal schools.

7. Material and methods

7.1 Source of data

Data will be collected from primary School Children who are studying in both selected Mid-day meal and non Mid-day meal Schools in Mangalore.

7.1.1 Research design

Research design in this study is comparative study design as the objectives of comparative study of nutritional status of children between mid-day meal and non mid-day meal schools located in same geographical area with similar socio-economic status.

10 7.1.2 Setting

The settings of the study are mid-day meal and non mid-day meal schools in Mangalore. The total numbers of schools selected for the study are 2, i.e., 1 school from mid-day meal receiving school and 1 school from the non mid day meal schools located in same geographical area with similar socio-economic status.

7.1.3 Population

The populations in this study are primary School Children i.e. from I-V class studying in both Mid-day meal and non Mid-day meal Schools.

7.2 Method of data collection

7.2.1 Sampling procedure

The samples for this study will be recruited by simple random technique from both mid-day meal and non mid day meal schools.

7.2.2 Sample size

Sample size consists of 80 samples from both mid-day meal receiving and non mid- day meal receiving primary schools i.e. 40 from the mid-day meal receiving school and 40 from the non mid-day meal receiving school

7.2.3 Inclusion criteria for sampling

 Students those who are studying in both mid-day meal receiving and non mid-day meal receiving primary schools located in the same geographical area and similar socio-economic status.

 Children of age between 9-12 years.

 Children who are regular to classes.

7.2.4 Exclusion criteria for samplings

1. Both schools from different geographical area and different socioeconomic status.

11 2. Children who are irregular to classes.

Variables

Dependent variables: Dependent variable in this study is the nutritional status of primary school children.

Independent variables: The independent variable in this study is mid-day-meal program.

7.2.5 Instruments intended to be used

The tool consisted of 2 sections,

Section-I: Demographic variables.

Section-II:

Part-A: It consists of anthropometric measurements, such as weight and height was measured by using standardized measurement scales.

Part-B: It deals with the Semi structured observational check list on clinical examination of the selected samples done to know the nutritional status of the children in both mid-day meal receiving and non mid-day meal receiving schools respectively.

7.2.6 Data collection method

Measuring the anthropometric measurement of school children from both mid-day meals receiving and non-receiving schools.

7.2.7 Plan for data analysis

The data will be analyzed using both descriptive and inferential statistics. Descriptive statistics planned to be used are mean, percentage, and standard deviation. Inferential statistics will be paired ‘t’ test and chi-square test.

7.3 Does the study require any investigations or interventions to be conducted on patients, or other animals? If so please describe briefly.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

12 Yes, ethical clearance has been obtained.

8. References

1. Basavanthappa BT. Community health nursing. 2nd ed. New Delhi: Jaypee Brothers Publication (P) Ltd; 2008.

2. Marlow DR. Textbook of paediatric nursing. 6th ed, New Delhi: Elsevier India (P) Ltd; 2007.

3. Park K. Textbook of preventive and social medicine. 19th ed. Jabalpur: Banarsidas Bhanot Publications; 2001.

4. Swaminathan MS. Handbook of food and nutrition. 5th ed. New Delhi: Harcourt Publications; 2001.

5. Mid day Meal Scheme. [online]. Available from: URL: http://en.wikipedia.org/wiki/Mid-day_Meal_Scheme

6. Child protection & child rights. [online]. Available from: URL:http://www.childlineindia.org.in/Mid-day-Meal-Scheme.htm

13 7. Akshay Patra, Bangalore. [online]. Available from: URL:http://www.akshayapatra.org/

8. Mid-day Meal Scheme in India. [online]. Available from: URL:http://education.nic.in/elementary/mdm/Releases_Information.htm

9. India’s malnutrition dilemma. [online]. Available from: URL:http://en.nytimes.com/2009/10/11/magazi8ne/11.FOB-Rieff-f.html.

10. Swaminathan MS. Research Foundation Website. [online]. Available from: URL:http://en.wikipedia.org/wiki/Malnutrition_in_India

11. Malnutrition in India. [online]. 2009. Available from: URL:http://en.wikipedia.org/wiki/Malnutrition_in_India

12. Sharma AK, Singh S, Meena S, Kannan AT. Impact of NGO run Mid Day meal Program on nutritional status and growth of primary school children. Indian Journal of Paediatrics 2010;77(7):763-769.

13. Kristjansson EA, Robinson V. School feeding for improving the physical and psychosocial health of disadvantaged elementary school children. Cochrane Database System Review 2007;Jan;24(1):CD004676.

14. Shakya SR, Bhandary S, Pokharel PK. Nutritional status and morbidity pattern among governmental primary school children in the Eastern Nepal. Kathmandu University Medical Journal 2004;2(8):307-14.

15. Wickramasinghe VP, Lamabadusuriya SP. Nutritional status of school children in an urban area of Sri Lanka. Ceylon Medical Journal 2004;49:114- 8.

16. Heath DL, Panaretto KS. Nutritional Status of primary school children in Townsville. The Australian Journal of Rural Health 2005;13(5):282-9.

17. Medhi GK, Barua A, Mahanta J. Growth and nutritional status of school age children (6-14 years) of tea garden worker of Assam. J Hum Ecol 2006;19(2):83-5.

18. Haboubi GJ, Shaikh RB. A comparison of the nutritional status of adolescents from selected schools of South India and UAE: A cross-sectional study. Saudhi Journal of Medicine 2009;34(2):108-11.

14 19. Sarma R, Rao HD. Impact of mid-day meal program on educational and nutritional status of school-going children in Andhra Pradesh. Asian Pac Journal of Public Health 1995 Jan;8(1):48-52.

20. Laxmaiah A, Sarma KV, Rao DH. Nutritional Status of children in a welfare home. Indian Paediatrics 1999;36(7):499-506.

21. Misra SN, Behera M. Child nutrition and primary education: a comparative study of mid-day meal programme in Orissa and Tamil Nadu. Indian Journal of Social Development 2003;3(2):267-99.

22. Afridi F. Mid-day meals in two states: comparing the financial and institutional organization of the program. Economic and Political Weekly 2005 Apr 9-Apr 15;40(15):1528-34.

15 9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of (in block letters)

11.2 Guide MRS. JINCY. C. P ASSIT. PROFESSOR INDIRA NURSING COLLEGE, FALNIR, MANGALORE

11.2 Signature

11.3 Co-guide (if any) MR. DAYANAND. V. B

11.4 Signature

12 12.1 Head of the department MRS. JINCY. C. P ASSIT. PROFESSOR INDIRA NURSING COLLEGE, FALNIR, MANGALORE

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal

13.2 Signature