Health and nutrition in children under 2 years of age in three areas of the Russian Federation.

Health and nutrition in children under 2 years of age in three areas of the Russian Federation K. Welch,1 N. Mock,2 B. Sorensen,3 & 0. Netrebenko4 The study objectives were to determine the nutritional status of children under 2 years of age in selected areas of the Russian Federation, to estimate the proportion of children potentially at risk for nutritional problems, and to characterize such a vulnerable group in terms of demographic variables. A cross-sectional sample of children under 2 years of age was used. Six areas - Moscow, St Petersburg, Ekaterinburg, and their surrounding oblasts - were sampled, and data were collected for approximately 800 children in each area between July and December 1993. A low prevalence of children with a weight-for-age Z-score below -2 was found, indicating that at the time of the survey protein-energy malnutrition was not a serious problem for this age group. However, other survey results indicating high morbidity, low immunization rates, the possibility of food insecurity, and poor infant-feeding practices imply that children's health could easily deteriorate. Therefore, food security and children's nutrition should be monitored to avoid serious consequences in the future. The results also show that there is ample scope for public health interventions that encourage more effective immunization coverage, emphasize prevention of childhood diseases, and promote proper infant-feeding practices. Introduction From February 1992 to May 1994, the U.S. humani- tarian-relief organization CARE implemented an emergency food-aid programme in the Russian Fed- eration distributing milk powder, baby food, and family food packages to families and individuals. With financial support from the U.S. Agency for International Development (USAID), CARE estab- lished a survey unit whose task was to identify nutri- tionally vulnerable groups and assess their needs. One component of the programme was to assess the nutritional status and needs of children under 2 years of age. CARE conducted a nutritional and child- health survey in three cities (Moscow, St Petersburg, and Ekaterinburg) and the three surrounding oblasts (provinces). The surveys were carried out by person- nel hired and supervised by CARE technical staff. I Formerly Director, Survey unit, CARE, Russian Federation; currently Researcher, Department of International Health and De- velopment, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2200, New Orleans, LA 70112- 2737, USA. Correspondence should be sent to Ms Welch at the latter address. 2 Associate Professor, Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA. 3Coordinator of Data Management, Department of AIDS Surveil- lance, Louisiana Department of Public Health, New Orleans, LA, USA. 4Professor, All-Russian Institute of Nutrition, Moscow, Russian Federation. Reprint No. 5744 The surveys provided information that was pre- viously unavailable. Few epidemiological studies on nutritional status had been conducted in the Russian Federation, and their results have been considered unreliable. The Institute of Medical and Socioeco- nomic Information of the Ministry of Health of the Russian Federation has reported that, during the Soviet era, data acquired concerning the health of the population were coloured by political objectives: "contrived criteria, methods of accounting, and forms of documentation were used for intentional distortion ... in order to present an ideal picture of the country ... and hinder comparative analysis with data from other countries (1)." The results of the children-under-two survey are particularly useful during this time of rapid change in the country, where little information on the nutritional and health status of the population has been available. Subjects and methods Sample design and size The study design was based on a cross-sectional rep- resentative sample of children under 2 years of age. Six areas - Moscow, St Petersburg, Ekaterinburg, and their surrounding oblasts - were sampled. The sampling procedures used in the cities and oblasts were somewhat different because of the unavailabil- ity of complete lists of polyclinics in the oblasts. In the cities, children's polyclinics were the first- stage sampling units, as their registers cover more Bulletin of the World Health Organization, 1996, 74 (6): 605-612 © World Health Organization 1996 605 K. Welch et al. than 95% of the population under 2 years of age. A total of 30 polyclinics were randomly selected from a complete list of polyclinics in each city. In Ekaterinburg, however, all polyclinics were selected, as there were only 27. From a list of children under 2 years of age in each polyclinic, 30 children (34 in Ekaterinburg) were selected randomly in the second and final sampling stage. Although for first-stage se- lection, probability-proportional-to-size (PPS) sam- pling was not used because of insufficient data, the distribution of the selected polyclinics was later ana- lysed and was found to be very close to that which would have been obtained using a PPS method. For sampling in the oblasts, a three-stage cluster design was used because of the unavailability of polyclinic lists for each oblast. For the first stage, a list of rayons (administrative subregions) was gener- ated and classified as urban or rural according to the proportion of the population that lived in cities (<60% = rural). Rayons were then selected using a PPS method. Table 1 shows the proportion of rural households sampled in the three oblasts. The Ekaterinburg oblast had the highest proportion of rural households sampled, i.e. approximately 50%. For the second stage, a list of all polyclinics in the selected rayons was obtained from the regional ad- ministrative authority. Polyclinics were then selected by a PPS method, although in a small number of cases (<5%) simple random sampling was used, as data on the number of registered children were not available. For the third stage, 30 children under 2 years of age were randomly selected in each polyclinic. Data collection and quality control Data collection was carried out by means of a ques- tionnaire that was administered to the mother of each selected child by a team of two Russian inter- viewers, one of whom was a medical doctor. Ques- tions were designed to elucidate infant-feeding practices, the level of food security, the mothers' level of nutritional knowledge, and trends in family food consumption. The weight of children was also obtained, and WHO recommendations were followed when measuring weight-for-age at the time of the interview (2). Historical weight and height measurements - including birth weight - were ob- tained from children's medical records. A history of anaemia was evaluated by reviewing haemoglobin measurements and red-blood-cell counts in the medical records. To identify predictors of nutritional risk, we collected individual and household demographic information during interviews, along with socio- economic data and information on immunization status, infant-feeding practices, and disease history. Some information on immunization and morbidity history was collected from medical records. In order to verify the questionnaire, it was trans- lated from English to Russian and back-translated from Russian to English, and a pretest was con- ducted throughout the survey areas. Interviews were performed in the polyclinics. Mothers of selected children were contacted by the survey team and asked to participate in the study. Three attempts were made to complete interviews for all mothers. Table 1: Demographic and socioeconomic characteristics of the study population Mothers Mean age Mean age with low of children of mothers Mothers' education Area (months) (years) parity' (%)b Russian Rural mothers households (%)C (%) House- House- hold hold sized incomee Food Sample expenditure' size City Moscow St Petersburg Ekaterinburg Oblast Moscow St Petersburg Ekaterinburg 13.6 12.8 13.0 12.3 12.2 12.8 27.0 26.7 26.0 25.6 25.6 25.0 2 2 2.6 6.0 6.0 4.2 7.2 9.5 90.5 NA9 90.1 NA 88.5 NA 4.2 4.0 4.2 92.4 28.4 4.3 88.6 34.5 4.0 85.2 48.9 4.2 45 34 38 53 42 43 29 25 23 34 32 26 756 836 810 816 783 859 a Mean number of births per mother. bNot completing secondary school. cAs reported during interviews. d Mean number of people per household. eMean monthly income per adult household member (US$ equivalent). 'Mean monthly food expenditure per adult household member (US$ equivalent). 9NA = not applicable. WHO Bulletin OMS. Vol 74 1996606 Health and nutrition in Russian children Immediately after each interview, question- naires were reviewed with mothers present in order to complete missing information or rectify inconsis- tencies. A subsample of 10% of interviewees was contacted and re-interviewed for selected sections of the questionnaire. After this review, data entry was carried out using a customized survey module developed with Epi Info, version 5.01a, software. A double-entry validation procedure was used. The survey response rate was 90%: only 1% of mothers refused to participate, 7% were absent, and 2% had moved. Results are based on 2402 interviews (cities) carried out between 21 July and 6 October 1993, and 2458 interviews (oblasts) carried out be- tween 10 October and 1 December 1993. Results Demographic characteristics In 1993, annual births in the Russian Federation were one-third of those in 1988. The crude birth rate in the country is now among the lowest in the devel- oped world. In 1993, the birth rate per 1000 popula- tion was 9.1, compared with a U.S. birth rate of 16.a The data presented in Table 1 reflect low fertility among mothers sampled (average age, 26 years). The low parity of 1-2 births per mother is consistent with other estimates showing low fertility in the Russian Federation. Mothers in the sample were relatively well edu- cated (<10% had not completed high school). Mos- cow had the lowest percentage of mothers who did not complete high school, i.e. 2.6%, and the Ekaterinburg oblast the highest, i.e. 9.5%. Results from a 1989 census of the Soviet Union and a recent World Bank study confirm that Russian women tend to have a high level of education (3). Approximately 90% of mothers were Russian, with 10.6% (cities) and 11.6% (oblasts) describing themselves as of Ukrainian, Byelorussian, Tatar, or other ethnic origin. The Ekaterinburg oblast, which neighbours the Tatarstan and Bashkir autonomous republics, had the highest percentage of non-Russian mothers, i.e. 14.8%, of which 5.4% were Tatar, 1.5% Bashkir, and 7.9% other. The ethnic composition of the sample was consistent with 1989 census figures, which reported that approximately 90% of the popu- lation in each of the six survey areas was Russian (4). The average household size was 4.1 persons in all six areas, higher than the 1989 census figure of a Davis C. Russia's health reform: a complicated operation. The newsletter about reforming economies, 1993, 4(7): 1 (World Bank). 2.65 (4). More than half of the households consisted of a nuclear family. The non-nuclear-family house- holds were typified by a grandparent living with the family. Approximately 4% of mothers did not report a male adult living in the household. The data in Table 1 suggest that economic conditions in the sample were poor. Over 50% of mothers reported a monthly household income <30000 roubles (approximately US$ 30) per adult household member, the cost in September 1993 of the minimum subsistence food basket defined at that time by the government of the Russian Federation (5). The high number of households living in poverty is reflected by the high proportion of mothers who reported that >50% of household income was uti- lized for food (average food expenditure, 60-80% of income per adult household member, by area). Nutritional status The prevalence of protein-energy malnutrition, as indicated by low weight-for-age (Z-score <-2), was not elevated by comparison with international refer- ence standards (Table 2, Fig. 1). The prevalence of malnutrition was low and was relatively constant for different age groups. This similarity across age groups suggests historical stability of nutritional sta- tus in the population sampled. Data obtained from medical records in all six areas reveal that obesity (weight-for-height Z-score > +2) is more of a prob- lem than protein-energy malnutrition (prevalence of obesity, 4-8.7%, by area). Weight-for-age measurements obtained during the survey were consistent with weight-for-age data extracted from medical records (data not reported). Mean height-for-age and weight-for-height as meas- ured during the survey were similar to the same vari- ables as extracted from medical records (Table 3). Monthly estimates of the prevalence of height-for- age Z-scores <-2 varied from 1.6% to 4.5% (cities) and from 0.9% to 3.9% (oblasts). Monthly estimates of the prevalence of low weight-for-height varied from 0% to 1.5% (cities) and from 0.6% to 4.5% (oblasts). The prevalence of low birth weight (<2500g) was also low, ranging between 3.7% and 7.1% in the different survey areas. The prevalence of low birth weight in the sample was comparable to that in Western countries (e.g. the prevalence of low birth weight in the USA was 7.1% in 1992) (6). Low birth weight was associated with low weight-for-age in the study: a child aged <12 months with a low birth weight as obtained from medical records was 6.5 times more likely to have a weight-for-age Z-score <-1 than a child with normal birth weight. WHO Bulletin OMS. Vol 74 1996 607 K. Welch et al. Table 2: Nutritional status of the study children % prevalence of: Age group (months)/ Mean weight- Mean weight- Low birth Area No. of children for-agea for-heighta Z-score <-2 Z-score >+2 weightb c Anaemiab,d 0.23 (0.92) 0.37 (1.01) 0.36 (1.10) 0.34 (1.19) 0.33 (1.08) 0.8 0.7 0.6 1.0 0.8 0.29 (0.98) 0.51 (1.08) 0.35 (1.14) 0.15 (1.09) 0.08 (0.20) 0.31 (1.09) 0.46 (1.08) 0.36 (1.11) 0.19 (1.05) 0.49 (1.10) 0.42 (1.04) 0.09 (1.10) 1.1 0.9 1.1 1.9 3.1 1.4 0.3 0.8 1.3 0.7 0.9 2.3 1.7 (0.55) 1.7 (0.53) 1.8 (0.55) _ 1.8 (0.57) 1.8 (0.54) - 1.9 (0.48) 4.8 (750) 12.9 (399) 6.4 (830) 11.6 (415) 6.1 (792) 15.3 (427) 3.7 (812) 4.9 (758) 7.1 (851) 28.6 (518) 27.1 (468) 24.9 (571) 5.6 4.0 6.5 8.7 7.8 6.0 a Figures in parentheses are the standard deviation. bThe number of children sampled for this variable is shown in parentheses. Low birth weight is defined as birth weight < 2500g. Anaemia is defined as haemoglobin <11 g/dl. The prevalence of anaemia was high, particu- Fig. 1. Comparison of the weight-for-age distributions larly among the population living in oblasts, with of the reference, oblast, and city populations. approximately one-fourth of such children being anaemic (i.e. haemoglobin -11 g/dl). This preva- 25- lence was much higher than that found recently in Reference the USA (the NHANES II study estimated that 20 Oblast 5.7% of children under 2 years of age were anaemic) /> ~City (7). A high level of anaemia was consistent with the /< \\ dietary changes mothers reported. Over one-third of 15- the mothers in the sample reported reduced house- hold food consumption in 1992. Many mothers re- 10- porting such a reduction explained that less meat (75% of mothers) and less fruit (90% of mothers) // \\ were eaten. The majority of children in the sample 5 /t T I ' < i ° (78%) did not take any vitamin supplements. 0 Immunization status and disease history -5 -4 -3 -2 -1 0 1 2 3 4 5 Z-score Immunization cards or medical records were avail- WHO Bulletin OMS. Vol 74 1996 City 0-5 6-11 12-17 >18 All ages Oblast 0-5 6-11 12-17 18-23 -24 All ages city Moscow St Petersburg Ekaterinburg Oblast Moscow St Petersburg Ekaterinburg city Moscow St Petersburg Ekaterinburg Oblast Moscow St Petersburg Ekaterinburg 383 560 625 799 2369 453 574 616 630 97 2371 747 830 789 473 749 814 463 806 795 756 664 749 608 Health and nutrition in Russian children Table 3: Nutritional status of the study children, at the time of the survey, compared with historical data from medical records Cities: Oblasts: Age group Mean weight- Mean height- Mean weight- Mean height- (months) for-height for-age for-height for-age 0-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 0.082 (-0.060)a 0.292 (0.437) 0.485 (0.507) 0.610 (0.490) 0.559 (0.393) 0.389 (0.337) 0.386 (0.260) 0.429 (0.277) 0.221 (0.167) 0.023 (-0.016) -0.098 (-0.067) -0.030 (-0.100) -0.040 (-0.087) -0.251 (0.113) -0.251 (0.090) 0.159 (0.207) -0.067 (-0.215) 0.350 (0.369) 0.623 (0.547) 0.703 (0.630) 0.553 (0.439) 0.628 (0.419) 0.408 (1.003) 0.573 (0.852) 0.264 (0.395) 0.166 (0.788) -0.015 (-0.031) -0.118 (0.150) -0.231 (-0.490) -0.067 (-0.526) -0.191 (-0.876) -0.284 (0.137) a Figures in parentheses are the mean, as extracted from medical records. able for 96% of children in cities and 99% in oblasts. Coverage with BCG was satisfactory (>90% for both cities and oblasts) (Table 4). Complete poliovirus and diphtheria-tetanus-pertussis (DTP) vaccine coverage, however, was far from good, with as many as 26-410% of children not covered for po- liomyelitis and 34-58% not covered for DTP at 12 months of age. Measles coverage was even lower, with only 12-39% of children at 1 year of age immu- nized. Survey morbidity findings (Table 5) indicate a high prevalence of respiratory illness, especially in Ekaterinburg oblast, where 30.7% of children were reported to have had a respiratory disease during the autumn of 1992. Infant feeding practices Initiation of breast-feeding was high among the women sampled and showed no significant differ- ences between cities and oblasts. Although breast- feeding was common, infant-feeding practices differed substantially from WHO recommendations (Table 6). Initiation of breast-feeding was often de- layed: >26% of women did not breast-feed their children within 24 hours. Among children less than 4 months of age, very few were exclusively or fully breast-fed. Contrary to WHO recommendations, a large percentage of children <4 months of age were breast-fed according to a schedule. Water and solids were introduced at a very early age. Most often mothers introduced water within the first month of life and fruit juices between the first and second months. Over 65% of children less than 4 months of age received semi-solid foods, such as fruit purees, cereals, egg yolks, and cottage cheese. These practices are consistent with infant-feeding recom- mendations from the Soviet era. Mothers had been advised to introduce water and juices as early as the first 2 months of life, and solids such as egg yolks and cottage cheese at 3 and 4 months. Other weaning foods, such as vegetable pur6es and cereals, were recommended as early as the fourth month of life. Mothers were also advised to feed their infants according to a fixed schedule, i.e. approximately every 3 hours (seven times a day) at 3 months of age, and five to six times a day at 6 months of age. Breast-feeding was discontinued quite early throughout the survey population in both cities and oblasts. The median duration of breast-feeding was 3 months. Lack of milk was the most commonly cited reason for the cessation of breast-feeding (ca. 50%). Other frequently cited reasons included the child's Table 4: Immunization status, at the time of the survey, of children aged 12- 14 months Area No. of children BCG (%) Polio (%) DTP (%) Measles (%) 93.2 69.5 97.2 59.2 94.2 73.9 100.0 72.7 57.6 97.0 70.2 58.2 93.8 67.2 65.6 WHO Bulletin OMS. Vol 74 1996 City Moscow St Petersburg Ekaterinburg Oblast Moscow St Petersburg Ekaterinburg 59 71 69 66 67 64 50.8 42.3 43.5 11.9 21.1 17.4 25.8 38.8 31.3 609 K. Welch et al. Table 5: Respiratory disease prevalence among study children, by season Area No. of children Wintera Springb Summerc Autumnd City Moscow 585 17.0% 12.0% 9.0% 24.8% St Petersburg 613 15.8% 11.4% 9.0% 19.4% Ekaterinburg 615 22.0% 12.0% 16.0% 29.1% Oblast Moscow NA" NA NA NA NA St Petersburg 483 13.0% 9.0% 12.0% 21.9% Ekaterinburg 547 17.0% 13.2% 15.0% 30.7% a Dec. 1991-Feb. 1992. b Mar. 1992-May 1992. c June 1992-Aug. 1992. d Sept. 1992-Nov. 1992. e NA = not available. refusal to breast-feed (15%) and maternal illness (10%). Bottle-feeding was common in both cities and oblasts. The prevalence of bottle-feeding among children <4 months of age was high; >70% of chil- dren in this age range received infant formula and >59% consumed milk other than breast milk. Discussion The results of this study are consistent with other findings concerning the health status of the popula- tion of the Russian Federation and also provide some explanatory information. In 1993, the report from the Ministry of Health of the Russian Federa- tion reported that diphtheria and measles were epidemic. Cases of diphtheria and measles had quadrupled compared with the previous year (8). This survey provides a partial explanation for the rise in the prevalence of these diseases. Completion of poliovirus and DTP vaccination schedules was far from good, with as many as 26-41% of children at 1 year of age not covered. Measles coverage was even lower, with only 12-39% of children at 1 year of age immunized. More effective immuniza- tion programmes are essential to prevent further deterioration in child health in the Russian Federation. Another group of illnesses that poses a serious health threat among the study population is respi- ratory illnesses. Survey findings indicate a high frequency of respiratory illness among the children- under-two population, especially in the Ekaterin- burg oblast, where 30.7% of the children were reported to have suffered from a respiratory illness during the autumn of 1992. This may be an under- estimate of the true frequency of respiratory illness Table 6: Breast-feeding indicators for study children aged 0-4 months Breast-fed children (%): Median Given Given duration No timely first By Given other solid or semi- Area (months) sucklinga Anyb Exclusivec FulId schedule formula (%) milk (%) solid food (%) city Moscow 3 33.4 (337)e 64.6 (65) 3.1 (65) 12.3 (5) 52.4 (42) 79.0 (596) 81.2 (604) 81.5 (604) St Petersburg 3 34.7 (350) 62.0 (100) 6.0 (100) 22.0 (100) 46.0 (63) 75.0 (512) 59.5 (664) 78.9 (664) Ekaterinburg 3 31.9 (322) 69.0 (84) 1.2 (84) 11.9 (84) 65.5 (58) 78.9 (513) 79.5 (654) 85.0 (654) Oblast Moscow 3 43.5 (400) 61.1 (96) 0.0 (96) 10.4 (96) 44.1 (59) 79.4 (475) 83.5 (639) 85.0 (639) St Petersburg 3 26.5 (244) 70.8 (89) 4.5 (89) 20.2 (89) 49.2 (63) 77.7 (503) 67.3 (608) 66.9 (608) Ekaterinburg 3 30.0 (276) 68.5 (111) 0.0 (111) 10.8 (111) 67.1 (76) 70.8 (367) 82.1 (705) 78.7 (703) 8 Did not initiate breast-feeding within 24 hours of birth. b Breast-fed at least once. c Fed breast milk only. d Fed breast milk and water only. * Figures in parentheses are numbers of children. WHO Bulletin OMS. Vol 74 1996610 Health and nutrition in Russian children in the population, as this study enumerated only those children that sought medical care. In 1993, the Institute of Medical and Socioeconomic Information reported that respiratory illness during the perinatal period contributed the most to infant mortality in Russia, which had increased from 27 per 1000 live births in 1990 to 29 per 1000 live births in 1993 (1). The only nutritional deficiency documented by this study is anaemia. The high prevalence of anae- mia was particularly marked in the oblasts, where approximately one-fourth of the children were anae- mic. This prevalence is comparable to those found in the Caribbean and parts of Latin America, where approximately 25% of preschool children suffer from anaemia.b Such a prevalence of anaemia is con- sistent with the dietary changes reported. Protein-energy malnutrition was not high among children in the survey areas. On the contrary, data from children's medical records reveal that 4.0- 8.7% of children were obese, a finding which is con- sistent with the Russian Longitudinal Monitoring Survey. This survey showed that obesity is a serious public health problem and that high fat consumption is a major cause.' Though protein-energy malnutrition is not a problem in this population, recent socioeconomic findings indicate that the food security of Russian households may be threatened. Data from this sur- vey revealed that the average share of income spent on food ranged from 60% to 80% and that >50% of households reported incomes, per adult household member, below the subsistence level. The cessation of state subsidies for many foods, reductions in entitlements for mothers and children, rising un- employment, and high inflation also threaten food security. The high percentage of Russian households liv- ing in poverty is reflected in recent findings of the Russian Research Center, at Harvard University. In 1993, the Center estimated that 75% of household income is spent on food by the average Russian fam- ily (9). The World Bank in 1993 lowered the estimate of Russia's per capita income by 30% (from US$ 3220 to US$ 2680), ranking it below Venezuela, Ar- gentina, Brazil, and Mexico (10). Survey results also indicate that infant-feeding practices identified in the present study may be det- rimental to children's health, as they are inconsistent with WHO recommendations. Outdated recommen- bMaternal and child health goals for 1995 and indicators for moni- toring progress. World Summit for Children, Interagency Coordi- nating Committee for the Americas, unpublished document. c Popkin B et al. Nutritional risk factors in the former Soviet Union. Paper presented at Adult Health Priorities and Policies in the New Independent States, Washington, DC, 17-18 November 1994. dations from the Soviet era are still followed, result- ing in a delayed initiation of breast-feeding, feeding according to a schedule, and the early introduction of supplementary foods. A recent study from the Ukraine shows similar patterns (11). There is thus a clear need for nutritional education programmes. Such infant-feeding practices are particularly troubling in a country where access to safe water is deteriorating. The Russian Federation's Ministry of Health recently reported that 50% of Russian peo- ple drank water that did not its meet safety guide- lines, and that typhus and dysentery had increased more than fourfold compared with 1992 levels (8). The early introduction of water, formula, and other types of milk could contribute to an increased fre- quency of gastrointestinal infections among and higher consumption of toxic substances by young children. In conclusion, it is clear that both health and food security should be addressed in order to protect the health of Russian children. Food security and health surveillance should both be given priority, in light of the deteriorating economic conditions in the Russian Federation. Acknowledgements We thank D. Headley, J. Szekeley, and B. West, as well as N. Krivchanskaya and L. Negrustuevna. We are grateful to L. Flachet, D. Rush, F. Reilly, and B. Magnani. We also thank S. Laumark for her advice while Director of CARE, Russian Federation, in 1992, and R. Roome for making the survey data available while Director of CARE, Russian Federation, from 1992 to 1994. Resume Sante et nutrition chez les enfants de moins de deux ans dans trois regions de Federation de Russie De juillet a decembre 1993, l'organisation d'aide humanitaire CARE a r6alis6 un programme d'en- quetes en F6deration de Russie afin d'identifier les groupes vulnerables sur le plan nutritionnel et d'evaluer leurs besoins. Trois villes (Moscou, St P6tersbourg et Ekaterinbourg) et les oblasts environnants ont e 6tudi6s par questionnaire, mesure directe des parametres de sant6 et collecte d'informations a partir des registres m6dicaux. Un 6chantillon repr6sentatif d'enfants de moins de deux ans a 6t6 constitue selon une proc6dure en deux 6tapes (villes) ou trois 6tapes (oblasts). Les listes d'enfants ont ete etablies a partir des registres des polycliniques, ou les meres ont ete interrog6es. WHO Bulletin OMS. Vol 74 1996 611 K. Welch et al. Les enfants ont ete peses conform6ment aux recommandations de l'OMS, et leur dossier medical a ete consult6. Le questionnaire 6tait destin6 a recueillir des informations sur les pratiques d'alimentation des nourrissons, le degr6 de securite des approvision- nements alimentaires, le niveau de connaissances nutritionnelles de la mere et les tendances familiales en matiere de consommation alimentaire. On a recherch6 dans les dossiers m6dicaux les antecedents de maladies respiratories et d'anemie ainsi que l'6tat vaccinal de l'enfant. La pr6valence de la malnutrition prot6ino- 6nerg6tique, indiquee par les valeurs de Z cor- respondant a un rapport poids/age insuffisant, a ete trouv6e faible. Les principaux problemes nutritionnels rencontr6s etaient l'obesite et l'an6mie, la pr6valence de cette derniere pouvant depasser 25% dans les oblasts. La morbidite due aux maladies respiratoires 6tait 6galement 6lev6e, ce qui peut s'expliquer par les faibles taux de vacci- nation observ6s pour certaines maladies. Ces taux etaient particulierement bas pour le DTC et surtout pour la rougeole, et etaient egalement faibles pour la poliomy6lite. Les pratiques d'alimentation des nourrissons s'6cartaient sensiblement des normes recommand6es par l'OMS. La securit6 des ap- provisionnements n'6tait pas assuree, plus du tiers des meres d6clarant une baisse de la con- sommation alimentaire l'ann6e pr6cedente, et la part du revenu familial consacr6e a l'alimentation 6tait tres 6lev6e (60-80%). Bien que les carences en macronutriments ne posent pas de probleme majeur dans cette popu- lation, la situation est loin d'etre satisfaisante etant donn6 la fragilit6 de l'etat de sant6 des enfants en Russie. 11 y a beaucoup a faire dans le domaine de l'education sanitaire et de la s6curit6 des approvisionnements, et des programmes destin6s a modifier les pratiques d'alimentation des nour- rissons, a encourager les vaccinations completes et a combattre l'anemie seraient les bienvenus. La population 6tudi6e 6tant vuln6rable, il faudra poursuivre la surveillance de fagon a pouvoir mettre en place des interventions appropri6es en cas de nouvelle d6gradation de 1'etat de sante et de 1'6tat nutritionnel des enfants. References 1. Komarov Y et al. [Health-care statistics and priority problems of health in CIS countries]. Moscow, Minis- try of Health, Institute of Medical and Socioeconomic Information, 1994 (in Russian). 2. How to weigh and measure children: assessing the nutritional status of young children in household sur- veys. New York, United Nations, Department of Tech- nical Co-operation for Development and Statistical Office, 1986. 3. Fong MS. The role of women in rebuilding the Rus- sian economy. Washington, DC, World Bank, 1993 (Studies of Economies in Transformation, No. 10). 4. [1989 All-Union census]. Soviet geography, 1991, 32: 209-248 (in Russian). 5. State Committee on Statistics. [1993 report]. Argumenty i fakty, November, 1993:1 (in Russian). 6. Health. United States: 1994. Hyattsville, MD, USA, National Center for Health Statistics, 1995. 7. Dallman PR et al. Prevalence and causes of anemia in the US: 1976-1980. American journal of clinical nutrition, 1984, 39: 437-445. 8. [Report on the health status of the Russian popula- tion: 1993]. Moscow, Ministry of Health, 1994 (in Russian). 9. Powell D. Russian health care is not in crisis but in a state of disaster. Washington Times, 16 February 1994: 10-11. 10. Reforming Russia's economy. Economist, 11 Decem- ber 1993: 23-25. 11. Ukraine maternity exit survey: a policy and technical monograph, Washington, DC, Ukraine Ministry of Health and Wellstart International, 1994. 612 WHO Bulletin OMS. Vol 74 1996