Soni Apurv, Fahey Nisha, Bhutta Zulfiqar, Li Wenjun, Moore Simas Tiffany, Nimbalkar Somashekhar, Allison Jeroan
Department of Medicine, UMass Chan Medical School, Worcester, Massachusetts, United States of America.
Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, United States of America.
PLoS Med. 2022 Apr 8;19(4):e1003957. doi: 10.1371/journal.pmed.1003957. eCollection 2022 Apr.
India launched the National Rural Health Mission (NRHM) in 2005 to strengthen its primary healthcare system in high-focus and northeast-focus states. One of the NRHM objectives was to reduce child undernutrition in India.
We used data from 1992, 1998, 2005, and 2015 National Family Health Survey (NFHS) of India to evaluate trends in child undernutrition prevalence before and after NRHM and across different categories of focus states. Stunting, Wasting, and Comprehensive Index of Anthropometric Failure (CIAF) were assessed using the World Health Organization (WHO) growth curves to assess chronic, acute, and overall undernutrition. The study included 187,452 children aged 3 years or under. Survey-weighted and confounder-adjusted average annualized reduction rates (AARRs) and predicted probability ratios were used to assess trends and socioeconomic disparities for child undernutrition, respectively. Nationwide, the prevalence of all types of undernutrition decreased from 1992 to 2015. However, the trends varied before and after NRHM implementation and differentially by focus states. After NRHM, acute undernutrition declined more rapidly among high-focus states (AARR 1.0%) but increased in normal-focus states (AARR -1.9% per year; p-value for the difference <0.001). In contrast, the prevalence of chronic undernutrition declined more rapidly (AARR 1.6%) in the normal-focus states in comparison to high-focus states (0.3%; p-value for the difference = 0.01). Income and caste-based disparities in acute undernutrition decreased but did not disappear after the implementation of the NRHM. However, similar disparities in prevalence of chronic undernutrition appear to be exacerbated after the implementation of the NRHM. Major limitations of this study include the observational and cross-sectional design, which preclude our ability to draw causal inferences.
Our results suggests that NRHM implementation might be associated with improvement in wasting (acute) rather than stunting (chronic) forms of undernutrition. Strategies to combat undernutrition equitably, especially in high-focus states, are needed.
印度于2005年启动了国家农村卫生使命（NRHM），以加强其在重点关注邦和东北部重点关注邦的初级卫生保健系统。NRHM的目标之一是减少印度儿童的营养不良状况。
我们使用了来自印度1992年、1998年、2005年和2015年全国家庭健康调查（NFHS）的数据，以评估NRHM实施前后以及不同类别重点关注邦儿童营养不良患病率的趋势。使用世界卫生组织（WHO）生长曲线评估发育迟缓、消瘦和人体测量失败综合指数（CIAF），以评估慢性、急性和总体营养不良情况。该研究纳入了187452名3岁及以下儿童。采用调查加权和混杂因素调整后的年均下降率（AARRs）以及预测概率比，分别评估儿童营养不良的趋势和社会经济差异。在全国范围内，1992年至2015年期间所有类型营养不良的患病率均有所下降。然而，NRHM实施前后的趋势有所不同，且因重点关注邦而异。NRHM实施后，重点关注邦的急性营养不良下降速度更快（年均下降率为1.0%），但正常关注邦的急性营养不良却有所增加（每年年均下降率为-1.9%；差异的p值<0.001）。相比之下，正常关注邦慢性营养不良的患病率下降速度（年均下降率为1.6%）比重点关注邦（0.3%；差异的p值=0.01）更快。NRHM实施后，急性营养不良在收入和种姓方面的差异有所减少，但并未消失。然而，慢性营养不良患病率的类似差异在NRHM实施后似乎有所加剧。本研究的主要局限性包括观察性和横断面设计，这使得我们无法得出因果推断。
我们的结果表明，NRHM的实施可能与改善消瘦（急性）形式的营养不良而非发育迟缓（慢性）形式的营养不良有关。需要制定公平应对营养不良的策略，尤其是在重点关注邦。
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