Association of trends in child undernutrition and implementation of the National Rural Health Mission in India: A nationally representative serial cross-sectional study on data from 1992 to 2015.
Association of trends in child undernutrition and implementation of the National Rural Health Mission in India: A nationally representative serial cross-sectional study on data from 1992 to 2015.
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DOI：
10.1371/journal.pmed.1003957
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发表时间：
2022-04
期刊：
影响因子：
15.8
通讯作者：
Allison, Jeroan
中科院分区：
文献类型：
--
作者：
Soni, Apurv;Fahey, Nisha;Bhutta, Zulfiqar;Li, Wenjun;Moore Simas, Tiffany;Nimbalkar, Somashekhar;Allison, Jeroan
印度于 2005 年启动了国家农村卫生任务 (NRHM)，以加强其重点关注和东北重点邦的初级医疗保健系统。 NRHM 的目标之一是减少印度儿童营养不良的情况。我们使用 1992 年、1998 年、2005 年和 2015 年印度全国家庭健康调查 (NFHS) 的数据来评估 NRHM 前后以及不同类别重点邦的儿童营养不良患病率趋势。使用世界卫生组织 (WHO) 生长曲线评估发育迟缓、消瘦和人体测量失败综合指数 (CIAF)，以评估慢性、急性和总体营养不良。该研究包括 187,452 名 3 岁或以下儿童。调查加权和混杂因素调整的平均年化减少率（AARR）和预测概率比分别用于评估儿童营养不良的趋势和社会经济差异。在全国范围内，从 1992 年到 2015 年，所有类型的营养不良发生率均有所下降。然而，在 NRHM 实施前后，趋势有所不同，并且因重点州而异。 NRHM 后，急性营养不良在高关注状态下下降得更快（AARR 1.0%），但在正常关注状态下增加（每年 ARR -1.9%；差异 p 值<0.001）。相比之下，与高度关注状态（0.3%；差异 p 值 = 0.01）相比，正常关注状态下慢性营养不良的患病率下降得更快（AARR 1.6%）。实施 NRHM 后，急性营养不良中的收入和种姓差异有所减少，但并未消失。然而，实施 NRHM 后，慢性营养不良患病率的类似差异似乎进一步加剧。这项研究的主要局限性包括观察性和横截面设计，这妨碍了我们得出因果推论的能力。我们的结果表明，NRHM 的实施可能与营养不良的消瘦（急性）而不是发育迟缓（慢性）形式的改善有关。需要制定公平应对营养不良的战略，特别是在高度关注的州。 Apurv Soni 和同事在执行国家农村卫生任务期间研究印度儿童营养不良问题。印度是全球营养不良儿童数量最多的国家。印度政府启动了一项名为“国家农村健康使命”（NRHM）的公共卫生计划，重点是改善孕产妇和儿童健康。人们已经研究了 NRHM 对婴儿死亡率的影响，但全国范围内 NRHM 与儿童营养不良率之间关系的估计仍不清楚。我们根据 1992 年、1998 年、2005 年和 2015 年通过全国家庭健康调查 (NFHS) 收集的具有全国代表性的系列数据，对总共 187,452 名儿童进行了一项横断面研究，这些数据代表了各个调查年份居住在印度的 3 岁及以下儿童的全国人口。该研究报告称，不同营养不良指标的营养不良发生率及其实施前后的变化趋势有所不同。在优先考虑 NRHM 的州，消瘦（急性营养不良）发生率在后 NRHM 时期下降得更快，而在后 NRHM 期间未实施 NRHM 的州，急性营养不良的发生率有所增加。相反，与高度关注州和东北关注州相比，后 NRHM 时期正常关注州的发育迟缓（慢性营养不良）患病率下降速度更快。随着时间的推移，长期和总体营养不良的社会经济差距持续存在或扩大。我们观察到，实施 NRHM 后，严重营养不良的财富、孕产妇教育、农村和种姓差异有所下降。根据 NRHM 制定的政策可能与减少儿童急性营养不良有关。根据 NRHM 制定的政策可能与财富、教育或基于种姓的差距的适度减少有关，从而导致严重的儿童营养不良；然而，儿童慢性营养不良的差异与 NRHM 无关。
India launched the National Rural Health Mission (NRHM) in 2005 to strengthen its primary healthcare system in high-focus and northeast-focus states. One of the NRHM objectives was to reduce child undernutrition in India. We used data from 1992, 1998, 2005, and 2015 National Family Health Survey (NFHS) of India to evaluate trends in child undernutrition prevalence before and after NRHM and across different categories of focus states. Stunting, Wasting, and Comprehensive Index of Anthropometric Failure (CIAF) were assessed using the World Health Organization (WHO) growth curves to assess chronic, acute, and overall undernutrition. The study included 187,452 children aged 3 years or under. Survey-weighted and confounder-adjusted average annualized reduction rates (AARRs) and predicted probability ratios were used to assess trends and socioeconomic disparities for child undernutrition, respectively. Nationwide, the prevalence of all types of undernutrition decreased from 1992 to 2015. However, the trends varied before and after NRHM implementation and differentially by focus states. After NRHM, acute undernutrition declined more rapidly among high-focus states (AARR 1.0%) but increased in normal-focus states (AARR −1.9% per year; p-value for the difference <0.001). In contrast, the prevalence of chronic undernutrition declined more rapidly (AARR 1.6%) in the normal-focus states in comparison to high-focus states (0.3%; p-value for the difference = 0.01). Income and caste-based disparities in acute undernutrition decreased but did not disappear after the implementation of the NRHM. However, similar disparities in prevalence of chronic undernutrition appear to be exacerbated after the implementation of the NRHM. Major limitations of this study include the observational and cross-sectional design, which preclude our ability to draw causal inferences. Our results suggests that NRHM implementation might be associated with improvement in wasting (acute) rather than stunting (chronic) forms of undernutrition. Strategies to combat undernutrition equitably, especially in high-focus states, are needed. Apurv Soni and co-workers study child undernutrition in India during implementation of the National Rural Health Mission. India has the largest number of undernourished children of any country worldwide. India’s government launched a public health program called National Rural Health Mission (NRHM) that had a focus on improving maternal and child health. The impact of the NRHM has been studied on infant mortality rate, but nationwide estimates of association of NRHM with child undernutrition rates remains unelucidated. We carried out a cross-sectional study based on nationally representative serial data gathered through the National Family Health Survey (NFHS) in 1992, 1998, 2005, and 2015 on a total 187,452 children, which represented national population of children aged 3 years and under residing in India in the respective survey years. The study reports that the prevalence of undernutrition and trends in its changes before and after implementation of NRHM differed across different indicators of undernutrition. The prevalence of wasting (acute undernutrition) declined at a faster rate in the post-NRHM period among the states where NRHM was prioritized, while the prevalence of acute undernutrition increased during the post-NRHM where NRHM was not implemented. Conversely, prevalence of stunting (chronic undernutrition) declined at a faster rate among the normal-focus states in the post-NRHM period in comparison to high- and northeast-focus states. Socioeconomic disparities for chronic and overall undernutrition persisted or widened over time. We observed a decline in wealth, maternal education, rural, and caste-based disparities for acute undernutrition after the implementation of the NRHM. Policies enacted under the NRHM may be associated with a reduction in acute form of child undernutrition. Policies enacted under the NRHM may be associated with modest reduction in wealth, education, or caste-based disparities for acute form of child undernutrition; however, the disparities for chronic undernutrition among children were not associated by the NRHM.
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