Prevalence and correlates of childhood malnutrition in the Terai region of Nepal

The c o n c l u s i o n s and v i s w s e x p r e s s e d i n t h i s p a p e r a r e t h o s e of t h e a u t h o r s and do n o t n e c e s s a r i l y r z f l c c t t h o s e of tha World Bank Group. ? o p u l a t i u u and tiurnan Zeaources E i v ? i s i o n D i s c u s s i o a Paper Xo. 31-35 PREVALENCE XND CORRELATES OF CHILDHOOD .%4LhVTRITI3N I N THE TERAI REGION OF .%PAL July 198'1 P r e p a r e d by: J o a n n e L e s l i e , J o h n s Xopkins U n i v e r s i t y B a l G o ~ a lBaidya, N e w ERA, Kathmandu Kalpana Nandwani , TlEDPE : T h i s ? a p e r -JaS p r e p a r e d a s ? a r t of Vorld aank r e s e s r c h p r o j e c t UCI 671-54, " E d u c a t i o n and. X u r a l i)evelopment'in Nepal and T h a i l a n d " . - The !Gorld ~ a n k . w a s h i n g t c . ~ , D.C. 20433 7. J.S.X. - e. I *  Abstract Data on 345 children aged 6 months to 6 years are analyzed to determine prevalence and correlates of malnutrition. The data are from the districts of Bara and Rautahat in the Terai region of Xepal and were pthered as part of a multisectoral study of the effects of education on subsistence farn households. Two sets of anthropometric and disease measures were made on the children, the first in the Fall of 1977 prior to the main annual rice harvest, and the second in the Spring of 1975. Sigh rates of malnutrition were found among these children, particularly in the Fall. At both surveys, slightly more than half the ( children were found to be suffering from chronic malnutrition (9% 0 of redian height-for-age). In the Fall of 1977, 292 were suffering from acute malnutrition (<80% of median weight-for-height). By the Spring, 1978, survey, the prevalence of acute malnutrition was down to 13% but this is still above the 9% reported for the Terai by the 1976 Nepal National Nutrition Survey. It was also found that children in Rautahat District tended to be more malnourished than children in Bara District. Prevalence of diarrhea and respiratory illness was found to be high among the children, especially at the Spring survey, and there was a significant association between illness and malnutrition. Socioeconomic 1 variables such as land ownership, crop output, caste and mother's score on,a test of cognitive ability were not found to be strongly associated with child nutritional status. There was, however, a definite tendency for children in - households owning more land to have higher nutritional status, oven though the effect was not statistically significant. w I The paper concludes that there are important differences in prevalence of child nalnutrition in the Terai by season, by district and by disease experience, but that available data on household characteristics do not show these to be major determinants of intra-sample variation in nu:ritional status.  PZVALENCE XTD COESXEUTES OF CHILDHOOD IX THE TERM REGION OF N E P . ~ WTRITION "r" Introduction R e s e a r c h from low-income countries has i d e n t i f i e d a considerable r a n g e of f a c t o r s a s s o c i a t e d , on a micro l e v e l , w i t h c h i l d m a l n u t r i t i o n . - Although t h e c a u s e s of m a l n u t r i t i o n d i f f e r i n i m p o r t a n t ways between c o u n t r i e s and between u r b a n and r u r a l communities w i t h i n t h e same c o u n t r y , t h e r e a r e a few f a c t o r s t h a t a r e q u i t e c o n s i s t e n t l y found t o be c o r r e l a t e d w i t h a h i g h e r p r e v a l e n c e of m a l n u t r i t i o n . I n terms of c h i l d v a r i a b l e s , p r o b a b l y t h e most important f a c t o r , i n a d d i t i o n t o age, a s s o c i a t e d with m a l n u t r i t i o n i s m o r b i d i t y , w i t h d i a r r h e a b c i n g t h e i l l n e s s most f r e q u e n t l y found t o be s i g n i f i c a n t l y a s s o c i a t e d w i t h m a l n u t r i t i o n ( T a y l o r , Kizlmann, and De Sweemer, 1979; Latham, 1975). I n terms of f a n i l y v a r i a b l e s , low income i s u s u a l l y found t o be t h e n o s t f i n p o r t a n t socioeconomic c o r r e l a t e of m a l n u t r i t i o n (The World Bank, 1980; Call & Levfnson, 1973). Although l e s s f r e q u e n t l y s t u d i e d , t h e r e is some e m p i r i c a l e v i d e n c e s u g g e s t i n g t h a t s p e c i f i c a a t e r t i a l c h a r a c t e r i s t i c s can be i m p o r t a n t d e t e r n i n a n t s of c h i l d n u t r i t i o n a l s t a t u s . N a t e r n a l e d u c a t i o n h a s been q u i t e c o n s i s t e n t l y found t o be p o s i t i v e l y a s s o c i a t e d w i t h b e t t e r c h i l d n u t r i t i o n a l s t a t u s (Cochrane, L e s l i e and O'Hara, 1980). h few s t u d i e s have a l s o found d i r e c t ineasures of t h e q u a l i t y of mate-rnal c a r e t o be s i g n i f i c a n t l y a s s o c i a t e d w i t h c h i l d nutritional s t a t u s L (Kielmann, 'Kielnann and Grewal, 1976; Graves, 1976; .P o l l i t t , r 1975). T h i s p a p e r d e s c r i b e s t h e p r e v a l e n c e of a a l n u t r i t i o n and m o r b i d i t y i n - i a p o p u l a t i o n of N e p a l i c h i l d r e n , measureJd once j u s t p r i o r t o t h e major a n n u a l L r i c e h a r v e s t and a g a i n s i x months l a t e r = a f t e r t h e wheat h a r v e s t . I t also I/ - The a u t h o r s a r e p a r t i c u l a r l y i n d e b t e d t o Dean T . Jamison and I b j e n d r a S h r e s t h a f o r h e l p f u l c o n v e r s a t i o n s on e a r l i e r d r a f t s of t h i s p a p e r . r e p o r t s on t h e c h i l d and h o u s e h o l d v a r i a b l e s t h a t were found t o be s i g n i f i c a n t l y associated with c h i l d n u t r i t i o n a l s t a t u s . X e p a l , w i t h a n e s t i m a t e d p e r c a p i t a income i n 1978 of $120.00 p e r • y e a r , r a n k s a s one of t h e p o o r e s t c o u n t r i e s i n t h e w o r l d . In addition to a low p e r c a p i t a income, Nepal a l s o h a s a n a d u l t l i t e r a c y r a t e of o n l y 19 I p e r c e n t , a n i n f a n t m o r t a l i t y r a t e of between 150 and 200 d e a t h s p e r 1,000 l i v e b i r t h s , and a c h i l d d e a t h r a t e , f o r c h i l d r e n between t h e a g e s of 1 and 4 y e a r s , of 32 p e r 1,000 p o p u l a t i o n . -1/ I n l i g h t of . ese s t a t i s t i c s , it is not s u r p r i s i n g t h a t t h e X a t i o n a l N u t r i t i o n Survey c o n d u c t e d i n 1976 u n d e r t h e a u s p i c e s of t h e X i n i s t r y of A g r i c u l t u r e of Yepal, w i t h s u p p o r t from t h e C n i t e d S t a t e s Agency f o r I n t e r n a t i o n a l Development a c d C e n t e r f o r D i s e a s e C o n t r o l , found a p r e v a l e n c e of c h r o n i c m a l n u t r i t i o n of 52% and a p r e v a l e n c e of a c u t e a l n u t r i t i s n of 6.7% ( B r i n k e t a l , 1976). Nethods T h i s s t u d y examined t h e n u t r i t i o n a l s t a t u s of r u r a l c h i l d r e n ( s i x t o s e v e n t y - n i n e n o n t h s ) i n two d i s t r i c t s i n t h e T e r a i r e g i o n of Kepal. The d i s t r i c t s s t u d i e d , Bara and R a u t a h a t , a r e j u s t n o r t h of t h e I n d i a n s t a t e of Bihar. During t h e l a s t t h r e e n o n t h s of 1977 a n d a g a i n i n A p r i l and Xay of 1978, a n t h r o p o n e t r i c measurements of a p p r o x i m a t e l y 600 c h i l d r e n were nade i n L - i - 1/ The c h i l d d e a t h r a t e and t h e a d u l t l i t e r a c y r a t e a r e from t h e World Development R e p o r t , 1980 (Washington, D.C. : The World 3ank, August, ? 1 9 8 0 ) . The Wofld Development S e p o r t , 1980, d i d n o t c i t e a n i n f a n t m o r t a l i t y rateHI'NR) f o r Yepal but a r e c e n t c o u n t r y economic r e p o r t , , - X e p a l : Development Performance and P r o s p e c t s (World Bank Country 2 S t u d y , December 1979), e s t i n a t e d a n IYR of 154 a s of 1977. The Yepal F e r t i l i t y Survey 1976 (Kathmandu: H i s >fa j e s t y 's Governrcent H e a l t h X i n i s t r y , Nepal Family P l a n n i n g and X a t e r n a l C h i l d t I e a l c h P r o j e c t ) c a l c u l a t e d a n IN7 of 152, which was s t a t e d t o be a low e s t i m a t e . s i x panchaya,t&/ of 3 a r a D i r ~ i i i : and s i x p a n c h a y a t s of R a u t a h a t ~ i s t r i c z j . Other i n f o r m a t i o n about. e a c h c 5 i d was o b t a i n e d , i n c l u d i n g l e n g t h of b r e a s t f e e d i n g , r e c e n t d i s e a s e e x p e r i e r ~ c eand r e l a t i o n s h i p t o t h e head of household. The age and h e i g h t of che c h i l d ' s mother was r e c o r d e d , a s w e l l a s t h e anounc of l a n d owned o r r s n t e d by che h o u s e h o l d , t h e c a s t e of t h e household and t h e number of c h i l d r e n i n t h e household. P a r e n t a l y e a r s of s c h o o l i n g were r e c o r d e d and b o t h p a r e n t s were g i v e n t e s t s of l i t e r a c y , numeracy, and a t e s t of g e n e r a l c o g n i t i v e a b i l i t y ( t h e Ravens P r o g r e s s i v e Xatrices Test). The h o u s e h o l d s t o be i n t e r v i e w e d were chosen randonly x i t h i n each panchayat. The h o u s e h o l d s a c t u a l l y i n t e r v i e w e d a r e a 15.25 p e r c e n t sample and t h e y a r e f a i r l y e v e n l y d i s t r i b u t e d among t h e Zwelve p a n c h a y a t s . Interviewers f o r t h e household v i s i t s were s e l e c t e d and t r a i n e d by New E M , t h e N e p a l i research organization with on-site responsibility f c r the projecc. The f i n a l f i e l d team comprised s e v e n n a l e s and seven f e m a l e s , who worked i d p a i r s . One p a i r was s o l e l y r e s ? o n s i b l e f o r t h e a n t h r o p o m e t r i c measurements and they were t r e i n e d by a UIVICEF/Nepal n u t r i t i o n i s t , who came down t o B i r g u n j from 'Kathmandu f o r t h e five-day t r a i n i n g session. Length o r h e i g h t was measured w i t h a wooden s t a n d i o m e t e r , c o n s t r u c t e d by :Jew ERA a c c o r d i n g t o s t a n d a r d i z e d g ~ i d e l i n e s ( J e l l i f f e , 1966). E e i g h t was measured t o t h e n e a r e s t t e n t h of a centimeter. For t h e s p r i n g , 1978, measurements, a S a l t e r hanging s p r i n g s c a l e P marked i n 100 gram i n t e r v a l s was used t o weigh a l l t h e c h i l d r e n . Because - - 1/ A panchayat i s t h e s m a l l e s t p o l i t i c a l and a d n i n i s t r a t i v e u n i t i n S e p a l . 2/ - Data . 8 collected on n u t r i t i o n a l s t a t u s and f a m i l y c h a r a c t e r i s t i c s ,;ere a s one s e c t i o n of a World Sank r e s e a r c h p r o j e c t examining t h e e f f e c t s of e d u c a t i o n and a g r i c u l t u r a l e x t e n s i o n on r u r a l development. The s i t e chosen f o r t h e p r o j e c t g a s d e t e r z i n e d by t h e m j o r r e s e a r c h o b j e c t i v e s . t h e s e s c a l e s d i d n o t a r r i v e i n t i m e f o r t h e F a l l , 1977, measurements, a f l o o r s c a l e - h a d t o be used. A f i v e k i l o g r a m s t a n d a r d w e i g h t was u s e d t o v e r i f y t h e s c a l e a f t e r each t h i r d o r f o u r t h c h i l d . I n t h e c a s e of a c h i l d who c o u l d not - s t a n d , t h e mother was wei-ghed w i t h and w i t h o u t h e r c h i l d aad :he child's w e i g h t was o b t a i n e d by s u b t r a c t i o n . I n t h e F a l l 1977 s u r v e y , x e i g h t was n e a s u r e d t o t h e n e a r e s t 500 g r a s and i n t h e S p r i n g 1978 s u r v e y , w e i g h t w a s z e a s u r e d t o t h e n e a r e s t 100 grams. I n t h e F a l l 1977 s u r v e y , a n c i r c u m f e r e n c e was measured w i t h a p l a s t i c t a p s developed by UNICEF f o r u s e i n Xepal. I t has t h r e e s e c t i o n s z a r k e d i n d i f f e r e n t c o l o r s , which c o r r e s p o n d t o t h e d e g r e e of salnutritior?. The g r e e n s e c t i o n i s 13.5 t o 17.0 c e n t i m e t e r s , t h e y e l l m s e c t i o n i s 12.5 t o 13.5 c e n t i m e t e r s , and t h e r e d s e c t i o n is 9.5 t o 12.5 centimeters. Arm c i r c u n f e r e n c e was simply r e c o r d e d as g r e e n , y e l l o w , o r red. In t h e S p r i c g 1978 s u r v e y , t h e Z u r f u s i n s e r t i o n t a p e s were used t o measure a m c i r c u m f e r e n c e and t h e measurement was r e c o r d e d t o t h e n e a r e s t t e n t h of a c e n t i m e t e r . No w r i t t e n b i r t h r e c o r d s were a v a i l a b l e f o r t h e c h i l d r e n . S t a t e d age was r e c o r d e d a s a g e i n months, and b i r t h d a t e was r e c o r d e d s e p a r a t e l y . Although f o r young c h i l d r e n n o t h e r s were r e a s o n a b l y c o n f i d e n t i n s t a t i n g a g e , t h e f f e l d workers d i d a s s i s t some by r e f e r e n c e t o a n n u a l f e s t i v a l s and i m p o r t a n t l o c a l evenits. The New EIU s t a f f l a t e r compared t h e s t a t e d a g e i n months w i t h t h e a g e c a l c ~ l a t e df r o a t h e b i r t h d a t e . In t h e c a s e of a d i s c r e p a n c y , a f u r t h e r check v a s made by r e f e r r i n g t o a f e r t i l i t y h i s t o r y of - t h e mothgr t h a t had been r e c o r d e d a t a d i f f e r e n t time d u r i n g t h e s u r v e y . '9 In - most c a s e s , by c o ~ p a r i n gt h e s t a t e d a g e s and b i r t h d a t e s r e c o r d e d i n t h e F a l l 1977 sur'vey w i t h t h o s e r e c o r d e d i n t h e S p r i n g 1378 s u r v e y (and r e f e r r i n g t o Q .. t h e f e r t i l i t y h i s t o r y i f n e c e s s a r y ) , i t was p o s s i b l e t o f e e l c o n f i d e n t of having a reasonably a c c u r a t e age f o r t h e c h i l d .  Gomez (Gomez e t a l , 1956) and V a t e r l o w (Waterlow, 1976) ~ o t h c l a s s i f i c a t i o n s of m a l n u t r i t i o n art? used t o d e s c r i b e t h e n u t r i t i o n a l s t a t u s o f t h e children. The r e l a t i o n s h i p between n u t r i t i o n a l s t a t u s , i l l n e s s and household c h a r a c t e r i s : i c s v a s p r i n a r i l y a n a l y z e d i n t e n s of t h e ' d a t e r l o w z a t e g o r i e s of s t u n t e d (<90Z o f median h e i g h t - f o r - a g e ) , which i s c o n s i d e r e d t o be a z e a s u r e of c h r o n i c a a l n u t r i t i o n , and wasted (<a02 of s e d i a n weight-for- h e i g h t ) , which i s c o n s i d e r e d t o be a n e a s u r e of a c u t e m a l n u t r i t i o n . A n a l y s i s of t h e d a t a was done w i t h t h e S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s (SPSS) . S i g n i f i c a n c e of d i f f e r e n c e s between g r o u p s -ms t e s t e d using Students 'It" test o r t h e Chi-square test. ill1 a n a l y s e s r e p o r t e d i n t h i s paper x e r e done on a sample of 345 c h i l d r e n ( I 6 4 g i r l s a n d 181 b o y s ) who were measured i n b o t h t h e Fall 1977 s u r v e y and t h e S p r i n g 1978 s u r v e y and whose r e c o r d s c o u l d be a a t c h e d . .-2 comparison of c ' h a r a c t e r i s t i c s o f t h i s m t c h e d sample w i t h t h e c h a r a c t e r i s t i c s of t h e f u l l sample of a l m o s t 600 c h i l d r e n who were measured i n t h e F a l l 1977 s u r v e y ( L e s l i e , 1978) showed t h a t t h e y do n o t d i f f e r s i g n i f i c a n t l y . Results T a b l e 1 compares t h e s e x , a g e , n u t r i t i o n a l s t a t u s , b r e a s t f e e d i n g s t a t u s , and i l l n e s s s t a t u s of t h e 345 sample c h i l d r e n a t t h e F a l l 1977 and S p r i n g Y978 s u r v e y s . It a l s o i n c l u d e s i n f o m a t i o n on t h e i r , p a r e n t s ' a g e s and heights. The a v e r a g e a g e of t h e g r o u p i n ti% S p r i n g of 1978 was a p p r o x i m a t e l y '5The six months o l d e r t h a n i n t h e F a l l of 1977. - o l d e r average age explains t h e - s i g n i f i c a n t l y g r e a t e r h e i s h t s and p a r t , b u b n o t a l l , of t h e s i g n i f i c a n t l y greater ueights. When a g e i s a d j u s t e d f o r by c a l c u l a t i n g h e i g h t - f o r - a g e and weight-for-age ( b o t h a r c c a l c u l a t e d a s a p e r c e n t a g e of t h e S a t i o n a l C e n t e r f o r  Table 1 - COl.LP.AXISON OF SXXF'LE CHARACTERISTICS BET'H'EEN FALL 1977 .L\3 SPRING 1 9 7 8 3y Xeans a n d S t a n d a r d D e v i a t i o n s F a l l 1977 S p r i n g 1978 Stacdard Standard Variable - Hean Deviation Deviatioc Age ( i n months) Height ( i n c n s ) Xeight ( i n kgs.) H e i g h t f o r Age Weight f o r Age Weight f o r H e i g h t 86.24 12.72 89.86* 10.66 X o t h e r ' s Age ( i n y e a r s ) 30.94 7.37 30.99 6.77 Yother's Height ( i n cns.) 146.86 4.92 149.15 5.74 F a t h e r ' s Age ( i n y e a r s ) N/A N/A 36.40 8.95 F a t h e r ' s H e i g h t ( i n cms.) X/A N /A 162.16 5.60 3y P e r c e n t a g e s Variable F a l l 1977 S p r i n g 1978 A r m Circum- g r e e n (13.5-17.0) 53.4 54.2* f erence y e l l o w (12.5-13.4) 31.8 22. l* ( i n ens.) red ( 9.5-12.4) 14.P 13.7 S t i l l breas tfeeding 46.4 42.8 Present Sespiratory Disease 42.0 48.5 ?resent Gastrointestinal Disease Past Respiratory Disease 19.6 31.2 56. l* - i Past Gastrointestinal Disease ' 20.6 51.9* ' f * F a l l 1977 v a i u e s i g n i f i c a n t l y d i f f e r e n t from S p r i n g 1975 v a l u e (p <.01)  -1- H e a l t h S t a t i s t i c s r e f e r e n c e w e i g h t s and h e i g h t s ) , we f i n d t h a t t h e r z is no s i g n i f i c a n t d i f f e r e n c e i n average height-for-age but t h e r e i s a s i g n i f i c a n t d i f f e r e n c e i n average v e i ~ h t - f o r - a g e . !hen we look a t w e i g h t - f o r - h a i g h t , an age i n d e p e n d e n t measures of s h o r t t e r n n u t r i t i o n a l s t a t u s , w e f i n d t h a t t h e c h i l d r e n had s i g n i f i c a n t l y D e t t 2 r w e i g h t - f o r - h e i g h t i n t h e S p r i n g of 1978. There were a l s o s i g n i f i c a n t l y more c h i l d r e n w i t h arm circumference g r e a t e r t h a n 13.5 cm i n t h e S p r i n g of 1978. A 1 1 t h e s e n e a s u r e s s u g g e s t t h e same t h i n g , t h a t t h e s h o r t t e r n n u t r i t i o n a l s t a t u s of t h e c h i l d r e n i d p r o v e d s i g n i f i c a n t l y between t h e F a l l of 1977 and t h e S p r i n g of 1978. The d i s e a s e p r e v a l e n c e d a t a a r e more d i f f i c u l t t o compare. It a p p e a r s t h z t =ore c h i l d r e n were r e p o r t e d t o be c u r r e n t l y s i c k i n t h e S p r i n g of 1978 t h a n i n t h e F a l l of 1977, b u t t h e n a g n i t u d e of t h e d i f f e r e n c e i s u n c l e a r b e c a u s e , d u r i n g t h e f i r s t s u r v e y mothers were asked whether t h e c h i l d had respiratory disease - o r g a s t r o i n t e s t i n a l d i s e a s e , whereas d u r i n g t h e second s u r v e y , t h e r e were s e p a r a t e q u e s t i o n s c o n c e r n i n g each d i s e a s e . The d i f f e r e n c e between t h e two s u r v e y s i n p a s t month p r e v a l e n c e of r e s p i r a t o r y d i s e a s e and of g a s t r o i n t e s t i n a l d i s e a s e i s v e r y l a r g e , b u t we have some c o n c e r n t h a t t h e low p r e v a l e n c e i n t h e F a l l of 1977 may p a r t i a l l y r e s u l t from t h e - ~ q yt h e q u e s t i o n was p h r a s e d . Both Gomez v e i g h t - f o r - a g e c a t e g o r i e s and Waterlow h e i g h t - f o r - a g e and weight-f o r - h e i g h t c a t e g o r i e s v e r e used t o n e a s u r e t h e p r e v a l e n c e and t o h a n a l y z e c o r r e l a t e s of m a l n u t r i t i o n - I n F a l l , 1977, of t h e 345 children, 6 7 2 were Gomez ? o r 3 (<75% w t / a g e ) , 55% were s t u n t e d ((90% h t / a g e ) , and 29% were wasted (<80% w t / h t ) . I n S p r i n g , 1978, 59% were Gomez 2 o r 3 , 54% were s t u n t e d , and 13% z e i e wasted. L'sing t h e s e cut-c~ff p o i n t s , ;re a g a i n f i n d N e v i d e n c e of an i m p r o v e ~ e n t i n weight s t a t u s , b u t - n o t i n h e i g h t s t a t u s , l u r i n g t h e s i x - s o n t h i n t e r v a l ( s e e t o t a l s on T a b l e 5).  The change i n n u t r i t i o n a l s t a t u s b e t v e e n t h e tw? s u r v z y s c a n be s e e n i n g r e a t e r d e t a i l ic F i g u r e 1. Yore t h a n t h r e e - q u a r t e r s of t h e 109 . ~ r m a l l y growing c h i l d r e n i n t h e ? a l l of 1977 were s t i l l i n t h i s c a t e g o r y i n t h e S p r i n g of 1978, l e s s t h a n t e n p e r c e n t had become w a s t e d , and none had d e c l i n e d i n t o t h e poorest nutrit:onal stat-JS category: s t u n t e d and wasted. Cf t h e 137 i n i t i a l l y s t u n t e d c h i l d r e n , nore than two-thirds remained i n t h a t c a t e g o r y , a b o u t o n e - f i f t h moved i n t o t h e normal c a t i g o r y , . and o n l y a s m a l l p r o p o r t i o n became x a s t e d o r s t u n t e d and w a s t e d . In c o n t r a s t , approximately half the w a s t e d c h i l d r e n aoved i n t o t h e normal c a t e g o r y , and a p ~ r o x i a a t e l ya n o t h e r t h i r d move; i n t o t h e s t u n t e d c a t e g o r y , which i n d i c a t e s c h r o n i c b u t n o t a c u t e malqutrition, Of t h o s e 52 c h i l d r e n who were b o t h s t u n t e d a n d w a s t e d i n t h e F a l l of 1977, a l n o s t t h r e e I a a r t e r s were s t i l l s t u n t e d but n c t wasted 5y t h e S p r i n g of 1978. ilowever, a b o u t o n e - f i f t h o f t h e s remained s t u n t e d and wasted s i x months i a t e r . I n f a c t , t h e s e 10 c h i l d r e n who had a l s o t s e n s t u n t e d and w a s t e d a t t h e t i m e of :be i n i t i a l s u r v e y r e p r e s e n t a l m o s t h a l f of a l l t h e c a s e s of s t u n t e d and wasted i n t h e S p r i n g of 1978. I n a d d i t i o n t o t h i s marked s e a s o n a l change i n n u t r i t i o r l a l s t a t u s , c o n s i s t e n t d i f f e r e n c e s were found b e t v e e n t h e r ~ t r i t i o n a ls t a t u s of c h i l d r e n i n Bara D i s t r i c t and c h i l d r e n i n b u t a h a t D i s t r i c t . When Gomez c a t e g o r i e s were used ( s e e T a b l e 2) t o d e s c r i b e n u t r i t i o n a l s t a t u s we found t h a t , i n F a l l 1977, t h e n u t r i t i o n a l s t a t u s of c h i l d r e n x a s s i g n i f i c a n t l y v o r s e i n R a u t a h a t 8 I t h a n i n Bara ( x = 18.5, p <.001). I n S p r i n g 1978, t h e n u t r i t i o n a l s t a t u s of - c h i l d r e n i n b o t h d i s t r i c t s had improved; i t h e d i f f s r e n c e between t h e d i s t r i c t s r e m e n e d b u t i t had b e c o ~ el e s s s i g n i f i c a n t ( x = 8.9, .01 < p <.05). - - h s l i g h t l y d i f f e r e n t p i c t u r e emerged w h ~ nn u t r i t i o n a l s t a t u s i n t h e - s two T i s t r i c t s was conpared on t h e b a s i s of w a s t i n g and s t u n t i n g ( s e e T a b l e . 3). I n F a l l 1977, t h e r e was s i g n i f i c a n t l y n o r e w a s t i n g i n b u t a h a t t h a n in Table 2 - DISTRIBUTION OF 345 CdILDREN BY DISTRICT ikW GOXEZ WEIGHT PO2 AGE C YTZGORIZS, FALL 1977 A\9 SPRING 1978 Gomez F a l l 1977 S p r i n g 1978 categories 3ara Rautahat Bara Bautahat - Normal 51 2% 13% 7% - >90% wt/age (7) (4) (20) (13) Grade 1 38% 20% 35% 27X 7 52-892 wt/age (57) (39) (52) (53) Grade 2 41Z 5 1% 43% 541 60%-74% ;rt/age (61) (100) (64) (106) Grade 3 16% 27% 9% 12% (60% wt/age (24) (53) (13) (24) N (Total) 149 196 149 196  Table 3 - DISTRIBUTION OF 3L5 SXYPLE CHILDREN BY T)ISTSLCT, -XYD WATERLOW HSIGHT-FOR-AGE LSD k'5LGHT-FOR-8EIG-dT CATEGORLSS; FALL, 1977, ASD SPSING, 1978 \Ja t e r low F a l l 1977 _ S p r i n g 1973 categories Sara .bucahac aara :butahat Stunted 542 552 442 62% (90% h t /ape :?orma1 80% 652 S9X 862 - >80% w t / h t N'as t e d 20% 35% i 1% 14% (80% w t / h t N (Total) 149 196 149 196 a a r a (35% corrpared w i t h 20%, x = 9.2, p <.002), b u t t h e r e has a v e r y s i n i l a r l e v e l of s t u n t i n g (55% compared w i t h 5 4 X ) . I n S p r i n g 1978, t h e d i f f e r e n c e i n w a s t i n g was no l o n g e r s i g n i f i c a n t (10% f o r R a u t a h a t c o s p a r e d w i t h 11% f o r b S r a ) , but t h e r e ws s i g n i f i c a n t l y more s t u n t i n g i n h u t a h a t (67% compared - w i t h 46X, X = 9.7, p <.002). ; h e n t h e n u t r i t i o n a l s t a t u s of c h i l d r e n was e x a n i n e d s e p a r a t e l y f o r e a c h p a c h a y a t some v a r i a t i o n was f o u n d , b u t t h e o n l y s i g n i f i c a n t d i f f e r e n c e s v e r e found t o be t h o s e between t h e t v o d i s t r i c t s . T a b l e 4 shows t h e p a t t e r n s of s t u n t i n g and w a s t i n g by a g e group a t t h e two s u r v e y s . !Je n o t e f i r s t t h a t t h e p e r i o d of g r e a t e s t n a l n u t r i t i o n , i n t e n s e i t h e r of s t l m t i n g o r of -wasting was 12-23 months. There were a l s o t h e g r e a t e s t p r o p o r t i o n of c h i l d r c n w i t h low weight-for-age i n t h e 12-23 n o n t h g r o u p , e x c e p t f o r t h e f - 1 1 -nth c h i l d r e n i n t h e F a l l survey. The second i n t e r e s t i n g o b s e r v a t i o n t o be a a d e from T a b l e 4 i s t h a t = s t i n g v a r i e d more by age than did s t u n t i n g ; i n t h e F a l l o f 1977 t h e r e .+as a p a r t i c u l a r l y d r a m a t i c d e c l i n e i n wascing a f t e r 35 s o n t h s . D i s e a s e a l s o peaked i n t h e 12-23 inonth a g e group i n t h e F a l l 1977 s u r v e y , b u t t h e a g e d i f f e r e n t i a l s a r e much l e s s s t r i k i n g t h a n f o r .&sting. For S p r i n g 1978, t h e d i s e a s e d a t a were b e t t e r because c u r r e n t d i s e a s e , a s w e l l a s d i s e a s e i n t h e p r i o r month, were s e p a r a t e d f n t o g a s t r o i n t e s t i n a l and respiratory disease. The o v e r a l l r e p o r t e d d i s e a s e p r e v a l e n c e was h i g h e r i n I f S p r i n g 1978 t h a n i n F a l l 1977 a n d t h e r e was more s i m i l a r i t y between c u r r e n t Q i s e a s e and d i s e a s e i n che p r i o r a o n t h . A s c a n be s e e n i n T a b l e 5 , d i s e a s e i S u v a l e n c e was c o n s i s t e n t l y h i g h e s t i n t h e 12-23 month a g e group and l o w e s t &r c h i l d r e r . over 6 y e a r s . - ! m - There v a s a s i g n i f i c a n t c o r r e l a t i o n between d i s e a s e and d i s z r i c t of - residence. s 'nigher p r e v a l e n c e of d i s e a s e For a l l d i s e a s e i i e a s u r e s , t h e r e ~ 2 a  Table 4 - DISTRISUTION OF 345 SXYPLE CHILDREN BY AGE A L ' D ?JWTRITIONAL STATUS, FALL 1977 . U 4D SPRING 1 9 7 8 F a l l 1977 Age g r o u p <7 5 X -at/ a g e <90% h t / a g e <80% w t / h t N Total 67% 55X S p r i n g 1978 ilge Group <75% w t / a g e <90% h t / a g e <80% w t / h t N Total 59% 54% 13X 345  - -- 5- 3ISTBI3LlTIOX OF 341 SAMPLE CHILDEN - --;r+e - 3ISZASE CATEGORIES I N SPRIXG 1978 &Y AGE AYD ~25% -*- ;-z :-.+Lzztnt Current P a s t ?lonth P a s t ?lonth P .-- * -PA= --- - 3-2tass Resp. D i s e a s e G I Disease Sesp. Disease - Xumber a/ --:- -- ;r% 68% 62% 63% 60 6- ---- -- : ,& - LE A -2d i s e a s e items, numbers were one o r two s m a l l e r due t o .- 7* - -. ~=smibilses. r e p o r t e d i n Bara t h a n i n R a u t a h a t , and f o r most z e a s u r e s t h e d i f f e r e n c e was s t a t i s t i c a l l y significant- 1I . I n s p i t e of t h e seeming c o n t r a d i c t i o n of more d i s e a s e b u t b e t t e r n u t r i t i o n a l s t a t u s anong t h e Bara c h i l d r e n , w e s t i l l found a s t r o n g c o r r e l a t i o n between d i s e a s e and n u t r i t i o n s t a t u s . Xowever, t h e a s s o c i a t i o n b e t z e e n d i s e a s e and n u t r i t i o n a l s t a t u s was much s t r o n g e r i n t h e F a l l of 1977 t h a n in t h e S p r i n g of 1978. Table 6 shows t h a t i n t h e P a l l of 1977 t h o s e r e p o r t e d ill had c o n s i s t e n t l y p o o r e r n u t r i t i o n a l s t a t u s and t h e d i f f e r e n c e . a s s t a t i s t i c a l l y s i g n i f i c a n t f o r a l l c a s e s e x c e p t t h e a s s o c i a t i o n between crasting and r e s p i r a t o r y d i s e a s e d u r i n g t h e p r i o r month. I n t h e S p r i n g of 1978, t h e r e was no a s s o c i a t i o n between s t u n t i n g and ' d i s e a s e s t a t u s . Those r e p o r t e d ill were c o n s i s t e n t l y more wasted b u t t h e d i f f e r e n c e .as s t i i t i s t i c a l l y s i g n i f i c a n t o n l y f o r t h e a s s o c i a t i o n between c u r r e n t g a s t r o i n t e s t i n a l d i s e a s e and w a s t i n g . S e v e r a l p a r e n t a l and household c h a r a c t e r i s t i c s were examined s e p a r a t s l y f o r possible associations with c h i l d n u t r i t i o n a l s t a t u s . Three a g r i c u l t u r a l a e a s u r e s f o r e a c h c h i l d ' s h o u s e h o l d were e x a n i n e d : per c a p i t a l a n d , p e r c a p i t a o u t p u t ( i n c l u d i n g b o t h r i c e and wheat) a n d p e r c a p i t a v a l u e of o u t p u t i n r u p e e s ; t h e f i n d i n g s were somewhat i n c o n c l u s i v e . I n t h e F a l l of 1977, t h e r e were s i g n i f i c a n t l y more s t u n t e d c h i l d r e n i n t h e f a m i l i e s w i t h t h e l e a s t l a n d compared w i t h t h e f a m i l i e s w i t h t h e most l a n d ; the difference remained b u t was n o t s t a t i s t i c a l l y s i g n i f i c a n t i n S p r i n g 1978 (,s& Table 7 ) . No a s s o c i a t i o n was 5ound between per c a p i t a l a n d and w a s t i n g a t e i t h e r survey. However, i n t h e F a l l of 1977, t h e r e were s i g n i f i c a n t l y more wasted c h i l d r e n i n t h e f a m i l i e s w i t h t h e l o w e s t p e r c a p i t a o u t p u t com$ared w i t h t h e - 1/ On a v e r a g e , h o ~ s e h o l d si n t h e R a u t a h a t s t u d y a r e a had e a s i e r a c c e s s t 3 a h e a l t h c l i n i c and t o b a s i c n e d i c i n e s t h a n h o u s e h o l d s i n t h e Bara s t u d y area.  Table 6 - PERCENTAGEOF VASTFYD AND STUNTED CHILDREN 3Y DISEASE CATEGORIES, FALL 1977 - 1 9SPRISG 1973 Fall 1977 Spring 1978 Vast ed Stunted Wasted Stunted . Current GI or W Yes 401" 62X* 1 2'0 2 1% 5 1% Current GI Yes No Current RD Yes No Past Yonth GI Yes Xo' Past lionth XD Yes No * Difference between those reported ill and those reported not-ill was statistically significant.  Table 7 - PEilCENT.\GE OF WAST5D .L?ii STUhTED CHILDREN SY ?EX CXPITX LX\- OF HOUSEHOLD; ?.ALL 1977 XW SPRING 1973 P e r C a p i t a Land ( i n b i g h a s ) F a l l 1977 Wasted 30% 28% 29% 36% 21% Stunted 62% 63% 54% 5 31: 44% S p r i n g 1978 Wasted 16% 15% 10% 15% 10% Stunted 62% 59X 46% 36% 52%  - 18 - f a m i l i e s w i t h t h o h i g h e s t p e r c a p i t a o u t p u t and t h e saae s i g n i f i c a n t a s s o c i a t i o n sms found f o r p e r c a p i t a v a l u e of o u t p u t . T5e a s s o c i a t i o n between v a s t i n g and per c a p i t a oucput was no l o n g e r s t a t i s t i c a l l y s i g n i f i c a n t i n . S p r i n g 1978. No a s s o c i a t i o n was found between s t u n t i n g a n d p e r c a p i t a o u t p u t a t e i t h e r survey. - C a s t e a f f i l i a t i o n v a s coded t o d i v i d e t h e sample h o u s e h o l d s i n t o s i x groups. Groups 1 t h r o u g h 4 a r e h i e r a r c h i c a l : Group 1 i s h i g h c a s t e h o u s e h o l d s s u c h a s Brahman, R a j ~ u tand 'Kayastha; Group 2 i s " b u s i n e s s " c a s t e s s u c h a s Saha, Kalwar a n d ;Gnu; Group 3 i s " f a r n i n g " c a s t e s s u c h as b u t , :Qhato, G i r i , Chaudhary a n d Yadav; Group 4 i s " o c c u p a t i o n a l " c a s t e s s u c h a s S a h n i , b s , Chamar, Thakur , Dusadh a n d De-an. Group 5 i n c L u d e s a l l t h e h o u s e h o l d s from t h e h i l l c a s t e s ( S h r e s t h a , Upadhyaya, P r a d h a n ) , a n d Group 6 i n c l u d e s t h e few h o u s e h o l d s t 5 a t d i d n o t f i t i n t o a n y of t h e o t h e r groups. No s t r o n g a s s o c i a t i o n was found between c a s t e g r o u p a n d c h i l d n u t r i t i o n a l s t u a t u s ( s e e T a b l e 8 ) b c t i f j u s t g r o u p s 1 t h r o u g h 4 a r e c o n s i d e r e d , we s e e t h a t t h e r e a r e a h i g h e r f r a c t i o n c f s t u n t e d c h i l d r e n i n groups 3 and 4 than i n groups 1 a n d 2. Because few of t h e rcothers had a t t e n d e d s c h o o l , we -Jere unable t o examine t h e r e l a t i o n s h i p b e t v e e n m a t e r n a l e d u c a t i o n a n d c h i l d n u t r i t i o n a l s t a t u s a s had been i n t e n d e d . However, T a b l e 9 shows t h e r e l a t i o n s h p between c h i l d n u t r i t i o n a l s t a t u s a d a o t h e r s ' s c o r e on t h e Xavens P r o g r e s s i v e ?latrice? I T e s t , which i s b a s i c a l l y a n i n t e l l i g e n c e t e s t . I n t h e F a l l o f 1977, t h e r e w a s some t e n d e n c y Eor t h e r e t o b e l e s s m a l n u t r i t i o n ( b o t h i n t e r n s f f w a s t i n g a n d * - ' of s t u n t i n g ) among t h e c h i l d r e n of m o t h e r s who a c h i e v e d h i g h e r ftT>I s c o r e s b u t I . i n t h e S B i n g o f 1978, t h e h i g h e r s c o r i n g mothers had s i g i E i c a t l y n o r e vasted children. - i I n S p r i n g , 1978, t h e p e r c e n t a g e of s t u n t e d c h i l d r e n was  Table 8 - PERCENTAGE DISTRI3UTLON OF VASTED ddW STUNTED CHILDREN BY CASTE; FALL 1977 .LD SP3ISG 1978 \ Caste Fall 1977 Was t ed 30% 27% 37% 22% 27% Stunted 49% 48% 65% 602 59% 48% Spring 1978 Wasted Stunted 19% 512 155: 50% 13% 57% 16% 59% 1 14% 45% 3% 53% X (Total) 47 62 46 70 58 62  Table 9 - PERCENTAGE OF VASTE;) . L- STUNTED C H I L D E N 3Y 'DTEER'S \ S T ,:CN RAVZSS P R C G E S S I V F , >LATRICES TEST; 1977 -LSD S P R I S G 1375 >!other's RP?! Score - a/ P a l l 1977 %asted 34% 31X 25% 29% 23% Stunted 63% 6 7% 63% 58% 5&% Spring 1979 Wasted 5;6 8% 14% Stunted 68% 69% 46% N (Total) 38 36 - a/ . and . This is the sum of the score on the A G I subtests. lower among t h e h i g h e r s c o r i n g z o t 5 e r . j b u t t h e d i f f e r e n c e anong t h e f i v e c a t e g o r i e s was n o t s i g n i f i c a n t . No s i g n i f i c a n t c o r r e l a t i o n -&isfound between s e x ar.d c h i l d ' s nutritional status. Y e i t h e r inat-.rnal 9sr p t e r n a l h e i g h t were a s s o c i a t e d w i t h c h l l d n u t r i t i o n a l s t a t u s , x h i c h s u g g e s t s t h a c i n t h i s popula.tion low h e i g h t f o r a g e i s a o r e a s e a s u r e of l o n g t e n n c r ~ i t i o n a ls t a t u s t h a n a measure o f genetic height potential. There - a s a l s o no s i g n i f i c a n t a s s o c i a t i o n found between p a r e n t a l a g e a n d c h i l d n u t r i t i o n a l s t a t u s , but t h e r e was a s i g n i f i c a n t a s s o c i a t i o n b e t x e e n c h i l d a g e and c h i l d n u t r i t i o n a l s t a t u s , a s r~ass e e n i n Table 4. Discussion Perhaps t h e inost i n t e r e s t i n g and r o b u s t findir'g f r o n t h i s s t u d y of n u t r i t i o n a l s t a t u s ineasured a t two tiaes was t h 2 d e c r e a s e i n p r e v a l e n c e of a c u t e m a l n u t r i t i o n found between F a l l , 1977, and S p r i n g , 1978. The F a l l , 1977, s u r v e y . a s made b e f o r e t h e = i n rice h a r v e s t , which c o n e s i n Sovember/December, and t h i s i s g e n e r a l l y a t l m e when food s u p p l i e s a r e low. b u t a h a t was v i s i t e d a f t e r 3 a r a and t h u s t h e c h i l d r e n were f u r t h e r i n t o t h e "hungry season" when t h e y were measured. There -&is a s i g n i f i c a n t n e g a t i v e a s s o c i a t i o n found between weight f o r h e l g h t and number of d a y s i n t o t h e s u r v e y f o r t h e F a l l , 1977, v i s i t b u t not f o r t h e . S p r i n g , i978, v i s i t . Observatjons nade by t h e f i e l d workers were t k a t s t o r e s of food were n o r e reduced i n -- R a u t a h a t t h a n i n 3 a r a vhen fhey z a d a t h e F a l l , 1977, v i s i t ( a s evidenced by - :* more f a m i l i e s e a t i n g sweet p o t a t o e s ) b u t t h i s d i f f e r e n c e i n consumption b e t v e e n t h e two d i s t r i c t s * not n o t i c e d d u r i n g t h e S p r i n g , 1938, v i s i t . The I p r e v a l e n c e of m l n u t r i t i o n found i n i5e T e r a i by t h e Nepal Y a i i o n a l ! i u t r i t i o n Survey ( B r i n k e t a l . , 1975) .*as i 5 . 1 Z s t u n t e d and 8.7% y a s t e d . I2 our s t u d y  - 22 - a r e a , c;e foucd a p p r o x i s a t e l y 552 s t u n t e d i n b o t h F a l l , 1977, and S p r i n g , 1979, b u t 29% v a s t e d i n F a l l , 1977, and ! 3 X wasEec! i n S p r i n g 1978. The S e p a l Y a t l o n a l B u t r i t i o n Survey as done b e t x e e n j a c u a r y a c d Yay 1975. Ve c o n c l u d e t h a t c h i l d r e n i n o u r s t u d y x e r e somewhat more m l n o u r i s h e d t h a n t h e a v e r a g e f o r the T e r a i but t h a t t h e r e 2 1 ~ 0seem t o be s i g n i f i c a n t d i f f e r e n c e s i n p r e v a l e n c e of a c u t e o l a l c u t r i t i o n by s e a s o n a n d d i s t r i c t i n t h e T e r a i and t h a t t h i s must be c o n s i d e r e d i n p l a n n i n g a n y f u r t h e r s u r v e y s o r s t u d i s s i n t h e r e g i o n t h a t i n c l u d e n e a s u r e a e n t of n u t r i t i o n a l s t a t u s . I n a d d i t i o n t o t h e t r o a d p a t t e r n s of d i f f e r e n c e i n p r e v a l e n c e of w l n u t r i t i o n by s e a s o n a n d d i s t r i c t , we a l s o found a s t r o n g r e l a t i o n s h i p b e t y e e n d i s e a s e e x p e r i e n c e and n u t r i t i o n a l s t a t u s . The a s s o c i a t i o n between d i a r r h e a a n d z l n u t r i t i o n ;ms s t r o n g e r t h a n t h e a s s o c i a t i o n between r e s p i r a t o r y d i s e a s s and a a l n u t r i t i o n ; the only significant association between r e s p i r a t o r y d i s e a s e a l o n e and n u t r i t i o n a l s t a t u s was t h e f i n d i n g , i n F a l l 1977, of n o r e s t u n t e d c h i l d r e n among t h o s e xho r e p o r t e d r e s p i r a t o r y d i s e a s e d u r i n g t h s p a s t ruonth. Xo s i g n i f i c a n t r e l a t i o n s h i p - a s found b e t y e e n our d i s e a s e v a r i a b l e s a n d change i n n u t r i t i o n a l s t a t u s between F a l l , 1977, and S p r i n g , 1 9 7 8 , perhaps b e c a u s e none of t h e d i s e a s e v a r f a b l e s provided a n a c c u r a t e measure of i l l n e s s d u r i n g t h e i n t e r v e n i n g months. S u r p r i s i n g l y l i t t l e a s s o c i a t i o n v a s found between t h e f a a i l y c h a r a c c e r i s t i c s n e a s y r 2 d i n t h i s s u r v e y and c h i l d n u t r i t i o n a l s t a t u s . , Iq a follow-up s a r v e y done i n t h i s same p o p u l a t i o n L n December 1980/ J a n m r ; ~ 1981, q u a l i t a t i v e d i e t a r y i n t z k e i n f o m a t i o n x a s o b t a i n e d ir. a e d i t i o n t o n o s t of zhe 'I - s a a e socioeconomic a n d i l l n e s s a e a s u r e s . - I t i s hoped t t a t a n a l y s i s of t h e s e a g i t i o n a l d a t a -xi11 a l l o v u s t o e x p l a i a n o r e of t h e var'ation fmnd i n - &I n u t r i t i o n a l s t a t u s acocg t h e c h i l d r e n i a t h i s study a r e a .  X e f e- - rences S r i r - k , E.Y., W a n , I.H., S p l i t t e r , J . L . , S t a e h l i n g , X.W., Lane, J.\l., Nichaman, X.2. S ! u t r i t i o n a l s t a t - , s of c h i l d r e n i n N e p a l , 1975. ! 3 u l l . , World H e a l t h O r g a n i z a t i o n , 1976: 311-318. d Call, D. L. . L e v i n s o n , F.J. X s y s t e m a t i c approach t o n u t r i t i o n i n t e r v e n t i o n programs. I n Berg, A., Scrimshaw, X.S., i a l l , D.L., e d s . , N ~ t r i t i o n , S a t i o n a l Development and P l a n n i n g . Zambrldge, The YIT P r e s s : 165--197. Cochrane, S.H., L e s l i e , J., O'Hara, D.J. P a r e n t a l education and c h i l d h e a l t h . I n Cochrane, S.H., O'Hara, D . J . , L e s l i e , J . , e d s . The E f f e c t s of Z d u c a t i o n on H e a l t h . Washington, D.C., The X o r l d Bank, J u l y 1980: 56-91 ( I i o r l d Bar.k S t a f f Working Taper No. 505). Gomez, e t a l . X a r t a l i t y .in second and t h i r d d e g r e e m a l n ~ t r i t i o n . J . Trop. Ped. 1956; 2: 77. G r a v e s , P.L. S u t r i t i o n , i n f a n t b e h a v i o r , and m t e r n a l c h a r a c t e r i s t i c s : s p i l o t s t u d y i n West B e n g a l , I n d i a . Amer J. C l i c . Y Q t r . 1976; 29: 305-319. J e l l i f f e , D.B. The . h s e s s m e a t of t h e Y u t r i t i o n a l S t a t u s of t h e Community. Geneva: The World H e a l t h O r g a n i z a t i o n , 1966. Kielmann, N.S., Kielmann, X.X., Grewal, C.K. E t i o l o g i c a l d e t e r m i n a n t s of p r o t e i n c a l o r i e u n d e r n u t r i t i o n i n a rural c h i l d co~rxzunitjr. A c t a T r o p i c a Separatum. 1976; 33: 342-368. Latham, M.C. S u t r i t i o n and i n f e c t i o n i n n a t i o n a l develapment. I n Abelson, P.H. ed. Food: P o l i t i c s , Economics, S u t r i t i o n and R e s e a r c h . Washington D.C.: American A s s o c i a t i o n f o r t h e Advancement of S c i e n c e , 1975; 69-73. L e s l i e , J. Family C h a r a c t e r i s t i c s and t h e X u t r i t i o n a l S t a t u s of C h i l d r e n i a t h e T e r a i Region of Neapal. B a l t i m o r e : The 2ohns Hopkins S c h o o l of Hygiene and P u b l i c H e a l t h , 1978 ( u n p u b l i s h e d X a s t e r of S c i e n c e t h e s i s ) . P o l l i t t , E. F a i l u r e t o t h r i v e : s o c i o e c o n o m i c , d i e t a r y i n t a k e and mother- c h i l d i n t e r a c t i o n d a t a . F e d e r a t i o n Proc. 1975; 34: 15?1-1597. T a y l o r , C.E., Kielmann, A.X., DeSueemer, C. . N u t r i t i o . . and i n f e c t i o n . In i i e c h c i g l J r . H., ed. Y u t r i t i o n and E h e B o r l d Food Froblem. B a s e l : S. '(arger, 1979: 218-243. Waterlow, J . C . C l a s s i f i c a t i o n and d e f i n i t i o n of p r o t e i n - e n e r g y i n a l n u t r i t i o n . I n B e a t o n , G.H. and Bengoa, eds. X u t r i t i o r i i n P r e v e n t i v e X e d i c i n e . Geneva: The World H e a l t h O r g a n i z a t i o n , . 1976. ' - i ?! - 1 Xte p o r t , 1980. The Vorld 3ank. World ~ e v g l o ~ m e n Washington, D.C.: The World Bank, August, 1P80. I * ..  TOPULkTION & Ht?L\X RESOLXCES DIVISION DISCUSSION PXPSBS [A * by t h e number i n d i c a t e s t h e p a p e r i s Sank-confidential o r otherwise r e s t r i c t e d . ] Oey 4. Y e e s o o ~ , "Den- r a p h i c C h a r a c t e r i s t i c s of I n d i v i d u a l s and t h e L . Measurenent o f L i f e t i n e Income". F e b r u a r y 1981. Susan 3. Cochrane, "The Economics o f F e r t i l i t y w i t h Examples from Asia". F e b r u a r y 1981. Rashid F a r u q a e , " S o c i a l I n z r a s t r u c t u r e and S e r v i c e s i n Zimbabwe". F e b r u a r y 1981. Richard S a b o t , e t a l . , " C o g n i t i v e S k i l l s : T h e i r D e t e r m i n a n t s and I n f l u e n c e on E a r n i n g s i n Two Poor Urban Economies". F e b r u a r y 1981. Dean T. J a m i s ~ ~ ne, t a l . , "Inproving Elementary V a t h e m a t i c s E d u c a t i o n i n Nicaragua: An E x p e r i m e a t a l Study of t h e I s p a c t o f Textbooks and Rad.-o on Achievement". >larch 1981. Rashid F a r u q e e , "Analyzing t h e Impact o f H e a l t h S e r v i c e s : Xarargwal and O t h e r E x p e r i e n c e s " . March 1981. J . B . Knight and R.H. S a b o t , "Labor X a r k e t D i s c r i m i n a t i o n i n a Poor Urban Economy". Xarch 1981. 0ey A. Meesook, "Interrelationships between Demcgraphic F a c t o r s and Incorxz D i s t r i b u t i o n : Problems o f Xeasurement , D e s c r i p t i o n and 1r.terpretation". A p r i l 1981. Susan H. Cochrane, " F e r t i l i t y A t t i t u d e s and B e h a v i o r i n t h e Nepal Terai". A p r i l 1981. J.B. Knight and R i c h a r d S a b o t , "The R o l e of t h e F i r m i n Wage ' , D e t e r m i n a t i o n : An A f r i c a n , C a s e Study". A p r i l 1981. b ' J . B . Knight and R i c h a r d S a b o t , "The R e t u r n s t o E d u c a t i o n : I n c r e a s i n g w i t h E x p e r i e n c e o r Decreasing w i t h Expansion?". %rch 1981. J .a. Knight and R i c h a r d S a 5 o t , "Fron X i g r a n t s t o P r o l e t a r i a n s : Employment E x p e r i e n c e , W o b i l i t y and Dages i n Tanzania". Xarch 1981. . A. B e r r y and B i c h a r d S a b o t , "Unempl.oynent and Economic Dev2jopnent". A p r i l 1981. . l a s t . I F a r u q e e and Ethna Johnson, " H e a l t h , N u t r i t i o n and Family P l a n n i n g : X S u r r e y o f Experiments and S p e c i a l Proj e t t s i n I n d i a . " A p r i l 1981. 31-15 Dean T. Jamison and F r a c c o i s O r i v e l , "The C o s t - e f f e c t i v e n e s s or' . D i s : a ~ e Teaching f o r School Equivalency", June 1981. 81-16 P i c h a r d S a b o t , "Labor F o r c e Growt!~, Enplolment and E a r n i n g s in Eg;rpt: 1966-1968", Hay 1981. 81-17 K.C. Z a c h a r i a h , "Anomaly of t h e 4 e r t i l i t y D e c l i n e i n b r e l a : S o c i a l Development, A g r a r i a n R e f o m s , o r t k e Family P l a n n i n g Prcgram". Yay 1981. 81-18 "hichazd Sabot e t a l . , "Education Expansion and Labor X a r k e t Adj u s t n e n t 13 .Qnya and Tanzania - A Sackground Paper". Yay 1981. 81-19 Xancy a i r d s a l l and Oey Xeesook, "Child S c h o o l i n g , Nunber o f C h i l d r e n and I n t e r g e n e r a c l o n a l T r a n s m i s s i o n of I n e q u a l i t y : A S i a u l a t i o n " . May 1981 81-20 Frac~ois O r i v e l , "The k p a c t of A g r i c d t u r a l E x t e n s i o n S e r v i c e s : A Review of t h e ~ i t e r a t ~ r e , J"u l y 1981. 81-21 Sancy E i r d s a l l and X. Louise Fox. "T;hy X a l e s Earn >!ore: L o c a t i o n , J o b P r e f e r e n c e s and J o b D i s c r i m i n a t i o n h c n g a r a z i l i a n S c h o o l t e a c h e r s " . 1981. 81-22 A l t h e a B i l l , "The Demographic S i t u a t i o n i n Sub-Saharan A f r i c a : A Background Paper", ?fay 1981. 81-23 Re S a b o t , A. B e r r y , A. Fazlevood and J - Knight, "Does t h e Expansicn Compress t h e S t r u c t u r e of Wages and Reduce the I n e q u a l i t y of Pay? A P r e l i m i n a r y A n a l y s i s " - J u l y 1981. 81-24 Xancy B i r d s a l l , Sulekha P a t e l and !LC. Z a c h a r i a h , " A l t e r n a t i v e P r c j e c t i o n s o f t h e Chinese P o p u l a t i o n " . June 1981. .. 81-25 31-,30 V i c e n t e paq;eo, "A Household P r o d u c t i o n :fcdel of School Enrollment : A P r o b i t A n m y s i s of t h e 1978 3 i c o l ? l u l t i p u r p o s e S u r i e y Cata". June 1981.- 31-31 a r g a n L. a o u l i e r and Vicente 3. ?aqueo, "On t h e Theory and X e a s u r e n e n t s of t h e D e i e r n i n a n t s of Y o r t a l i t y " . June 1981. 81-32 Reynaldo X a r t o r e l l , " N u t r i t i o n and H e a l t h S t a t u s I n d i c a t o r s : S u g g e s t i o n s f o r S u r r e y s of t h e S t a n d a r d of Living i n Developing Countries". June 1981- 81-33 R. S a b o t , A. B e r r y , A. Hazelwood and J. K n i g h t , " C o r r e l a t e s of E d u c a t i o n a l A t t z i m e n t i n Tanzaaia". J u l y 1981. 81-34 Susan 'H. Coc5rane. "The D e t e m i a z x t s of F e r t i l i t y and Child S u r v i v a l i n t h e Nepal Terai". J u l y 1981. 81-35 J o a n n e L e s l i e , B.G. Baidya, and K. Nanlvani. " P r e v a l e ~ c eand C o r r e l a t e s of Childhood M a l n u t r i t i o n i n t h e T e r a i Region of Nepal". J u l y 1961.