assessing malnutrition in juanga tribe

8/15/2019 Assessing Malnutrition in Juanga Tribe

1/44

Assessing Malnutrition, Screening children for

developmental milestones and the effect of malnutrition on child development in the Juang

tribe in Kendujhar District of Orissa

( INDIA)

By

Dr Samrat Kumar

School of Public Health

SRM University

Centre for Children Studies

KSRM, KIIT University

Patia, Bhubaneswar


2/44

Report

On

Assessment of Malnutrition, Child development and the effect of

malnutrition on child development in the Juang tribe of Orissa

Submitted to:

Centre for Children Studies,

KSRM, KIIT University, Bhubaneswar-751031

Submitted by:

Dr Samrat Kumar

MPH Scholar, School of Public Health,

SRM University.


3/44

Dedicated to My Parents


4/44

ContentsList of Tables and Bar Diagrams: 5

Acknowledgements: 6

Acronyms and Definitions 7

Developmental Milestones: 7

Introduction 8

Indian Context 10

Orissa Context: 11

Rationale of the study: 18

Objectives 19

Review of literature 20

Methodology 23

Data collection 24

Results and Discussion 25

Conclusions 35

Recommendations 36

Annexure 37


5/44

List of Tables and Bar Diagrams:

Tables

Table 1 Adivasi Child Mortality 10

Table 2 Nutritional Status Children under 6 years 15

Table 3 Population of Orissa 15

Table 4 ST population Orissa 21

Table 5 Kendujhar Sub-division Population 21

Table 6 Socio-demographic Details 25

Table 7 Chi Square Analysis 26

Table 8 WHO guidelines on prevalence of malnutrition 34

Bar Diagrams

Bar Diagram 1 Nutritional status of children (India) 11

Bar Diagram 2 Fertility rate and wealth 12

Bar Diagram 3 Children receiving Anganwadi services 13

Bar Diagram 4 Trends in children nutritional Status 14

Bar Diagram 5 Anemia among women and children 15

Bar Diagram 6 Nutritional status of children( Juang Tribe) 26

Bar Diagram 7 Weight for age status 26

Bar Diagram 8 Weight for height status 28

Bar Diagram 9 Height for age status 29

Bar Diagram 10 Status of milestones achieved 30

Bar Diagram 11 Weight for age and milestones Status 31

Bar Diagram 12 Weight for height and milestones Status 32

Bar Diagram 13 Height for age status and milestones 33

Figure

Analytical Framework…………………………………… 22


6/44

Acknowledgements:

I take this opportunity to thank Centre for children studies (CCS), KIIT School of Rural Management,KIIT University, Bhubaneswar and State Office of UNICEF Orissa, for allowing me to be a part of the

internship programme.

I have taken efforts in this project. However, it would not have been possible without the kind support

and help of many individuals and organizations. I would like to extend my sincere thanks to all of them.

I am highly indebted to Mrs Nandini Sen, Mrs Kalika Mahaptra, Mr Nihar Singh, Dr Unmesh Patnaik and

Prof. L K Vaswani for their guidance and constant supervision as well as for providing necessary

information regarding the project & also for their support in completing the project.

I would like to express my gratitude towards Dr Vishal, Fatma Alam, Bikash, my parents and my brother

for their kind co-operation and encouragement which help me in completion of this project.

Sincere thanks to Mr Trinath, Mr Dilip and all the Anganwadi workers and helpers in the Banspal area for

giving me such attention and time while data collection which made the fieldwork a valuable learning

experience.

My thanks and appreciations also go to my mentor Dr Rajan R Patil , Dr Anil I Krishna, Ms Geetha andmy colleague Emmanuel O Salawu for the help in developing the project and people who have willingly

helped me out with their abilities.

Finally, special thanks to CCS coordinator Mr Onkar Nath Tripathi who helped me at every stage from

beginning till the end. I extend my gratitude for his unrelenting support, inspirational guidance, light-

hearted humour and his concern for humanity. More than just a coordinator, he has been a mentor andguide to me during the entire study period.


7/44

Acronyms and Definitions

AWC Anganwadi Centre

AWW Anganwadi Worker

ICDS Integrated Child Development Scheme

WHO World Health OrganizationW/A Weight for age

W/H Weight for Height

H/A Height for Age

NFHS National Family Health Survey

Developmental Milestones: Skills such as taking a first step, smiling for the first time, and waving "byebye" are called developmental milestones. Children reach milestones in how they play, learn, speak,

behave, and move (crawling, walking, etc.).

(CDC National Center on Birth Defects and Developmental Disabilities, Atlanta,US).


8/44

Introduction

As children are the future of every country, their situation is always of concern to policy makers, their

parents and the general public. Ensuring children's health is a universally supported goal of development.

In developing countries, children and adults are vulnerable to malnutrition because of low dietary intakes,

infectious diseases, lack of appropriate care, and inequitable distribution of food within the households(1).

Malnutrition has long been recognized as a consequence of poverty. It is widely accepted that higher rates

of malnutrition will be found in areas with chronic widespread poverty. Malnutrition is the result of

marginal dietary intake compounded by infection. In turn, marginal dietary intake is caused by household

food insecurity, lack of clean water, lack of knowledge on good sanitation, and lack of alternative sourcesof income. It is also compounded by, inadequate care, gender inequality, poor health services, and poor

environment. While income is not the sum of total of people's lives, health status as reflects by level of

malnutrition is.

Because having good health condition is important precondition for escaping poverty and because

improved health and sanitation contribute to growth, investment in people's health and nutritional status is

fundamental to improving a country’s general welfare, promoting economic growth, and reducing

poverty(2). Meeting primary health care needs and the nutritional requirements of children are

fundamental to the achievement of sustainable development. In the United Kingdom and a number of

Western European countries about half their economic growth achieved between 1790 and 1980 has been

attributed to better nutrition and improved health and sanitation conditions (3). Malnutrition in childhoodis known to have important long-term effects on the work capacity and intellectual performance of adults.

Health consequences of inadequate nutrition are enormous. It was estimated that nearly 30% of infants,

children, adolescents, adults and elderly in the developing world are suffering from one or more of the

multiple forms of malnutrition, 49% of the 10 million deaths among children less than 5 years old each

year in the developing world are associated with malnutrition, another 51% of them associated with

infections and other causes(4). Recent studies have also pointed out those women who were malnourished

as children are more likely to give birth to low birth-weight children and thus there is an intergenerational

effect of child malnutrition. A practical advantage of using child malnutrition as a poverty indicator over

income level is that this measure does not have to be adjusted for inflation and would not be constrained

by any inadequacy of price data. Measures of child nutritional status can help capture aspects of welfare,

such as distribution within the household which are not adequately reflected in other indicators. Child

malnutrition standards are applicable across cultures and ethnicities.

Evaluation of nutritional status is based on the rationale that in a well-nourished population, there is a

statistically predictable distribution of children of a given age with respect to height and weight. In any

large population, there is variation in height and weight; this variation approximates a normal distribution.

Use of a standard reference population as a point of comparison facilitates the examination of differences

in the anthropometric status of subgroups in a population and of changes in nutritional status over time.

The use of a reference population is based on the empirical finding that well-nourished children in all

population groups for which data exist follow very similar growth patterns before puberty. Adequate


9/44

nutrition is critical to child development. The period from birth to two years of age is important for

optimal growth, health, and development. At this age, children are particularly vulnerable to growth

retardation, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute

respiratory infections (ARI).

THE MAGNITUDE OF MALNUTRITION AND DIARRHEA Global mortality among children under the age of 5 years approximates 9.7–10.6 million deaths each year

(or 26,000–29,000 children each day), of whom 18% (i.e., 1.9 million per year or over 5000 per day) die

due to diarrhea(5). Moreover, fully 53% (5.6 million) of these deaths are associated with malnutrition.

Furthermore, it is estimated that maternal and childhood under nutrition is the underlying cause of 3.5

million deaths and 35% of the disease burden in children younger than 5 years, accounting for fully 11%

of the total global DALYs (disability adjusted life years)(5).We suggest that a substantial proportion of global malnutrition is due to impaired intestinal absorptive function resulting from multiple and repeated

enteric infections. These include recurrent acute infections as well as persistent infections, even those

without overt liquid diarrhea. Furthermore, impaired innate and adaptive host immune responses and

disrupted intestinal barrier function due to malnutrition and diarrheal illnesses likely combine to render

weaning children susceptible to repeated bouts of enteric infections leading to intestinal injury and,

consequently, nutrient malabsorption during the developmentally critical first 2 years of life. Evidence

from the existing literature suggest that the impact of heavy diarrheal burdens and multiple enteric

infections in the early formative years of childhood extends long beyond the infection itself and affects

both growth and cognitive development in affected children(5).

Malnutrition during childhood can also affect growth potential and risk of morbidity and mortality in later

years of life. Malnourished children are more likely to grow into malnourished adults who face

heightened risks of disease and death. Poor nutritional status of women has been associated with a higher

age at menarche(6) and a lower age at secondary sterility(6).


10/44

Indian Context

Almost half of children under five years of age (48 percent) are stunted and 43 percent are underweight.The proportion of children who are severely undernourished (more than three standard deviations below

the median of the reference population) is also notable—24 percent according to height-for-age and 16

percent according to weight-for-age. Wasting is also quite a serious problem in India, affecting 20 percent

of children under five years of age. Very few children under five years of age are overweight. Less than 2

percent have a weight-for-height estimate more than two standard deviations above the median for the

reference population and less than 1 percent are more than two standard deviations above the median on

the weight-for-age indicator(1).

Under nutrition is substantially higher in rural areas than in urban areas. Even in urban areas, however, 40percent of children are stunted and 33 percent are underweight. Children who are judged by their mother

to have been small or very small at the time of birth are more likely to be undernourished than those who

were average size or larger. Under nutrition has a strong negative relationship with the mother’s

education. The percentage of children who are severely underweight is almost five times as high forchildren whose mothers have no education as for children whose mothers have 12 or more years of

education. Children from households with a low standard of living are twice as likely to be

undernourished as children from households with a high standard of living. Inadequate nutrition is aproblem throughout India, but the situation is considerably better in some states than in others. Even in

these states, however, levels of under nutrition are unacceptably high.

ST children in India: 53.9% stunted, 24.7 are wasted and 54.5% are underweight(1).

Table 1

The mortality in the tribal children had been found to be more in relation to their share of the totalpopulation in rural areas. The table above describes the situation in different communities as per NFHS

2005 data.


11/44

Bar Diagram 1

The proportion of children under three years of age who are underweight decreased from 43 percent in

NFHS-2 to 40 percent in NFHS-3(1), and the proportion severely underweight decreased from 18 percent

to 16 percent. Stunting decreased by a larger margin, from 51 percent to 45 percent. Severe stunting also

decreased, from 28 percent to 22 percent.

Orissa Context:

All but 3 percent of households in Orissa have household heads who are Hindu. One percent of

households have Muslim heads and 1 percent had Christian heads. One-fifth of households belong to a

scheduled caste, 23 percent belong to a scheduled tribe, and 27 percent belong to Other Backward Classes

(OBC). Thirty percent of Orissa’s households do not belong to scheduled castes, scheduled tribes, orother backward classes. Compared to the national average, Orissa’s population is poor as 40 percent of

Orissa's population is in the lowest wealth quintile, compared to 20 percent of India's population. Forty-

two percent of Orissa’s households (48% in rural areas and 13 percent in urban areas) are in the lowest

wealth quintile and only 21 percent are in the two highest wealth quintiles combined (1).

51

20

4345

23

40

0

10

20

30

40

50

60

stunted wasted underweight

Percent of children under 3 years of age , India

NFHS 2

NFHS 3


12/44

Bar Diagram 2

The average size of the family is high among the low income families, as shown above; it affects the

nutritional status of the child in the low income families. Source: NFHS-3(1)

The infant mortality rate in NFHS-3 is estimated at 65 deaths before the age of one year per 1,000 live

births, down from the estimate of 81 in NHFS-2 and 112 in NFHS-1. The under-five mortality rate is 91

deaths per 1,000 live births. Infant and child mortality rates in Orissa are higher than the nationalestimates. The higher rates of infant and child mortality in Orissa imply that, despite declines in mortality,

1 in 15 children still die within the first year of life, and 1 in 11 die before reaching age five. The ICDS

programme provides nutrition and health services for children under age six years and pregnant orbreastfeeding women, as well as preschool activities for children age 3-5 years. These services are

provided through community-based anganwadi centres. Among the 80 percent of children under six years

in Orissa who are in areas covered by an anganwadi centre, two-thirds (66%) receive services of some

kind from a centre. The most common services children receive are growth monitoring (56% of children

age 0-59 months), supplementary food (53% of children under six years of age), health check-ups and

immunizations (42-43% of children under six years of age). Twenty-eight percent of children ages 3-5

years receive early childhood care or preschool services. Thirty percent of mothers of children who wereweighed at an anganwadi centre received counseling from an anganwadi worker after the child was

weighed


13/44

Bar Diagram 3

Children of mothers with less education and mothers in the lowest wealth quintile are most likely and

children of mothers who have completed high school or who are in the highest wealth quintile are least

likely to take advantage of the services offered at anganwadi centres. Children from scheduled castes and

scheduled tribes are more likely to receive services from an anganwadi centre than children from othergroups.

Infant feedingAlthough breastfeeding is nearly universal in Orissa, only 51 percent of children under 6 months are

exclusively breastfed, as the World Health Organization recommends(4). Eighty-two percent are put to

the breast within the first day of life, including 55 percent who started breastfeeding in the first hour of

life, which means that the majority of infants in Orissa received the highly nutritious first milk

(colostrums) and the antibodies it contains. Mothers in Orissa breastfeed for an average of 34 months,which is almost a year longer than the minimum of 24 months recommended by WHO for most children.

It is recommended that nothing be given to children other than breast milk in the first three days when the

milk has not begun to flow regularly. However, 42 percent of children are given something other than

breast milk during that period.

Children’s nutritional statusForty-five percent of children under age five are stunted, or too short for their age, which indicates that

they have been undernourished for some time. Twenty percent are wasted, or too thin for their height,

which may result from inadequate recent food intake or a recent illness. Forty-one percent are

underweight, which takes into account both chronic and acute.


14/44

Bar Diagram 4

undernutrition. Even during the first six months of life, when most babies are breastfed, 26 percent of

children are stunted, 28 percent are wasted, and 36 percent are underweight. Children in rural areas aremore likely to be undernourished, but even in urban areas, more than one-third of children (35%) suffer

from chronic undernutrition. The majority of scheduled-tribe children are stunted (57%) or underweight

(54%). Girls and boys are about equally likely to be undernourished. Children’s nutritional status inOrissa has improved since NFHS-2 by all three standard measures of nutrition. Both chronic and acute

undernutrition was less widespread in Orissa at the time of NFHS-3 than they were seven years earlier.

Anaemia: Sixty-one percent of women in Orissa have anaemia, including 45 percent with mild anaemia,

15 percent with moderate anaemia, and 2 percent with severe anaemia. Two-thirds of women who are

pregnant (69%) and who are breastfeeding (65%) are anaemic. The prevalence of anaemia is lower among

the more educated and among those who are in the higher wealth quintiles; however, in every other groupmore than half of women are anaemic.


15/44

Bar Diagram 5

Anaemia among children age 6-35 months was slightly higher in NFHS-3 than it was seven years earlier

at the time of NFHS-2. Around 71% of Schedule Tribe people have the lowest quintile in the wealth

index as per NFHS-3.

The Birth order of 4+ is 36.7% in ST Population, 30.7% in the lowest wealth quintile, 33.5 % among the

illiterate mothers.

Table 2

Children under 6 years (% age) Nutritional Status:

Height/ Age Weight/Height Weight/Age

< -3sd < -2sd Mean Z

score


score


score

ST 28.4 57.2 -2.1 8.2 27.6 -1.3 22.9 54.4 -1.9Source: NFHS-3

Table 3

Source: Census of India-2011

57% stunted and 54.4 % are underweight among the Schedule Tribe children of Orissa.

Population of Orissa: 41,947,358

1. Child Population (0-6 years): 5,035,6502. Child sex ratio(0-6 years): 934 females/1000 male children3. Literacy rate: 73.45% Male: 82.4% Female: 64.36%

Kendujhar District:1. Population:2. Child sex ratio(0-6yrs):3. Child population(0-6yrs):

1,802,777 (4.3% of Population of Orissa)

957 females/1000 males

253,418


16/44

JUANGThe Juangs are mostly concentrated in Banspal, Telkoi and Harichandanpur Blocks. They claim

themselves to be the autochthons of the area from where they have migrated to other parts of the state.

They classify themselves into two sections, viz. the Thaniya (those who dwell in their original habitation)and the Bhagudiya (those who have moved away to other places). The Juangs believe that in ancient times

their tribe emerged from earth on the hills of Gonasika where the river Baitarani has its source, not far

from the village Honda in Keonjhar. In their language the word "Juang" means man. In other words, man

emerged from the earth at the same place where the river Baitarani emerged. The Juang also refer tothemselves as patra-savaras (patra means leaf). By this they mean that they are that branch of the Savara

tribe whose members used to dress themselves in leaves. They have got their own dialect which has been

described by Col. Dalten as Kolarian. They have acquired many Oriya words by coming in contact withthe Oriya speaking people. Most of them know and speak Oriya.

In the Juang society, the village is the largest corporate group with formally recognized territory. Within

the delineated land boundaries they possess their land both for settled and shifting cultivation and the

village forests for exploitation. They shift their village sites frequently as they consider it inauspicious tolive at a particular place for a longer period.

Each Juang village is marked by the presence of a dormitory known as Majang where their traditional

dance takes place and the village panchayat sits. It also serves as a guest-house for the visitors to the

village. The Pradhan who is the secular headman and the Nagam or Boita or Dehuri, the village priest

constitute the traditional village panchayat of the tribe. A group of neighbouring villages constitute a pirh

which is headed by a Sardar who decides inter-village disputes.

The Juangs are patrilineal and their society is marked by the existence of totemistic clans which are

divided into two distinct groups known as "Bandhu clans" and "Kutumba clans". The totem is never

destroyed or injured by its members. The clans are exogamous and marriage within the same clan is

considered incestuous. Monogamy is commonly prevalent while polygamy is not ruled out . Levirate and

sororate type of marriage is prevalent on the Juang society.A Juang husband generally worships the "Sajana"(drum stick) tree if his wife turns out barren and gives

her a paste made of "Sajana" flowers and seeds to eat or he ties a sevenfold cotton string with seven knots

round his wife's neck, believing this to be a kind of talisman which will cause conception. The Juangs do

not allow their pregnant women to go to "Devisthan". She must not tie up anything, must not weave mat

or plaster a house with mud.

The Juang cremate their dead. The corpse is laid on the pyre with the head to the south . The ashes may be

left on the spot of cremation, or alternatively they may be thrown into stream. For their livelihood they

depend mainly on primitive shifting cultivation and collection of minor forest produce.

The Juang life is marked by the celebration of a number of religious festivals in honour of their gods and

goddesses. For them Dharam Devta and Basumata are the supreme deities. The former is identified withSun God and the latter with Earth Goddess. Gramashree is the presiding deity of the village. There are

also a number of hill, forest and river deities in the Juang pantheon. They believe in the existence of

spirits and ghosts.

They observe Pusha Purnima as a mark of the beginning of the agricultural cycle, Amba Nuakhia as thefirst eating of mango fruits, Akhaya Trutiya as the ceremonial sowing of paddy, Asarhi, marking the

beginning of transplanting and weeding, Pirha Puja for the protection of crops, Gahma for the welfare of

domestic cattle and other auspicious days for the ceremonial eating of new rice harvested from differenttypes of lands . All these occasions are marked by dancing and singing. They use a kind of drum known

as changu at the time of dancing.

For the socio-economic development of the Juangs a micro-project has been established in the Juangpirh

at Gonasika. The project has assumed the responsibility for various development activities of the Juang.


17/44

Gradually the Juangs have started settled cultivation with modern technology. The podu ravaged areas are

being covered with trees of different species. They have also started subsidiary occupation like tasar

cultivation, tasar reeling, weaving, tailoring etc.

Different infrastructural developments like communication, village electrification, social forestry, anddrinking water supply are being implemented for their benefit. Under social activities, education, health

care and preservation of the human values existing in them are being taken care of.

(http://kendujhar.nic.in)


18/44

Rationale of the study:

The evaluation will show the magnitude of child malnutrition in the primitive Tribe ( Juang) of Orissa.Empirical studies show that child malnutrition is closely linked to income level and the socio-economic

status. A study also shows that child malnutrition is reflective and indicative of other desirable

development outcomes i.e. gender equality, intra-household distribution, and health environment quality.

That the relationship between child malnutrition and poverty is most sensitive at the lower end of the

income range makes child malnutrition a good indicator for development intervention projects and

programs, which generally target this section of the population.

While child malnutrition could not universally be adopted as a poverty indicator at this point of time due

to lack of universally available data, it's strength and relevance as a poverty indicator, particularly for

monitoring poverty impacts on the low income population, is gradually being recognized by governments

and international agencies around the globe. The Food and Agriculture Organization of the United Nation

(FAO) and the International Funds for Agriculture and Development has recently included child

malnutrition as one of the indicators to be assessed in their projects and programs.

India is experiencing a rapid economic boom due in part to the opening of its markets in the 1990s and the

emergence of a knowledge-based economy. However, this prosperity has not translated into well-being

among the country’s young children. The prevalence of underweight (a widely used indicator of

undernutrition) among children under age five in India is one of the highest in the world 43% in 2006

surpassed only by Bangladesh, Yemen and Timor(7). India is home to 55 million of the world’s

underweight children under age five about one third of the global burden of underweight in this age

group. During the prosperous 1990s, the average rate of decline in prevalence of underweight has been

around 0.9% per year among Indian children aged below five years, whereas in China, another Asian

country with a rapidly growing economy, it declined by approximately 5% per year. The nutritional status

of young children is an important indicator of health and development—it is not only a reflection of past

health insults but an important indicator of future health trajectories. Children under age three are

particularly vulnerable to undernutrition, and because the growth rate in this period is greater than any

other age period, it increases the risk of growth retardation. Furthermore, undernutrition among young

children captures the extent of development in a society and is thus a marker for the overall well being of

a population.

With this study, we are analysing the extent of malnutrition and its impact on child development in the

Juang tribe in rural areas of Orissa. We have screened the children for the developmental milestones forthe different age groups less than 3 years. The various intervention programs like ICDS, MDM and SNP

are working to lower down the malnutrition among preschool children. ICDS is also contributing for the

adequate child development by providing preschool education at the Anganwadi centers, which includes

the social, emotional, cognitive and motor skills in the children.

This study is an attempt to understand the level of malnutrition existing in the Juang Tribe, which is a

primitive tribe of Orissa, and as such there is no such nutritional data available specifically for the Juang

tribe. We are trying to find out the malnutrition and its coexistence with the poor performance in respect

of the Child development milestones. As studies have shown the nutrient deficiencies affect the normal

development of the child like cognition, motor skills and also the other skills like social and emotional


19/44

which are related with the social and cultural environment. The various background characteristics of the

population affect the nutrition of the child as it is an environmental factor and similarly the child

development. The study will reveal the situation of the children in the Juang community, the prevalence

of malnutrition i.e. Underweight, Stunted and Wasted Children, the achievement of developmental

milestones and various factors associated with nutritional status of the children less than 3 years of age.

Objectives

To assess the status of Malnutrition in children less than 3 years of age in the Juang tribe inkendujhar district of Orissa.

To assess the level of Development in children less than 3 years of age in juang tribe.

To determine the impact of malnutrition on children development in the juang tribe.


20/44

Review of literature

The various studies conducted to assess the nutritional status of the children explain about the various

underlying factors responsible for malnutrition.

Harishanker et al (8) found that the maximum overall prevalence of malnutrition was recorded in the age

group 13-24 months, prevalence of malnutrition was 56.63% in Schedule Cast population, low

educational status of parents, low socioeconomic status and large family size are the probable

precipitating factors. Poverty, illiteracy and ignorance are the main reasons which lead to malnutrition.

ICMR Bulletin 2003, A study carried out recently by RMRC, Bhubaneswar amongst four primitive tribes

of Orissa, revealed an infant mortality rate (per 1000 live birth) of 139.5 in Bondo, 131.6 in Didayi, 132.4

in Juanga and 128.7 in Kondha (Kutia); a maternal mortality rate (per 1000 female population) of 12 inBondo, 10.9 in Didayi, 11.4 in Juanga and 11.2 in Kondha tribe. The wide spread poverty, illiteracy,

malnutrition, absence of safe drinking water and sanitary conditions, poor maternal and child health

services, ineffective coverage of national health and nutritional services, etc. have been found, as possiblecontributing factors of dismal health condition prevailing amongst the primitive tribal communities of the

country

Guerrant et al.2008,(5) Global mortality among children under the age of 5 years approximates 9.7–10.6

million deaths each year (or 26,000–29,000 children each day), of whom 18% (i.e., 1.9 million per year or

over 5000 per day) die due to diarrhea. Moreover, fully 53% (5.6 million) of these deaths are associated

with malnutrition. Diarrhea and enteric infections impair weight and height gains, physical and cognitive

development. The longterm impact of malnutrition on economic productivity has recently been

documented by followup studies of 1–2-year-old male children treated with nutrient-dense atole in

Guatemala between 1962 and 1977; the individuals now earn 46% more than their peers at ages 25–42

years. Further intervention studies are needed to document the relevance of these mechanisms and, most

importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their fullpotential.

Subramanyam et al. 2010,(9) Social disparities in childhood undernutrition in India either widened or

stayed the same during a time of major economic growth. While the advantages of economic growth

might be reaching everyone, children from better-off households, with better educated mothers appear to

have benefited to a greater extent than less privileged children. The nutritional status of young children is

an important indicator of health and development—it is not only a reflection of past health insults but an

important indicator of future health trajectories. Children under age three are particularly vulnerable toundernutrition, and because the growth rate in this period is greater than any other age period, it increases

the risk of growth retardation. Furthermore, undernutrition among young children captures the extent of

development in a society and is thus a marker for the overall well being of a population. Social disparities

in childhood undernutrition in India either widened or stayed the same during a time of major economicgrowth. While the advantages of economic growth might be reaching everyone, children from better-off

households, with better educated mothers appear to have benefited to a greater extent than less privileged

children.


21/44

Study Area: Orissa is regarded as the Homeland of Adivasis. More than 7 million tribal live in Orissa.

They cover 22.21% of the total population of orrisa. It is 11% of the total tribal population of the country.

Out of the 62 tribal communities in Orissa, 13 are the most primitive from cultural and technological

point stand. The State of Orissa occupies an important place in the country having a high concentration of Scheduled Tribe and Scheduled Caste population. In terms of ST population, it is the second biggest in

the country. Both Scheduled Tribe and Scheduled Caste constitute nearly 38.66% of the total State

Population (S.Ts 22.13% and S.Cs 16.53% as per 2001 Census). The population of the members of the

Scheduled Tribes and Scheduled Castes, as per 2001 Census(10) is as follows:

Table 4

TOTAL POPULATION OF THE STATE 36804660

SCHEDULED TRIBES (S.T.) POPULATION 8145081

PERCENTAGE OF S.T. POPULATION TO TOTAL

POPULATION

22.13

S.T. COMMUNITIES 62

Source: ST & SC Development Department, Government of Orissa

Percent of population of Kendujhar which comes under ST.

Kendujhar Total 44.50%

Kendujhar Rural 47.81%

Kendujhar Urban 23.56%

As per 1991 census there were 46 Scheduled Tribes in the district. Out of these the principal tribes were

Bathudi, Bhuyan, Bhumij, Gond, HO, Juang, Kharwar, Kisan, Kolha, Kora, Munda, Oraon, Santal, Saora,

Sabar and Sounti. These sixteen tribes constituted 96.12 % of the total tribal population of the

district. The concentration of Scheduled Tribes is the highest in Keonjhar and lowest in the Anandapur

Sub-Division. The study has been conducted in the Banspal Block in Kendujhar District of Orissa(India).The Juang villages are surveyed for the data collection in the Banspal block. The majority of

Juang population is located in the Banspal block, and random selection of children under 3 years of age

was done.

Table 5

KEONJHAR SUB-DIVISION POPULATION

RURAL

01. Keonjhar Sadar 58,036

02. Patna 41,972

03. Saharpada 39,732

04. Harichandanpur 54,340

05. Ghatagaon 55,122

06. Banspal 56,013

07. Telkoi 37,915

URBAN

01. Daitary Census Town 1,566

TOTAL :- 3,55,088

The total population of Juangs in Kyunjhar district is about 20000. It is supposed to be one of the main

poverty pocket of Orissa, just as kalahandi-naupada districts are considered to be the poverty sricken

pockets of the whole world.The juang inhabited panchayats are ravanapalsi, Badapalspal,

Pithagoda,Hunda, Janghira,Badagoara, Gonasika, Kodiposa and Banspal. The deaths due to hunger occur

regularly in these areas.


22/44

RESEARCH DESIGN: Cross-sectional Study, Descriptive Study (Prevalence Study)

Research Framework:

Outcome that this study would produce

Child Malnutrition Child Development

Methods of Assessing Child

Malnutrition: (WHO Standards for

Children) Height for age (H/A)

Weight for age (W/A)

Weight for height (W/H)

Tools: Questionnaire as well as physical anthropometric assessment

Statistical Analyses: Descriptive Statistics (with emphases on Proportions); Inferential Statistics (with emphases

on Comparing 2 Population Proportions)

Screen the children for

Developmental

milestones less than 3

years of age inJuanga

tribe Odisha

Know whether

malnutrition has significant

effect on child

development

Prevalence of Malnutrition in children

less than 3 years of age

in Juang community

If yes, then to

what extent?

Method of Assessing Child Development:Assessing the child development

on the basis of developmental milestones

achieved by the child in the particular age

group.

(National Institute of public cooperation and

child development, New Delhi)

Minimum Sample Size: 105

Sampling Method adopted: Multistage sampling protocol was adopted. It was such

that 6 villages were selected randomly, then random sampling would be done within

each cluster

Will describe the

nutritional status of the

children in the Juang tribe

and the status of child

development .

To understand the social

and demographic details

of the target population.


23/44

Methodology

The random selection of the children is done from the 7 Juang dominated villages in the Banspal block.

There are around 47 villages of Juangs in the Banspal block. We have randomly selected around 7villages and covered the households with at least one child under 3 years of age. The total of 105 children

under 3 years of age are observed for the milestones of development and the physical anthropometric

measurements were recorded as per the standard procedures. Supine measurements for length are taken

for the children under 2 years. The international System of units is followed.

Measuring Malnutrition in the targeted Children

Anthropometry: The measurements of weight and height of the children is done as per the guidelines

given by CDC, USA. The weight in Kilograms and height in Centimeters is recorded for all the children.

The most standardized indicators of malnutrition in children were used in this study. These indicators are

based on measurements of the body to know if growth pattern is normal and adequate.

• Height for age (H/A), is an indicator of chronic malnutrition. A child exposed to inadequatenutrition for a long period of time will have a reduced growth - and therefore a lower height

compared to other children of the same age (stunting).

• Weight for age (W/A), is a composite indicator of both long-term malnutrition (deficit inheight/"stunting") and current malnutrition (deficit in weight/ "wasting").

• Weight for height (W/H), is an indicator of acute malnutrition that tells us if a child is too thinfor a given height (wasting).

In each of the 3 indicators (W/H, W/A, H/A), A comparison of the individual measurements tointernational reference values for a healthy population (NCHS/WHO/CDC reference values) is done and

the cases with the values less than the -2SD from the median of the reference population of WHO are

categorized as malnourished. The cases with measured values less than -3sd are categorized as Severely

Malnourished.

Measuring the Level of Development in the targeted Children

Child development was assessed as per the status of developmental milestones achieved. The details of

the milestones achieved age wise as illustrated by the National Institute of Public cooperation and child

development, New Delhi.

A structured format for collecting the information on background characteristics of the household is used

along with anthropometric records of the child. Checklist of developmental milestones was used to screen

the child and observations for individual child are recorded in the response sheet.


24/44

Data collection

This cross-sectional study was undertaken in Kendujhar district of Orissa in June 2011. The study was

intended to assess the nutritional status of children under 3 years of age and associated factors. A sample

size of 98 was required assuming a 60% prevalence of malnutrition, margin of error of 10% and a 20%

contingency for non response. A structured format for collecting the information on background

characteristics of the household is used along with anthropometric records of the child. Checklist of

developmental milestones was used to screen the child and observations for individual child are recorded

in the response sheet.

The questionnaire comprised three different parts: socio demographic, anthropometrics measurement

together with the screening of the child for developmental milestones. The data were collected with the

help of a translator who were trained for two days. The data were checked every day by the investigator

who stayed with data collectors for the duration of the survey, which was 10 days.

Measurements on weight and height were taken from children under 36 months. The socio-demographic

characteristics included in the questionnaire were: sex, caste, ownership of land, educational status of the

mothers, and household income. Digital weight scale was used for weighing the under three children

while height measure for older children above two years of age, and length of the young children and

infants below two years of age were measured by recumbence scale. The nutritional status of the study

children was assessed using the indicators weight-forage, weight-for-height, and height-for-age,

according to the NCHS (4;11)reference standard taking –2.S.D as the cut-off point indicating malnutrition

(under weight, stunting, and wasting).Verbal consent was obtained from heads of households.


25/44

Results and Discussion

The study included a total 105 children out of which 55(52.3%) were males and 50(47.6%) were female.

The number of children in the age group of 12-35 months constituted more than 67% of the study

population. The socio-demographic characteristics of the study subjects are shown in Table 6.

Table 6

Socio-demographic

Characteristics

Age in months Total

1-2 3-5 6-8 9-11 12-17 18-23 24-35

No % No % No % No % No % No % No % No %

SexMale

Female

0

2

0

1.9

7

5

6.6

4.7

5

4

4.7

3.8

7

4

6.6

3.8

14

10

13.3

9.5

7

9

6.6

8.5

15

16

14.2

15.2

55

50

52.3

47.6

Education of mother

Illiterate

Literate

1

1

0.95

0.95

11

1

10.4

0.95

9

0

8.5

0

9

2

8.5

1.9

21

3

20.0

2.8

14

2

13.3

1.9

31

0

29.5

0

96

9

91.4

8.57

Birth order

1

2

3 or more

2

0

0

1.9

0

0

2

5

5

1.9

4.7

4.7

3

2

4

2.8

1.9

3.8

1

3

7

0.95

2.8

6.6

13

3

8

12.3

2.8

7.6

2

4

10

1.9

3.8

9.5

2

6

23

1.9

5.7

21.9

25

23

57

23.8

21.9

54.2

Monthly income

2000

1

1

0.95

0.95

6

6

5.7

5.7

2

7

1.9

6.6

6

5

5.7

4.7

12

11

11.2

10.4

11

5

10.4

4.7

11

19

10.4

18.0

49

54

47.5

52.4

Economic status

BPL 2 1.9 12 11.42 9 8.5 11 10.4 24 22.8 16 15.2 31 29.5 105 100

Total

2 1.9 12 11.42 9 8.5 11 10.4 24 22.8 16 15.2 31 29.5 105 100

According to the NCHS reference standard taking –2.S.D as cutoff point, the study children who fell

below –2 S.D. of the indicators (Underweight, Stunted, and Wasted) were computed as 92.3%, 45.8% and94.3%, respectively. In this study, there were no cases of over nutrition. In order to investigate the

association of selected demographic and socio-economic variables with the anthropometric results, Chi

square test of association was used. However, there was no statistically significant association with sex,

maternal education, birth order and monthly income (Table 7).


26/44

Table 7 Chi square Analysis:

Variable Variabl

Malnutrition Sex of

Malnutrition Mother

Malnutrition Monthl

Malnutrition Birth o

Nutritional Status of Juang Tr

Bar Diagram 6

The status of children less thanscores for reference population

moderately underweight, 59% s

category. But in case of wasting

normal, 24.8% moderately w

malnutrition is stunting, there w

are moderately stunted and only

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

WFA(Underweig

7.60%

33.30%

59

le Chi square value( Calculated)


27/44

Bar Diagram 7

The status of children in their rethat the peak prevalence of und

nearly 90% of children in age g

18-23 months, 68% in 24-35 mo

age of the child the proportion o

0

10

20

30

40

50

60

70

80

90

1-2

months

3-5

months

50

16.7

50

41.7

0

41.7

pective age groups showing the underweight pererweight children is between the age groups 6

roup 6-8 months, 72% in 9-11 months, 70.8% i

nths were severely underweight. It was observed

malnourished children increased as depicted in

6-8

months

9-11

months

12-17

months

18-23

months

24-

mon

0 0 0 0

9.711.1

27.3 29.2

18.822

88.9

72.7 70.8

81.3

Weight for Age Status

centage. It was observedonths to 35 months, as

n 12-17 months, 81% in

that with the increasing

he Bar Diagram 7.

5

hs

.6

67.7

Normal

moderate

severe


28/44

Weight for Height Status (Chil

Bar Diagram 8

The weight for height which in

majority of the children in eacwasted children was observed in

0

10

20

30

40

50

60

70

80

90

100

1-2

months

3-5

months m

50

91.7

66

dren< 3 years):

icates the wasting percentage among the childr

age group are under the normal category. Ththe age group 18-23 months.

6-8

onths

9-11

months

12-17

months

18-23

months

24-35

months

.763.6

45.8

37.5

48.4

n observed, reveals that

e highest percentage of

Normal

Moderate

Severe


29/44

Height for Age Status (Childr

Bar Diagram 9

Height for age status of the chil

of malnutrition was observed inchronic malnutrition prevalent i

73% in the age group 9-11 mont

and 68% in the age group 24-3increased age of the child depict

0

10

20

30

40

50

60

70

80

90

1-2

months

3-5

months

50

16.7

50

41.7

0

41.7

n


30/44

Developmental Milestones Sta

Bar Diagram 10

The developmental milestones sthe children who had achieved

placed in the achieved category

guidelines were put in the categ

The poor performance of the

developmental level of the ch

described that with the advancin

0

10

20

30

40

50

60

70

80

90

100

1-2

months

3-5

months

100

75

0

25

us (%):

tatus of the children in their particular age groull the milestones as given in the guidelines of

and the children who could not achieve all the

ry of developing.

hildren in respect of the achievement of the

ildren whether they were normally developin

g age the developmental deficit is also increasing

6-8

months

9-11

months

12-17

months

18-23

months

24-3

mont

55.6

63.6

100

12.5

25.8

44.4

36.4

0

87.5

7

had been observed andIPCCD, New Delhi was

ilestones as given in the

ilestones indicated the

g or not. The diagram

.

s

.2

achieved

developing


31/44

Weight for age and milestones

Bar Diagram 11

The coexistence of underweigh

reveals that among the normunderweight children 66% were

had yet to achieve the develop

moderate to severe underweig

compromised had increased con

0

10

20

30

40

50

60

70

80

Normal

50 50

status (%):

and developmental deficit had been shown he

l weight children around 50% were still destill developing and in severely underweight chil

ental milestones. The diagram shows the tren

ht category, the proportion of children who

iderably.

Moderate Severe

34

27

66

73

re in bar diagram 11. It

eloping, in moderatelydren 73% of the children

that as we move from

were developmentally

Achieved

Developing


32/44

Weight for height and milesto

Bar Diagram 12

The comparative study of the

normal children around 65% ha

here as well that with the incre73% of children in the severe w

0

10

20

30

40

50

60

70

80

Normal

35

65

es (%):

status of wasting and the milestones achieved

ve not achieved the milestones yet. The similar

asing level of malnutrition the developmental dsted category had yet to achieve the milestones.

Moderate Severe

27 27.3

73 73

showed that among the

trend had been observed

ficit was also rising, as

achieved

Developing


33/44

Height for Age and milestones

Bar Diagram 13

The 75% of the severely stuntethere existed a considerable d

malnutrition level, as 55.6% of

milestones corresponding to thei

0

10

20

30

40

50

60

70

80

normal

50 50

(%):

d children also failed to achieve all the milestovelopmental deficit. And this deficit was in

he children in the moderate malnutrition catego

r age group.

moderate severe

44.4

25

55.6

75

nes which indicated thatreasing with the rising

y had yet to achieve the

achieved

developing


34/44

Key Findings:

The peak in prevalence of malnutrition is found in children between 6 months and 35months which indicate that with the advancing age and as soon as the breast feeding is stopped,the children suffer from malnutrition because there is no replacement for the mother milk in the

juang community. They don’t use cow milk for feeding children.

The developmental delays are most prominent in between 18 to 35 months. The delays indevelopment were also related with the advancing age of the children as it was observed that the

prevalence of malnutrition also increases with age as detailed above.

The developmental delays are mostly prevalent in the children in the severe malnutritioncategory, due to the reason that malnutrition is impacting the growth and development in the

juang community.

There was no significant gender difference in the prevalence of malnutrition. The study hasfound that malnutrition has no relationship with the sex of the child.

92.5% of children are underweight, which is a composite indicator of both chronic and currentmalnutrition.

The achievement of milestones is delayed with the increase in prevalence of malnutrition. Extremely high malnutrition prevalence in comparison to the normal population of Orissa

as per the data available from NFHS 3 for Orissa.

According to WHO guidelines for assessing the severity of malnutrition in a community:

Table 8

Indicator Severity of malnutrition by prevalence ranges (%) Findings of

study

medium high Very high

Stunting 20-29 30-39 >40 94.3

Underweight 10-19 20-29 >30 92.3

wasting 5-9 10-14 >15 45.8


35/44

Conclusions

Extremely high prevalence of malnutrition among the Juang tribe Children (


36/44

Recommendations

For nutritional interventions, ‘Catch’ the children young – before 3 years – before malnutritionsets in and before the child gets compromised regarding the overall growth and development.

Detection of malnutrition at an early stage, so that moderate cases may not progress to severeform of malnutrition.

Providing nutritional education to mothers regarding low cost, highly nutritive food stuffs. The high prevalence of malnutrition is also related to the purchasing power of the community, so

effort should be made to increase the income of the tribal families by various ways.

Special attention is needed for the primitive tribes like Juanga. The Tribal development is very much dependent on the status of the children, so we really need

look into the grave situation of the tribal children in particular, which is big hurdle to save the

primitive tribes from the danger of extinction.


37/44

Annexure

Structured format for collecting Anthropometric measurement to assess nutritional status along with

checklist for the milestones of development for assessing the child development for different age

groups for the children between 0 to 3 years of age in the JUANG tribal community in KENDUJHAR

district of the state of Orissa, India

Sir/madam,

I am an Intern from Centre for children studies, KSRM, KIIT university is conducting a study to assess nutritional

status and child development in children under 3 years of age in the JUANG tribal community. The purpose to

conduct the study is to fulfill the academic requirement, to understand the level of malnutrition and the status of

child development; and to assess if there is any relationship between developmental delays and malnutrition in

children less than 3 years of age.

Date……………….. Time …………………. Sr. No…………………..

SOCIO-DEMOGRAPHIC DETAILS:

1. District2. Block 3. Village

House Hold factors:

4. Father’s name………………………………………5. Education of father………………………………6. Occupation of father……………………………7. Mother’s name……………………………………8. Mother’s education……………………………9. Cast

1. General 2. SC 3. ST 4. OBC10. Name of tribe……………………………………….11. Name of the child………………………………….12. Date of Birth………………………………………….13. Sex of the child….1)Male 2) Female


38/44

14. Total no. of children……………………………..15. Birth order of child……………………………..16. Provided with nutritional Information during pregnancy………………17. No. of family meals per day…………………………18. Family status: BPL……………, APL……………..19. Family income ………………………from Agriculture……………………, Job……………….,

Labour……………, Land holdings…………………., any other source…………………

20. Expenditure …Food……………, education………………, Health………………..,Clothing…………, Festival…………………., Travel………………………..,

Other factors:

21. Distance of Anganwadi centre ………………22. AWC details:………………………………………….23. AWC/ICDS services availed………………......

Anthropometric Measurements

Sr No. Birth Weight

( W)

Age of the

child (A)

Weight(Kg)

(W)

Height(cm)

(H)1 Present Weight

2 One month before

3 Two months before

4 Three months before


39/44

Developmental milestones status:

Age Group Codes of the Milestones achieved

1 month 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9

3 months 3.1

6 months 6.1

9 months 9.1

12 months 12.1

18 months 18.1

24 months 24.1

36 months 36.1

Check list for the Developmental milestones:

Yes…………………….1

No……………………..2

Age group (1) Milestones of Development YES NO

One month 1.1 Cries in hunger or discomfort1.2 Turns his head towards a hand that is stroking the child’s cheek or mouth

1.3 Brings both hands towards her/his mouth

1.4 turns towards familiar voices and sounds

1.5 suckles the breast and touches it with her/his hand


40/44


41/44

Age group (9) Milestones of Development YES NO

Nine months 9.1 Sits up from lying position9.2 Picks up with thumb and finger9.3 Sits without support9.4 Crawls on hands and knees

Age group

(12)

Milestones of Development YES NO

One Year

( 12 months)

12.1 Stands without support12.2 Tries to imitate words and sounds12.3 Waves Bye -Bye12.4 Enjoys playing and clapping12.5 Says Papa & Mama

12.6 Starts holding objects such as a spoon or a cup and attempts self feeding

Age

group(18)


Eighteen

months

18.1 Walks well18.2 Expresses wants18.3 Stands one foot with help18.4 Points to objects or pictures when they are named ( e.g. eyes, rose)18.5 Starts saying names of objects

18.6 Puts pebbles in a cup


42/44

Age group(24) Milestones of Development YES NO

Two Years 24.1 Walks, climbs and runs24.2 Says several words together24.3 Follows simple instructions24.4 Scribbles if given a pencil or crayon24.5 Enjoys simple stories and songs

24.6 Imitates the behavior of others on household work

24.7 Begins to eat by herself or himself

Age group

(36)


Three Years 36.1 Walks, runs, climbs, kicks and jumps easily36.2 Recognizes and identifies common objects and pictures by

pointing

36.3 Makes sentences of two or three words36.4 Says his/her own name and age36.5 Can name colours

36.6 Can understand numbers36.7 Uses make-believe objects in play36.8 Expresses affection36.9 Feeds herself or himself


43/44

REFERENCE LIST

(1) GHOSH S. NATIONAL FAMILY HEALTH SURVEY-3 (2007). INDIAN PEDIATRICS

2007;44(8):619.

(2) WORLD B. WORLD DEVELOPMENT REPORT 1993. INVESTING IN HEALTH: WORLD

DEVELOPMENT INDICATORS. OXFORD UNIVERSITY PRESS; 1993.

(3) SETBOONSARNG S. CHILD MALNUTRITION AS A POVERTY INDICATOR: AN

EVALUATION IN THE CONTEXT OF DIFFERENT DEVELOPMENT INTERVENTIONS IN

INDONESIA. ASIAN DEVELOPMENT BANK (ADB) INSTITUTE DISCUSSION PAPER

2005.

(4) DE ONIS M, BL÷SSNER M. THE WORLD HEALTH ORGANIZATION GLOBALDATABASE ON CHILD GROWTH AND MALNUTRITION: METHODOLOGY ANDAPPLICATIONS. INTERNATIONAL JOURNAL OF EPIDEMIOLOGY 2003;32(4):518.

(5) GUERRANT RL, ORIΒ RB, MOORE SR, ORIΒ MOB, LIMA AAM. MALNUTRITION ASAN ENTERIC INFECTIOUS DISEASE WITH LONG-TERM EFFECTS ON CHILD

DEVELOPMENT. NUTRITION REVIEWS 2008;66(9):487.

(6) HOSSAIN MDG, ISLAM S, AIK S, ZAMAN TK, LESTREL PE. AGE AT MENARCHE OF

UNIVERSITY STUDENTS IN BANGLADESH: SECULAR TRENDS AND ASSOCIATION

WITH ADULT ANTHROPOMETRIC MEASURES AND SOCIO-DEMOGRAPHIC

FACTORS. JOURNAL OF BIOSOCIAL SCIENCE 2010;42(5):677.

(7) MISHRA VK, LAHIRI S, LUTHER NY. CHILD NUTRITION IN INDIA. 1999.

(8) HARISHANKAR1 SD, DABRAL SB, WALIA DK. NUTRITIONAL STATUS OF CHILDREN

UNDER 6 YEARS OF AGE.

(9) SUBRAMANYAM MA, KAWACHI I, BERKMAN LF, SUBRAMANIAN SV.

SOCIOECONOMIC INEQUALITIES IN CHILDHOOD UNDERNUTRITION IN INDIA:

ANALYZING TRENDS BETWEEN 1992 AND 2005. PLOS ONE 2010;5(6):E11392.

(10) GENERAL R. CENSUS COMMISSIONER. CENSUS OF INDIA 2001;2001.

(11) GRAITCER PL, GENTRY EM. MEASURING CHILDREN: ONE REFERENCE FOR ALL.

THE LANCET 1981;318(8241):297-9.

Websites:

• http://www.adbi.org/discussion-paper/2005/01/14/869.malnutrition.poverty.indonesia/measuring.malnutrition/

• http://www.who.int/en/ • http://www.cdc.gov/ • http://www.nfhsindia.org/ • http://www.unicef.org/india/state_profiles_4346.htm


44/44

• SC/ST development, minorities & backward classes welfare Department, Govt. Of Orissa.

• http://censusindia.gov.in/ • www.kendujhar.nic.in/ • www.google.com • www.youtube.com • http://www.rchiips.org/ • http://nipccd.nic.in/

assessing malnutrition in juanga tribe

Documents