Positive deviance study of malnutrition

coercive deviance theatre of mal sustainmentIntroductionMalnutrition is the underlying ca accustom of every nonp atomic number 18il out of two deaths in tikeren under 5 eld of suppurate.Bryce J, Boschi-Pinto C, Shibuya K, Black RE, and the WHO Child Health Epidemiology refereeerence Group. WHO estimates of the causes of death in baberen. fizgig 2005 365 1147-52.It is a largely preventable cause of over a trey-3.5 million- of altogether child deaths. Four-Fifths of undernourished children live across 4 regions-Africa, Asia, Western Pacific and the Middle East-. These be last precession nations for action. The first of the millennium development goals was to one- half between 1990 and 2015 the proportion of stack who suffer from hunger.U.N.Mellinium Project 2005. Halving hungerIt stop be done. London and Sterling, VATask force on hunger, 2005. regimen is a miss aspect of child health which is non justifiable as we know that it is a major risk factor for sickness.Lope z AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001systematic analysis of population health data. Lancet 2006 3671747-57.Inappropriate feeding practices and their consequences are major obstacles to sustainable socioeconomic development and poverty reduction. Governments allow be unsuccessful in their efforts to accelerate development in any epochal long-term sense until optimal child fruit and development, especially finished appropriate feeding practices, is determined.WHO Global Strategy on Infant Young Child Feeding Report of the Secretariat 55th World Health Assembly, April 2002(5)The power by which progress is measured is the prevalence of under heaviness in children under five, specifically, the contribution of children geezerhoodd 0-59 months who fall below minus two standard deviations from the average weight for age of the standard lengthiness population.http//www.unicef.org/progressforchildren/2006n4/ index_undernutrition.htmlWorld Bank Report on 11th May 2006, there is a dominant focus on food supplementation that detracts from aspects that are more crucial for improving child nutritional outcomes, such as improving m other(a)s feeding and caring behavior For example, exactly 40 percent of Indian mothers practice exclusive breastfeeding.Also delivery of services is not sufficiently focuse on the youngest children (under three), who could potentially benefit most(prenominal) from ICDS interventions increment-faltering starts during pregnancy, and approximately 30 percent of children in India are born with low yield weight, and by the age of two years most lifetime growing retardation has taken place, and is largely irreversibleThe flowchart below depicts the interactions between underlying and immediate causes of malnutrition The tyrannical diversion concept which forms the basis of this exact focuses on two direct demeanoural causes of malnutrition at the stick outh old level, namely inadequate dietary ingestion and disease prevention.This culture measures childhood malnutrition using the new growth standards that have been recently released by the World Health Organization. The new standards are based on children from Brazil, Ghana, India, Norway, Oman and the US and adopt a fundamentally prescriptive progression designed to describe how all children should grow rather than merely describing how children grew in a single reference population at a specified time.Garza C, de Onis M. (for the WHO Multicentre Growth Reference Study Group). Rationale for developing a new international growth reference. Food Nutr Bull 2004 25 (Suppl. 1) S5-14.Magnitude of MalnutritionMalnutrition is a amplely familiar problem in India and one of astonishing magnitude. According to the National Family Health Survey 3 (NFHS III, 2005-06), just about a third of Indias children are born underweight, about 44 percent of children under five are underweight, 48 perce nt are stunted, 20 percent are wasted and 70 percent are anaemic. NFHS II (1992-93), more than half (53%) of children below four years of age are under nourished. In 1998, 29.1% children between 1-5 years of age suffered from moderate and 12.3% from monstrous under nutrition. This shows only a gradual decrease in the prevalence of under nutrition in India over twelve years. nutritionary adequacy is one of the key determinants of the health and well being of the children. Under-nourishment not only retardsphysical developmentsolely also hampers the reputationing and cognitive process, leading to sluggish educational, social and economic development, according to Sanjeev Kumar in his study Malnutrition in Children of the Backward States of India and the ICDS Programme.According to the NFHS III data, Tamil Nadu, although considered one of the better performing states, recorded to have nearly 35% of its rural children as undernourished. This value was certainly dishonor than the n ational rural average of 49%, but according to the NNMB survey based on the NCHS standards in 2001, there was a rise in the levels of severe malnutrition in both boys and girls in the under 5 age group in Tamil NaduTherefore the focus of this study is to investigate how some children living in the same surroundings escape the ill-effects of malnutrition and thrive in spite of poverty and limited resources, and use these practices to eliminate malnutrition among the rest.The Positive Deviance Approach and its benefitsPositive Deviance is based on the fact that solutions to some friendship problems already exist within the community and need to be discovered. It is a strength-based or asset-based approach based on the belief that in every community there are certain individuals (Positive Deviants) whose special, or uncommon, practices and behaviours enable them to mother better ways to prevent malnutrition than their neighbours who share the same resources and face the same risks.Th rough a dynamic process called the Positive Deviance Inquiry (PDI), these practices are discovered to contribute to a better nutritional outcome in under nourished child This intervention is designed to enable families with malnourish children to learn and practice these and other beneficial behaviours. The programme actively involves the mother and child in rehabilitation and learning in a berth like blank space and work to enable the families to sustain the childs enhanced nutritional spot at home. The typical session consists of nutritional rehabilitation and education over a twelve-day distributor point followed by home visits.The development of a community-based nutrition rehabilitation model called PD/ home was promoted by USAID and other international organizations such as UNICEF.The Hearth approachIn the Hearth approach, caregivers of malnourished children practice new cooking, feeding, hygiene and caring behaviours shown to be successful for rehabilitating malnourishe d children. The selected practices come from both the findings of the Positive Deviance Inquiry and emphasis behaviours highlighted by public health experts. The Hearth session consists of nutritional rehabilitation and education over a twelve-day period followed by home visits.The Hearth approach promotes behaviour change and empowers caregivers to take responsibility for nutritional rehabilitation of their children using local knowledge and resources. After two weeks of being ply additional high-calorie foods, children become more energetic and their appetites emergence. Visible changes in the child, coupled with the learning by doing method, results in improved caregiver confidence and skills in feeding, child care, hygiene andhealth-seeking practices. Improved practices, regardless of mothers education levels, enhance child growth and development. This approach successfully take mountains malnutrition in the target community by enabling community members to discover the wisd om of Positive Deviant mothers and to practice this wisdom in the workaday Hearth sessions.Positive Deviance/Hearth is an impelling tool in discovering the solutions from within.Need for the StudyMaternal and child under nutrition is highly prevalent in low and middle income countries like ours, resulting in change magnitude mortality rate and overall disease burden.It is well recognised that among the basic and underlying causes of under nutrition include environmental and economic factors with poverty having a central role. olibanum for a sustainable solution to this very common problem, there needs to be an ecological and holistic approach rather than the current and commonly used approach of the government giving supplementary feeds to those who are malnourished. The latter approach not only puts a financial strain on the government but also make the community members dependent on this external aid. Therefore this study concentrates on identifying affordable and sustainable solutions within a community which can be used to prevent undernutrition. This approach is also not resource hungry unlike the traditional approaches where the focus is on finding and fixing what is amiss(p) and missing in the community rather than identifying what is already working and build on the strengths of exist healthy practices within the community that is protecting them from undernutrition even though they are faced with same constraints of resources. This approach is known as the Positive Deviance approach.Knowledge shared by this approach not only changes behaviour but also changes how a community perceives malnutrition and their ability to change the situation. The Positive Deviant approach has been shown in other studies and projects to quickly eliminate malnutrition and through the sustainable new behaviour the younger siblings have also received these benefits. Positive deviance is a successful approach to decrease malnutrition and has enabled hundreds of commun ities the world over to reduce and prevent malnutrition. This approach is also culturally acceptable which helps bring about change in our society.However, there are only a few studies that use this concept to reduce malnutrition in India, whereas the potential here is very high. And , although Tamil Nadu has shown gains in terms of reduction of the problem of malnutrition, it still has a high percentage of malnourished children and therefore this study was undertaken to estimate prevalence in fourteen villages within the rural field practice scene of action of the department of community medical specialty of PSG Institute of Medical Science and Research and explore the feasibility, sustainability and effectiveness of combating the problem by using the Positive Deviance concept and approach.Tamil Nadu has a high prevalence of malnutrition. Recently, there has been a paradigm shift in the primary focus from Management of Malnutrition to Prevention of Malnutrition. Towards achieving this, strategies and activities have been proposed under various components for the year 2006-07 with priority for greater attention on the health and nutritional status, by the Government of Tamil Nadu. One of the guiding principles suggested to help achieve Malnutrition free Tamil Nadu, is effective nutrition intervention, and communication to bring about behavioural change. To help achieve this goal, this study was undertaken in fourteen villages under the rural field practice area of the department of community medicine of PSG Institute of Medical Science and Research using the Positive Deviance concept.ObjectivesTo estimate the prevalence of under 3yrs undernutrition in 14 villages of Vedapatti.To identify Positive Deviant practices in the community.To rehabilitate undernourished children identified in the most affected village.To reassess families at their homes after 6 months and ensure sustainability of Positive Deviant practices.Review of literatureClassification of under nutritionUnder nutrition is defined as the outcome of insufficient food intake and repeated infectious diseases. It includes being underweight for ones age, too short for ones age (stunted), dangerously thin for ones height (wasted) and deficient in vitamins and minerals (micronutrient malnutrition) according to UNICEF. Low weight for age is termed as underweight.Weight for age classifications are widely used in assessing nutritional status of children as it gives a picture of both bully and chronic onset malnutrition. The earlier classifications include Gomez, Indian Association of Paediatrics, and Welcome. These classifications use different reference standards, but the current recommended standards are the WHO references.This study uses the WHO references to classify underweight. In a study done by Bridget Fenn and Mary E. Penny across three countries, fewer children were classified as underweight according to the WHO classification when compared to the NCHS reference standards. Another study done by Marc-Andre Prost et al showed contrasting results. The WHO standards gave a prevalence of underweight 3.6 times higher early in infancy,0 4 months (6.1% against 1.7%) and half the estimated prevalence of the NCHS reference in the second half of infancy, 11 15 months(6.6% against 13.6%)Implication of New WHO Growth Standards on Identification of Risk Factors and Estimated Prevalence of Malnutrition in Rural Malawian InfantsMarc-Andre Prost1*, Andreas Jahn1,2, Sian Floyd1, Hazzie Mvula2, Eleneus Mwaiyeghele2, Venance Mwinuka2, Thomas Mhango2, Amelia C. Crampin1,2, Nuala McGrath1,2, Paul E. M. Fine1, Judith R. Glynn1In a study done by P.R. Deshmukh et al , in Anji, Maharashtra, the prevalence of underweight as assessed by WHO standards was evidentially lower when compared with the assessment based on NCHS reference (p0.05).Newly Developed WHO Growth Standards Implications for Demographic Surveys and Child Health Programs P.R. Deshmukh, A.R. Dongre, S.S. Gupta and B.S. GargPrevalence of under nutritionThe World Bank estimates that India is ranked 2nd with 47% after Bangladesh for the most number of children who suffer with malnutrition (in 1998). The prevalence of underweight children in India is among the highest in the world, and is nearly two-fold that of Sub-Saharan Africa with dire consequences for mobility, mortality, productivity and economic growth.According to the National family health survey -3 the percentage of under 3 children who were underweight in Tamilnadu were 33.2 % (31.3% in the urban areas and 34.8% in rural areas)The National Nutrition Monitoring Bureau observed that in about 40% of the households, the intake of dietary energy by preschool children was inadequate. just about 55% of the preschool age children were underweight, 52% were stunted and 15% were wasted.In a study done by Bhanderi D et al, the prevalence of under weight (wt. for age below 2SD) was 43.67%.An epidemiological study of health and nutritional s tatus of under five children in semi-urban community of Gujarat.Bhanderi D, Choudhary SK.A study done to find the prevalence of malnutrition in Uttar Pradesh showed that the maximum over all prevalence of malnutrition was in the age group of 13-24 months. The maximum number of grade IV malnutrition was found in the age group 25-36 months.Harishankar, Shraddha Dwivedi, S.B. Dadral, D.K. Walia, nutritional status of children under 6 years of age Indian daybook of Preventive and Social Medicine. Vol. 35 No.3 4 2004Methods of assessing nutritional statusNutritional assessments can be done by both direct and indirect methods. The method used can result in a wide variation in the prevalence of malnutrition.P. Mohanan et al in their study evaluated the efficacy of Body Mass Index, Mid-Arm Circumference and Weight-for-age in detecting Malnutrition in terms of sensitivity, specificity and prophetic value and concluded that weight-for-age is the best indicator.P.Mohanan, A.Kamath, B.Motha, M.Philip. Evaluation of Anthropometric Indices of Malnutrition in under-five children. Indian Journal of Public Health 1994 July-September28 (3) 91-94.A Comparison of Anthropometric Methods for Assessing Nutritional Status of Preschool Children in the Philippines was done to identify the most reliable anthropometricmeasurements that reflect nutritional status and the Dugdales nutritional index, weight/height, was a reliable measurement for malnutrition. This is exceptionally useful when the age of the child is not know.A Comparison of Anthropometric Methods for Assessing Nutritional Status of Preschool Children The Philippines Study Marilyn D. Johnson, MS,William K. Yamanaka, PhDandCandelaria S. Formacion, MSFactors associated with malnutritionGenderA case-controlled study conducted in a rural area in Tamil Nadu, India, on 97,000 children showed that female gender was a significant risk factor for malnutrition.YALE JOURNAL OF BIOLOGY AND medication 70 (1997), pp. 149-160. Copyrigh t C 1997. All rights reserved. A Case-Control Study of Maternal Knowledge of Malnutrition and Health-Care-Seeking Attitudes in Rural South India Kaori Saito, Joshua R. Korzenika, James F. Jekel and Sara BhattacharjiAlso another study in Tamilnadu on a total of 2954 children attending the TamilNadu Integrated Nutrition Project (TINP), showed that there was an experience between female sex and malnutrition. In this study the malnourished children were referred to as negative deviants.Use of Positive-Negative Deviant Analyses to Improve Programme Targeting and Services Example from the TamilNadu Integrated Nutrition ProjectMEERA SHEKAR, JEAN-PIERRE HABICHT AND MICHAEL C LATHAMGirls showed only a slightly higher level of prevalence of malnutrition in the study done by The Research and Special Studies Division of the Department of Census and Statistics, Sri LankaA study done in the slums of Chandigarh on 1286 preschool children found no significant gender difference. This study shows si milar reports as our study in Vedapatti.H.M. Swami, J.S.Thakur, S.P.S.Bhatia, Vikas Bhatia. Nutriotional status of preschool children in an ICDS closing of Chandigarh. Journal og Indial Medical Association 99(10) 554-556The sex of the child was found to be significantly high in association to malnutrition. The percentage of female children that were malnurished was higher in school going children.Epidemiology of malnutrition in a rural field practice are of Navi Mumbai By Sumedha Joshi and Santosh S. Walgankar Indian Journal of Preventive and Social Medicine Vol 35, 1 and 2, 2004Mothers LiteracyThe Research and Special Studies Division of the Department of Census and Statistics, Sri Lanka, undertook a methodological study to investigate the prevalence of malnutrition in children under five years of age, and the factors lend to such a situation. The study found that 25% of pre-school children that were undernourished had mothers who had not gone beyond the primary level of school ed ucation. The effected proportion dropped to 11% when the mother has had at least(prenominal) secondary education.Mother literacy was found in this study to have a positive effect on bringing down the incidence of malnutrition in socio-economically backward villages somewhat Agra.Positive Deviance determinants in Young Infants in rural Uttar Pradesh by Vani Sethi1, Sushma Kashyap1, Veenu Seth1 and Siddharth Agarwal, Department of Foods and Nutrition, Lady Irwin College, New Delhi, India. Indian Journal of Pediatrics Volume 74, June 2007.Sandip Kumar et al in a study among 600 under 5 children in West Bengal showed that illiteracy of both parents was a significant risk factor for malnutrition.Sandip Kumar Ray, Anima Halder, Biswajit Biswas, Raghunath Mishra, Satish Kumar. Epidemiology of Under Nutrition. Indian Journal of Pediatrics 2001 November 681025-1030.Socio-economic statusThis study in 2003 on 4187 children showed contrasting results in Nigeria. The southeast and southwester n United States regions had large inequalities between the poor and the rich whereas northeast and northwest regions had a considerably small gap between the rich and the poor on malnutrition. victimisation extended concentration and achievement indices to study socioeconomic inequality in chronic childhood malnutrition the case of NigeriaOlalekan A Uthmancorresponding author1,2A study done in mebibyte under 5 children in Rajasthan showed that 82% of the malnourished children belonged to the socio economic classes 4 and 5.Nutritional disorders in rural Rajasthan A.L.Soni1, R.N.Singh1and B.D.Gupta. Indian Journal of Peadiatrics, May, 1980,Vol 47 199-202.A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural Tamilnadu, showed that socio-economic status was a stronger risk factor for malnutrition than health-care availability and health-care-seeking attitudes.A case-control study of maternal knowledge of malnutrition and health-care-seeki ng attitudes in rural South India, Saito K,Korzenik JR,Jekel JF,Bhattacharji S.Birth orderThe study done by Vani Sethi et al also evaluated other factors that contribute to malnutrition in the society and found that third or earlier born infants escaped malnutritionPositive Deviance determinants in Young Infants in rural Uttar Pradesh by Vani Sethi1, Sushma Kashyap1, Veenu Seth1 and Siddharth Agarwal21Department of Foods and Nutrition, Lady Irwin College, New Delhi, India. Indian Journal of Pediatrics Volume 74, June 2007Another study in Uttar Pradesh observed that grade III malnutrition was absent in the children whose birth order was one and two. A significant rise in Malnutrition was found in the children of birth order IV and above.Health and Population Perspectives Issues 4(2)106-112, 1981A community based, cross-sectional study was conducted in the Mollasimla village of Hooghly district of West Bengal, showed a significantly higher proportion of malnutrition was found to be present among female children of higher birth order and those belonging to families with lower per capita income compared to the males.Gender inequality in nutritional status among under five children in a village in Hooghly district, West Bengal. Dey I,Chaudhuri RN.PROTEIN ENERGY MALNUTRITION IN CHILDREN A CASEFOR THE NEED OF A PLANNED FAMILY Deoki Nandan*, J. V. Singh** and B. C SrivastavaA study done by Harishankar et al showed that the highest percentage of malnourished children was seen in the first born children (47.2%) and the least in children with birth order 3 and above (17.8%)Harishankar, Shraddha Dwivedi, S.B. Dadral, D.K. Walia,Nutritional status of children under 6 years of age Indian Journal of Preventive and Social Medicine. Vol. 35 No.3 4 2004SpacingThe same study in Uttar Pradesh, by Deoki Nandan et al also studied the relationship to spacing and malnutrition showed that there was a direct association between Protein energy Malnutrition and less spacing between s ibilings.Health and Population Perspectives Issues 4(2)106-112, 1981. Protein Energy Malnutrition In Children A Case For The Need Of A Planned Family Deoki Nandan*, J. V. Singh** and B. C SrivastavaStudies using Positive Deviance conceptsThe successful application of the PD approach has been documented in more than 41 countries in nutrition and a mixing of other sectors from public health to education to business.Positive deviance is not specific to nutrition practices, but can be used for many other behaviours.Refhttp//www.positivedeviance.org/PD_Evaluation_Report_for_DEPKES_FINAL.pdfPositive Deviance was used in two Colombian hospitals to combat the spread of MRSA Infection. All hospital staff up to the security obtain involved themselves by reminding the visitors to practice good hand hygiene. As a result the infection rates have dropped down my more than 75% from 1.1 infections per 1000 patient days to less than 0.2 infections per 1000 patient days.Ref http//www.positivedev iance.org/projects/healthcare.html?id=49In West Bengal, India, ICDS has undertaken pilots projects in the use of the PD approach in Nutrition and Child Care Program (NCCP) in 4 districts to improve the nutritional status of children under three years of age. The projects substantially decreased the number of malnourished children by promoting good care practices. The PD informed project enabled families to break the dependence on donated food, by identifying cheap locally open and bringing it daily to the NCC session to prepare and feed their malnourished children. Every month the malnourished child is weighed and in most cases, mothers find their children gaining weight between 100 and 600 gm.Refhttp//www.positivedeviance.org/projects/nutrition.html?id=77Refhttp//www.unicef.org/india/nutrition_1557.htmIn 1990 Save the Children initiated a PD program in Viet Nam to enable poor villages to address the pervasive problem of childhood malnutrition. At that time 60% of children under th e age of 5 suffered from malnutrition in Viet Nam. The initial pilot project was in the first 4 villages. In each of the villages, half dozen of the poorest families with well nourished kids were chosen and caretakers were questioned and observed. In every instance where a poor family had a well-nourished child, the mother or father was collecting piddling shrimps or crabs or snails (the size of one joint of one finger) from the rice paddies and adding these to the childs diet along with the greens from sweet potato tops. Although readily available and free for the taking, the conventional wisdom held these foods to be inappropriate, or even dangerous, for young children. Along with these food and atypically strict hand hygiene in 5 of the 6 PD households, other positive deviant behaviors emerged, involving frequency and method of feeding and quality of care and health-seeking behaviors. Through the PD inquiries, community members had discovered for themselves what it took for a v ery poor family to have a well-nourished child. Rehabilitation started as for two weeks every month, mothers or other caretakers would bring their malnourished children to a neighbors house for a few hours every day. Together with the health volunteer, they would prepare and feed an extra nutritious meal to their children. This showed great success by reducing malnutrition by as much as 80%. The project was then applied in large scale reaching more than 2 million people and in 250 communities and sustainabily rehabiliteted 50,000 malnourished children under the age of 5. This is probably the best known and best documented large scale application of PD.Ref http//www.positivedeviance.org/projects/nutrition.html?id=105In Nepal a PD project to cover more than 8000 children under 3 years of age from 15 very disadvantaged communities was started with an aim of reducing child malnutrition in a sustainable manner. Positive practices regarding child feeding, caring, health seeking and matern ity care are identified from the poor families having well nourished children through the PDI and then are made accessible to the families with malnourished children through a learning by doing process.Ref http//www.positivedeviance.org/projects/countries.html?id=82In the year 2000 a Positive Deviance Inquiry to identify specific behaviors and strategies that contribute to healthy pregnancy outcomes amongst poor women was conducted. The inquiry determined that mothers-in-law played a central role in assisting women in obtaining medical care. Low-income women with weight gain greater than 1.5 kg per month in the second trimester ofpregnancy reported multiple antenatal care contacts, increased rest during pregnancy, and more consumption of meat and vegetables. These results were incorporated into a program for 200 women that resulted in a decrease in the prevalence of low birth weight.Ref http//www.positivedeviance.org/projects/public_health.html?id=117The following is illustrative of the impact of Positive Deviance over the last 15 yearsSustained 65 to 80% reduction in childhood malnutrition in Vietnamese communities, reaching a population of 2.2 million people. Significant reduction in childhood malnutrition in communities in 41 countries around the world. Reduction in neo-natal mortality morbidity in Pashtun communities in Pakistan and minority communities in Vietnam with near universal adoption of protective behaviors and social change. Estimated 50% increase in primary school student retention in 10 participating schools in Missiones, Argentina.Community intervention methods to combat under nutrition conventional nutrition interventions include growth monitoring, counselling and the provision of supplemental foods and micronutrients But over decades the weighing of children undertaken by several National health ministries has brought little or no change to the nutritional status. In fact, in a study done by Sridhar Seetharaman, in Uttar Pradesh and Rajasth an, it was found that the Mid Day Meal did not make any appreciable and significant impact on improving the nutritional status of the children.Impact Of Mid Day Meal On The Nutritional Status Of School Going Children, Sridhar Seetharaman, NIRD, HyderabadZulfiqar A Bhutta et al used a cohort model to study the interventions that affect maternal and child undernutrition and nutrition-related outcomes. The interventions included onward motion of breastfeeding strategies to promote complementary feeding, with or without provision of food supplements micronutrient interventions general supportive strategies to improve family and community nutrition. They found that these interventions could reduce stunting at 36 months by 36% mortality between birth and 36 months by about 25% and disability-adjusted life-years associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%.prof Zulfiqar A Bhutta PhDa, Tahmeed Ahmed PhDb, Prof Robert E Black MDc, Prof Simon Cousens PhDd, Prof Kathryn Dewey PhDe, Elsa Giuglianif, Batool A Haider MDa, Prof Betty Kirkwood PhDd, Saul S Morris PhDd, Prof HPS Sachdevg, Meera Shekar PhDhand for the Maternal and Child Undernutrition Study Group, Lancet Volume 371, 8 February 2008, Pages 417-440Reasons for age selectionCare is an important determinant of nutritional status. It determines the delivery of food and health care resources to the child by optimizing the existing resources to promote good health and nutrition in children.Ramakrishnan U. UNICEF-Cornell colloquium on care and nutrition of the young child-planning. F Nutr Bull 1995 16 286-92.The first two years of life are the window of opportunity to prevent early childhood undernutrition that causes largely irreversible damage. This is proved by the following studies across the world.Study shows more benefit from reaching all at-risk children

discipline Essay -- essays research papers

The Practice of DisciplineCertain challenges in life back tooth be described as being inevitable. Nearly every nonpareil must face such typical events throughout the course of their life where surpassing a specific challenge is a sign of growth and experience, and, having been dealt with, such a trial is not expected to arise again. Most individuals in our night club are old(prenominal) with such periods in their lives where they were made to begin walking as infants, coached into learning how to ride a bicycle later on, encouraged to start driving a car during the teenage years, earned a high school and/or college degree, etc. Such challenges and ordeals are expected. They are perceived as being all natural and acceptable. Society encourages the pursuit of them and rewards their conquering. Many of us, however, face challenges of a diametric sort in our lives. These challenges stem from decisions made by the individual, not by society or its norms. In fact, the very reason wh y such a decision quite often sets challenges ahead for the individual who makes it is due to the fact that it goes on the whole against societal expectations. The initial conscious decision to go against the grain and not fall into line often sets the stage for a slue of hardships and tribulations, and, chances are it get out result in a life-long battle to maintain devotion. I made such a decision. Around the age of 17, I began to notice that my belief outline was becoming increasingly opposed to that of my peers, my family, and even some good friends. For the first time, I began thinking nigh what I truly believed in and about the steerage in which I was headed. One would be hard pressed to find an individual who has not experienced distress over such thoughts. At one time or another, pressure from these or similar thoughts ordain plague just about everyone during their lives, especially throughout the teen years. The differences in the individual will be shown and defined through the kind of choices that are made during such a period. At that point, when the questions concerning my identity first came into play, I was not much different from the average adolescent. However, when I began to ponder precisely how and what I felt about many pressing issues in my life, I noticed my opinions were quite contrary to those verbalised by most people a... ...e I know where I stand is where others will fall. Unfortunately, standing up for ones beliefs can, at times, bring about instances of very open physical aggression from those who are in opposition of that individual. I witnessed this first hand on a night when I was approached by a fellow student while exiting my dorm hall at school. He had noticed the Xs on my hands, a prominent token and show of expression in the Straightedge community. The interaction began when the young manwho, ironically enough, was intoxicated at the timeproceeded to pin me against a wall and scream in my face which was quickly fo llowed by some hateful words expressing his contempt for the Straightedge lifestyle and an invitation to engage in a fight. During, and directly following, the event, I was in a total state of shock, for I was not used to opposition quite that extreme. Though seemingly ridiculous and unfair at the time, this experience was indeed a wake up call that helped to reiterate the fact that my decision to go against the norm is not, and never will be, an easy task. The main purpose here is to educate. By using examples and sharing I hope to help others.

Flat Tax Essay -- Economics

Flat TaxAn Analysis of the Flat Tax Rate trunkShould the matted evaluate direct system be implemented? No, the flat tax rate system should not be implemented. In this paper, the pro arguments will be presented, which will corroborate the thesis. Then the con arguments will be presented. A rebuttal will then follow, and finally, the authors conclusion will be offered.The loudest clamor against the flat tax would come from fundamentowners, Realtors, and builders, who would be hammered as the flat tax does away with deductions for mortgage interest payments and local property taxes. If not negotiated with skill, this issue could be the flat tax movements Achilles heel. An analysis by the economic consulting firm DRI/McGraw-Hill estimates that the market value of all homes could swing out by 15 share if the tax were introduced without a phase-in period. The brunt of the blow would be borne by those in middle and upper income groups. The flat tax could cause mortgage interest rate s to drop by a full percentage point, which would chore up prices. But even so, the DRI economists calculate that were the flat tax enacted with no phase-in period, the price of a $150,000 home could fall to $113,571, a decline of 24 percent. (Dishman 39)Middle class votes who have most of their money tied up in home and hearth will scream blue murder. Nor will they be soothed by economists armchair arguments that the governments roughly $80-billion-a-year tax subsidy to owner-occupied housing has led to a Brobdingnagian overbuilding of the nations housing stock. Roger E. Brinner, DRIs chief economist, figures the plunge in housing value would wipe out more than $1.5 trillion of householders net worth. The collapse of the housing market and new home construction, Brinner predicts, would slice 1.2 percent off GDP the year after the flat tax passed, and 1.6 percent in the second year. (Dishman 39)A potentially troublesome law lurks in the flat tax plan of House Majority Leader Richa rd Armey. The Armey flat tax plans to eliminate business exemption for most fringe benefits, especially employer paid health care. Flat tax enthusiasts like Harvard University economist Dale Jorgenson argue that employers, who look at the total cost of compensation, would simply increase their employees cash compensation, leaving them free to purchase their own health insurance. In theory, the workers then bec... ...rth noting that, for the politician who withdraws money from a campaign fund for personal use, even if it is unlawful to do so, this is taxable under the present law. But it appears to be tax-free under the flat tax. The regular(prenominal) wage earner certainly has the right to be skeptical about this fair and honest tax. (Robertson 26)In conclusion, it is clear that the flat tax rate is not a good concept which would be beneficial to the people. The current tax system, for now, is by far the better choice.BibliographyWorks CitedAstrikson, John, Flattening Taxes, Cons umer Reports December 1995, 34-37Darell, Bobby, Modern Economy, New York Harper, 1994Dishman, Kris, The skill of Taxation, New Haven Yale, 1996Flanegan, Jim, The Treasury, Cambridge Harvard UP, 1995Henderson, Margaret. A Look at the Economy, New York Dell, 1994McAfee, Charles, The National Debt, New York Appleton, 1993McNamara, Ellen, Your Tax Dollars at Work, New York Bowker, 1995Miller, Shawn, Commerce and You, New York Norton, 1996Robertson, Oliver, Learning the System New York Grove, 1994Tarik, Alfred, The Economy and the System Boston Houghton, 1993

Analysis of Kate Chopins The Story of an Hour Essay -- Kate Chopin St

Back in 1894, the American writer Kate Chopin wrote the short-story The Story of an Hour. Chopin, natural OFlaherty, wasnt renowned as a writer during her time, but she has achieved recognition in the 20th century especially with her 1899 novel The Awakening. Her stories about strong women pretend really been paid attention to in relation to this centurys sexual liberation debate. This short-story revolves around what goes through a persons head when informed that a close family fellow member has perished. However, I wouldnt say that this is the theme of the story, which Ill get back to. Louise Mallard is a young, yet married woman who suffers from heart trouble, and thats why her closest relatives feel that they control to break the news to her as gently as possible. Immediately after hearing the shocking news, Louise starts crying, and storms into her room. Since Louise spends the majority of the short-story in her room, this is the setting of the story. Noone really knows ear ly in the story how Louise really feels about her husband dying. But the author certainly gives some evident hints. The fourth paragraphs content, which revolves around the period of time where Louise has just entered her room, is sensibly surprising. Everyone would expect Louise to weep with agony and pain, but instead she sits calmly down There stood, facing an open window, a comfortable, roomy armchair. The interested reader ordain already here discover that something is terribly wrong, since a word like comfortable is used. A newly widdowed woman would probably not look upon a chair as comfortable shortly after receiving the terri... ...t she starts dreaming about it. That shows that she has an enormous respect for her husband, and doesnt dare to do anything that breaks or is in variance with his rights, restrictions and groundrules. right away we have procedures and laws regarding womens rights when it comes to feeling trapped in a marriage and urging to end it. Getting a divorce from ones husband is about as halcyon for women nowadays as opening a can of beer. Nevertheless, Chopins story tells a lot about the situation women were in a century ago, and its morale has blossomed deep following the recent liberation debate. The Story of an Hour has probably inspired a great deal of women to oppose their husbands if they feel like their marriage isnt preferably as jolly as it ought to be.

Siddhartha Gautama :: essays research papers

Siddhartha GautamaSiddhartha Gautama was born about 563 BC in what is now modern Nepal. Hisfather, Suddhodana, was the ruler of the Sakya people and Siddhartha grew upliving the extravagant life on a tender prince. According to custom, he marriedat the young age of sixteen to a miss named Yasodhara. His father had orderedthat he live a life of total seclusion, but one day Siddhartha ventured out intothe world and was confronted with the reality of the inevitable trauma oflife. The next day, at the age of twenty-nine, he left his kingdom and new-bornson to lead an modest life and determine a way to relieve cosmopolitan suffering.For six years, Siddhartha meditated under a bodhi tree. But he was never fullysatisfied. One day he was offered a bowl of rice from a young girl and heaccepted it. In that moment, he realized that physical hardships were not themeans to freedom. From then on, he encouraged people not to exercising extremes intheir life. He called this The Middle Way. That night Siddhartha sat underthe bodhi tree, and meditated till dawn. He cleared his mind of all worldlythings and claimed to get enlightenment at the age of thirty-five, thus earningthe title Buddha, or "Enlightened One." For the remainder of his eighty years,the Buddha preached the dharma in an effort to help other people reachenlightenment. When Siddhartha is a Brahmin, he believes in the existence ofmany gods, and performs sacrifices to them. After a while he realizes this ismeaningless and decides to leave his family and community and become a Samana.As a Samana, he tries to destroy himself in may ways. He feels if he killshimself, with its passions and emotions, he will find the great secret.Siddhartha doesnt spend much time as Buddha, although he has an crucialrevelation. He discovers he cant find peace by learning from a master. Hefinds the only way to have peace with the world is by determination it for himself.When Siddhartha leaves Buddha, he is enthralled with th e world. He startspaying more(prenominal) attention to the world because he knows he must get experience forhimself. As he walks he comes upon a town. He stays and becomes a merchant.At first he looks at his actions as a game. After a while he becomes moreserious. He starts drinking and gambling and becomes lazy. Siddhartha seesthis and decides to leave the town.He wanders through a forest and comes upon a

Comparing Power in Cry, The Beloved Country and The Women of Brewster Place :: comparison compare contrast essays

True Power in Cry, the Be grappled County, One daylight in the Life of Ivan Denisovich, and The Women of Brewster Place The world sets reveal to disappoint man. There exists a constant battle in which man has to prove himself by rising up against inevitable pain and destruction. When the struggle we salute will end is unknown to us, and remains a mystery. The question of why we are forced to struggle regular goes unanswered. Yet to overcome everything trying to disempower man, completely we need is love. Through endless possibilities we can both love and use this power to create something more, something so great it enables us to transcend those who try to disempower. rase though this love exists in so many forms and pervades every moment of our lives, the challenge remains to find it. In Cry, the Beloved County by Alan Paton, One Day in the Life of Ivan Denisovich by Solzhenitsyn, and The Women of Brewster Place by Gloria Naylor, the characters depict our endless search for love and the power it carries with it. Perhaps it is the innocence that lures man to them, perhaps it is even their helplessness that compels man to reach out to them, but whatever the cause, people so often find their love within fryren. Being with a child eliminates all other worries and pains of the world. Paton says as much when he declares, Now God be thanked that there is a beloved one who can quash up the heart in suffering, that one can play with a child in the face of such misery (Paton 62). Though Kumalo experiences continuing hardships on his trip to Johannesburg, nothing brings him greater pleasure than when he plays with the child of his daughter. When he plays with the child, there is something that comes out of him so that he is changed (Paton 118). Expressed even further is the love created with a child of ones own. Luciela Turner, of Women of Brewster Place, looks at her daughter as her only source of love that has ever come without pain, and the child brings her so much pleasure. The playful laugh of her daughter, heard more often now, brought a sort of redemption, Naylor says (96).

The Ninja :: essays research papers

Master of the OrientTHE NINJABorn and raised in New York City, Eric Lustbader graduated from Columbia University in 1969. Lustbader has had a number of fascinating best-selling novels, including Black Heart and Angel Eyes, he introduced Elton John to the American music scene. He spent fifteen years in the music industry in various capacities, including working for both Elektra and CBS Records. He is a former writer for Cash Box magazine where he wrote feed stories on new rock acts. In that capacity, he was the first person in the United States to predict the success of Jimi Hendrix, David Bowie and Satana, among many others.Lustbader has taught in the All-Day Neighbourhood prepare Division of the NYC Public School System and has also taught pre-schoolers in special early Childhood programmes.Eric Lustbader, who travels worldwide in researching his novels, lives in Southampton, New York, with his wife capital of Seychelles Lustbader, who works for the Nature Conservancy.Well, I don t want to give the whole report card away in this report, so I am going to summarise the story very briefly.The book isnt really just about a few selected people, but instead the author tries to see it from a lot of different perspectives. whence the reader get to know a variety of personalities. The Ninja is a high-voltage novel of intrigue and sensuality, richly characterised, fuelled by relentless suspense, an extraordinary thriller, least to say.If theres a main character in the book I think it would be Nicholas Linnear, a man of half-English, half-Oriental origin. A quite special man I impart tell you more about later in this report. Anyway, the story begins with a murder, a clean, silent and mysterious murder. The police dont have a clue, so they shout in Nicholas, an expert on this type of murders. Nicholas doesnt want to tell the others in the beginning, but he has his thoughts. As the story continues he start to split up the problem and suddenly everything is crystal cl ear. This isnt the usual type of murder, instead something even worse. An assassination, performed by a man bound by the blackest code of honour and skillful in the deadliest martial arts. This was the work of a ninja, a far remnant of the East. Nicholas must fight against a past he cant escape, trapped in a web of old lust and present passions, he uses all his skill and knowledge to survive.