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Title:
Maternal knowledge, attitudes and practices and health outcomes of their preschool-age children in urban and rural Karnataka, India
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Book
Language:
English
Creator:
Lloyd, Angela
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University of South Florida
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Subjects / Keywords:
Diarrhea
Acute respiratory infections
Nutrition
Anganwadi
Preschool
Dissertations, Academic -- Global Health -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: This cross-sectional, community-based study was designed to compare the health outcomes of 2 - 5 year-old children in different types of preschools. The Integrated Child Development Services (ICDS), run by the government of India, created a system of preschools, called anganwadis, to combat malnutrition, provide health education for mothers, and preschool for children 2 - 6 years old in 1975. Many children attend their local anganwadis, while others attend private schools, and others do not attend school at all. A pre-tested questionnaire was used to interview 125 urban and 130 rural mothers regarding their knowledge, attitudes, and practices about acute diarrheal disease (ADD), acute respiratory infections (ARI), and nutrition (practice only) as they pertained to their 2 - 5 year-old child. Two-week and four-week health recalls were obtained to determine which children had experienced diarrhea or ARIs during those time periods.Anthropometric measurements of the children (weight, height, upper-arm circumference) were collected whenever possible. The study was carried out in an urban slum rural villages surrounding in and surrounding Bangalore, India. Data was collected from March through May of 2009. Through data analysis, KAP and child health scores were calculated to compare four preschool types: anganwadis receiving health check-ups from a medical college, anganwadis not receiving the medical check- ups, other (non-anganwadi) preschools and children not attending preschool. Analyses were performed to identify gaps in KAP, determine the impact of KAP on nutritional status, determine the impact of KAP on ADD and ARI, and determine if preschool type influences KAP scores. Children not attending preschool of any type are at higher risk of ADD, ARI, and being underweight. These children have mothers with the lowest attitude scores.Mothers of children in other preschools have the highest percentage of good knowledge and practice scores. Children who attend other preschools also have the lowest prevalence of underweight. This information can be useful in designing interventions for specific populations.
Thesis:
Thesis (M.S.P.H.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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Statement of Responsibility:
by Angela Lloyd.
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Title from PDF of title page.
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Document formatted into pages; contains 182 pages.

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University of South Florida
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aleph - 002068279
oclc - 606599158
usfldc doi - E14-SFE0003118
usfldc handle - e14.3118
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Maternal Knowledge, Attitudes a nd Practices a nd Health Outcomes o f t heir Preschool Age Children i n Urban and Rural Karnataka, India b y Angela Lloyd A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Global Health College of Public Health University of South Florida Co Major Professor: Norbert Wagner, M.D., Ph.D. Co Major Professor: Boo Kwa, Ph.D. Committee Member: Ricardo Izurieta, M.D., Dr. P.H. Date of Approval: July 17, 2009 Keywords: diarrhea, acute respiratory inf ections, nutrition, anganwadi preschool India urban, rural Copyright 2009, Angela Lloyd

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Acknowledgements I would like to thank the faculty and staff of the Community Health Department at Joseph for arranging my project and stay in Bangalore and those of Dr. Dominic for his support and assistance throughout my data collection. Additionally, I appreciate the support, friendliness, and welcoming nature of all of the members of The Department. Thank you for taking me in as one of your own and making my stay in Bangalore so enjoyable. The data collection would not have been possible without the great efforts of Dr. of my questions, connecting me with the people needed to actually carry out the research, and for just looking out for me in general while in India. Sudha and Mohan Kumari worked long days in the heat to collect the data from the mothers and children. They have an obvious rapport with these communities and have my utmost respect and gratitude. I would also like to thank Dr. Kwa for providing guidance from the beginning of my time at USF. I appreciate you advising me over the last three years and putting me in contact with future thesis committee members. Dr. Izurieta has been a professor and a mentor over the last two years and I appreciate your posit ive attitude, encouraging nature, and guidance through the thesis process. Thank you for sharing your Global Health experiences and providing a glimpse of what my next career has in store. This project never would have taken place without the efforts of D r. Wagner. I cannot begin to express in words my gratitude for your investm ent of time and your gui dance from the beginning of this process I admire your teaching and advising style, professionalism, and understanding which allows an overwhelmed student to make it through this arduous process. I thank you for challenging me to broaden my horizons to experience a part of the world I may not have otherwise.

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I would also like to thank the founders of the Brenda Welling Scholarship and the USF College of Public Health for providing the funding which made this project possible. Finally, thank you to my family, friends, and co workers at the USF HIV Clinical have made i t though without you mil gracias for listening, encouraging, just being there, and for providing much needed distractions when you knew I needed them.

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i Table of Contents List of Tables ................................ ................................ ................................ ..................... iii List of Figures ................................ ................................ ................................ .................... vi List of Abbrevia tions ................................ ................................ ................................ ........ vii Abstract ................................ ................................ ................................ ............................ viii Chapter One ................................ ................................ ................................ ........................ 1 Introduction and Background ................................ ................................ .......................... 1 Research Question ................................ ................................ ................................ ....... 2 Literature Review ................................ ................................ ................................ ........ 2 National Health Situation in India ................................ ................................ ............... 6 CHAPTER TWO ................................ ................................ ................................ .............. 13 Study Design & Methods ................................ ................................ .............................. 13 Theory ................................ ................................ ................................ ........................ 13 Purpose of Study ................................ ................................ ................................ ........ 13 Study Design ................................ ................................ ................................ .............. 17 Methods ................................ ................................ ................................ ......................... 17 Organizational setting ................................ ................................ ................................ 17 Selection of Study Population ................................ ................................ ................... 18 Data Collection ................................ ................................ ................................ .......... 21 Data Analysis ................................ ................................ ................................ ............. 30 Ethical Considerations ................................ ................................ ............................... 31 CHAPTER THREE ................................ ................................ ................................ .......... 32 Results ................................ ................................ ................................ ........................... 32 Scores ................................ ................................ ................................ ......................... 36 ADD & ARI ................................ ................................ ................................ ............... 42

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ii Nutritional status ................................ ................................ ................................ ........ 43 Height for age. ................................ ................................ ................................ .......... 48 Weight for height. ................................ ................................ ................................ ..... 52 BMI for age. ................................ ................................ ................................ .............. 56 Mid upper arm circumference for age. ................................ ................................ ..... 61 Research Questions ................................ ................................ ................................ .... 66 CHAPTER FOUR ................................ ................................ ................................ ............. 84 Discussion ................................ ................................ ................................ ..................... 84 Limitations of Study. ................................ ................................ ................................ 84 Discussion of Results ................................ ................................ ................................ 84 Research Questions ................................ ................................ ................................ .... 87 Conclusion ................................ ................................ ................................ ................. 91 Appendices ................................ ................................ ................................ ........................ 96 Appendix 1: Area Maps ................................ ................................ ............................... 97 Appendix 2: Approval and Certification Letters ................................ ........................ 102 Appendix 3: Informed Consent Forms 16DEC2008 ................................ .................. 106 Appendix 4: Informed Consent Forms 01APR2009 ................................ .................. 122 Appendix 5: Questionnaire 27FEB2009 ................................ ................................ .... 138 Appendix 6: Questionnaire 01APR2009 ................................ ................................ .... 162

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iii L ist of Tables Table 1: Community Street Selection ................................ ................................ ............... 19 Table 2: Study Scores and Definitions ................................ ................................ .............. 24 Table 3: Demographic Variables ................................ ................................ ...................... 26 Table 4: Health Recall Variables ................................ ................................ ...................... 27 Table 5: Child Demographics, History and Measurement Variables .............................. 28 Table 6: Study Population ................................ ................................ ................................ 32 Table 7: Preschool Type ................................ ................................ ................................ 33 Table 8: Demographic Characteristics ................................ ................................ .............. 34 Table 9: Living Scores ................................ ................................ ................................ ...... 36 Table 10: Living Scores Percent Good by Preschool Type & Overall .......................... 37 Table 11: KAP Scores by Location ................................ ................................ .................. 37 Table 12: KAP Scores by Preschool Type ................................ ................................ ....... 38 Table 13: KAP Scores Percent Good by Preschool Type ................................ .............. 39 Table 14: Child Scores by Location ................................ ................................ .................. 40 Table 15: Child Scores by Preschool Type ................................ ................................ ...... 41 Table 16: Child Scores Percent Good by Preschool Type ................................ ............. 42 Table 17: Prevalence of ADD ................................ ................................ ........................... 43 Ta ble 18: Prevalence of ARI ................................ ................................ ............................. 43 Table 19: Weight for Age ................................ ................................ ................................ .. 44 Table 20: Weight for Age Urban ................................ ................................ ................... 45 Table 21: Weight for Age Rural ................................ ................................ .................... 45 Table 22: Weight for Age SJMC Anganwadi ................................ ............................... 46 Table 23: Weight for Age Non SJMC Anganwadi ................................ ....................... 46 Table 24: Weight for Age Other Preschool ................................ ................................ .... 47 Table 25: Weight for Age No Preschool ................................ ................................ ........ 47 Tabl e 26: Height for Age (Stunting) ................................ ................................ ................. 48

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iv Table 27: Height for Age Urban (stunting) ................................ ................................ .... 48 Table 28: Height for Age Rural (stunting) ................................ ................................ ..... 49 Table 29: Height for Age SJMC Anganwadi (stunting) ................................ ................ 49 Table 30: Height for Age Non SJMC Anganwadi (stunting) ................................ ....... 50 Table 31: Height for Age Other Preschool (stunting) ................................ ................... 51 Table 32: Height for Age No Preschool (stunting) ................................ ....................... 51 Table 3 3: Weight for Height (Wasting) ................................ ................................ ............ 52 Table 34: Weight for Height Urban (wasting) ................................ ............................... 53 Table 35: We ight for Height Rural (wasting) ................................ ................................ 53 Table 36: Weight for Height SJMC Anganwadi (wasting) ................................ ............ 54 Table 37: Weight for Heig ht Non SJMC Anganwadi (wasting) ................................ .... 55 Table 38: Weight for He ight Other Preschool (wasting) ................................ .............. 55 Table 39: Weight for Height No Preschool (wasting) ................................ ................... 56 Table 40: BMI for Age ................................ ................................ ................................ ..... 57 Table 41: BMI for Age Urban ................................ ................................ ........................ 57 Table 42: BMI for Age Rural ................................ ................................ ......................... 58 Table 43: BMI for Age SJMC Anganwadi ................................ ................................ .... 59 Table 44: BMI for Age Non SJMC Anganwadi ................................ ............................ 59 Table 45: BMI for Age Other Preschool ................................ ................................ ........ 6 0 Table 46: BMI for Age No Preschool ................................ ................................ ............ 61 Table 47: Mid Upper Arm Circumference for Age ................................ .......................... 62 Table 48: Mid Upper A rm Circumference for Age Urban ................................ ........... 62 Table 49: Mid Upper Arm Circumference for Age Rural ................................ ............. 63 Table 50: Mid Upper Arm Circumference for Age SJMC Ang anwadi ......................... 63 Tabl e 51: Mid Upper Arm Circumfere nce for Age Non SJMC Anganwadi ................ 64 Table 52: Mid Upper Arm Circum ference for Age Other Preschool ........................... 65 Table 53: Mid Upper Arm Cir cumference for Age No Preschool ................................ 65 Table 54: Knowledge vs. Practice vs. Attitude S cores Urban ................................ ...... 6 6 Table 55: Knowledge vs. Prac tice vs. Attitude Scores Rural ................................ ....... 67 Table 56: Knowledge vs. Practice vs. Attitude Scores SJMC Anganwadi .................. 67 Table 57: Knowledge vs. Practice vs. Attitude Scores Non SJMC Anganwadi ....... 68

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v Table 58: Knowledge vs. Practice vs. A ttitude Scores Other Preschool ....................... 68 Table 59: Knowledge vs. Practice vs. Attitude Scores No Preschool ........................... 69 Table 60: ADD Practice as an Outcome of ADD Knowledge Parameters ....................... 69 T able 61: ARI Practice as an Outcome of ARI Knowledge Parameters ........................... 70 Table 62: ADD Practice as an Outcome of ADD Attitude Parameters ............................ 71 Table 63: ARI Practice as an Outcome of ARI Attitude Parameters ................................ 72 Table 64: Nutritional Status as an Outcome of KAP ................................ ....................... 73 Table 65: Underweight Children by Preschool Type ................................ ...................... 73 Table 66: Nutrition al status as an Outcome of KAP by Preschool Type .......................... 74 T able 67: ADD as an Outcome of KAP and Location ................................ ..................... 75 Table 68: ARI as an Outcome of KAP ................................ ................................ ............ 77 Table 69: Child Health Score as an outcome of KAP Scores and Location .................... 79 Table 70: KAP Score Means Overall ................................ ................................ ............. 79 Table 71: KAP Score Means by Location ................................ ................................ ....... 80 Table 72: KAP Score Means by Preschool Type ................................ ............................. 8 0 Table 73: Good Scores Frequencies by Location and Preschool Type ........................ 81 Table 74: Good Knowledge Modeled as an Outcome ................................ ..................... 82 Table 75: Good Attitude Modeled as an Outcome ................................ .......................... 82 Table 76: Good Practice Modeled as an Outcome ................................ ........................... 83

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vi List of Figures Figure 1: Concept Map ................................ ................................ ................................ ..... 1 6

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vii List of Abbreviations ADD ................................ ............................... Acute diarrheal disease(s) ARI ................................ ................................ Acute respiratory infection(s) ICDS ................................ .............................. Integrated Child Development Services ICF ................................ ................................ Informed consent form IERB ................................ .............................. Institutional ethics review board IRB ................................ ................................ Institutional review board KAP ................................ ................................ Knowledge, attitudes and practices MDGs ................................ ............................. Millennium Development Goals ORS ................................ ................................ Oral rehydration solution ORT ................................ ................................ Oral reh ydration therapy SES ................................ ................................ Socio economic status SJMC ................................ .............................. USF ................................ ................................ University of South Florida WHO ................................ .............................. World Health Organization

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viii Maternal Knowledge, Attitudes, and Practices and Health Outcomes of their Preschool Age Children in Urban and Rural Karnataka, India Angela Lloyd Abstract This cross sectional, community based study was designed to compare the health outcomes of 2 5 year old children in different types of preschool s The Integrated Child Development Services (ICDS), run by the government of India, created a system of preschools, called anganwadis, to combat malnutrition, provide hea lth education for mothers, and preschool for children 2 6 years old in 1975 Many children attend their local anganwadis, while others attend private schools, and others do not attend school at all. A pre tested questionnaire was used to interview 125 urban and 130 rural mothers regarding their knowledge, at titudes, and practices about acute diarrheal disease (ADD) acute respiratory inf ections (ARI) and nutrition (practice only) as they pertained to their 2 5 year old child Two week and four week health recalls were obtained to determine which children had experienced diarrhea or ARIs during those time periods. Anthropometric measu rements of the children (weight, height, upper arm circumference) were collected whenever possible. The study was carried out in an urban slum rural villages surrounding in and surrounding Bangalore, India Data was collected fro m March through May of 2009 Through data analysis, KAP and child health scores were calculated to compare f our preschool types : anganwadis receiving health check ups from a medical college, anganwadis not receiving the medical check ups, other (non anganwadi) preschools and c hildren not attending preschool. Analyses were performed to identify gaps in KAP,

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ix determine the impact of KAP on nutritional status, determine the impact of KAP on ADD and ARI, and determine if preschool type influences KAP scores. Child ren not attendin g preschool of any type are at higher risk of ADD, ARI, and being underweight. These children have mothers with the lowest attitude scores. Mothers of children in other preschools have the highest percentage of good knowledge and practice scores. Childr en who attend other preschools also have the lowest prevalence of underweight. This information can be useful in designing interventions for specific populations.

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1 Chapter One Introduction and Backgrou nd Worldwide, mothers are charged with the task of feeding and providing care for their children, regardless of the environment or resources available to them. Quantity and quality of food, maternal knowledge of common infections and how they care for t being. Malnutrition as an outcome of poor resources and education is an important risk factor contributing to child mortality, particularly in developing countries. It is well documented in the literature that malnourished children are more susceptible to infectious diseases. (Muller & Krawinkel, 2005; Murray & Lopez, 1997; United Nations., n.d.) Acute respiratory infections (ARI) and acute diarrheal disease (ADD) cause 36% of all deaths among children under five years of age. Even more staggering, underlying approximately half of all child deaths is malnutrition. (Muller & Krawinkel, 2005) As primary care takers, mothers are charged with feeding a nd caring for their sick children, so their practices in these situations have important implications. M aternal knowledge, attitudes, and practices (KAP) regarding ARI, ADD and nutrition directly a ffect the care received by their children. Maternal educa tion has been found to have a positive influence on the knowledge, attitudes, and practices of mothers regarding ARI (Simiyu, Wafula, & Nduati, 2003) and use of oral rehydration therapy (ORT) (Shaw, Jacobsen, Konare, & Isa, 1990) This is more complex than knowledge alone, however, and cultural, socioeconomic and environmental factors must be considered as well.

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2 Research Question Given the multiple factors influencing maternal knowledge and care practices, this study investi gate s influences materna l care practices and b) differences among children in different types of preschools in terms of ADD, ARI and nutrition. Literature Review The literature reveals that, while the mothers may have correct knowledge, their accompanying practices are not always appro priate. (Simiyu, et al., 2003) K nowledge, attitudes and cultural beliefs underlying child care practices a nd some traditional home care practices can delay the seeking of medical care. Gaps between knowledge and practice in the treatment of childhood illness exist and need to be address ed in a culturally sensitive manner. (Kumar, Goel, Kalia, Swami, & Sing h, 2008; Rashid, Hadi, Afsana, & Begum, 2001) Prior Studies in India In conducting literature searches for this study, it was necessary to narrow the scope of the search significantly. It was discovered through many methodical searches in PubMed, BioMed Central, and Web of Knowledge that articles describing studies that to ok place in India (and published in Indian journals) are very difficult to obtain. Upon arrival in India, articles were obtained to provide more country specific background. The literature review involved two PubMed searches. One used the search terms: maternal knowledge, child health, preschool, and India. The second used the search terms: child health and anganwadi. They yielded 78 and 82 results, respectively. In a review of the titles and abstracts, article s were kept on the list if they: were published in 1990 or later (with the exception of one article from 1989); pertained to young children (2 6 years old rather than infants or school aged); involved diarrhea or acute respiratory infections; studied nutr

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3 considered health outcomes of the Integrated Child Development Services (ICDS) program. This title and abstract review brought the total num ber of eligible articles down to and 21 and 16, respectively. Next, all available articles were obtained from Florida Shimberg Health Sciences Library. More articles were re moved from the list upon obtaining and reading their abstracts (which were not previously available). Nine articles were not available from any source, narrowing the list to 24 articles. Further reading disqualified four additional articles as they did n ot relate significantly to this study. The final list consisted of 20 articles. Fourteen of the articles were Health Sciences Lirbrary and 7 from online sources. Twelve of the articles pertain to maternal KAP; diarrhea and/or acute respiratory infections in children; five pertain to ICDS; two to nutrition; and one to growth standards. The literature specifically related to India is consistent with the literature from the res t of the world in that mothers are the most important person in terms of child care, and ultimately, child health. As the primary caretakers, their responsibilities typically include feeding children, nursing them when they are ill, and maintaining a hygi enic environment in the home. Their level of knowledge regarding infections, nutrition, and hygiene is crucial to their corresponding practices which impact their (Bhatia, Swami, Bhatia & Bhatia, 1999; Datta, John, Singh, & Chaturvedi, 2001; M. C. Gupta, Mehrotra, Arora, & Saran, 1991; Kapoor, Reddaiah, & Murthy, 1990; Kaur, Chowdhury, & Kumar, 1994; Mangala, Gopinath, Narasimhamurthy, & Shivaram, 2001; Mangla, Gopinath, Narsimhamurthy, & Shivram, 2000; Saini, Gaur, Saini, & Lal, 1992; Saito, Korzenik, Jekel, & Bhattacharji, 1997; Sood & Kapil, 1990) While knowledge is necessary for the appropriate practice to follow, it is not sufficient enough to guarantee corresponding action will ensue. But, lower levels of knowledge lead to decreased levels of the desired practice. That is, without the knowledge the practice will most likely not occur, but having the knowledge does not guarantee that it will be applied

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4 correctly or at all. (Saini, et al., 1992; Sood & Kapil, 1990) For example, several studies asked mothers about their knowledge regarding oral rehydration solution (ORS). Many of the mothers had the knowledge that it was a liquid solution made with sugar and salt they should make at home for their children when suffering from diarrhea, but either did not know how to prepare it correctly or did not prepare it at all. (Bhatia, et al. 1999; Datta, et al., 2001; N. Gupta, Jain, Chawla, Hossain, & Venkatesh, 2007; Kaur, et al., 1994; Mangala, et al., 2001; Sood & Kapil, 1990) Maternal literacy and/or level of education are other factors significantly related to child health as measured by episodes or diarrhea, ARI, and nutritional status. Better practices are observed among mothers with higher literacy levels, translating into lower rates of infection for their respective children. (Bhatia, et al., 1999; Borooah, 2004; Datta, et al., 2001; M. C. Gupta, et al., 1991; Mangala, et al., 2001; Saito, et al., 1997; Singh, et al., 1992) This does not mean, however, that mothers with lower levels of education cannot increase their knowledge level, and in turn, i mprove their practices. Educational interventions can and do work to improve knowledge regarding matters such as p roper preparation and use of ORS increased feeding rather than food elimination, hand washing, and correct storage of drinking water, regard less of maternal literacy or educational level. (Bhatia, et al., 1999; Datta, et al., 2001; Mangala, et al., 2001) Mothers sometimes need multiple exposures to the information or reinforcement after a period of time to re emphasize the importance of certain practices. (Mangala, et al., 2001; Mangla, et al., 2000) Another factor playing an important role i n child health is socio economic status (SES of their family. (Bhatia, et al., 1999; Borooah, 2004; Datta, et al., 2001; Saito, et al., 1997; Sharma & Thakur, 1995; Singh, et al., 1992) ound to have a significant impact on (Saito, et al., 1997; Singh, et al., 1992) The Government of India recognized the myriad of factors contributing to increased rates of infection and widespread malnutrition decades ago. In 1975 they

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5 launched the largest maternal and child health program in the world called the Integrated Child Development Service (ICDS) (Ghosh, 1995; Kapil & Pradhan, 1999; B. N. Tandon, 1989; Trivedi, Chhaparwal, & Thora, 1995) The ICDS was designed to provide a package of services to address the issues of malnutrition, health of children under six years of age preschool and health services and education for mothers. (Ghosh, 1995; Kapil & Pradhan, 1999; Prinja, Thakur, & Bhatia, 2009; B. N. Tandon, 1989; Trivedi, et al., 1995) The eight key services offered through ICDS for pregnant and lactating women and/or children under 6 years old include: (a) supplementary feeding (bot h), (b) immunizations (both), (c) health check ups (both), (d) referrals (both), (e) health and nutrition education (mothers), (f) micronutrient supplementation (children), (g) growth monitoring (children), and (h) preschool (children). (Prinja, et al., 2009) These services strive to meet the program objectives, to: (a) improve the nutrition and health status of preschool children in the age group 0 6 years, (b) lay the foundation for proper psychological development of the child, (c) reduce the incidence of mortality, morbidity, malnutrition and school dropout, (d) achieve effective coordination of policy and implementation amongst the various departments to promote chi ld development, and (e) enhance the capability of the mother to look after the health and nutrition needs of the child through proper nutrition and health education. (Ghosh, 1995) ICDS realized overwhelming success in its early years. A significant decrease in severe (grade III and IV) malnutrition and a significant increase in grade I malnutrition and normal children who were beneficiaries of ICDS services. (Kapil & Pradhan, 1999; B. N. Tandon, 1989) There is debate, however, surrounding the on going and current success of the program. Studies comparing ICDS and non ICDS program areas publish conflicting result s. Groups of researchers evaluating the degree of malnutrition in ICDS and non ICDS program areas have concluded that ICDS groups have significantly lower proportions of grade III and IV malnutrition and higher proportions of grade I malnutrition and heal thy children. Other researchers conclude there is no statistically significant difference between the two

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6 groups regarding nutritional status of children. (Ghosh, 1995; Kapil & Pradhan, 1999; B. N. Tandon, 1989; M. Tandon & Kapil, 1998; Trivedi, et al., 1995) The synergistic relationship between malnutrition a nd infectious disease is well documented i n the literature Malnourished children are more susceptible to bouts of diarrhea and ARI. (Muller & Krawinkel, 2005; Murray & Lopez, 1997; United Nations., n.d.) These two conditions alone account for 36% of deaths among children under five years of age, 50% of whom are malnourished. (Muller & Krawinkel, 2005) Deficiencies in Previous Studies. As stated above, many studies have been conducted to measure the effectiveness of the ICDS system as compared to areas where these services are not available. (Ghosh, 1995; B. N. Tandon, 1989; Trivedi, et al., 1995) Anganwadi services are provided free of cost, and are not mandatory. Therefore, someone living in an anganwadi service area may choose to seek services, such as preschool elsewhere or none at all. This author did not find studies or other literature discussing health of children living in an anganwadi area but attending a different preschool or no preschool with the children attending the anganwadi. Therefore, one aim of this study is to compare maternal KAP and child health outcomes among children living in anganwadi service areas, but who may be seeking other types of preschools, or none at all. National Health Situation in India India Mothers caring for children in India are in a ch allenging position due to the overall context within which t hey are expected to provide such care. As the second most populous country in the world, India has over one billion people and is untry it stretches from the Himalayas to the tropics, covering an area of 3,287,263 km 2 (1,269,219 mi 2 ). Its diversity is reflected in the geography, people, social, economic, and health issues. India is made up of 28 states and 7 union territories, and is home to 114 languages and 216 dialects. (Oldenburg, 2009) In spite of the fact that India is ranked

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7 as the 10 th industrialized country in the world, was the 6 th to go to space, and has experienced a booming economy in recent years, poverty and health disp arities persist at extreme levels. (Murray & Lopez, 1997) India continues to face the problems of developing countries such as communicable diseases and maternal and child health issues; while at the same time struggling with issues more common in developed countries, such as an ageing population and non commun icable diseases. (World Health Organization., 2006a) rural settings. This dichotomy and its associated issues are not new for India. The Indian national government recognized the complex issue of malnutrition, childhood illness, and maternal care giving decades ago. To address the widespread problem of malnutrition and it s su bsequent effects, the ICDS program was launched in 1975. ICDS targets preschool children, providing them with nutritional supplements, informal preschool education, growth monitoring, as well as services for mothers, such as education and supporting wom (Embassy of India., n.d.) These services are provided within the community through preschools, known as anganwadis. (Ministry of Health and Family Welfare., 2007b) While this program is widespread and utilized by many mothers and children (but not all), the nutritional supplements provided through this progra m are not necessarily a consistent or sufficient source of sustenance for the children in the resource poor setting of rural India. Nation wide only 33% of children actually receive any kind of service and only 26% receive supplementary food. (Ministry of Health and Family Welfare., 2007b) In spite of this widespread program, in 200 5 children country wide are still stunted (38%), wasted (19%), and underweight (46%). (Ministry of Health and Family Welfare., 2007c) As of 2 005 i n the State of Karnataka, 38% of children are stunted, 18% are wasted, and 41% are underweight (Ministry of Health and Family Welfare., 2007a)

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8 With regard to the Millennium Development Goals (MDGs) India is making progress. The number of people living below the poverty line has decreased from 37.5% (1990) to 26.1% (2000). The number of undernourished people has been reduced from 62.2% (1990) to 53% (2000) and the proportion of undernourished chil dren has been reduced from 54.8% (1990) to 47% (2000). The adult literacy rate has increased from 64.3% (1990) to 73.3% (2001). Gains have also been made with respect to access to improved drinking water sources: 55.54% (1990) to 90% (2005) of the rural population and 81.38% (1990) to 82.94% (2001) in urban areas. Progress has been made regarding access to sanitation and hygiene as well: 9.48% (1991) to 32.36% (2005) in rural areas, and 47% (1991) to 63% (2001) in urban areas. Advancement is being mad e toward all MDG indicators. According to government sources the target for the proportion of people living in rural areas with access to improved water sources has been surpassed (achieved 90% in 2005, goal was 80.5% by 2015). (Government of India., 2005) In spite of this impressive official progress reports India still ranks 127 out of 177 countries in the Human Development Index. (World Health Organization., 2006c) India also lags behind countries in its own World Heal th Organization (WHO) region. It has a lower life expectancy for males an d females and a higher under 5 mortality rate and maternal mortality ratio than the WHO South East Asia regional average. (World Health Organization., 2006b) National Family Health Survey The third National Family Health Survey (NFHS 3) was conducted from November 2005 to August 2006 by the Ministry of Health and Family Welfare, Government of India The survey is extensive. A total of 198,754 men and women representative of national and state demographics were interviewed regarding household characteristics, education, fertility, family planning, infant and child mortality, child health, maternal health, adult health and health care, empowerment, and domestic violence. (Ministry of Health and Family Welfare., 2007b) The key indicators illustrate that progress has been made toward improved health of Indians nation wide but there have been set backs as we ll

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9 Household characteristics make up one section of the survey. Wealth is concentrated in the urban areas, but two thirds of the Indian population lives in rural areas. Over 90% of urban homes have electricity as compared to just over 50% of their rur al counterparts. Still, 55% of homes overall and 75% of rural homes do not have toilet facilities. In fact, a set back revealed by the household data is that fewer households have toilet facilities (64% to 55%) than seven years ago. Improved sources of drinking water are utilized by 88% of the population (95% urban, 85% rural), but 75% of homes do not have water piped directly into their home or plot of land. (Ministry of Health and Family Welfare., 2007b) Education data are collected as well. Education levels are low throughout the country, but particularly for women. Among adults aged 15 49, 41% of women and 18% of men have received no schooling. Of those who have been fortunate enough to receive an education, only 35% of men and 22% of women have co mpleted ten years of school. (Ministry of Health and Family Welfare., 2007b) Ch ild health indicators and outcomes make up another section of the survey. Improvements have been made in child health since NFHS 1 Vaccination coverage of children under two years old has improved overall and in the rural areas from NFHS 2 (1998 1999) t o NFHS 3. There was also improvement in the percentage of non vaccinated children (14% to 5%) and a marked progress in polio vaccine coverage (63% to 78%). Coverage for BCG vaccine improved slightly (72% to 78%), three doses of DPT remained unchanged (55 %), and measles vaccine coverage increased (51% to 59%). There have also been some set backs since NFHS 2 in that the percentage of fully vaccinated urban children has decreased (61% to 58%). (Ministry of Health and Family Welfare., 2007c) A two week health recall for children under 5 years was included in the survey. Six percent of these children experienced symptoms of acute respiratory infections (other than blocked or runny nose), 15% experienced fever, and 9% were reported to have had diarrhea during that time frame. Health facilities were utilized by caretakers of 69%, 71%, and 60% of these children, respectively. While 39% of the children who suffered from diarrhea received some sort of oral rehydration

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10 therapy (ORT), 25% received no treatment, 16% were given antibiotics (not recommended for children with diarrhea), and almost 40% of these children were given less to drink instead of more. (Ministry of Health and Family Welfare., 2007b) The ICDS continues to play an important role in child development and health. According to NFHS 3 data, 81% of Indian childr en less than six years old reside in areas in which anganwadi services are available. Of these children, 33% receive service(s) of some sort. Supplementary food is provided for 26% of these children, preschool to 23%, immunizations to 20%, and growth mon itoring for 18%. (Ministry of Health and Family Welfare., 2007b) Nutrition is a nother key section of the survey. are measured to calculate prevalence of wasting and stunting. Wasting indicates low weight for height and stunting indicates low height for age. (Ministry of Health and Family Welfare., 2007b) Advancement has been made in severe malnutrition and status overall since NFHS 1 (1992 1993). The percentage of children who are stunted and underweight has decreased. The percentage of wasted children, however, has increased (16% to 19%). (Ministry of Health and Family Welfare., 2007c) In spite of the overall improvement, approximately 50% of children under five years old are stunted, 20% are wasted, and 43% are underweight. Most children are breastfed, but it may not begin from birth, may not be exclusive for the first six months, and these children may be undernourished in the first six months of their life. (Ministry of Health and Family Welfare., 2007b) National Family Health Survey: Karnataka In the state of Karnataka, where this study was conducted, key indicator results tend to be better than the national averages, but it still ranks roughly in the middle when compared to the rest of the states. A representative sample of 6,008 women and 5,528 men aged 15 49 years old participated in the survey in Karnataka. Fo rty percent of the population lives in urban areas while 60% reside in rural areas. The majority of the population is Hindu (85%), followed by 10% Muslim and 3% Christian. Seventy five percent of men and 60% of women are literate (have attended school th rough the 6 th standard or more). Almost 40% of men and 28% of women have attended school for ten years or more, but

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11 unfortunately, 34% of women and 17% of men have never attended school. In Karnataka, fewer women are in the lowest quartile of education al status and more are in the highest quartile when compared to India as a whole. (Ministry of Health and Family Welfare., 2007a, 2007c) Living conditions are no t the worst in India. Overall, 55% of its people live in pucca houses and 97% of urban and 84% of rural inhabitants have electricity in their homes. The infrastructure for toilet facilities is not as widespread as 53% of Karnatakans have no toilet facili ty in their home, 78% of those being rural inhabitants. Drinking water is an issue as 33% drink water from a public tap or standpipe and only 26% have water piped directly to their home or plot (40% urban, 16% rural). Even though they may have to go out of their personal dwelling to obtain the water, 86% do have access to an improved source of drinking water (88% urban, 85% rural). Drinking water is treated by 43% of Kartakans: 19% strain the water through a cloth, 17% boil it, 12% use a filter, and 3% use another method of treatment. (Ministry of Health and Family Welfare., 2007a) range of India n states, but still only 55% of children 12 23 months are fully vaccinated against the six major childhood illness. In fact, the percentage of fully vaccinated children decreased from 60% in NFHS 2 and the other coverage rates have basically plateaued. T hese statistics are, however, still better than the country as a whole and most children are at least partially vaccinated. Those who are most likely to be fully vaccinated have mothers who are from urban areas, are more educated, and come from wealthier households. Two week health recalls revealed that among children under 5 years of age, 2% had experienced symptoms of acute respiratory infections (ARI) (not i ncluding blocked or runny nose) 13% had fever, and 9% suffered from diarrhea. Of these childre n 69%, 78%, and 66% were taken to a health center, respectively. Many of the mothers had knowledge of oral rehydration solution (ORS), but less than half actually provided it for their child when suffering from diarrhea. Only 10% of the children with dia rrhea received more liquid than usual, 55% actually received less

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12 liquid, and 23% received no treatment at all. (Ministry of Health and Family Welfare., 2007a) Breastfeeding is well practiced in Karnataka, but not necessarily done as is recommended by the WHO. Just over half (56%) of children are exclusively breastfed for si x months as per the guidelines and the average length of breastfeeding is 21 months, instead of the recommended 24. These practices often result in children being malnourished from a very young age, and contribute to 44% of children under 5 years being st unted, 18% wasted, and 38% underweight. Karnataka has a lower percentage of wasted and underweight children than India, but the number of stunted children is actually equal to that of the nation and has increased by 1% since NFHS 2. (Ministry of Health and Family W elfare., 2007a, 2007b) The government sponsored ICDS is widespread throughout Karnataka. In fact, 93% of children reside in areas where anganwadi services are available. Of these children, 36% receive some kind of service(s): 33% preschool, 28% suppl ementary food, 26% immunizations, 18% growth monitoring, and 17% receive health check ups. The anganwadis are more utilized in the rural areas and mothers with lower education and less wealth are more likely to take their children to anganwadis. (Ministry of Health and Family Welfare., 2007a) Like India, Karnataka is showing improvement in areas which impact the health of the population. Sustaine d progress is needed to continue to lessen the burden of the overwhelming health disparities and improve the quality of life for the Indian people. In sum, t he literature overwhelmingly supports the finding that maternal KAP is a determining factor in chi ld health in terms of diarrhea, ARI and nutritional status. There are conflicting results among researchers regarding differences in nutritional status between children in ICDS and non ICDS program areas. The NFHS 3 demonstrate s that child health is in n eed of continued and further improvement. Therefore this study aims to identify any differences that may exist in the health of children based on the type of preschool they attend, if any, and if this preschool scenario impacts maternal KAP.

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13 CHAPTER TWO Study Design & Methods Theory The theoretical perspective used in the development of this project and in the analysis of the collected data is t he Precaution Adoption Process Model (PAPM) framework. The PAPM identifies seven stages along the path f rom lack of awareness to action: unaware of issue, unengaged by issue, deciding about acting, decided to act, act, maintenance. (Karen Glanz, 2002; Weinstein & Sandman, 1992) Given the nature of the questionnaire bei ng utilized in this study, this theory provides a proper framework this project as it is related to KAP The questionnaire focuses on KAP of mothers rega rding ADD ARI, and nutrition for their children. A wareness that certain environmental factors, such as contaminated water and exposure to cigarette smoke, are harmful for children must exist (stages 1, knowledge). The mothers must then become engaged by and decide to act upon this knowledge (stages 2 4, attitude). Finally, in stages 5 7 the mother is acting upon the issue and possibly working her way to maintain this action (practice). The literature supports the finding that having knowledge does not automatically translate into a related practice. This framework provides a structure in which we may analyze how mothers proceed along the seven step continuum and how attitude (stages 2 4) may be a link between knowledge and practice. Purpose of Study This study used a cross sectional community based survey to identify deficits in maternal knowledge, attitudes, and practices (KAP) regarding nutrition, ADD,

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14 ARI, and their impact on child health, specifically the gap between knowledge and practi ce. These diseases are chosen as a proxy to "health impact" because of their major importance in morbidity and mortality of under five children, their p ossible home treatment by mothers and their two different transmission pathways (air and water/food). The study will utilize a maternal questionnaire and child growth outcomes to compare four groups: GROUP 1: Mothers of and children 2 5 years not attending preschool GROUP 2: Mothers of and children 2 5 years attending anganwadis not being serviced by SJ MC GROUP 3: Mothers of and children 2 5 years attending anganwadis receiving medical check GROUP 4: Mothers of and children 2 5 years attending any non anganwadi pre school The research questions gu iding this study are: 1. What are the gaps between maternal knowledge, attitudes, and practices regarding nutrition, ADD, and ARI for each of the four groups? 2. W hat is the impact of KAP on the anthropometric measurements of children for each of the four groups ? 3. What is the impact of KAP on the incidence and duration of ADD and ARI for each of the four groups? 4. care practices? The objectives of this study are: 1. To understand interactions and influencing factors which ultimately influence child health outcomes and anthropometric measurements. 2. To provide SJMC with specific information about the communities in which they work regarding maternal KAP and its impact on ARI, ADD,

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15 and nutrition. SJMC will be able to compare the results between serviced and non serviced populations. The concept map (Figure 1) illustrates the proposed relationships among study variables. Maternal KAP scores are influenced by living condit ions and SES, demographic characteristics of the mother, maternal education, and possibly their history score (breastfeeding and immunization status), and episodes of A DD and ARI. The episodes and duration of ADD and ARI are compiled to obtain the child health score.

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16 Figure 1 Concept Map MATERNAL KAP Living Conditions Score (environmental factors of home and SES) Demographic characteristics of mother ( i.e. age, religion,.) Education level of mother Preschool scenario of child ARI CHILD HEALTH OUTCOMES ADD Nutritional Status Child history score Child health score Figure 1. ADD=Acute diarrheal disease, ARI=Acute respiratory infections, KAP=knowledge, attitudes, practices The proposed causal pathway and relationships among study v ariables. Maternal KAP are influenced by living conditions score (comprised of environmental conditions and socio economic status (SES)), demographic characteristics, education level of the mother, and preschool scenario of the child. Maternal KAP are determining factors in child health outcomes: nutritional status, child history score (breastfeeding and immunization history), ARI, and diarrhea. Nutritional status and history also influence ARI and diarrhea episodes. Child health scores in this study are calcula ted based on the two week health recall of ARI and diarrhea. Legend Direct impact Influence

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17 Study Design This cross sectional commu nity based questionnaire was administered in both rural and urban communities being serviced by SJMC (chosen out of convenience). As SJMC does not pr ovide services in all community anganwadis (some children attend convent schools, and some children do not attend school), all four groups were reached by going door to door in rural and urban co mmunities. Data collection occur red for each intervention sc enario as outlined in the table below. The comparison of the four inte rvention scenarios is based on collection of quantitative data, including a structured maternal questionnaire, anthropometric measurements of the children (height, weight, upper arm cir cumference), and a 14 day and 30 odes (incidence and duration). Methods Organizational setting SJMC faculty members and post graduate students are actively involved in principal city, Bangalore. One example of these outreach efforts is performing medical check ups in anganwadis for approximately 110 children in rural and 50 60 anganwadis with medical check up services, they are not able to service them all. (Joseph, 2008) The impact (if any) of providing medical check ups for children in some anganwadis has not been compared to nearby anganwadis which they do not service. While anganwadis are available to all community members they serve, attendance is not mandatory and not all families participate. Some children attend convent (privat e) preschools, and others do not attend preschool at all. This study

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18 will provide the Department of Community Health with information regarding the health outcomes of children in the areas in which they work, based on their preschool scenario. Selection of Study P opulation The communities selected for the study were Medical College Department of Community Health works or has connection with the anganwadi teacher: an urban area called Lakshman Rao Nagar was selected for pilot te sting. A n urban area called Adugodi Bande Slum ( commonly referred to as Bande Slum) and the villages surrounding the SJMC rural health center in Mugalur were utilized for the main data collection. Sample Size Calculation Sample size was determined ba sed on the total population of the rural area in which SJMC works and NFHS 3 prevalence data. In rural areas surrounding the Mugalur Community Health Center, there are an estimated 1500 households with a total of approximately 5 50 children age 5 or under. A matching urban area was identified in the urban areas near SJMC in Bangalore. Sample size calculations are therefore based on a total population of approximately 550 rural children and 550 urban children, all age 5 or below. Results from the NFHS 3 i ndicate the following prevalence data in Karnataka (rural, urban): underweight (41.1%, 30.7%), wasting (18.2%, 16.5%), stunting (47.7%, 36.0%), diarrhea (8.4%, 9.0%), ARI (1.7%, 1.8%). (Ministry of Health and Family Welfare., 2007a) Given a 95% confidence level, and .05 confidence interval (ability to detect diarrhea within +/ 5% of the reference prevalence sample size estimates were calculated independently to determine what size sample would be needed to detect each of the growth and health outcomes (rural, urban): underweight (222, 205), wasting (162, 153), stunting (226, 216), diarrhea (98, 103) and acute respiratory infections (25, 26). Th e greatest sample siz e required is that for stunting, but this is not a primary outcome of the study. Therefore the sample size needed to detect diarrhea was selected: 98 child ren for the rural sample and 103 children for the urban

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19 sample. Given that th is is a door to door survey and mothers and children may not be home or interested in participating, oversampling of 10% ( 108 rural, 113) urban) will be added when randomly selecting ho mes to approach. Therefore, 108 rural children, 108 rural mothers, 113 urban children and 113 urban mothers will be targeted as participants of this study. Site Selection. Sites were selected from the SJMC service area. SJMC does a limited amount of work in each of three urban slums Bande Slum was selected for sampling a s SJMC has had a presence there for the longest of the three sites and the known to the community. SJMC Department of Community Health provides the majority of its services in a nd around a village called Mugalur. The entire service area is made up of 16 villages surrounding its Rural Health Center. Mugalur was chosen as the first village for data collection as it is the largest and receives the most services from SJMC. From th e list of the remaining villages six were identified in which SJMC does the most work and is therefore the most well known to the villagers. These six villages were assigned numbers and the numbers were then drawn to determine the order in which they woul d be sampled. Villages were sampled until the sample size of 130 mothers/children was reached. Three villages beyond Mugalur were sampled: Panditagaratha, Thiruvaranga, and Bagur. Household Select ion Following the Random Walk Method (Milligan, Njie, & Bennett, 2004) in both the urban and rural settings the approximate center of the community was determined and streets leading out from that point wer e numbered. The order in which the streets were sampled was determined by randomly drawing numbers from an envelope. Once the street number had been drawn a subsequent drawing was done to determine if the right or left side of the street would be surveye d first. All houses on each street were approached to inquire as to whether 2 5 year old (inclusive) children lived there and if so, if their mother was home and interested in participating in a study.

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20 Community Mapping. In the urban area, there was a n intersection approximately in the center of the community. The main road was divided at the point where the second street intersected it (See Appendix 1. Map: Bande Slum) The random selection of the streets determined that we proceed through the community in the following order (street, side): 3 right, 1 left, 3 left*, 1 right, 2 left, 2 right. The streets off the main road were not straight and often times there were houses behind one another. When this was the case, the house closest to the street was attempted first and then those behind it were attempted next. The same was true for any multiple story building: the apartment/home on the ground floor was approached first, then the second floor, followed by the third floor. In this manner, all houses which were accessible off of the side street were approached. After both sides of streets 1, 2, and 3 had been canvassed, it was realized that there was one section of the community which had not been reached via these streets. The remaining streets were thus numbered and the order in which they were approached th Cross left, 5 th Cross left, 5 th Cross right). All streets of the community were included in the study and a total of 125 questionnaires were completed. called Mugalur. Including Mugalur, there are sixt een villages surrounding the clinic. Mugalur and six others (Thattanur, Thiruvaranga, Bagur, Kuthaganahalli, Kogur, and village sampled was Mugalur (by convenience). The sub sequent villages were randomly selected to determine the order in which they would be included until the sample size was met (sample size was determined based on the population of Mugalur and the surrounding sixteen villages). Again, the approximate cente r of the village was determined and the streets from that point outward were numbered and the order in which they would be canvassed was randomly determined. The order as determined by random selection was as follows: Panditagrahara, Thiruvaranga, Bagur Thattanur, Kuthaganahalli, and Kogur. Only Panditagrahara, Thiruvaranga, and Bagur were necessary beyond Mugalur to obtain the required sample size. A

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21 total of 130 questionnaires were completed. The street selection for each village is described in Ta ble 1 below (R = right, L = left): Table 1 Community Street Selection Village Street Selection Mugalur Street 3 L, 4 R, 3 R, 1 R, 4 L, 1 L, 2 L, 2 R Panditagrahara Main Road L, Main Road R Thiruvaranga Street 1 L, 2 L, 4 R, 3 R Bagur Left side of village: Main Road L, Main Road R Right side of village: Street 3 R, 2 R, 2 L, 3 L, 1 L, 1 R Note. L =left side of street, R=right side of street. After Mugalur, villages were selected randomly and streets were assigned a random order for data collecti on. Rural village data collection outlined above. Participant Selection. Once the order of the streets had been determined, all streets and alleys in the urban and rural areas were canvassed and all homes were approached to find mothers of 2 5 year olds who were home and willing to participate in the study. Mothers were included in the study if they were 18 years or older and they had a 2 5 year old child. Children were included in the study if they were 2 5 years old and their mother was at home and willing to answer the questionnaire. Children were not included if they were under the care of anyone other than their mother. Data Collection Data w ere collected from each participant who signed the informed consent form (ICF). Pilot testing occurr ed from March 30 April 1, 2009. Urban data collection began on April 2, 2009, and rural data collection began on April 8, 2009.

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22 All data collection ended May 15, 2009. Data was collected by an SJMC social worker (SW) in the urban area and a community health worker (CHW) in the rural area. The SW spoke English and Kannada and the CHW spoke broken English and Kannada All questionnaires were administered in Kannada. In addition to the q uestionnaire, the mothers were asked to recall the incidence and duration (in days) of any ADD and/or ARI episodes experienced by their 2 5 year old child over the last 14 days and the last 30 days. Finally, measurem ents of the child were taken (before or after questionnaire). The SW /CHW read the questions as they are printed on the form so that all questionnaires are administered in a uniform fashion. It could be administered orally, the mother may have read it herself, or a combination of the two methods was used. The SW/CHW recor ded all answers on the questionnaire form. Questionnaire Development and Design. The questionnaire was developed based on reference questionnaires: NFHS (International Institute for Population Sciences., 2005) and the NFHS 2 Household Questionnaire (International Institute for Population Sciences., 1998) Questions pertaining to such as toilet facility and w ater source were either used verbatim or adapted. The original questionnaire contained questions to collect information regarding demographic information; environmental/living conditions; maternal KAP regarding ADD, ARI, and nutrition; and child ADD, ARI and school information. The questionnaire was reviewed by faculty members at SJMC Department of Community Health. Feedback regarding wording, cultural appropriateness (in the specific study area) was incorporated, as were additional questions regarding child history of breast feeding and immunization status. After pilot testing, nutrition knowledge and attitude sections were removed entirely for the sake of time, questions and answers which were confusing were adapted or thrown out. The final version o f the questionnaire asks 64 questions,

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23 many of which are multi part and collects height, weight and mid upper arm circumference for one child. Pilot Testing. An urban area fairly similar to the one to be used for study data collection was selected for p ilot testing Lakshman Rao Nagar Slum After the area had been mapped and the fist street randomly selected, the anganwadi teacher accompanied us the SW and principal investigator (PI) to the first house to introduce us and explain our purpose for being t here. Pilot testing occurred over three days, March 30 April 1, 2009. Three questionnaires were completed on each of the first two days. They took approximately one h our each. Based on feedback from the SW administering the questionnaire and feedback from the participants, sections were removed for the sake of brevity, and three questions were marked for revision. On day three, a shortened version of the questionnaire was utilized. There were no wording changes, simply omission of questions. The sh ortened version of the questionnaire took 30 40 minutes was better received by the study participants. Measurements. Measurements of the children were taken if they were home, the mother (and father if home) agreed for their child to participate, and the child was cooperative. The height was taken against the wall in the home. The children were asked and positioned such that their heels were against the wall, they were standing up straight, and their chin was in a neutral position (neither up nor down). A The distance from the mark on the wall down to the floor was measured with a measuring tape to the nearest 0.5 centimeter. Mid upper arm circumference was taken usin g the same measuring tape. The shoulder and the elbow was determined. This point was then measured so the measuring tape was flat against the skin, but not so tight that the skin bulged out from the sides of the measuring tape. The mid upper arm circumference was measured to the nearest millimeter.

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24 Weight was taken using scales regularly used by the Community Health standardized bathroom weighing scale was utilized (scale is calibrated by the Department once a month). It was checked before each child to ensure that is was zeroed before the child stepped onto the scale. A Salter scale (Model 235) was used in the rur al area. This scaled required that there be a place to hang the scale and that the child be willing to sit in the harness to be weighed. In both cases, weight was measured to the nearest 0.5 kilogram. Variables In order to compare KAP and child health, score variables were created based on the respons es to the questionnaire. Table 2 below defines each of the scores based on the questions from which it is determined. Table 2 Study Scores and Definitions Score Definition Living Conditions Sum of points earned from questions regarding living condition/environmental information: type of house, if the family owns or rents, kitchen a separate room/same room, cooking fuel, light source, water source, toilet facilities Knowledge ADD knowledge score + ARI knowledge score; ADD knowledge score=total number of points earned from ADD knowledge questions; ARI knowledge score=total number of points earned from ARI knowledge questions

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25 Attitude ADD attitude score + ARI attitude score; ADD attitude score=total number of points earned from ADD attitude questions; ARI attitude score=total number of points earned from ARI attitude questions Practice ADD practice score + ARI practice score + nutrition practice score; ADD practice score=total number of points earne d from ADD practice questions, ARI practice score=total number of points earned from ARI practice questions, nutrition practice score=total number of points earned from nutrition practice questions Child health Sum of points earned from two week and four week recalls of ADD and ARI and the duration of each; lower score indicates better health Child history Sum of points earned from immunization history (full, partial, none), whether the immunization record could be verified (versus verbal confirmatio n), and breastfeeding (from none at all to breastfeeding for one year, takes into account weaning food as well) Table 1. Defines the study scores as they will be used in data analysis. Note ADD = acute diarrheal disease, ARI = acute respiratory infect ion, SES = socio economic status

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26 Data were collected which was not compiled into scores. This includes demographic information of the mother, schooling information of the child, and child anthropometric measurements. Table 3 list s the demographic and school information variables. Table 3 Demographic Variables Demographic Variables Type School Information Variables Type Age Categorical Type of preschool Categorical Religion Categorical Length of attendance Categorical Work (mother) Categorical Food received from preschool (frequency) Categorical Work type (mother) Categorical Health check up from preschool Categorical Frequency of work (mother) Categorical Weight measured at school Categorical Work type (father) Categorical Counseling received by mother from preschool Categorical

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27 Total number of children Numerical (discrete) Child immunization on schedule Categorical Number of 2 5 year olds Numerical (discrete) Verification of immunization status Categorical Education level (mother) Categorical Reading frequency Categorical Table 4 lists the health recal l variables used to calculate the child health score. This is a compilation of ADD and ARI (two and four week health recalls) and duration of the episode. Table 4 Health Recall Variables Health recall Type Health recall Type ADD in last 2 weeks Categorical ARI in last 2 weeks Categorical If ADD, duration Categorical If ARI, duration Categorical If ADD, treatment Categorical If ARI, treatment Categorical

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28 ADD in last 4 weeks (without duplicate reporting from 2 week recall) Categorical ARI in last 4 weeks (without duplicate reporting from 2 week recall) Categorical If ADD, duration Categorical If ARI, duration Categorical If ADD, treatment C ategorical If ARI, treatment C ategorical Table 5 lists child history and anthropometric measurement variables (used to calculate nutritional status) Table 5 Child Demographics, History and Measurement Variables Child history variables Type Anthropometric measurements Type Breastfeeding history Categorical Height Continuous Birth weight C ategorical Weight Continuous Birth weight verified with record Categorical Mid upper arm circumference Continuous

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29 Child Demographics Variable Type Variable Type Gender Categorical Age Continuous Data Security and Entry. All forms were placed in an opaque envelope upon completion so as not to reveal the names of any study participants while traveling from house to house. The answers indicated by the mother and child measurements were recorded on the questionnaire itself. All answers were then entered into an Excel spreadsheet etc.) For questions requiring or allowing for an explanation, the recorded answer was entered verbatim into the spreadsheet. All measurements were entered according to the nearest 0.5 cm for height, 0.5 kg for weight, and the nearest millimeter for uppe r arm circumference. Data were entered onto a password protected laptop and backed up on an external hard drive each time questionnaires were entered. For travel purposes, the data was also backed up on a CD. Data Quality Control All data was double c hecked for accuracy. Of the 125 questionnaires which were completed in the urban area, 77 were found to be entered correctly, 6 were changed for minor/editorial reasons (i.e. height recorded to the nearest mm and entered this way originally, but edited to be rounded to the nearest 0.5 cm), 5 were updated to include a question which had not been entered as a part of the original data entry, 25 were found to have 1 data entry error, 4 were found to have 2 data entry errors, 7 were found to have 3 or more dat a entry errors, and 1 was determined to be unusable as many questions had been left blank or changed many times as the child was special needs and the mother had a difficult time answering the questions. In a review of the rural data entry, 97 were found to have no data entry

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30 errors, 3 had minor editorial changes made, 22 had 1 error, 4 had 2 data errors, 3 had 3 or more errors, and 1 questionnaire was not available to be checked. Data Analysis Data Cleaning. Raw data were entered into an Excel spreadshe et exactly as it was recorded on the questionnaire. From there a copy was made and data was cleaned. All missing answers were coded with zero as well as any questions containing two answers. An additional spreadsheet was made which contained only catego rical and numerical data (no explanations for jobs or home treatment of ADD/ARI). Each version of the data has been saved and previous versions have not been discarded. Handling of Missing Values. If missing answers were found upon data entry, the home was revisited at a later date. Approximately 40 homes each were revisited in the urban and rural areas. Any data which was unable to be obtained was entered in as zero, or missing. The statistical software, SAS 9.2, is able to handle data with missing variables. The program will process all variables for each observation that are present; it is not necessary to delete a participant entirely due to missing data. Definition and Calculation of Scores Scores were compiled based on the answers to the questionnaire. For mothers, 11 scores were calculated: living (living conditions/SES); knowledge ARI, diarrhea; attitude ARI, diarrhea; practice ARI, diarrhea, nutrition; and overall knowledge, at titude and practice scores. Two scores were calculated for the children: child history and child health. A point value nswers. Higher scores indicated better c onditions or better skills, with one exception; a lower chi ld health score indicated fewer episodes of ARI and/or ADD Raw scores were then d to score 70% or more of the available points beyond the minimum to be categorized as good.

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31 Statistical Methods. Various statistical methods are used in data analysis. Chi square statistics, means and frequencies, logistic regression, and multiple regression, depending on the type of variable and the desired outcome. The tables below indicate which statistical method is used for each model. Ethical Considerations Oversight The study protocol, methods, informed consent form, and survey instrument were approved by both the IRB of USF and also the IERB of SJMC Informed Consent. Mothers who were 18 years and older were asked if they would like to volunteer to participate in the study. If they agreed, the Social Worker (SW) or Community Health Work er (CHW) provided the mother with the informed consent form (ICF), explained the procedures of the study, and ensured that the mothers understood that this was a research study, they were going to be asked approximately 70 questions. Additionally, consent was obtained from the mother and circumference) to be taken. Upon obtaining informed consent from the mother for her participation as well as the participation of her ch ild, the tracking form was completed to record their names and address, the questionnaire administered and the were taken. (The questionnaire and measurements were done in the order and place most convenient for that mother and child, but after the ICF has been signed and the tracking form completed.)

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32 CHAPTER THREE Results A total of 244 questionnaires were eligible for data analysis. The questionnaire was comprised of 113 individual questions to gather information about practices regarding diarrhea and ARI; and practices regarding nutrition. Other questions pertained to their 2 5 year old child: schooling information, two and four week r ecalls of ADD and ARI incidence, and medical history questions regarding weight, upper arm circumference) were taken whenever possible. The tables below illustrate the overa ll breakdown of the study population by location and preschool type. Table 6 Study Population (N=244) Location Mothers Male children Female children Urban 124 60 64 Rural 120 61 59

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33 Table 7 Preschool Type (N=244) Location SJMC Anganwadi Non SJMC anganwadi Other Preschool None Urban 0 32 30 62 Rural 53 24 25 18 Note. ups; Non SJMC = SJMC does not provide health check ups. Demographics. Mothers involved in the study lived in a low income area of Bangalore or in a village nearby the SJMC Rural Health Center in Mugalur. The age distribution was younger in the rural area as 43% of mothers were 18 23 years and 30% of urban mothers were in the same age range. Hindism is the prominent religion in both areas (72% urban, 96% rural). Twenty percent of urban mothers work and 13% of rural mothers work. Domestic work for others is the most prominent job class for urban mothers (15%), and for rur al mothers, daily labor (11%). Nineteen percent of urban working mothers work four days or more and 10% of rural working mothers work four days a week or more. Eighty nine percent of urban fathers work at jobs other than agriculture and daily labor. Fif ty three percent of rural fathers work in agriculture on their own land and 27% perform daily labor. Most urban and rural families had two or three children (69% urban, 77% rural) and 24% of urban families had two 2 5 year olds at home as compared to 4% of rural families. Education level is lower in the urban area with 83% of mothers having completed the 6th standard or more, while 95% or rural mothers have completed 6 th standard or higher. Twenty one percent of urban mothers have no formal education a nd 12% of rural mothers are uneducated. Reading frequency is higher in urban areas. Fifty seven percent of urban mothers and 3% of rural mothers read dai ly or weekly. Table 8 provides further detail regarding demographic characteristics of the study pop ulation.

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34 Table 8 Demographic Characteristics Characteristic Urban n=124 Rural n=120 Age 18 23 years 24 29 years 30+ years 37 (29.84) 51 (42.50) 62 (50) 57 (47.50) 25 (20.17) 12 (10) Religion Hindu Muslim Christian Other 89 (71.77) 115 (95.83) 28 (22.58) 5 (4.17) 6 (4.84) 0 (0) 1 (.81) 0 (0) Mother work Yes No 25 (20.16) 16 (13.33) 99 (79.84) 104 (86.67) Mother type of work Domestic (for others) Agriculture (own land) Daily based labor Other n/a (n=119) 19 (15.32) 0 z90z0 0 (0) 2 (1.68) 0 (0) 11 (9.24) 9 (7.26) 96 (77.4 2) 0 (0) 4 (3.36) 102 (85.71) 0 (0)

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35 Mother frequency of work 4+ days/week 2 3 days/week 1 day/week N/A, no answer 23 (18.55) 12 (10) 0 (0) 5 (4.17) 101 (81.45) 103 (85.83) Father work type Agriculture (own land) Daily based labor Other N/A, no answer ( n=123 ) (n=117) 0 (0) 62 (52.99) 12 (9.76) 32 (27.35) 109 (88.62) 2 (1.63) 16 (13.68) 3 (2.56) Total children in home 1 2 3 4+ 32 (25.81) 25 (20.83) 86 (69.36) 92 (76.67) 6 (4.84) 3 (2.5) Total 2 5 year olds 1 2 94 (75.81) 115 (95.83) 30 (24.19) 5 (4.17) Education level (mother -(standard completed) 6 th + 1 st 5 th None 83 (66.94) 95 (79.17) 20 (16.13) 13 (10.83) 21 (16.94) 12 (10)

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36 Reading frequenc Daily 37 (29.84) 1 (.83) Weekly 34 (27.42) 2 (1.67) Monthly 13 (10.48) 47 (39.17) Never No answer 37 (29.84) 3 (2.42) 70 (58.33) 0 (0) Note. Values enclosed in parenthesis represent percent of total of mothers in that location. Scores Points were awarded for each answer on the questionnaire. With the points. Scores are calculated as continuous numerical variables and then converted into the categorical var the points available beyond the minimum were obtained. Living conditions/SES Living conditions and SES are determined by the living score. The mean living score is higher in the urban area an d there is a wider range of scores in the rural area. Table 9 outlines the range and means of the living score according to location. Table 9 Living Scores Score & location Range Mean Living Overall (n=244) Urban (n=124) Rural (n=120) 13 35 21 35 13 35 27.1 29.64 24.48 Note Available range 8 36.

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37 Table 10 Living Scores Percent Good by Preschool Type & Overall Good Overall n=244 Urban n=124 Rural n=120 SJMC n=53 Non SJMC n=56 Other n=55 No preschool n=80 Living score 128 (52.46) 93 (75) 35 (29) 20 (37.74) 26 (46.43) 35 (63.64) 47 (58.75) Note. Good = 70% of points possible beyond minimum. SJMC = ups, non SJMC = ups. Values enclosed in parenthesis represent percen t of total of mothers in that school type category. Maternal scores. Knowledge, attitude and practice scores are calculated for the mothers. The range and mean for each score according to location are listed in Table 11. The range and mean for each sc ore according to preschool type are listed in Table 12. Table 11 KAP Scores by Location Score & location Range Mean Knowledge Overall (n=244) Urban (n=124) Rural (n=120) 23 38 23.5 38 23 36.5 32.38 32.42 32.34 Attitude Overall (n=244) Urban (n=124) Rural (n=120) 6.2 28.2 6.2 28.2 19.7 25.6 22.17 19.83 24.59

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38 Practice Overall (n=238) Urban (n=118) Rural (n=120) 28.2 55.8 30.2 55.4 28.2 55.8 44.87 45.31 44.44 Note KAP = Knowledge, attitudes, and practices. SJMC = St. check ups, Non does not provide health check ups. Possible range knowledge score = 15.5 35, attitude score 6 30, practice 11.6 60. Table 12 KAP Scores by Preschool Type Score & location Range Mean Knowledge SJMC (n=53) Non SJMC (n=56) Other (n=55) None (n=80) 23 35.5 24 38 23.5 37 24 37 32.01 32.46 32.92 32.21 Attitude SJMC (n=53) Non SJMC (n=56) Other (n=55) None (n=80) 19.7 25.3 6.3 28.2 9.9 27.3 6.2 28.2 24.65 21.95 23.06 20.07

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39 Practice SJMC (n=53) Non SJMC (n=54) Other (n=52) None (n=79) 28.2 55.8 33 55.4 29.4 55.6 30.2 54.5 44.31 44.89 45.92 44.54 Note. KAP = Knowledge, attitudes, and practices. SJMC provides health check ups, Non provide health check ups. Possible range knowledge score = 15.5 40, attitude score 6 30, practice 11.6 60. Table 13 KAP Scores Percent Good by Preschool Type Score Good Overall n=244 Urban n=124 Rural n=120 SJMC n=53 Non SJMC n=56 Other preschool n=55 No preschool n=80 Knowledge 106 (43.44) 57 (45.97) 49 (40.83) 21 (36.8) 22 (39.3) 30 (52.6) 37 (43.5) Attitude 160 (65.57) 57 (45.97) 103 (85.83) 47 (82.5) 39 (69.6) 36 (63.2) 44 (51.7) Practice 104 (42.62) 59 (47.58) 45 (37.50 23 (40.4) 17 (30.4) 33 (57.9) 35 (41.2) Note. KAP = Knowledge, attitudes and practices. SJMC = Anganwadi where Medical College provides health check ups, Non SJMC = Anganwadi where Medical College does not provide health check ups. Good = minimum. Values enclosed in parenthesis represent perc ent o f total.

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40 scores. Child history scores are comprised of breastfeeding history and immunization status. Child health scores are comprised of two and four week incidence and du ration of ADD and/or ARI. A lower score indicates better health for the child. Table 14 Child Scores by Location Score & location Range Mean Child history Overall (n=244) Urban (n=124) Rural (n=120) 2 20 2 20 5 20 14.21 15.11 13.28 Child health a Overall (n=231) Urban (n=117) Rural (n=114) 8 36 8 22 8 36 10.49 10.22 10.76 Note Child history range available = 5 25. Child health range available = 8 40) Incomplete data results in an actual range lower than allowed. a Lower score indicate better health

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41 Table 15 Child Scores by Preschool Type Score & location Range Mean Child history score SJMC (n=53) Non SJMC (n=56) Other (n=55) None (n=80) 5 18 6 20 6 20 2 20 12.94 14.59 14.91 14.3 Child health a SJMC (n=50) Non SJMC (n=52) Other (n=54) None (n=75) 8 25 8 24 8 36 8 24 10.92 9.88 9.87 11.07 Note SJMC = Anganwadi where College provides health check ups, Non SJMC = Anganwadi where provide health check ups. Child history range available = 5 25. Child health range available = 8 40) a Lower score indicate better health

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42 Table 16 Child Scores Percent Good by Preschool Type Score Good Overall Urban Rural SJMC Non SJMC Other preschool No preschool Child history 0 n=240 0 n=120 0 n=120 0 n=53 0 n=56 0 n=55 0 n=76 Child health a 224 (91.8) n=244 117 (94.35) n=124 107 (89.17) n=120 46 (86.79) n=53 54 (96.43) n=56 52 (94.55) n=55 72 (90) n=80 Note. College provides health check ups, Non SJMC = ups. Good = child history, which is Val ues enclosed in parenthesis represent percent of total of mothers in that school type category. a Lower score indicates better health ADD & ARI Mothers were asked to recall episodes of ADD and ARI for their child for the last two weeks. Tables 17 18 display the incidence of ADD and ARI overall, by location (urban vs. rural), and by preschool type.

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43 Table 17 Prevalence of ADD ADD prevalence Overall Urban Rural SJMC Non SJMC Other preschool No preschool 32/244 (13.11) 21/124 (16.9) 11/120 (9.17) 3/53 (5.66) 6/56 (10.71) 3/55 (5.45) 20/80 (25) Note. health check ups, non check ups. Number in parenthesis ( ) is incidence rate. Based on two week recall provided by moth ers. Table 18 Prevalence of ARI ARI incidence Overall Urban Rural SJMC Non SJMC Other preschool No preschool 40/244 (16.39) 16/124 (12.9) 24/120 (20) 12/53 (22.64) 8/56 (14.29) 7/55 (12.73) 13/80 (16.25) provides health check ups, non health check ups. Number in parenthesis ( ) is incidence rate. Based on two week recall provide d by mothers Nutritional status calculated in terms of z scores for weight for age, height for age, weight for height, BMI for age, and mid upper arm circumference for age.

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44 Weight for age. Z scores are calculated for weight for age. Z scores < 2 standard deviations f rom the mean indicate the child is underweight. Z scores < 3 SD indicate the child is severely underweight. Table 19 Weight for Age Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 0 60 208 8.2 (4.2, 12.1) 29.3 (22.9, 35.8) 1.44 1.04 24 35 73 8.2 (1.2, 15.2) 26.0 (15.3, 36.8) 1.19 1.18 36 47 69 7.2 (0.4, 14.1) 27.5 (16.3, 38.8) 1.43 0.98 48 60 66 9.1 (1.4, 16.8) 34.8 (22.6, 47.1) 1.72 0.88 5 years 24 16.7 (0.0, 33.7) 41.7 (19.9, 63.5) 2.08 0.78 Note. < 2 SD is underweight, < 3 SD is severely underweight.

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45 Table 20 Weight for Age -Urban Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 0 60 94 8.5 (2.3, 14.7) 28.7 (19.0, 38.4) 1.49 1.00 24 35 35 5.7 (0.0, 14.8) 22.9 (7.5, 38.2) 1.15 1.11 36 47 27 14.8 (0.0, 30.1) 33.3 (13.7, 53.0) 1.69 0.91 48 60 32 6.3 (0.0, 16.2) 31.3 (13.6, 48.9) 1.70 0.85 5 years 21 19.0 (0.0, 38.2) 42.9 (19.3, 66.4) 2.18 0.70 Note. < 2 SD is underweight, < 3 SD is severely underweight. Table 21 Weight for Age -Rural Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 0 60 114 7.9 (2.5, 13.3) 29.8 (21.0, 38.7) 1.39 1.08 24 35 38 10.5 (0.0, 21.6) 28.9 (13.2, 44.7) 1.22 1.25 36 47 42 2.4 (0.0, 8.2) 23.8 (9.7, 37.9) 1.26 1.01 48 60 34 11.8 (0.0, 24.1) 38.2 (20.4, 56.0) 1.74 0.92 5 years 3 0.0 (0.0, 16.7) 33.3 (0.0, 100.0) 1.38 1.16 Note. < 2 SD is underweight, < 3 SD is severely underweight.

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46 Table 22 Weight for Age SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 51 5.9 (0.0, 13.3) 33.3 (19.4, 47.3) 1.38 1.05 24 35 20 5.0 (0.0, 17.1) 30.0 (7.4, 52.6) 1.15 1.17 36 47 21 0.0 (0.0, 2.4) 28.6 (6.9, 50.3) 1.30 0.90 48 60 10 20.0 (0.0, 49.8) 50.0 (14.0, 86.0) 2.01 0.91 5 years 0 ----Note. ups < 2 SD is underweight, < 3 SD is severely underweight. Table 23 Weight for Age Non SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 49 8.2 (0.0, 16.9) 28.6 (14.9, 42.2) 1.45 1.07 24 35 13 15.4 (0.0, 38.8) 15.4 (0.0, 38.8) 0.90 1.22 36 47 15 0.0 (0.0, 3.3) 6.7 (0.0, 22.6) 1.11 0.77 48 60 21 9.5 (0.0, 24.5) 52.4 (28.6, 76.1) 2.04 0.90 5 years 7 28.6 (0.0, 69.2) 28.6 (0.0, 69.2) 2.15 0.88 Note. Non ups. < 2 SD is underweight, < 3 SD is severely underweight.

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47 Table 24 Weight for Age Other Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 45 6.7 (0.0, 15.1) 20.0 (7.2, 32.8) 1.30 0.93 24 35 7 0.0 (0.0, 7.1) 14.3 (0.0, 47.4) 1.15 1.06 36 47 16 6.3 (0.0, 21.2) 18.8 (0.0, 41.0) 1.20 0.94 48 60 22 9.1 (0.0, 23.4) 22.7 (2.9, 42.5) 1.42 0.92 5 years 9 11.1 (0.0, 37.2) 44.4 (6.4, 82.5) 1.84 0.82 Note. < 2 SD is underweight, < 3 SD is severely underweight. Table 25 Weight for Age No Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 63 11.1 (2.6, 19.7) 33.3 (20.9, 45.8) 1.57 1.10 24 35 33 9.1 (0.0, 20.4) 30.3 (13.1, 47.5) 1.33 1.21 36 47 17 23.5 (0.4, 46.6) 52.9 (26.3, 79.6) 2.08 1.07 48 60 13 0.0 (0.0, 3.8) 15.4 (0.0, 38.8) 1.50 0.56 5 years 8 12.5 (0.0, 41.7) 50.0 (9.1, 90.9) 2.29 0.67 Note. < 2 SD is underweight, < 3 SD is severely underweight.

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48 Height for age. Z scores are calculated for height for age. Z scores < 2 standard deviations from the mean indicate the child is stunted. Z scores < 3 SD indicate the child is severely stunted. Table 26 Height for Age (Stunting) Note. < 2 SD is stunted, < 3 SD is severely stunted. Table 27 Height for Age Urban (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 0 60 92 13.0 (5.6, 20.5) 38.0 (27.6, 48.5) 1.38 1.40 24 35 33 9.1 (0.0, 20.4) 33.3 (15.7, 50.9) 1.10 1.68 36 47 27 7.4 (0.0, 19.1) 37.0 (17.0, 57.1) 1.37 1.14 Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 0 60 206 16.5 (11.2, 21.8) 40.8 (33.8, 47.7) 1.62 1.42 24 35 72 16.7 (7.4, 26.0) 38.9 (26.9, 50.8) 1.50 1.72 36 47 68 10.3 (2.3, 18.3) 30.9 (19.2, 42.6) 1.42 1.21 48 60 66 22.7 (11.9, 33.6) 53.0 (40.2, 65.8) 1.95 1.21 5 years 24 0.0 (0.0, 2.1) 16.7 (0.0, 33.7) 1.54 0.69

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49 48 60 32 21.9 (6.0, 37.8) 43.8 (25.0, 62.5) 1.69 1.25 5 years 21 0.0 (0.0, 2.4) 14.3 (0.0, 31.6) 1.55 0.62 Note. < 2 SD is stunted, < 3 SD is severely stunted. Table 28 Height for Age Rural (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mea n SD Total 0 60 114 19.3 (11.6, 27.0) 43.0 (33.5, 52.5) 1.81 1.41 24 35 39 23.1 (8.6, 37.6) 43.6 (26.7, 60.4) 1.84 1.69 36 47 41 12.2 (1.0, 23.4) 26.8 (12.0, 41.6) 1.45 1.27 48 60 34 23.5 (7.8, 39.3) 61.8 (44.0, 79.6) 2.20 1.13 5 years 3 0.0 (0.0, 16.7) 33.3 (0.0, 100.0) 1.49 1.29 Note. < 2 SD is stunted < 3 SD is severely stunted Table 29 Height for Age SJMC Anganwadi (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mea n SD Total 24 60 52 13.5 (3.2, 23.7) 40.4 (26.1, 54.7) 1.58 1.40 24 35 21 14.3 (0.0, 31.6) 38.1 (14.9, 61.2) 1.52 1.61

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50 36 47 21 9.5 (0.0, 24.5) 33.3 (10.8, 55.9) 1.46 1.32 48 60 10 20.0 (0.0, 49.8) 60.0 (24.6, 95.4) 1.97 1.12 5 years 0 ----Note. ups. < 2 SD is stunted < 3 SD is severely stunted Table 30 Height for Age Non SJMC Anganwadi (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 49 20.4 (8.1, 32.7) 40.8 (26.0, 55.6) 1.66 1.64 24 35 13 7.7 (0.0, 26.0) 23.1 (0.0, 49.8) 0.96 2.12 36 47 15 6.7 (0.0, 22.6) 20.0 (0.0, 43.6) 1.18 1.28 48 60 21 38.1 (14.9, 61.2) 66.7 (44.1, 89.2) 2.45 1.20 5 years 7 0.0 (0.0, 7.1) 14.3 (0.0, 47.4) 1.73 0.61 Note. Non ups. < 2 SD is stunted < 3 SD is severely stunted

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51 Table 31 Height for Age Other Preschool (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 44 9.1 (0.0, 18.7) 36.4 (21.0, 51.7) 1.50 1.07 24 35 6 16.7 (0.0, 54.8) 33.3 (0.0, 79.4) 1.39 1.69 36 47 16 6.3 (0.0, 21.2) 31.3 (5.4, 57.1) 1.38 1.09 48 60 22 9.1 (0.0, 23.4) 40.9 (18.1, 63.7) 1.63 0.89 5 years 9 0.0 (0.0, 5.6) 22.2 (0.0, 54.9) 1.53 0.79 Note. < 2 SD is stunted, < 3 SD is severely stunted. Table 32 Height for Age No Preschool (stunting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD Mean SD Total 24 60 61 21.3 (10.2, 32.4) 44.3 (31.0, 57.5) 1.69 1.49 24 35 32 21.9 (6.0, 37.8) 46.9 (28.0, 65.7) 1.72 1.64 36 47 16 18.8 (0.0, 41.0) 37.5 (10.7, 64.3) 1.63 1.17 48 60 13 23.1 (0.0, 49.8) 46.2 (15.2, 77.1) 1.68 1.56 5 years 8 0.0 (0.0, 6.3) 12.5 (0.0, 41.7) 1.40 0.70 Note. < 2 SD is stunted, < 3 SD is severely stunted.

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52 Weight for height. Z scores are calculated for weight for height. Z scores < 2 standard deviations from the mean indicate the child is wasted. Z scores < 3 SD indicate the child is severely wasted. T able 33 Weight for Height (Wasting) Age groups (months) N Prevalence (9 5% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 207 3.9 (1.0, 6.7) 15.0 (9.9, 20.1) 9.2 (5.0, 13.4) 1.9 (0.0, 4.0) 1.0 (0.0, 2.5) 0.69 1.31 24 35 71 4.2 (0.0, 9.6) 15.5 (6.4, 24.6) 12.7 (4.2, 21.1) 2.8 (0.0, 7.4) 1.4 (0.0, 4.9) 0.50 1.40 36 47 69 2.9 (0.0, 7.6) 15.9 (6.6, 25.3) 5.8 (0.0, 12.0) 0.0 (0.0, 0.7) 0.0 (0.0, 0.7) 0.83 1.23 48 60 66 4.5 (0.0, 10.3) 13.6 (4.6, 22.7) 7.6 (0.4, 14.7) 1.5 (0.0, 5.2) 0.0 (0.0, 0.8) 0.81 1.19 5 years Reference data not available for >60 months Note. < 2 SD is wasted, < 3 SD is severely wasted.

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53 Table 34 Weight for Height Urban (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 93 3.2 (0.0, 7.4) 24.7 (15.4, 34.0) 8.6 (2.4, 14.8) 1.1 (0.0, 3.7) 1.1 (0.0, 3.7) 0.95 1.35 24 35 33 0.0 (0.0, 1.5) 21.2 (5.7, 36.7) 12.1 (0.0, 24.8) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 0.70 1.25 36 47 27 7.4 (0.0, 19.1) 33.3 (13.7, 53.0) 3.7 (0.0, 12.7) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 1.34 1.45 48 60 32 3.1 (0.0, 10.7) 21.9 (6.0, 37.8) 6.3 (0.0, 16.2) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 1.02 1.12 5 years Reference data not available for >60 months Note. < 2 SD is wast ed, < 3 SD is severely was ted. Table 35 Weight for Height Rural (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 114 4.4 (0.2, 8.6) 7.0 (1.9, 12.1) 9.6 (3.8, 15.5) 2.6 (0.0, 6.0) 0.9 (0.0, 3.0) 0.48 1.24 24 35 38 7.9 (0.0, 17.8) 10.5 (0.0, 21.6) 13.2 (1.1, 25.2) 5.3 (0.0, 13.7) 2.6 (0.0, 9.0) 0.33 1.51 36 47 42 0.0 (0.0, 1.2) 4.8 (0.0, 12.4) 7.1 (0.0, 16.1) 0.0 (0.0, 1.2) 0.0 (0.0, 1.2) 0.50 0.94

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54 48 60 34 5.9 (0.0, 15.3) 5.9 (0.0, 15.3) 8.8 (0.0, 19.8) 2.9 (0.0, 10.1) 0.0 (0.0, 1.5) 0.61 1.24 5 years 21 0.0 (0.0, 2.4) 14.3 (0.0, 31.6) 1.55 0.62 Note. < 2 SD is wast ed, < 3 SD is severely was ted. Table 36 Weight for Height SJMC Anganwadi (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 51 5.9 (0.0, 13.3) 9.8 (0.7, 18.9) 9.8 (0.7, 18.9) 2.0 (0.0, 6.7) 0.0 (0.0, 1.0) 0.73 1.30 24 35 20 10.0 (0.0, 25.6) 15.0 (0.0, 33.1) 15.0 (0.0, 33.1) 5.0 (0.0, 17.1) 0.0 (0.0, 2.5) 0.54 1.66 36 47 21 0.0 (0.0, 2.4) 4.8 (0.0, 16.3) 9.5 (0.0, 24.5) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.68 0.95 48 60 10 10.0 (0.0, 33.6) 10.0 (0.0, 33.6) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 1.24 1.08 5 years Reference data not available for >60 months Note. ups < 2 SD is wasted, < 3 SD is severely wasted.

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55 Table 37 Weight for Height Non SJMC Anganwadi (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD > +3 SD Mean SD Total 24 60 49 0.0 (0.0, 1.0) 16.3 (5.0, 27.7) 6.1 (0.0, 13.9) 2.0 (0.0, 7.0) 0.0 (0.0, 1.0) 0.67 1.18 24 35 13 0.0 (0.0, 3.8) 23.1 (0.0, 49.8) 7.7 (0.0, 26.0) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.49 1.20 36 47 15 0.0 (0.0, 3.3) 13.3 (0.0, 33.9) 0.0 (0.0, 3.3) 0.0 (0.0, 3.3) 0.0 (0.0, 3.3) 0.63 1.10 48 60 21 0.0 (0.0, 2.4) 14.3 (0.0, 31.6) 9.5 (0.0, 24.5) 4.8 (0.0, 16.3) 0.0 (0.0, 2.4) 0.81 1.25 5 years Reference data not available for >60 months Note. Non College does not provides health check ups < 2 SD is wasted, < 3 SD is severely wasted. Table 38 Weight for Height Other Preschool (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 44 4.5 (0.0, 11.8) 15.9 (4.0, 27.9) 9.1 (0.0, 18.7) 0.0 (0.0, 1.1) 0.0 (0.0, 1.1) 0.60 1.21 24 35 6 0.0 (0.0, 8.3) 16.7 (0.0, 54.8) 16.7 (0.0, 54.8) 0.0 (0.0, 8.3) 0.0 (0.0, 8.3) 0.38 1.24

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56 36 47 16 0.0 (0.0, 3.1) 18.8 (0.0, 41.0) 12.5 (0.0, 31.8) 0.0 (0.0, 3.1) 0.0 (0.0, 3.1) 0.59 1.27 48 60 22 9.1 (0.0, 23.4) 13.6 (0.0, 30.2) 4.5 (0.0, 15.5) 0.0 (0.0, 2.3) 0.0 (0.0, 2.3) 0.66 1.20 5 years Reference data not available for >60 months Note. < 2 SD is wasted, < 3 SD is severely wasted. Table 39 Weight for Height No Preschool (wasting) Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 63 4.8 (0.0, 10.8) 17.5 (7.3, 27.6) 11.1 (2.6, 19.7) 3.2 (0.0, 8.3) 3.2 (0.0, 8.3) 0.73 1.50 24 35 32 3.1 (0.0, 10.7) 12.5 (0.0, 25.5) 12.5 (0.0, 25.5) 3.1 (0.0, 10.7) 3.1 (0.0, 10.7) 0.50 1.39 36 47 17 11.8 (0.0, 30.0) 29.4 (4.8, 54.0) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 1.42 1.48 48 60 13 0.0 (0.0, 3.8) 15.4 (0.0, 38.8) 15.4 (0.0, 38.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.72 1.22 5 years Reference data not available for >60 months Note. < 2 SD is wasted, < 3 SD is severely wasted. BMI for age. Body mass index (BMI) is an additional indicator of nutritional status. Z scores are calculated for BMI for age. Z scores < 2 standard deviations from the mean indicate the child is underweight Z scores < 3 SD in dicate the child is severely underweig ht

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57 Table 40 BMI for Age Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 206 4.4 (1.3, 7.4) 13.6 (8.7, 18.5) 12.1 (7.4, 16.8) 1.9 (0.0, 4.1) 1.0 (0.0, 2.6) 0.55 1.38 24 35 71 5.6 (0.0, 11.7) 14.1 (5.3, 22.9) 18.3 (8.6, 28.0) 4.2 (0.0, 9.6) 2.8 (0.0, 7.4) 0.31 1.57 36 47 69 4.3 (0.0, 9.9) 15.9 (6.6, 25.3) 8.7 (1.3, 16.1) 0.0 (0.0, 0.7) 0.0 (0.0, 0.7) 0.69 1.30 48 60 66 3.0 (0.0, 7.9) 10.6 (2.4, 18.8) 9.1 (1.4, 16.8) 1.5 (0.0, 5.2) 0.0 (0.0, 0.8) 0.65 1.24 5 years 24 4.2 (0.0, 14.2) 37.5 (16.0, 59.0) 0.0 (0.0, 2.1) 0.0 (0.0, 2.1) 0.0 (0.0, 2.1) 1.64 0.99 Note. BMI = Body mass index. < 2 SD = underweight < 3 SD is severely underweight Table 41 BMI for Age Urban Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 92 3.3 (0.0, 7.4) 21.7 (12.8, 30.7) 12.0 (4.8, 19.1) 0.0 (0.0, 0.5) 0.0 (0.0, 0.5) 0.89 1.38 24 35 33 0.0 (0.0, 1.5) 18.2 (3.5, 32.9) 18.2 (3.5, 32.9) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 0.58 1.40

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58 36 47 27 11.1 (0.0, 24.8) 33.3 (13.7, 53.0) 7.4 (0.0, 19.1) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 1.23 1.55 48 60 32 0.0 (0.0, 1.6) 15.6 (1.5, 29.8) 9.4 (0.0, 21.0) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 0.91 1.15 5 years 21 4.8 (0.0, 16.3) 38.1 (14.9, 61.2) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 1.80 0.87 Note. BMI = Body mass index. < 2 SD = underweight < 3 SD is severely underweight. Table 42 BMI for Age Rural Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 114 5.3 (0.7, 9.8) 7.0 (1.9, 12.1) 12.3 (5.8, 18.7) 3.5 (0.0, 7.3) 1.8 (0.0, 4.6) 0.28 1.33 24 35 38 10.5 (0.0, 21.6) 10.5 (0.0, 21.6) 18.4 (4.8, 32.1) 7.9 (0.0, 17.8) 5.3 (0.0, 13.7) 0.09 1.68 36 47 42 0.0 (0.0, 1.2) 4.8 (0.0, 12.4) 9.5 (0.0, 19.6) 0.0 (0.0, 1.2) 0.0 (0.0, 1.2) 0.35 0.99 48 60 34 5.9 (0.0, 15.3) 5.9 (0.0, 15.3) 8.8 (0.0, 19.8) 2.9 (0.0, 10.1) 0.0 (0.0, 1.5) 0.41 1.28 5 years 3 0.0 (0.0, 16.7) 33.3 (0.0, 100.0) 0.0 (0.0, 16.7) 0.0 (0.0, 16.7) 0.0 (0.0, 16.7) 0.57 1.27 Note. BMI = Body mass index. < 2 SD = underweight < 3 SD is severely underweight.

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59 Table 43 BMI for Age SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 51 7.8 (0.0, 16.2) 9.8 (0.7, 18.9) 11.8 (1.9, 21.6) 3.9 (0.0, 10.2) 2.0 (0.0, 6.7) 0.57 1.44 24 35 20 15.0 (0.0, 33.1) 15.0 (0.0, 33.1) 20.0 (0.0, 40.0) 10.0 (0.0, 25.6) 5.0 (0.0, 17.1) 0.36 1.89 36 47 21 0.0 (0.0, 2.4) 4.8 (0.0, 16.3) 9.5 (0.0, 24.5) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.53 1.02 48 60 10 10.0 (0.0, 33.6) 10.0 (0.0, 33.6) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 1.05 1.12 5 years 0 -------Note. BMI = Body mass index (weight/height 2 ). Body mass index. < 2 SD=underweight < 3 SD is severely underweight. College provides health check ups Table 44 BMI for Age Non SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 49 2.0 (0.0, 7.0) 14.3 (3.5, 25.1) 10.2 (0.7, 19.7) 2.0 (0.0, 7.0) 0.0 (0.0, 1.0) 0.52 1.29 24 35 13 0.0 (0.0, 3.8) 23.1 (0.0, 49.8) 7.7 (0.0, 26.0) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.39 1.39

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60 36 47 15 6.7 (0.0, 22.6) 13.3 (0.0, 33.9) 13.3 (0.0, 33.9) 0.0 (0.0, 3.3) 0.0 (0.0, 3.3) 0.54 1.23 48 60 21 0.0 (0.0, 2.4) 9.5 (0.0, 24.5) 9.5 (0.0, 24.5) 4.8 (0.0, 16.3) 0.0 (0.0, 2.4) 0.59 1.33 5 years 7 0.0 (0.0, 7.1) 28.6 (0.0, 69.2) 0.0 (0.0, 7.1) 0.0 (0.0, 7.1) 0.0 (0.0, 7.1) 1.57 0.95 Note. BMI = Body mass index (weight/height 2 ). Body mass index. < 2 SD=underweight < 3 SD is severely underweight. College provides health check ups Table 45 BMI for Age Other Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 44 2.3 (0.0, 7.8) 11.4 (0.8, 21.9) 11.4 (0.8, 21.9) 0.0 (0.0, 1.1) 0.0 (0.0, 1.1) 0.49 1.23 24 35 6 0.0 (0.0, 8.3) 0.0 (0.0, 8.3) 33.3 (0.0, 79.4) 0.0 (0.0, 8.3) 0.0 (0.0, 8.3) 0.23 1.44 36 47 16 0.0 (0.0, 3.1) 18.8 (0.0, 41.0) 12.5 (0.0, 31.8) 0.0 (0.0, 3.1) 0.0 (0.0, 3.1) 0.48 1.31 48 60 22 4.5 (0.0, 15.5) 9.1 (0.0, 23.4) 4.5 (0.0, 15.5) 0.0 (0.0, 2.3) 0.0 (0.0, 2.3) 0.57 1.17 5 years 9 0.0 (0.0, 5.6) 22.2 (0.0, 54.9) 0.0 (0.0, 5.6) 0.0 (0.0, 5.6) 0.0 (0.0, 5.6) 1.26 1.00 Note. BMI = Body mass index (weight/height 2 ). Body mass index. < 2 SD=underweight < 3 SD is severely underweight.

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61 Table 46 BMI for Age No Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 62 4.8 (0.0, 11.0) 17.7 (7.4, 28.1) 14.5 (4.9, 24.1) 1.6 (0.0, 5.6) 1.6 (0.0, 5.6) 0.60 1.54 24 35 32 3.1 (0.0, 10.7) 12.5 (0.0, 25.5) 18.8 (3.7, 33.8) 3.1 (0.0, 10.7) 3.1 (0.0, 10.7) 0.27 1.51 36 47 17 11.8 (0.0, 30.0) 29.4 (4.8, 54.0) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 1.22 1.62 48 60 13 0.0 (0.0, 3.8) 15.4 (0.0, 38.8) 23.1 (0.0, 49.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.59 1.36 5 years 8 12.5 (0.0, 41.7) 62.5 (22.7, 100.0) 0.0 (0.0, 6.3) 0.0 (0.0, 6.3) 0.0 (0.0, 6.3) 2.14 0.90 Note. BMI = Body mass index (weight/height 2 ). < 2 SD is underweight < 3 SD is severely underweight Mid upper arm circumference for age. Z scores are calculated for mid upper arm circumference for age. Z scores < 2 standard deviations from the mean indicate the child is malnourished Z scores < 3 SD indicate the c hild is severely malnourished

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62 Table 47 Mid Upper Arm Circumference for Age Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 208 2.9 (0.4, 5.4) 16.8 (11.5, 22.2) 1.0 (0.0, 2.5) 0.0 (0.0, 0.2) 0.0 (0.0, 0.2) 1.10 0.96 24 35 73 5.5 (0.0, 11.4) 21.9 (11.7, 32.1) 1.4 (0.0, 4.7) 0.0 (0.0, 0.7) 0.0 (0.0, 0.7) 1.04 1.10 36 47 69 1.4 (0.0, 5.0) 11.6 (3.3, 19.9) 1.4 (0.0, 5.0) 0.0 (0.0, 0.7) 0.0 (0.0, 0.7) 1.05 0.84 48 60 66 1.5 (0.0, 5.2) 16.7 (6.9, 26.4) 0.0 (0.0, 0.8) 0.0 (0.0, 0.8) 0.0 (0.0, 0.8) 1.22 0.92 5 years Reference data not available for >60 months Note. < 2 SD is malnourished < 3 SD is severely malnourished Table 48 Mid Upper Arm Circumference for Age Urban Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD > +1 SD >+2 SD >+3 SD Mean SD Total 0 60 93 0.0 (0.0, 0.5) 6.5 (0.9, 12.0) 1.1 (0.0, 3.7) 0.0 (0.0, 0.5) 0.0 (0.0, 0.5) 0.64 0.77 24 35 34 0.0 (0.0, 1.5) 2.9 (0.0, 10.1) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 0.49 0.71 36 47 27 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 3.7 (0.0, 12.7) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 0.59 0.64 48 60 32 0.0 (0.0, 1.6) 15.6 (1.5, 29.8) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 0.82 0.91 5 years Reference data not available for >60 months Note. < 2 SD is malnourished, < 3 SD is severely malnourished.

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63 T able 49 Mid Upper Arm Circumference for Age Rural Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 0 60 115 5.2 (0.7, 9.7) 25.2 (16.8, 33.6) 0.9 (0.0, 3.0) 0.0 (0.0, 0.4) 0.0 (0.0, 0.4) 1.47 0.94 24 35 39 10.3 (0.0, 21.1) 38.5 (21.9, 55.0) 2.6 (0.0, 8.8) 0.0 (0.0, 1.3) 0.0 (0.0, 1.3) 1.51 1.17 36 47 42 2.4 (0.0, 8.2) 19.0 (6.0, 32.1) 0.0 (0.0, 1.2) 0.0 (0.0, 1.2) 0.0 (0.0, 1.2) 1.34 0.83 48 60 34 2.9 (0.0, 10.1) 17.6 (3.4, 31.9) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 0.0 (0.0, 1.5) 1.59 0.77 5 years Reference data not available for >60 months Note. < 2 SD is malnourished, < 3 SD is severely malnourished. Table 50 Mid Upper Arm Circumference for Age SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 52 7.7 (0.0, 15.9) 30.8 (17.3, 44.3) 0.0 (0.0, 1.0) 0.0 (0.0, 1.0) 0.0 (0.0, 1.0) 1.63 0.92 24 35 21 19.0 (0.0, 38.2) 52.4 (28.6, 76.1) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 1.93 1.10

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64 36 47 21 0.0 (0.0, 2.4) 14.3 (0.0, 31.6) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 1.33 0.74 48 60 10 0.0 (0.0, 5.0) 20.0 (0.0, 49.8) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 0.0 (0.0, 5.0) 1.63 0.64 5 years Reference data not available for >60 months Note. ups < 2 SD is malnourished, < 3 SD is severely malnourished. Table 51 Mid Upper Arm Circumference for Age Non SJMC Anganwadi Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 49 0.0 (0.0, 1.0) 18.4 (6.5, 30.2) 2.0 (0.0, 7.0) 0.0 (0.0, 1.0) 0.0 (0.0, 1.0) 1.14 0.96 24 35 13 0.0 (0.0, 3.8) 15.4 (0.0, 38.8) 7.7 (0.0, 26.0) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.60 1.21 36 47 15 0.0 (0.0, 3.3) 6.7 (0.0, 22.6) 0.0 (0.0, 3.3) 0.0 (0.0, 3.3) 0.0 (0.0, 3.3) 0.97 0.64 48 60 21 0.0 (0.0, 2.4) 28.6 (6.9, 50.3) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 1.60 0.79 5 years Reference data not available for >60 months Note. Non does not provide health check ups < 2 SD is malnourished, < 3 SD is severely malnourished.

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65 Table 52 Mid Upper Arm Circumference for Age Other Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 45 4.4 (0.0, 11.6) 13.3 (2.3, 24.4) 2.2 (0.0, 7.6) 0.0 (0.0, 1.1) 0.0 (0.0, 1.1) 0.90 1.02 24 35 7 0.0 (0.0, 7.1) 14.3 (0.0, 47.4) 0.0 (0.0, 7.1) 0.0 (0.0, 7.1) 0.0 (0.0, 7.1) 0.47 1.01 36 47 16 6.3 (0.0, 21.2) 12.5 (0.0, 31.8) 6.3 (0.0, 21.2) 0.0 (0.0, 3.1) 0.0 (0.0, 3.1) 0.82 1.09 48 60 22 4.5 (0.0, 15.5) 13.6 (0.0, 30.2) 0.0 (0.0, 2.3) 0.0 (0.0, 2.3) 0.0 (0.0, 2.3) 1.09 0.96 5 years Reference data not available for >60 months Note. < 2 SD is malnourished, < 3 SD is severely malnourished. Table 53 Mid Upper Arm Circumference for Age No Preschool Age groups (months) N Prevalence (95% CI) z scores < 3 SD < 2 SD >+1 SD >+2 SD >+3 SD Mean SD Total 24 60 62 0.0 (0.0, 0.8) 6.5 (0.0, 13.4) 0.0 (0.0, 0.8) 0.0 (0.0, 0.8) 0.0 (0.0, 0.8) 0.76 0.75 24 35 32 0.0 (0.0, 1.6) 6.3 (0.0, 16.2) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 0.0 (0.0, 1.6) 0.75 0.70

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66 36 47 17 0.0 (0.0, 2.9) 11.8 (0.0, 30.0) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 0.0 (0.0, 2.9) 0.97 0.82 48 60 13 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.0 (0.0, 3.8) 0.50 0.78 5 years Reference data not available for >60 months Note. < 2 SD is malnourished, < 3 SD is severely malnourished. Research Questions Question 1. What gaps exist between KAP regarding ADD, ARI and nutrition for each group? Two analyses are included to address this question. First, chi square analyses compare knowledge (good vs. poor) and practice (good vs. poor), k nowledge and attitude, and attitude and practice. When the entire study sample is taken, poor 2 (1, n=244) = 19.2956, p = < 2 (1, n=244) = 5.3283, p = .0210]. Poor attitude is not significantly associated to poor 2 (1, n=244) = 3. 4359, p = .0638]. See Table 54 for the c hi square results a nd Tables 55 and 56 for results stratified by location and school type. Table 54 Knowledge vs. Practice vs. Attitude Scores -Urban Scores 2 DF n p value Poor knowledge vs. poor practice 21.5932 1 124 <.0001 Poor knowledge vs. poor attitude 12.5509 1 124 .0004 Poor attitude vs. poor practice 15.4074 1 124 <.0001 Note. 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to chance.

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67 Table 55 Knowledge vs. Practice vs. Attitude Scores -Rural Scores 2 DF n p value Poor knowledge vs. poor practice 1.9339 1 120 .1643 Poor knowledge vs. poor attitude .0010 1 120 .9752 Poor attitude vs. poor practice .7721 1 120 .3796 Note. 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to error. Tab le 56 Knowledge vs. Practice vs. Attitude Scores SJMC Anganwadi Scores 2 DF n p value Poor knowledge vs. poor practice .0043 1 53 .9475 Poor knowledge vs. poor attitude .8753 1 53 .3495 Poor attitude vs. poor practice .0385 1 53 .8445 Note. health check 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to error.

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68 Table 57 Knowledge vs. Practice vs. Attitude Scores Non SJMC Anganwadi Scores 2 DF n p value Poor knowledge vs. poor practice 3.9066 1 56 .0481 Poor knowledge vs. poor attitude 4.7919 1 56 .0286 Poor attitude vs. poor practice 1.8652 1 56 .1720 Note. Non health check 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to error. Table 58 Knowledge vs. Practice vs. Attitude Scores Other Preschool Scores 2 DF n p value Poor knowledge vs. poor practice 6.4313 1 55 .0112 Poor knowledge vs. poor attitude 1.8992 1 55 .1682 Poor attitude vs. poor practice .3274 1 55 .5672 Note. 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to error.

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69 Table 59 Knowledge vs. Practice vs. Attitude Scores No Preschool Scores 2 DF n p value Poor knowledge vs. poor practice 12.1549 1 80 .0005 Poor knowledge vs. poor attitude 10.2094 1 80 .0014 Poor attitude vs. poor practice 8.0284 1 80 .0046 Note. 2 = chi square statistic, DF = degrees of freedom, n = sample size, p value = probability outcome is due to error. Multiple regression analysis was conducted to determine which knowledge and attitude questions are better predictors of practice than others Eleven ADD knowledge questions (parameters) are modeled as predictors of ADD practice. Eighteen ARI knowledge questions are modeled as predictors of ARI practice. For attitude predictors, 11 ADD and 3 ARI attitude questions are modeled to identify bet ter predi ctors of practice. See tables 60 63 for results. Statistically significant and nearly significant p values ( Pr > t ) are in bold print. Table 60 ADD Practice as an Outcome of ADD Knowledge Parameters (n = 238) Parameter P E SE t value p value Q1 1.18518 1.02380 1.16 0.2482 Q2 2.12376 1.08886 1.95 0.0524 Q3 0.19016 0.92096 0.21 0.8366 Q4 0.37716 0.90512 0.42 0.6773 Q5 0.27498 0.78168 0.35 0.7253

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70 Q6 0.87572 0.74777 1.17 0.2428 Q7 0.30075 0.69352 0.43 0.6650 Q8 0.23231 0.79097 0.29 0.7693 Q9 1.80268 0.89035 2.02 0.0441 Q10 0.74632 0.12893 5.79 <.0001 Q11 0.74853 0.13883 5.39 <.0001 Note. ADD = acute diarrheal disease, Q = knowledge question p value is significant indicating this parameter (knowledge addressed in this question) is one of the better predictors of ADD practice PE=parameter estimate, SE=standard error Table 61 ARI Practice as an Outcome of ARI Knowledge Parameters (n = 244) Parameter P E SE t value p value Q1 0.61992 1.72585 0.36 0.7198 Q2 0.52854 1.66254 0.32 0.7508 Q3 0.29762 1.60887 0.18 0.8534 Q4 1.00689 1.42808 0.71 0.4815 Q5 1.84149 0.74228 2.48 0.0138 Q6 1.60511 1.34637 1.19 0.2344 Q7 1.34433 1.54636 0.87 0.3856 Q8 0.51022 0.49292 1.04 0.3017 Q9 ** ** ** ** Q10 2.28668 1.94714 1.17 0.2415 Q11 1.86207 1.84356 1.01 0.3136 Q12 2.26166 1.50852 1.50 0.1352 Q13 0.39477 0.43064 0.92 0.3603 Q14 2.23977 1.16535 1.92 0.0559 Q15 0.31196 1.62225 0.19 0.8477

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71 Note. ARI = acute respiratory infection, Q = knowledge question p value is significant indicating this parameter (knowledge addressed in this question) is one of the better predictors of ADD practice, PE=parameter estimate, SE=standard err ** Parameter removed from model due to confounding. Table 62 ADD Practice as an Outcome of ADD Attitude Parameters (n = 238) Parameter P E SE t value p value Q1 7.95134 3.12479 2.54 0.0116 Q2 4.54309 4.47621 1.01 0.3112 Q3 0.01435 3.47421 0.00 0.9967 Q4 0.88895 1.62927 0.55 0.5859 Q5 0.26171 1.65634 0.16 0.8746 Q6 0.31906 3.58427 0.09 0.9291 Q7 3.43183 3.06662 1.12 0.2643 Q8 0.55699 2.67585 0.21 0.8353 Q9 7.36486 3.26307 2.26 0.0250 Q10 0.76140 0.32457 2.35 0.0198 Q11 0.49119 0.32024 1.53 0.1265 Note. ADD = acute diarrheal disease, Q = knowledge question p value is significant indicating this parameter (knowledge addressed in this question) is one of the better predictors of ADD practice, PE=parameter estimate, SE=standard error Q16 3.24619 1.27704 2.54 0.0117 Q17 0.17463 1.51940 0.11 0.9086 Q18 0.05818 1.45344 0.04 0.9681

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72 Table 63 ARI Practice as an Outcome of A RI Attitude Parameters (n = 244) Note. ARI = acute respiratory infection, Q = attitude question p value is significant indicating this parameter (knowledge addressed in this question) is one of the better predictors of ADD p ractice, PE=parameter estimate, SE=standard err ** Parameter removed from model due to confounding. Question 2. What is the impact of KAP on nutritional status (weight for age) of children in each group? Logistic regression equations are used in the analysis of eigh t for age (WFA) is < 2 SD (stan dard deviations) from the mean. Of the 238 children entered into the model, 95 are underweight and 143 are of normal weight. Parameters included in the full model include knowledge, attitude and practice scores (as continuous variables); location (urban vs. rural), and preschool type. Table 64 illustrate s the results of the full model. Tables 65 66 show the results as calculated for each preschool type, in which the parameters are knowledge, attitude and practice scores; and location. Parameter P E SE t value p value Q1 0.55211 0.40479 1.36 0.1739 Q2 0.70285 0.38476 1.83 0.0690 Q3 0.27818 0.28705 0.97 0.3335

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73 Table 64 Nutritional Statu s as an Outcome of KAP (n = 238) Note. KAP = Knowledge, attitudes, and practices. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regressio n model including terms for all variables in the table. Location = urban vs. rural * Nearly statistically significant p value, should not be discarded Table 65 Underweight Children by Preschool Type (n = 238) Note. SJMC = Anganwadi where provides health check ups, Non SJMC = Anganwadi where ups. Number is parenthesis ( ) represents the percent of underweight children for that preschool type. Parameter OR* CI p value Knowledge score 1.047 (.942 1.162) .3943 Attitude score .989 (.935 1.046) .7021 Practice score .976 (.934 1.021) .2882 Location** .537 (.284 1.016) .0560* Preschool type .940 (.716 1.233) .6527 Preschool type Normal Underweight SJMC anganwadi 33 19 (36.54) Non SJMC anganwadi 35 20(36.36) Other 29 26 (47.27) No preschool 46 30 (39.47)

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74 Table 66 Nutritional status as an Outcome of KAP by Preschool Type Parameters OR* (CI) SE p value SJMC anganwadi (n = 52) Knowledge score Attitude score Practice score Location* 1.025 (0.819 1.282) 0.856 (0.729 1.005) 1.126 (1.002 1.265) -0.1141 0.0819 0.0595 -0.8302 0.0573 0.0461 -Non SJMC anganwadi (n = 55) Knowledge score Attitude score Practice score Location 0.986 (0.777 1.252) 1.042 (0.932 1.166) 0.907(0.819 1.005) 0.813 (0.212 3.114) 0.1216 0.0572 0.0523 0.6853 0.9103 0.4680 0.0614 0.7621 Other preschool (n = 55 ) Knowledge score Attitude score Practice score Location 1.117 (0.886 1.406) 1.004(0.829 1.217) 0.979 (0.879 1.091) 0.144 (0.042 0.493) 0.1178 0.0980 0.551 0.6289 0.3494 0.9653 0.7055 0.0020 No preschool (n = 76 ) Knowledge score Attitude score Practice score Location 1.142 (0.927 1.405) 0.983 (0.888 1.089) 0.925 (0.849 1.008) 1.482 (0.465 4.721) 0.1061 0.0522 0.0438 0.5911 0.2119 0.7439 0.0754 0.5057 Note. Anganwadi ups, Non

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75 check ups. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regression mod el including terms for all variables in the table. Question 3. What i s the impact of KAP on prevalence and episode duration of ADD and ARI for each group? Logistic regression equations model the outcomes scores and location Table 67 ADD as an Outcome of KAP and Location Parameters OR* (CI) SE p value Overall (n = 238) Knowledge score Attitude score Practice score Location .98 5 1.003 1.105 .489 (.842 1.151 ) (.911 1.104 ) (1.023 1.194 ) (.216 1.108) .0797 .0491 .0395 .4170 .8470 .9572 0111 .0865 Urban (n = 119) Knowledge score Attitude score Practice score .941 .942 1.093 (.773 1.145) (.841 1.056) (.996 1.201) .1001 .0581 .0477 .5430 .3053 .0608 Rural ( n = 108 ) Knowledge score Attitude score Practice score 1.111 1.150 1.125 (.814 1.517) (.886 1.492) (.968 1.306) .1588 .1329 .0762 .5066 .2942 .1235

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76 Note. the last 2 SJMC = Anganwadi where health check ups, Non SJMC = Anganwadi where provide health check ups. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, fr om logistic regression model including terms for all variables in the table. SJMC anganwadi (n = 49 ) Knowledge score Attitude score Practice score Location 5.693 .687 1.053 -(.850 38.150) (.380 1.243) (.787 1.409) -.9706 .3023 .1485 -.0731 .2149 .7273 -Non SJMC anganwadi (n = 55) Knowledge score Attitude score Practice score Place 1.045 .983 1.04 9 .523 (.716 1.526 ) (.833 1.1160 ) (.900 1.223 ) (.068 3.999) .1931 .0843 .0743 1.0381 .8181 .8393 5424 .5321 Other preschool (n = 55) Knowledge score Attitude score Practice score Location .428 1.927 1. 651 999.999 (.115 1.593 ) (.143 25.985 ) (.796 3.424 ) (<.001 >999.99) .6708 1.3273 .3721 .231.2 .2057 .6211 1779 .9533 No preschool (n = 57 ) Knowledge score Attitude score Practice score Location .883 1.054 1.1 20 .553 (.707 1.104 ) (.923 1.204 ) (1.01 1.251 ) (.128 2.381) .1136 .0680 .0562 .7450 .2 747 .4376 .04 32 .4263

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77 Table 68 ARI as an Outcome of KAP Parameters OR* (CI) SE p value Overall (N = 238) Knowledge score Attitude score Practice score Location .979 1.010 .99 1 1.793 (.856 1.119 ) (.940 1.085 ) (.934 1.051 ) (.870 3.698) .0682 .0367 0300 .3692 .7516 .7829 7559 .1136 Urban (n = 119) Knowledge score Attitude score Practice score .941 .942 093 (.773 1.145 ) (.841 1.056 ) (.996 1. 201 ) .1001 .0581 .472 .5430 .3053 0608 Rural (n = 119) Knowledge score Attitude score Practice score 1.111 1.150 1.125 (.814 1.517 ) (.886 1. 492 ) (.968 1.306 ) .1588 .1392 .0762 .5066 .2942 1235 SJMC anganwadi (n = 52) Knowledge score Attitude score Practice score Location 1.030 1.291 .951 -(.782 1.356) (.986 1.691) ( .853 1.060) -.1404 .1375 .0555 -.8341 .0632 .3663 -Non SJMC anganwadi Knowledge score Attitude score Practice score Location .842 .852 .997 .203 (.586 1. 211 ) (.718 1.0 11 ) (.858 1.1 5 8) (.013 3.198) .1853 .0874 .0764 1.4068 .3538 .0668 .9 650 .2569

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78 Note. ARI = acute respiratory infection. Logistic regression model with outcome SJMC = Anganwadi where provides health check ups, Non SJMC = Anganwadi where College does not provid e health check ups. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logi stic regression model. The child health score incorporates the two and four week ADD and ARI recalls as well as the duration of any episodes. Multi ple regression is used to calculate the child health score as a function of KAP scores Table XX displays results for the m ultiple regression equation w hen the child health score is taken as an outcome of knowledge, attitude and prac tice scores and locati on Other preschool (n = 55) Knowledge score Attitude score Practice score Location 1.104 1.184 1.115 11.125 (.695 1.754 ) (.693 2.021 ) (.927 1. 340 ) (1.128 109.77 ) .2363 .2729 .0939 1.1680 .6740 .5368 2476 .0391 No preschool (n = 76) Knowledge score Attitude score Practice score Location .900 1.035 .932 .957 (.695 1.165) (. 909 1.178 ) (.840 1.03 5) (.207 4.416) .1318 .0661 .0534 .7802 .4247 .6032 .18 88 .9551

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79 Table 69 Child Health Score as an outcome of KAP Scores and Location (N = 226) Not e. KAP = knowledge, attitude practic e. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regression model including terms for all variables in the table. Question 4. score are calculated by each school type and by location. Means of the knowledge and practice scores are similar across locations and school types. Mean attitude score is higher in the rural a rea as well as for SJMC anganwadi and other preschool mothers. Tables 70 72 display these data. Table 70 KAP Score Means Overall Parameters OR* (CI) SE p value Parameters Knowledge score 17636 11080 1.59 1129 Attitude score .10833 .0 6142 1.76 0792 Practice score .01976 .0 4851 41 6842 Location .56761 .58310 .97 .3314 Score N Mean SD Minimum Maximum Knowledge 244 32.3811 2.8394 23 38 Attitude 244 22.1692 5.3327 6.2 28.2 Practice 238 44.8697 6.3337 28.2 55.8

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80 Table 71 KAP Score Means by Location Note. KAP = knowledge, attitude, and practice Table 72 KAP Score Means by Preschool Type Score n Mean SD Minimum Maximum Urban Knowledge 124 32.4194 3.2034 23.5 38 Attitude 124 19.8306 6.6419 6.2 28.2 Practice 118 45.3051 6.2359 30.2 55.4 Rural Knowledge 120 32.3417 2.4193 23 36.5 Attitude 120 24.5858 .9407 19.7 25.6 Practice 120 44.4417 6.4257 28.2 55.8 Score N Mean SD Minimum Maximum SJMC anganwadi Knowledge 53 32.0094 2.6064 23 35.5 Attitude 53 24.6453 1.1180 19.7 25.3 Practice 53 44.3057 7.2439 28.2 55.8 Non SJMC anganwadi Knowledge 56 32.4554 2.7933 24 38 Attitude 56 21.9536 5.6534 6.3 28.2 Practice 54 44.8926 5.6493 33 55.4

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81 Note. KAP = knowledge, attitude, and practices Table 73 Good Scores Frequencies by Location and Preschool Type Good Score Overall Urban Rural SJMC Non SJMC Other preschool No preschool K 106/244 (43) 57/124 (46) 49/120 (41) 19/53 (36) 22/56 (39) 29/55 (53) 36/80 (45) A 160/244 (66) 57/124 (46) 103/120 (86) 44/53 (83) 39/56 (70) 35/55 (64) 42/80 (53) P 104/244 (43) 59/124 (48) 45/120 (38) 22/53 (42) 17/56 (30) 33/55 (60) 32/80 (40) Note. KAP = knowledge, attitudes, and practices Logistic regression is used to model the outcomes knowledge, attitude and practice scores as functions of school type, living score an d maternal education. Table 74 displays the results. Other preschool Knowledge 55 32.9182 2.8067 23.5 37 Attitude 55 23.0564 3.6235 9.9 27.3 Practice 52 45.9173 6.3133 29.4 55.6 No preschool Knowledge 80 32.2063 3.0301 24 37 Attitude 80 20.0700 6.8021 6.2 28.2 Practice 79 44.5430 6.1728 30.2 54.5

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82 Table 74 Good Kn owledge Modeled as an Outcome (N =244) Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regression model including terms for all variables in the table. Table 75 Good Attitude Modeled as an Outcome Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regression model including terms for all variables in the table. Parameters OR* (CI) SE p value Parameters Preschool type 1.192 (.914 1.555) .1354 .1942 Location 1.299 (.646 2.613) .3564 .4623 Mother education 1.534 (1.035 2.274) .2009 .0331 Living conditions score 1.072 (1.005 1.142) .0327 .0348 Parameters OR* (CI) SE p value Parameters Preschool type .964 (.702 1.324) .1617 .9227 Location 8.512 (3.577 20.255) .4423 <.0001 Mother education 1.851 (1.222 2.804) .2119 .0037 Living conditions score 1.047 (.969 1.130) .0393 2519

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83 Table 76 Good Practice Modeled as an Outcome Note. Odds Ratio (OR*),Confidence Interval (CI) and Standard Error (SE) of the OR, from logistic regression model including terms for all variables in the table. Parameters OR* (CI) SE p value Parameters Preschool type 1.037 (.775 1.387) .1486 .8073 Location 1.835 (.855 3.941) .3899 .1193 Mother education 1.564 (1.016 2.406) .2198 .0419 Living conditions score 1.256 (1.162 1.357) .0397 .<0001

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84 CHAPTER FOUR Discussion Limitations of Study There are several limitations to this study. The study area was selected as an area of convenience, but this was corrected for as much as possible by randomly selecting the order of the streets in which each area was sampled. Data were collected during standard daytime working hours for the communities, Monday through Saturda y. Mothers who work regularly outside of the home would not have been home during these hours to be eligible to participate in the study and are systematically excluded by limitations of working hours. The score categories good and poor were arbitrarily a ssigned a cut off of 70%, so they may or may not actually indicate what they are said to represent. Discussion of Results Analyses are conducted on the data to obtain overall outcomes as well as outcomes according to location (urban, rural) and preschool type. The study population is almost equally divided between urban (n=124) and rural (n=120) settings and each group is fairly evenly distributed between males and females (urban 60, 64; rural 61, 59, respectively). The types of preschools attended by th e children are almost evenly distributed (SJMC anganwadi=53, non SJMC anganwadi=56, other preschool=55) but the largest fraction of the children do not attend preschool (80/244). A characteristic that must be taken into consideration when comparing groups of children according to preschool type is that this classification does not account for differences in location (urban or rural). For example, all SJMC anganwadi children reside in a rural setting while all other preschool types are made up of children from both locations.

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85 One observation of note regarding demographic characteristics of the mothers is that education level of rural mothers is higher than that of urban mothers as 67% of urban and 79% of rural mothers have an education at the 6 th standard o r above. The reading frequency, however, is the opposite in that 57% of urban mothers as compared to 2.5% of rural mothers read on a daily or weekly basis. Scores. Scores were used in this study to compare groups in terms of living conditions; compare mot hers in terms of knowledge, attitude, and practices; and to compare children in terms of their health (ADD and ARI recalls ). When comparing living conditions of each preschool type, it is important to consider it within the context of being urban or rural Urban living condition scores are higher than rural living condition scores, but the range of scores in the rural area is wider. SJMC anganwadis have the lowest living conditions score mean of all four groups, bu t it is the only preschool type which is entirely rural. The living conditio ns scores do, however, indicate that children attending anganwadis (SJMC and non SJMC) have a preschools and no preschool at all. Good li ving conditions scores are predominate in urban areas (75%) as opposed to the rural area (29%). Living conditions scores are possibly more associated with location than preschool type. Maternal knowledge scores have almost equal means when compared as ove rall groups (urban = 32.38 rural= 32.42 ) When compared according to preschool type, they are very similar as well: SJMC anganwadi=32.01, non SJMC anganwadi=32.46, other preschool=32.92, and no school=32.21. This is surprising as it was expected that mot hers of children in school of any type would have greater knowledge than those whose children do not attend preschool. Maternal attitude scores are not as similar to one another. The overall attitude mean is 22.17, urban mean is 19.83 and the rural mean is 24.59. Among preschool types the attitude score means vary as well: SJMC anganwadi=24.65, non SJMC anganwadi=21.95, other preschool=23.06, and no school=20.07. Attitude is not discussed specifically in the literature reviewed for this study, but it i s interesting to

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86 note as it is the score with the most variability among groups and is the lowest among mothers whose children do not attend preschool. Maternal practice scores are also consistent among groups. The practice score mean for the overall stu dy sample is 44.87, it is 45.31 for urban and 44.44 for rural mothers. Among preschool types the means are similar as well: SJMC anganwadi=44.31, non SJMC anganwadi=44.89, other preschool=45.92, and no preschool=44.54. Given the similarity among scores and the fact that the literature overwhelmingly identifies maternal KAP as important determinants of child health, we would expect to obtain similar health outcomes among the groups of children in this study. Child health scores indicate the overall health of the child in terms of ADD and ARI incidence (according to two week recalls) and the duration of these episodes. A lower child health score indicates better child health. The child health score mean overall is 10.49, 10.22 for urban, and 10.76 for rur al children, confirming the expectation based on the KAP scores. When child health is compared among preschool types, the means are still close, but more variable: SJMC anganwadi=10.92, non SJMC anganwadi=9.88, other preschool=9.87, and no preschool=11.0 7. It is interesting to note that child health scores are the lowest (best) for those children attending preschool of all types as opposed to those who do not. ADD and ARI. The incidence of ADD found in this study is surprisingly high. According to the NFHS 3, prevalence of ADD in urban and rural areas is 9.0% and 8.4%, respectively. This study finds 16.9% and 9.17% respectively, of the children to have had diarrhea within two weeks prior to participating in the study. It is possible there was an outbreak of ADD among urban children as the rural prevalence was not out of the expected range. ADD is not evenly distributed among preschool types: SJMC anganwadi=5.66%, non SJMC anganwadi=10.71%, other preschool=12.73%, an d no preschool=25%. So, children with the worst child health score (no preschool) also suffer from the most diarrhea among this study sample.

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87 The incidence of ARI in this study is also higher than expected. Prevalence of ARI based on the NFHS 3 is 1.8% and 1.7% in the urban and rural areas, respectively. In this study, 12.9% of urban and 20% of rural children experienced an ARI within two weeks prior to participating i n this study. Prevalence varied among preschool types: SJMC anganwadi=22.64%, non S JMC anganwadi=14.29%, other preschool=12.73, and no preschool=16.25%. The variation between this study and the NFHS 3 may be due to a more broad case definition of ARI in this study, which includes runny or blocked nose, and thus captures more mild cases of ARI. Nutrition. Weight for age z score calculations indicate that only certain groups are underweight according to age group means. However, the prevalence of underweight children is 29.3% and 8.2% for severely underweight children This is lower t han the prevalence of underweight children in Karnataka (38%) (Ministry of Health and Fam ily Welfare., 2007a) but still a large number of children. Sub groups whose means are classified as underweight are five year old children overall ( 2.08); urban five year olds ( 2.18); SJMC anganwadi 48 60 month olds ( 2.01); non SJMC anganwadi 48 60 month olds ( 2.04), and five year olds ( 2.15). It is interesting to note that it is the older children among the study sample who are underweight Research Questions Question 1. What gaps exist between KAP regarding ADD, ARI and nutrition practice, some chi square stati stic results are statically significant but not consistently so across all preschool types. It was not expected for all associations to be significant, but it was expected that the general pattern would be the same. For example, that poor knowledge is as sociated with poor practice. There is a pattern in that groups with more rural children (rural group, SJMC anganwadi) there is no association indicated among the knowledge, attitude, and practice categories (poor and good). In the urban group and the no preschool group all three associations are

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88 significant. It does not appear to be the small size of the SJMC anganwadi group as the non SJMC anganwadi group results indicate a significant association between poor knowledge and practice, and poor knowledge and attitude. The associations that do exist support findings i n the literature that maternal knowledge is associated with child care practices. (Bhatia, et al., 1999; Datta, et al., 2001; M. C. Gupta, et al., 1991; Kapoor, e t al., 1990; Kaur, et al., 1994; Mangala, et al., 2001; Mangla, et al., 2000; Saini, et al., 1992; Saito, et al., 1997; Sood & Kapil, 1990) This also aligns with the finding that decreased knowledge leads to decreased levels of practice. (Saini, et al., 1992; Sood & Kapil, 1990) In addition to chi square statistics, multiple regression analysis results indicate there are some knowledge questions on the questionnaire which may be used as better predictors of practice scores for both ADD and AR I. In terms of diarrhea knowledge questions, a question regarding treating water to clean food (fruits, vegetables ) was marginally significant (p value=.0524) and has a parameter estimate (PE) of 2.1237. Others which are significant include a question re garding god (p value=.0441, PE 1.8027), a question regarding proper stool disposal (p value=<.0001, PE .7463), and a question asking how much liquid should be given to a child when suffering from diarrhea (p value=<.0001, PE .7485). Three ARI knowledge qu estions were significant or marginally significant as predictor variables as well. A question about cooking inside with fire (p value=.0138, PE 1.8415), another regarding breath count decreasing when a child has an ARI (p value=.0559, PE 2.2398), and a t hird regarding the ability to hear respiratory sounds when a child has an ARI (p value=.0117, PE 3.2462). Attitude questions were analyzed in the same way and three statistically significant questions are identified. A question about the importance of dr inking clean water (p value=.0116, PE 7.95134), another about the importance of eating fresh food (p value=.0250, PE 7.36486), and a third question about the importance of stool disposal (p value .0198, PE .7614). In terms of gaps between knowledge and practice, and attitude and practice, this is important information. From the perspective of an educational intervention, it is important to know which questions serve as better indicators of practice outcomes

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89 because you can then focus your education effo rts on those topics where the gaps exist This questionnaire could serve as a pre assessment for an educational intervention which is geared toward the urban and rural communities in which SJMC Department of Community Health works. Question 2. What is t he impact of KAP on nutritional status (WFA) of children for each group? It was mentioned earlier that the means of WFA z scores are predominantly in the normal range. However, this statement does not account for individuals within each age group who are underweight (< 2 SD) or severely underweight (< 3 SD). In fact, 36.54% of SJMC anganwadi children are underweight or severely underweight, along with 36.36% of non SJMC children, 47.27% of other preschool children, and 39.47% of children who do not att end of underweight and severely underweight) is indicated as the outcome of knowledge score, attitude score, practice score, location, and preschool type. This model in dic ates that an urban setting could be marginally protective against being underweight or severely underweight (point estimate (PE)=.537, CI (.284 1.016), p value=.0560) but the WFA results in this study do not indicate that this is the case Models for ea ch preschool type are calculated as well. The outcome, underweight or severely underweight (combined) as predicted by knowledge score, attitude score, and practice score. Practice scores are either statistically significant or marginally so for three pre school types: SJMC anganwadis ( PE=1.126, CI (1.002 1.265), p value .0461), non SJMC anganwadis (PE=.907, CI (.819 1.005), p value .0614), and no preschool (PE .925, CI (.849 1.008), p value=.0754). The preschool group, no preschool, is tied for hav ing the highest prevalence of underweight (33.3%), has the highest prevalence of severely underweight (11.1%), has the highest child health score mean (indicating the worst health), as well as the highest prevalence of ADD (25%) and the second highest prev alence of ARI (16.25%). This confirms the well established reality that maternal practices do indeed impact child health in terms of nutritional status and ensuing ADD and ARI. (Muller & Krawinkel, 2005; Murray & Lopez, 1997; United Nations., n.d.)

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90 Question 3 What is the impact of KAP on incidence and duration of ADD according to the parameters knowledge, attitude and practice score s; and location (urban, rural). The logistic regression model yields very few sta tistically or marginally significant results. In the overall model for ADD, practice sc ore is statistically significant (PE 1.105 (1.023 1.194) p value=.0111), however the PE estimates the odds ratio and is hardly more than one, meaning and increase in practice score would only marginally impact the ADD outcome. In the no preschool group similar results are obtained for practice score as a predictor of ADD (PE 1.1 2 0, CI (1.01 1. 251 ), p value=.0 432 ) For ARI practice scores are marginally significant for the urban group (PE .093, CI (.996 1.201), p value=.0608) The PE is less than one, indicating protection against ARI, as we would expect. Finally, in the other group, location appears to be highly predictive according to its PE (PE 11.125 (1.128 109.770)) however the CI is extremely wide. This question did not yield the expected results. It is expected that p ractice scores would be predictors of ADD and ARI. Even further, it makes more sense for practice scores to be a protective factor against ADD and ARI, rather than have an odds ratio >1 indicatin g that this parameter increases the likelihood of the outcome. The PEs for practice are not consistently <1, but they are all fairly close to one, indicating little to no predictive value in the model. Child health score is a compilation of ADD and ARI two and four week regression model with child health score as the outcome indicates that the parameters, a ttitude and practice scores, while not statically significant, are inversely related to th e child health score (PE .10833 p value .0792; PE .01976 p value 684 2, respectively). This makes sense in this model since a lower child health score indicates better health so an increase in attitude or practice scores wo uld indicate a decr ease in the child health score. The strength of this model may be improved by including only two week ADD/ARI recalls as they are widely accepted as the

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91 standard recall period, and including four week ADD/ARI recalls could possibly in troduce a recall bias. Question 4. The only notable difference among the KAP score means is that the mean attitude score is higher among both rural and SJMC anganwadi groups. This was not expected. The logistic reg ression model, however, does support the literature that maternal education influences knowledge level. (Bhatia, et al., 1999; Borooah, 2004; Datta, et al., 2001; M. C. Gupta, et al., 1991; Mangala, et al., 2001; Saito, et al., 1997; Singh, et al., 1992) Maternal education is significantly associated with all three KAP scores as outcomes. As a predictor of KAP, maternal education level has the following values in the models: good knowledge score (PE 1.534 (1.035 2.274), p value=.0331), good attitude score (PE 1.851 (1.222 2.804), p value=.0037), and good practice score (PE1.564 (1.1016 2.406), p value=.0419). Living conditions score is also statistically significant in the knowledge a nd practice models, but the PEs are still close to one, indicating an odds ratio of very little difference (PE 1.072 (1.005 1.142), p value=.0348; PE 1.256 (1.162 1.357), p value=<.0001, respectively). Finally, location is highly predictive of good at titude scores, according to this model (PE 8.512 (1.222 2.804), p value=.0037). Conclusion In conclusion, the data analysis supports literature that maternal KAP impacts child health in terms of disease and nutrition. It also supports the fact that maternal education is an important factor in child health. This study compares rural and urban settings as well as four preschool types. The urban area has a higher living score, and better child history scores The urban area also has a greater prevale nce of wasting and below normal BMI than the rural area. Mothers in the rural area have a much higher attitude score than their urban counterparts. Most notably of interest in this study, however, are the similarities and differences among school types r egarding KAP, ADD, and ARI. There are no meaningful differences among knowledge or practice score means for the school types. Attitude score, however, is higher among

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92 SJMC anganwadi mothers. There are no notable differences in child health or child hist ory scores among the school types. It would be interesting to group the children by location and school type for analyses as location is a significant factor in child health and nutrition outcomes. In general, c hildren who do not attend preschool of any type are at higher risk of ADD, ARI, and being underweight. These children have mothers with the lowest attitude scores. Mothers of children in other preschools have the highest percentage of good knowledge and practice scores. Children who attend other preschools also have the lowest prevalence of underweight. This group is worth investigating further in terms of demographic information. It appears that attending preschool, to attending a government supported preschool, to attending a preschool specifically chosen by the family. provides services through the anganwadis. Instead of providing child health che ck ups, it may be worthwhile to invest in providing education for mothers based on KAP gaps identified in this study. As a whole, the SJMC anganwadi mothers have a positive attitude and would most likely be receptive to such a service, which would in turn improve the health of their children. Cultural Considerations Language and cultural differences came into play in both the designing of the questionnaire and the collection of data. Training data collectors to read the questionnaire word for word was n ot straight forward and the data collectors were not always supervised. Having a cultural outsider along for data collection was a distraction at times as many people gathered for the questionnaire administration and would offer answers for the mother par ticipating in the study. The issue of age is not concrete in the study area. Therefore, data stratified by age group (nutritional status) may or may not be accurate.

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93 References Bhatia, V., Swami, H. M., Bhatia, M., & Bhatia, S. P. (1999). Attitude and practices regarding diarrhoea in rural community in Chandigarh. Indian J Pediatr, 66 (4), 499 503. Borooah, V. K. (2004). On the incidence of diarrhoea among young Indian children. Econ Hum Biol, 2 (1), 119 138. Datta, V., John, R., Singh, V. P., & Chaturvedi, P. (2001). Maternal knowledge, attitude and practices towards diarrhea and oral rehydration therapy in rural Maharashtra. Indian J Pediatr, 68 (11), 1035 1037. Embassy of India. (n.d.). Integrated Child Development Ser vices (ICDS) Retrieved 11/23/2008, 2008, from < http://www.indianembassy.org/Policy/Children_Women/icds.html > Ghosh, S. (1995). Integrated Child Development Services programme. Healt h Millions, 21 (Souvenir), 31 36. Government of India. (2005). Millennium Development Goals India Country Report 2005 Retrieved June 15, 2009. from http://wbplan.gov.in/docs/MDG_India_country_Report.pdf Gupta, M. C., Mehrotra, M., Arora, S., & Saran, M. (1991). Relation of childhood malnutrition to parental education and mothers' nutrition related KAP. Indian J Pediatr, 58 (2), 269 274. Gupta, N., Jain, S. K., Chawla, U., Hossain, S., & Venkatesh, S. (2007). An evaluation of diarrheal diseases and acute respiratory infections control programmes in a Delhi slum. Indian J Pediatr, 74 (5), 471 476. International Institute for Population Sciences. (1998) Household Questionnaire. National Family Health Survey (NFHS 2) India 1998 1999 Retrieved 11/15/2008, 2008, from http://hetv.org/pdf/nfhs/india/indhhqre.pdf International Institute for Population Sciences. (2005). Women's Questionnaire. National Family Health Survey, India 2005 2006 (NFHS 3) Retrieved 11/15/2008, 2009, from http://www.nfhsindia.org/pdf/Woman_QRE.pdf Joseph, B. (2008). Direc tor Division of Work Environment, St. John's Medical College. In A. L. Norbert Wagner (Ed.) (Teleconference ed.). Tampa, FL. Kapil, U., & Pradhan, R. (1999). Integrated Child Development Services scheme (ICDS) and its impact on nutritional status of childr en in India and recent initiatives. Indian J Public Health, 43 (1), 21 25. Kapoor, S. K., Reddaiah, V. P., & Murthy, G. V. (1990). Knowledge, attitude and practices regarding acute respiratory infections. Indian J Pediatr, 57 (4), 533 535. Karen Glanz, B. K. R., Fances Marcus Lewis (Ed.). (2002). Health Behavior and Health Education: Theory, Research, and Practice (Third ed.). San

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94 Francisco, CA: Jossey Bass. Kaur, A., Chowdhury, S., & Kumar, R. (1994). Mothers' beliefs and practices regarding prevention and management of diarrheal diseases. Indian Pediatr, 31 (1), 55 57. Kumar, D., Goel, N. K., Kalia, M., Swami, H. M., & Singh, R. (2008). Gap between awareness and practices regarding maternal and child health among women in an urban slum community. Indian J Pe diatr, 75 (5), 455 458. Mangala, S., Gopinath, D., Narasimhamurthy, N. S., & Shivaram, C. (2001). Impact of educational intervention on knowledge of mothers regarding home management of diarrhoea. Indian J Pediatr, 68 (5), 393 397. Mangla, S., Gopinath, D., Narsimhamurthy, N. S., & Shivram, C. (2000). Feeding practices in under fives during diarrhea before and after educational intervention. Indian Pediatr, 37 (3), 312 314. Milligan, P., Njie, A., & Bennett, S. (2004). Comparison of two cluster sampling method s for health surveys in developing countries. Int J Epidemiol, 33 (3), 469 476. Ministry of Health and Family Welfare. (2007a). National Family Health Survey (NFHS 3), 2005 2006, Fact Sheet Karnataka from http ://www.nfhsindia.org/pdf/KA.pdf Ministry of Health and Family Welfare. (2007b). National Family Health Survey (NFHS 3), 2005 2006, India: Key Findings from http://www.nfhsindia. org/NFHS 3%20Data/NFHS 3%20NKF/Report.pdf Ministry of Health and Family Welfare. (2007c). National Family Health Survey (NFHS 3), 2005 2006, National Fact Sheet India from http://www.nfhsindia.org/pdf/ IN.pdf Muller, O., & Krawinkel, M. (2005). Malnutrition and health in developing countries. CMAJ, 173 (3), 279 286. Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. La ncet, 349 (9063), 1436 1442. Oldenburg, P. (2009). India. Retrieved June 21, 209, from Microsoft: http://encarta.msn.com/encyclopedia_761557562/India.html Prinja, S., Thakur, J. S., & Bh atia, S. S. (2009). Pilot testing of WHO child growth standards in Chandigarh: implications for India's child health programmes. Bull World Health Organ, 87 (2), 116 122. Rashid, S. F., Hadi, A., Afsana, K., & Begum, S. A. (2001). Acute respiratory infections in rural Bangladesh: cultural understandings, practices and the role of mothers and community health volunteers. Trop Med Int Health, 6 (4), 249 255. Saini, N. K., Gaur, D. R., Saini, V., & Lal, S. (1992). Acute respiratory infections in children: a study of knowledge and practices of mothers in rural Haryana. J Commun Dis, 24 (2), 75 77. Saito, K., Korzenik, J. R., Jekel, J. F., & Bhattacharji, S. (1997). A case control study of maternal knowledge of malnutr ition and health care seeking attitudes in

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95 rural South India. Yale J Biol Med, 70 (2), 149 160. Sharma, K. P., & Thakur, A. K. (1995). Maternal beliefs regarding diet during common childhood illnesses. Indian Pediatr, 32 (8), 909 910. Shaw, D. D., Jacobsen, C. A., Konare, K. F., & Isa, A. R. (1990). Knowledge and use of oral rehydration therapy for childhood diarrhoea in Tumpat District. Med J Malaysia, 45 (4), 304 309. Simiyu, D. E., Wafula, E. M., & Nduati, R. W. (2003). Mothers' knowledge, attitudes and pra ctices regarding acute respiratory infections in children in Baringo District, Kenya. East Afr Med J, 80 (6), 303 307. Singh, J., Gowriswari, D., Chavan, B. R., Patiat, R. A., Debnath, A. C., Jain, D. C., et al. (1992). Diarrhoeal diseases amongst children under five. A study in rural Alwar. J Commun Dis, 24 (3), 150 155. Sood, A. K., & Kapil, U. (1990). Knowledge and practices among rural mothers in Haryana about childhood diarrhea. Indian J Pediatr, 57 (4), 563 566. Tandon, B. N. (1989). Nutritional interven tions through primary health care: impact of the ICDS projects in India. Bull World Health Organ, 67 (1), 77 80. Tandon, M., & Kapil, U. (1998). Integrated child development services scheme: need for reappraisal. Indian Pediatr, 35 (3), 257 260; discussion 2 60 251. Trivedi, S., Chhaparwal, B. C., & Thora, S. (1995). Utilization of ICDS scheme in children one to six years of age in a rural block of central India. Indian Pediatr, 32 (1), 47 50. United Nations. (n.d.). United Nations Millenium Development Goals from http://www.un.org/millenniumgoals/childhealth.shtml Weinstein, N. D., & Sandman, P. M. (1992). A model of the precaution adoption process: evidence from home radon testing. Health Psyc hol, 11 (3), 170 180. World Health Organization. (2006a). India: Country Cooperation Strategy At A Glance from http://www.who.int/countryfocus/cooperation_strategy/ccsbr ief_ind_en.pdf World Health Organization. (2006b). Mortality Country Fact Sheet 2006: India. In W. H. Organization (Ed.). Geneva: World Health Organization. World Health Organization. (2006c). WHO Country Cooperation Strategy 2006 2011: India from http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ind_en.pdf

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96 Appendices

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97 Appendix 1: Area Maps Urban Area: Bande Slum

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98 Appendix 1: Area Maps (Continued) Rural Village: Mugalur

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99 Appendix 1: Area Maps (Continued) Rural Village: Pandithagaratha

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100 Appendix 1: Area Maps (Continued) Rural Village: Thiruvanga

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101 Appendix 1: Area Maps (Continued) Rural Village: Bagur

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102 Appendix 2: Approval and Certification Letters USF Institutional Review Board Approval Letter

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103 Appendix 2: Approval and Certification Letters (Continued) USF Institutional Review Board Approval Letter (Continued)

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104 Append ix 2: Approval and Certification Letters (Continued) SJMC Institutional Ethics Review Board Approval Letter

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105 Appendix 2: Approval and Certification Letters (Continued) Certificate of Translation

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106 Appendix 3: Informed Consent Forms 16 DEC2008

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122 Appendix 4: Informed Consent Forms 01APR2009

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138 Appendix 5: Questionnaire 27FEB2009

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Maternal knowledge, attitudes and practices and health outcomes of their preschool-age children in urban and rural Karnataka, India
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ABSTRACT: This cross-sectional, community-based study was designed to compare the health outcomes of 2 5 year-old children in different types of preschools. The Integrated Child Development Services (ICDS), run by the government of India, created a system of preschools, called anganwadis, to combat malnutrition, provide health education for mothers, and preschool for children 2 6 years old in 1975. Many children attend their local anganwadis, while others attend private schools, and others do not attend school at all. A pre-tested questionnaire was used to interview 125 urban and 130 rural mothers regarding their knowledge, attitudes, and practices about acute diarrheal disease (ADD), acute respiratory infections (ARI), and nutrition (practice only) as they pertained to their 2 5 year-old child. Two-week and four-week health recalls were obtained to determine which children had experienced diarrhea or ARIs during those time periods.Anthropometric measurements of the children (weight, height, upper-arm circumference) were collected whenever possible. The study was carried out in an urban slum rural villages surrounding in and surrounding Bangalore, India. Data was collected from March through May of 2009. Through data analysis, KAP and child health scores were calculated to compare four preschool types: anganwadis receiving health check-ups from a medical college, anganwadis not receiving the medical check- ups, other (non-anganwadi) preschools and children not attending preschool. Analyses were performed to identify gaps in KAP, determine the impact of KAP on nutritional status, determine the impact of KAP on ADD and ARI, and determine if preschool type influences KAP scores. Children not attending preschool of any type are at higher risk of ADD, ARI, and being underweight. These children have mothers with the lowest attitude scores.Mothers of children in other preschools have the highest percentage of good knowledge and practice scores. Children who attend other preschools also have the lowest prevalence of underweight. This information can be useful in designing interventions for specific populations.
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