ASSESSING NUTRITIONAL STATUS MANDAKINI KHANDEKAR OF PRE-SCHOOL CHILDREN:...
ASSESSING NUTRITIONAL STATUS
MANDAKINI KHANDEKAR
OF PRE-SCHOOL CHILDREN:
and
SOME ORGANIZATIONAL
PRATIBHA JOSHI* -
CONSIDERATIONS
INTRODUCTION
ing nutritional supplements to children
whose initial nutritional status is poor are
Child welfare is one of the most impor-
undertaken, the need arises to assess their
tant aspects of social welfare. For a long nutritional status at different points of time.
time, social welfare was associated with This need is felt not merely to make out
services for persons suffering from physical a case for such programmes, (the case hav-
or mental handicaps. While services for such ing been already made out), but mainly to
handicapped persons will naturally continue evaluate the results of the programmes. It
to form a part of the total welfare pro-
is found that when any large-scale pro-
gramme, greater attention is now being paid gramme of providing nutritional supple-
to the various services needed by normal ments is to be organized, it is easier to do
persons and more so by the children. It is so at places where children gather in fairly
recognized that the benefits of a healthy large numbers. Thus, it is found that schools
and happy childhood are numerous. An are focal points for distributing nutritional
adequate level of nutrition and protection supplements. Lack of suitable focal
from health hazards are very important to points for organizing the programme
a child in his development. However, it is of distribution of nutritional supplements
found that a large number of normal has been one of the reasons why such feed-
children in India do not have adequate ing programmes for pre-school children are
nutrition for one reason or another. We not as many as they need to be. As the
need not discuss these reasons here because programmes of starting recreational centres,
such a discussion will lead us to the socio-
balwadis, pre-primary schools, etc. gather
economic, cultural and even political pro-
momentum, the programme of distribution
blems of society in general. Suffice it to of nutritional supplements will also receive
say here that the need to provide nutritional fillip. But this raises several questions con-
supplements to a' very large number of cerning delivery of services, nutritional or
normal children has been recognized and otherwise, to the home-bound pre-school
that a number of such programmes are children; the roles of special purpose, general
operating in the country. So far as child welfare and child welfare agencies in such
welfare services are concerned, the stress, a delivery system; the need to resort to
during the Fifth Five Year Plan will be on unconventional methods of reaching the pre-
providing integrated child care services. school children; etc. But obviously, this is
Nutrition programmes for pre-school child-
not the place to enter into such a discussion.
ren will form an important segment of such
services.
Just as the nutrition programme needs
When large-scale programmes of provid-
to be on a large scale, the programme of
Miss M. Khandekar is Research Associate and Miss P. Joshi is Research Assistant, Unit
for Study of Urban Child and Youth, Tata Institute of Social Sciences, Deonar,
Bombay 400 088.
The authors wish to thank Dr. P. M. Shah, Institute of Child Health, J. J. Group of
Hospitals, Bombay, for helpful discussions on the subject.

12
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
assessing the nutritional status too will have in two wards of Greater Bombay. One was
to be on a large scale. It is obvious that a ward (G/south) from Bombay City and
such a large scale nutritional assessment the other (L) was from the Suburbs. Both
will have to be at once comprehensive are predominantly industrial in nature. The
enough to be worthwhile and useful, and objectives of the Area Study can be sum-
quick enough to be organizationally feasible. marized as follows:
The present paper describes and discusses
one such large-scale programme of Nutri-
(1) To obtain information on various
tional Assessment of pre-school children.
factors e.g. demographic and socio-
The stress is more on the organizational
economic characteristics and physical
problems involved. The Assessment under
environment; nutritional level of pre-
discussion was not connected with any pro-
school children and the parents'
gramme of distribution of nutrition sup-
understanding of the needs and pro-
plements but formed an important part of
blems of their pre-school children.
a research project. However, it can be
(2) To suggest guidelines for formulating
relevant for nutrition programmes as well.
a minimum programme of integrated
Before taking up the details of the Assess-
services for pre-school children in
ment, we will briefly describe the main
urban areas.
research project entitled "An Area Study
(3) To study the existing institutional
of the Needs and Problems of Pre-school
frame-work for child welfare in the
Children".
selected areas.
THE AREA STUDY
According to the research plan, 2,000
households were contacted for the necessary
In view of the growing trend towards information. Finally, 1,908 households furni-
urbanization in India and of the grave shed the data. In all, 3,499 children in the
problems that have followed in its wake, age-group 0-6 years were covered by the
the need to study the special problems of Main Study. It collected extensive data
urban children and youth was felt. It is about pre-school children and their parents
now recognized that large sections of urban in the sample households. The Area Study
children are, socially speaking, as handi-
had a few sub-projects attached to the Main
capped as are the rural children. But the Study of the Sample Households. They are
nature and the impact of such handicaps are mentioned below without any details.
different and need to be understood. Study-
ing the various aspects of the situation of
1. Views of the community influentials
urban children now forms a part of the
concerning the services for pre-school
research activity of the Tata Institute of
children.
Social Sciences. The Institute had, in 1969,
2. Follow-up study of the utilization of
set up a Unit for Study of the Urban Child
welfare services for pre-school children.
and Youth with financial assistance from
3. Nutritional Assessment of pre-school
the UNICEF. One of the studies undertaken
children.
by the Unit so far is an Area Study of the
4. Welfare Agencies — Their work and
Needs and Problems of Pre-school Children.
potentialities.
It was sponsored jointly by the Indian
5. A study of the existing institutional
Council for Social Science Research and
frame-work for child welfare in the
the UNICEF and was carried out in 1971
selected areas.

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
13
THE NUTRITIONAL ASSESSMENT
MAJOR COMPONENTS OF THE ASSESSMENT
The Nutritional Assessment was under-
The major components of the Nutritional
taken to fulfil one of the objectives of the Assessment were based on the objectives
overall Area Study. All the pre-school set out for it. They were.
children aged 1-6 years in the sample house-
holds were to be covered by the Assessment.
1. Application of the Quac Stick method
The data collected for the Main Study were
in assessing the nutritional status of
to be used for analyzing data on the health
Pre-school children.
and nutritional status of the pre-school
2. The assessment of different types of
children. The objectives of the Assessment
nutritional deficiencies and those lead-
were as follows :
ing to serious physical conditions.
3. The measurement of actual anthropo-
metric characteristics and expressing
1. To assess the nutritional status of the
them as percentages of the expected
children by employing a technique
measurements.
which would be simple, objective,
4. Conducting haemoglobin test and
replicable and easily learned. It was
stool examination and collection of
expected to be useful in comparative
data on the dietetic intake of the
studies also.
selected children, and
2. To relate the anthropometric measure-
5. Linking the Nutritional Assessment to
ments of the selected children regard-
the Main Study by utilizing the latter's
ing height, weight, head and chest
socio-economic data about the house-
circumferences, etc. to the expected
holds and the parents, and the special
measurements and to use these in
information about the children.
assessing the nutritional status of the
selected children.
THE QUAC STICK*
3. To relate the nutritional status of the
There are various methods for assessing
children to their socio-economic back-
nutritional status of children. As the Area
ground by using the data already col-
Study was concerned with pre-school chil-
lected through the Main Study.
dren, the Nutrition Sub-committee of the
4. To conduct a diet survey.
Indian Academy of Paediatrics decided to
test a newly developed method of assessing
5. To evaluate the following measure-
the nutritional status of pre-school children.
ments as indices of nutritional status: This is the Quac Stick. As this method was
i) Arm length,
yet too new and subject to confirmation,
ii) Arm circumference, and
it was also necessary to take the different
iii) Calf circumference; and
anthropometric measurements and to con-
6. To obtain statistics on protein-calorie duct clinical examinations and tests.
malnutrition, vitamin A and riboflavin
The method of Quac Stick (Quaker Arm
deficiencies, anaemia and rickets.
Circumference Stick) was developed for a
* For details of the Quac Stick Method refer to "Quac Stick — Field Measure for Quick
Assessment of Nutritional Status of Pre-school Children" by Amdekar, Rajadhyaksha,
Desai and Shah in Indian Paediatrics volume IX, Number 7, July 1972.

14
MANDAKINI RHANDEKAR AND PRATIBHA JOSHI
quick nutritional assessment of pre-school
3. Children whose arm circumference was
children in Eastern Nigeria in 1968-69 by
between 75 and 80 per cent, and
the Quaker Relief Team. As a result of the
4. Children whose arm circumference was
military operations, the Nigerian children
below 75 per cent.
suffered from frequent and severe malnutri-
tion and the relief agencies needed an in-
Since the question was one of priorities
dicator which could be used to guide their and the food supplements had to be given
programme of distribution of nutritional to those who needed them most, children
supplements. They were on the look-out for in the last two categories were given food
a simple technique which was both objective supplements. Children whose arm circum-
and reliable and which could, at the same ference was less than 75 per cent of the
time be learnt easily. With the help of such an expected arm circumference for their heights
indicator they wanted to compare one area were given proportionately more food sup-
with another and the same area at different plements so that they could make quick
points of time. They also wanted to deter-
progress. Children received food supple-
mine the quantity of nutritional supplements ments so long as they remained in the last
needed by individual children and to two categories. It also meant that such
guage the ultimate success of their pro-
supplements were withheld from those who
gramme. The handicap under which they made progress and crossed over to the first
worked was that a large number of the two categories.
Nigerians were unable to give the exact
It is possible to have only two broad
ages of the children.
groups of children, viz. those whose arm
The result of their search was the Quac circumference is 80 per cent or more of
Stick. They found that the relationship the expected arm circumference for their
between the arm circumference (which heights and those who are below this level.
depends upon the body tissues) and height The latter constitute the high-risk group
is a good indicator of a child's nutritional and receive food supplements while the
status. The maximum left arm circumference former can be expected to make do with
is measured when the arm is kept hanging whatever they get as a matter of routine.
by the side of the trunk. The other measure-
This is based on the general observation
ment that is required is height. This method by doctors that children in former category
is applicable to children who are over 12 do not need any special attention for their
months but not more than 72 months. So physical development.
long as they are within this range it is not
The Nutrition Sub-committee of the
necessary to know their exact ages.
Indian Academy of Paediatric and the In-
On the basis of the readings on the Quac stitute of Child Health at the J. J. Group
Stick, the children were grouped in four of Hospitals, Bombay are standardizing the
categories. In the case of the Nigerian child-
Quac Stick for Indian children. So far, two
ren, the Quaker Relief Team adopted the nutrition surveys have been conducted. One
following categories.
of them was the Nutrition Assessment of
pre-school Children conducted as a part of
1. Children whose arm circumference the Area Study described here. The other
was over 85 per cent of the expected was conducted in Palghar in Maharashtra
arm circumference for their heights,
and covered about 600 rural children.
2. Children whose arm circumference was
The paediatricians in charge of these
between 80 and 85 per cent,
surveys compared the results obtained with

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
15
the help of the Nigerian Quac Stick to the level will need special attention if their
results (for the same children) obtained on physical development is to be speeded with
the basis of weights. This was done because the help of nutritional supplements to their
the actual weight of a child expressed as a routine intake of food. Although different
percentage of the weight he is expected to gradations of nutritional status have been
have for his age (as per Harvard Standard) provided for in the Indian Quac Stick, it is
is considered to be the best indicator of possible, for the sake of a large-sale pro-
his nutritional status. When such a com-
gramme of distribution of nutritional sup-
parison was made, it was observed that plements, to have only two broad groups of
Indian children showed higher readings on children, viz. those who need supplements
the Nigerian Quae Stick. This was true of and those who don't.
the urban as well as the rural children in
At present, such programmes are operated
all the age-groups. The comparison indicated on a very gross level: the quantum and
that it was necessary to modify the Nigerian composition of the supplements are the
Quac Stick if the method was to be used same for all the children covered. The varia-
in the case of Indian children. This has tions, if any, are very few, As such, having
now been done by Dr. P. M. Shah and his two broad groups of children is all that
colleagues. The Indian Quac Stick is ready would be required.
but more research is needed in other parts
of India to make it standard. The objective
ORGANIZATION OF THE ASSESSMENT
in developing the Quac Stick is that the
results obtained through it should have a
The Nutritional Assessment was organized
high and direct correlation with the results by the Unit for Study of the Urban Child
obtained on the basis of the weights.
and Youth which devotes itself to a study
On the basis of the Indian Quac Stick of the social problems of children. As con-
the pre-school children are grouped in the ducting a nutritional assessment is a specia-
following categories:
lized job it was imperative for the Unit to
seek expert help, guidance and collabora-
1. Those whose arm circumference is 81 tion. The Indian Academy of Paediatrics was
per cent or more of the expected arm approached for such collaboration. At the
circumference for their heights,
request of the Academy, Dr. P. M. Shah
2. Those whose arm circumference is Convener of the Academy's Nutrition Sub-
between 71 and 80 per cent,
committee, took up the responsibility for
3. Those whose arm circumference is conducting the Nutritional Assessment of
between 51 and 60 per cent, and
the children covered by the Main Study.
5. Those whose arm circumference is
The Assessment thus was a collaborative,
50 per cent or less.
effort of the Unit and the Indian Academy
of Paediatrics. The latter carried the respon-
These categories have been adopted in sibility for all the technical work and for the
view of the very large number of malnouri-
medical examination of the children. The
shed children in India.
schedule used for recording the data was
Children whose arm circumference is 81 constructed by the Nutrition Sub-committee
per cent or more of their expected arm The Unit was in charge of organizing the
circumference for their heights may not be Assessment, preparing the codebook and
covered by the programme of the nutritional the scheme of analysis, and data processing
supplements. All those who are below this It was agreed that while the doctors engaged

16
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
in the assessment would write technical A — SELECTING THE CENTRES
reports, the Unit would analyze the Nutri-
tional Assessment data in the light of the
As the Nutritional Assessment was linked
socio-economic data obtained through the to a field research project, it was necessary
Main Study. Thus writing papers, reports, to carry out the work in the field. Simi-
etc. on Components 1 to 4 would be done larly, as the geographical coverage of the
by the doctors who had participated in the Main Study was fairly extensive, the
Assessment.
Assessment had to be conducted at different
The main organizational objectives kept centres. For determining the number and
in mind while conducting the assessment the location of centres, it was necessary to
were as follows:
take into consideration:
1. To get a good response. As the Main
i) the distance to be covered by the
Study and the Assessment were
parents for bringing the children to the
carried out at two different points of
centres,
time so far as each sample household
ii) the number of children to be examined
was concerned, it was necessary to
and the number of children one team
ensure that a maximum number of
can examine in about 3-4 hours, and
children covered under the Main
iii) the availability of suitable premises
Study attended Nutritional Assess-
to serve as a centre.
ment.
2. To ensure a smooth and regular
When the number of children to be exa-
work-flow at the time of the actual mined at a centre is small and yet it is
Assessment, especially because a child necessary to have a separate centre, it is
had to go from person to person be-
possible to arrange assessments at two
fore all the necessary technical data different centres by one team on the same
about him could be obtained. It may day but at two different points of time.
be mentioned here that a team of Necessary transport would, of course, be
doctors and technicians was required needed.
to gather the requisite information
It was but natural that the parents were
through various measurements and unwilling to spend more than 5-6 minutes
tests.
to go to a centre. Spending time is like
spending money and requires careful consi-
We will now describe how these objec-
deration. To describe the local situation in
tives were sought to be achieved and how the two selected areas, it was found that
the task was approached. In the process, the time the parents found most convenient
we will discuss the various aspects of orga-
for attending the assessment was between 9
nising the Nutritional Assessment. These in the morning and 12 noon, especially
are:
because the Assessment was conducted
only on Sundays to suit the convenience of
a) Selecting the centre
the doctors who worked in an honorary
b) Informing the parents
capacity. The Sundays suited most of the
c) Organizing the work-flow
parents as well. The average number of
d) Personnel
children who could be examined in an
e) Conveyance
hour was between 50 and 60. This average
f) Cost
number depended on a number of factors

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
17
such as the physical layout of the centre, pre-Assessment canvassing that even in a
the smoothness of the work-flow, the com-
city where multi-storeyed buildings are so
position and the strength of the assessment very common, mothers with young children
team, etc. Taking into consideration all did not like centres situated on even the
these points, it was decided to conduct the second or the third floor. So, efforts were
Assessment at 12 centres so far as the Area made to select agencies which could pro-
Study was concerned.
vide space on the ground floor. This was
The total number of children examined just as well because in the congested areas
at these 12 centres was 2,056. Of these, in which these disadvantaged households
about 150 had come uninvited but were lived, a ground floor, along with the adja-
examined just the same. Of the remaining, cent space, roads, grounds, etc. provided
1,576 were definitely those for whom de-
greater scope for a possible spillover of
tailed information was available in the men, women and children. The types of
Main Study. Some 330 were doubtful cases. agencies which were able to provide their
On account of the inadequate information premises were schools, community welfare
supplied by the adults (other than parents) centres, hospitals, etc. The average number
accompanying these children, we could not of children per centre was around 250. In
be sure that they had been covered by the a couple of cases as many as 350-400
Main Study. As such, they were not consi-
children came to one centre. As the children
dered for the final analysis. This problem were accompanied by their elders, the avail-
may not arise when nutritional assessment able space had to be sufficiently big. When
is not linked to a research study, as ours the number of children to be examined at
was. But one can foresee such a problem one centre was large, two teams of doctors
and take adequate steps to meet it. Pro-
and helpers worked simultaneously pro-
bably, the problem is such that it cannot vided the centre was big enough.
be solved completely, but efforts can be
A description of the work-flow is given
made to keep it to the minimum.
a little later. For a smooth work-flow in-
Once it was decided to have a centre in volving a very large number of people,
a locality, it was necessary to look for some ample space is needed. We found that
agency the premises of which could be used having a big hall with two or more doors,
for the Assessment. A centrally located some open space or varandahs outside the
agency was preferred. Another considera-
hall and a room, even if small, adjoining
tion in the choice of the agency, apart the hall, was desirable. The hall would be.
from the willingness of the agency to allow the place where the greater part of the
the use of its premises, was the total space overall work could be done. The open
and the facilities available. An idea of space or varandahs outside the hall could
the physical layout and area found most be used for forming the queue, and for
useful and convenient, is given at a later checking and registering the children. In
stage.
some cases, the collection of the completed
When it was not possible to have a centre schedules could also be done in this space.
within easy reach of the sample house-
A separate room adjoining the hall is found
holds response was improved by providing useful for collecting and examining the blood
transport to those who lived some distance and stool samples. The sight of the equip-
away from the centres. This was particu-
ment needed for this purpose as well as the
larly true in the case of mothers with very behavioural response of the children sub-
young children. We also found from our jected to these tests, has an adverse effect

18
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
on the general morale of other children. B — INFORMING THE PARENTS
It is, therefore, desirable to have a separate
room for these tests. Should a separate
It has already been mentioned that the
room be not available, it would be advis-
Nutritional Assessment was a sub-project
able to curtain off a corner of the hall for attached to the Main Study and that the
this purpose.
children to be assessed belonged to the
It goes without saying that a centre households constituting the sample for the
should have drinking water and sanitary Main Study. This meant that only selected
facilities. The task of conducting the households were to be informed about the
Assessment is facilitated, to a considerable Assessment and about what they were ex-
extent, if the centre itself can provide the pected to do. Even if such an Assessment
requisite furniture. As the model pattern is not linked to a field research project,
informing the parents would be a task by
for the work-flow had been planned and itself because of the content of information
worked out by the Nutrition Sub-Committee, and the need to motivate them to attend
it was possible for us to let the centre the Assessment. If the coverage of Assess-
have an idea of the different pieces of ment is not community-wise, it will be
furniture required. For this purpose again, necessary, as was the case with our Assess-
the overall work-flow was taken into con-
ment, to inform each selected household
sideration. The general requirement was individually. This task was assigned to the
for the following.
interviewers who had collected the data for
Four tables: One each for registration, the Main Study, because they could easily
for examination by the paediatricians, for locate the households even after a lapse of
examining the blood samples, and for col-
time. Depending upon the time-lag between
lecting the schedules.
the Main Study and the Assessment, in-
Six chairs: For those taking and re-
formation about the Assessment was given
cording the various measurements.
at the time of the interviews for the Main
Study or a few days before the Assessment.
One bench: For the blood test.
It was our experience, however, that even
A couple of stools: For keeping the when such time-lag was short, household's
small weighing machines.
response to the request to attend the
It is, of course, always possible to make Assessment improved if they were contacted
improvised arrangements. Where the cen-
again on the day of the Assessment.
tres themselves are unable to make the
necessary provisions, the organizers can hire
Conveying this new-fangled idea of the
furniture for the occasion.
assessment of the nutritional status of
The organizers should, it is almost super-
children to their parents is some task in-
fluous to add, take out all the necessary deed. In the first instance, the notion of
formal permissions well in advance of the having an apparently healthy child exa-
date fixed for conducting the Assessment. mined by a doctor, let alone a team of
It is our experience that the officials in the several doctors, is foreign to most of the
government and municipal departments and parents. To have them examined, moreover,
in the voluntary agencies are generally for purposes of the doctor's and social
most helpful in giving not only the neces-
investigator's profit — albeit profit know-
sary formal permissions but also active ledgewise — did not make much sense to
help. The organizers should, however, give many. That the results of the Assessment
them sufficient time for this purpose.
could lead to the formulation of some pro-

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
19
gramme of nutritional supplements for dis-
date and the time, etc. To ensure that older
advantaged children in general but not children did not come — the technique used
necessarily for their own children, seemed for assessing the pre-school children is un-
a remote possibility and failed to enthuse suitable for older children — we had to
them. We ourselves made no such pro-
tell the parents which of their children were
mises. Some parents were scared when they to be brought to the centre. For this pur-
came to know that a blood test was plan-
pose, we had to identify the children by
ned. We also found that some persons name. The children were those about whom
tended to view the Assessment as a show of we had collected detailed information
charity. Now, there are people, even during the course of our Main Study.
amongst the socially disadvantaged sections, Organizationally, it meant preparing lists of
who resent the idea of charity being ex-
parents to be informed and of children
tended to them. On the other hand, there to be assessed. These lists were prepared
are also those who not only "welcome it separately for each centre and were so
but demand it. Considered this way, an arranged that sub-area-wise parts of the
Assessment linked to a research project lists could be given to individual investi-
is at a disadvantage as compared to an gators. These lists proved very useful not
Assessment linked to a feeding programme. only for contacting the parents but also for
A great deal naturally depended upon the registering the children and for monitering
individual entrusted with the task of con-
the progress of work. Identification of
tacting the parents. The degree of response households from where children had not
at any one centre was a measure of his or attended the Assessment was easy and while
her persuasiveness.
the work was in progress, the investigators
could once again go round the locality
Persuading the parents to bring their making a last-minute bid to persuade the
children to the selected centres for the parents to come along with their children.
Nutritional Assessment soon acquired many Preparing such lists was easy as all the
of the characteristics of a small campaign! relevant particulars were available from the
And one now knows that the golden key Main Study. Only, when the time-lag be-
to success in such ventures is involving the tween the interviewing for the Main Study
local leaders and entrusting part of the job and the Assessment was short, we had to
to them. Here, we came across different work under pressure to beat the clock.
problems. In the two selected wards where
our Area Study was conducted there were
A field programme of nutritional assess-
some distinct localities which had some of ment and medical examination of children
the characteristics of a neighbourhood or cannot, even though undertaken for pur-
a community. There also existed, however, poses of research, be entirely devoid of the
some localities which shared the general element of service. So, the parents were
urban heterogeneity and anonymity. Depend-
given to understand that they could have
ing upon the situation, identifying the local their ailing young children examined by the
leaders was either an easy or a difficult job. paediatricians in the team. For minor ail-
ments, supplies of medicines to last 2-3
After the preliminaries of trying to per-
days were distributed on the spot. Although
suade the parents were taken care of, there an effort was made to restrict the Assess-
remained the task of ensuring that they ment to pre-school children covered by the
got the various particulars right — the name Main Study, it was inevitable that some
of the centre, its exact location, the day, older children and some pre-school

20
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
Chart showing the work — flow
1
C
Checking
2
R
Registration
3
W
Measurement of Weight
4
H
Measurement of Height
5
CHC
Measurement of Circumferences of head and chest
6
CAAL
Measurement of Circumference of Arm and Arm Length
7
QS
Reading on Quac Stick
8
P1 P2
Examination by two paediatricians and diet survey
9
HS
Haemoglobin test and Stool examination
10
CP
Collection of papers

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
21
children not covered by the Main Study we offered biscuits or toffees to the children
would troop in. They were examined in to secure their co-operation.
order to maintain good public relations, but
their data have not been included in the C — ORGANIZING THE WORK-FLOW
analysis.
For the purpose of the Assessment, it
The major part of the Assessment was
was necessary to record the correct ages devoted to the various anthopometric mea-
of the children. So, when the parents were surements and the medical examination of
contacted they were requested to be ready the children. Systematic organization of
with this information. Whenever possible, the flow of work was of vital importance
they were asked to consult birth certificates, as the number of children to be examined
horoscopes, hospital cards, etc. As an aid was large and as the work had to be com-
to determining the ages as nearly exact as pleted quickly. Recording the data was to
possible, the Nutrition Sub-Committee had be done simultaneously. The work-flow
devised a Local Events calender where a was taken into consideration while finaliz-
large number of major and minor Hindu, ing the sequence of the items included in
Muslim and Christian festivals and days the schedule. We now detail below the
of religious, cultural and social significance sequence of the different jobs that were done.
were recorded and their equivalents in the This sequence is from the point of view
Gregorian Calendar were identified for the of the child being examined. Each job was
preceding five years — five years because the special responsibility of one or two
the Quac Stick Method is applicable in the persons.
age-group 1-6 years. This Calendar was
used when the parents gave the date of birth
Job 1: Checking the children
according to, say, the Hindu Calendar or
The investigators had previously guided
with reference to some special day or event.
the parents and the children covered
After identifying the year of birth, it was
,by the Main Study to the Centre. An
possible, with the help of the Local Events
effort was made here to check once
Calendar, to place the child's date of birth
again that, as far as possible, only
as near to the exact date as possible. Such
those pre-school children who had been
a Calendar is, really speaking, a Special
covered by the Main Study, were pre-
Events Calendar and had to be prepared
sent. Simultaneously with the checking,
well in advance of the Assessment with
the children and their parents were
the help of old calendars, panchang, etc.
lined up in a queue.
The parents were requested to take the
children to the centres themselves as they
Job 2: Registering the children
but not others, could be expected to fur-
nish the necessary information required by
The children were registered for the
the doctor's team. One more practical as-
Assessment. Identification data for the
pect could be mentioned. Most of the
centre and for the child were recorded
young children are not inclined to view the
here. The schedule was then handed to
prospect of a medical examination with
the adult accompanying the child.
equanimity. It is in the interest of the
Persons performing the different jobs
organizers if the parents concerned could
had to make the necessary entries in the
be present to take the situation in hand by
schedule and hand it back to the
pacifying their crying babies! On our part,
clients.

22
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
Job 3: Recording the weight
the paediatricians to examine the children.
The persons over-viewing the queue had
Job 4: Recording the height
to regulate the work-flow considering the
paeditarician's work. As the job of medical
examination naturally requires more time
Job 5: Recording the circumference of than other jobs, it is desirable to have two
the head and the chest
paediatricians in one team. A diagramatic
representation of the work-flow is given on
Job 6: Recording the circumference of page 20.
the arm and the calf
D — PERSONNEL
Job 7: Recording the reading on the
Quac Stick
Closely linked to the question of orga-
nizing a smooth work-flow is the strength
Job 8: Clinical Assessment of Nutri-
of personnel required for it. When a large
tional status by the paediatrician number of pre-school children, who cannot
come to a centre unattended, are to be
The child was examined thoroughly at examined in a reasonably short time, it is
this stage. Recommendations for X-Ray necessary to have a sufficiently large team
were made, if found necessary.
to accomplish the task. While it was true
that doctors were to perform the essential
Job 9: Blood and Stool examination
jobs involved in the Nutritional Assessment
including medical examination, it was
Every eighth child was sent in for this equally necessary to give them adequate
purpose.
support in recording the data, organizing
the overall work and regulating the work-
Job 10: Diet Survey
flow. The following statement gives an
idea of the type and number of persons who
Every sixteenth child was sent in for took part in the Assessment organized by
this purpose.
the Unit.
Job 11: Collection of papers
Among the technical personnel, all ex-
cept the laboratory technicians who collec-
The filled-in schedule was collected ted and examined the blood and stool
after a child had gone through all the samples, were highly qualified doctors. It
stages of the overall work. The person may be mentioned that all the doctors and
collecting these schedules would make the laboratory technician worked without
sure that no items of data were missing. compensation. Practically all the doctors
If they were, the child was sent to the had an academic interest in the work and
appropriate person to have the requisite were to analyze the data to bring out
date recorded in the schedule.
technical papers as envisaged by the
objectives of the Assessment.
The children would move in single file
and go from one doctor to another. The
The supporting personnel was provided
pace of the overall work-flow was decided, by the Unit. The officers of the Unit and
in most of the cases, by the time taken by a couple of volunteers worked without com-

ASSESSING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
23
pensation. But temporary staff including in mind, it is seen that depending upon
interviewers, coders, etc. were compensated the number of children to be examined,
for the work they did for the Assessment. having one or two paediatricians to conduct
The work of Assessment was done by the the clinical examination is most essential.
paediatricians and their team. Taking care Similarly, a laboratory technician to collect
of the preliminaries, recording the measure-
and examine samples of blood and stool
ments, providing general assistance and will also be needed. But for other jobs, it
doing incidental jobs were assigned to the is not necessary to have highly qualified
supporting personnel. While selecting a doctors, unless of course, their voluntary
person for a specific job, the nature of the services are available. Less qualified medical
job and the person's familiarity with it or para-medical staff could be engaged. It
were taken into consideration. For example, would, however, be necessary to give them
the investigators for the Main Study were due instructions for taking the necessary
sent out to establish contacts with the measurements, especially those concerning
parents. The work of checking the names the exact locations for measurements. The
of the children was given to the person who use of fibreglass tapes to take the measure-
had compiled the lists of parents and ments would facilitate this work as these
children and was thus familiar with the tapes are inelastic and therefore suitable
lists.
for taking accurate measurements. The
point made here is that equipment would
Although a large number of doctors had render the task of giving orientation to the
offered their voluntary services for the persons concerned, easier. Appropriate
present Assessment, a question arises: What instructions would again be necessary if the
could be the composition of the overall persons in charge of recording the readings
team in terms of the necessary qualifications on the Quac Stick are not familiar with this
for the different jobs? When the different technique. This would be true of doctors as
jobs are reviewed with this consideration well as the less qualified persons.

24
MANDAKINI KHANDEKAR AND PRATIBHA JOSHI
To ensure a smooth work-flow, it is
of Paediatritics which had agreed to
suggested that the whole team should be
conduct the Assessment. The sum paid
assembled well in advance of the assess-
was Rs. 2,000. As mentioned earlier,
ment and a couple of dummy work sessions
all the doctors who worked for the
— dry rehearsals, in other words — could
Assessment did so without any com-
be held so that everybody knows what to
pensation. That was the reason why
do at what time. The jobs to be done are
they worked only on Sundays.
easy and what needs to be ensured is proper
co-ordination.
(2) Transport
E — CONVEYANCE
(a) for visiting the various centres
prior to the Assessment for select-
While discussing the questions concerning
ing the centres.
the selection of the centre, it was men-
tioned that one of the considerations should
(b) for bringing some of the children
be its easy accessibility to those who would
and their escorts on the days of
be called upon to come to it. We pointed
Assessment and reaching them
out that when such easy accessibility could
home, and
not be ensured, we provided transport to
(c) for the staff on the days of the
the people both ways. It helped in increasing
Assessment.
the response to the Assessment.
Similar support also helps in assembling (3) Compensation to the service staff of
a large team for concerted work. Necessary
the co-operating agencies which had
transport arrangements are also required for
made their premises available to serve
carrying the equipment to the various
as centres for the Assessment.
centres in the field.
(4) Payment to the temporary staff engaged
by the Unit for informing the parents.
It was pointed out that the paediatricians
sometimes indicated X-Rays for some of (5) Payments to the temporary staff engaged
the children. In such cases it is better to
by the Unit for help in conducting the
transport such children and their parents to
Assessment.
the Hospital where X-Ray can be taken (6) Refreshments.
and thereafter back to their localities. It
was our experience that a part of the (7) Printing the schedule.
organizational success of our venture can (8) Contingencies.
be attributed to the fact that both the
Unit and the Nutrition Sub-committee had
good transport facilities at their disposal.
The total cost of conducting the Assess-
The utility of such transport in a big city ment at 12 centres, came to Rs. 4,918. The
like Bombay cannot be underestimated.
total number of children whose data were
F — COST
taken for final analysis was 1,576. Thus
The items of expenditure for conducting the cost per child came to Rs. 3.15.
the Nutritional Assessment described here
were as follows :
While we give the cost of conducting the
Assessment described here, the point can
(1) Token payment to the Indian Academy be made that these costs would very much

ASSESING NUTRITIONAL STATUS OF PRE-SCHOOL CHILDREN
25
depend on the local conditions. The different children. Such assessment will be necessary
types of personnel available, the rates of if large-scale programmes of distribution of
payment, costs of transport, etc. are all local nutritional supplements have to be organized
factors and will differ from place to place. as well as evaluated. The discussion is based
In this article, we have discussed some of on the experience gained through con-
the important aspects of organizing a large-
ducting such an assessment in Greater
scale nutritional assessment of pre-school Bombay in 1971.