Measures of socioeconomic status for child health research: comparative results from Bangladesh and Pakistan

Faces of poverty: sensitivity and specificity of economic classifications in rural Vietnam

Aims: Poverty concepts and measurements have occupied philosophers for centuries and are subject to debate by researchers. A wide range of possible measures have been developed and used. Most research is country specific and different methods produce different pictures of poverty. This study aimed to compare measures of poverty within an epidemiological field laboratory in Bavi District, northern Vietnam (FilaBavi) and specifically to find out whether the official economic classification made by the local authority matched other measurements of socioeconomic status. Methods: Structured questionnaires were used to collect socioeconomic information in 11,547 households. In addition, the official classification for individual households was recorded. Five economic indicators were constructed: income, expenditure, household assets, housing conditions, and local authority's estimation. Results: Official economic classification and housing score were symmetrically distributed, while assets score and particularly income were highly skewed. Design effects were high because of high intra-cluster correlations. No indicator was closely correlated with any other. Sensitivity and positive predictive value for poverty were generally low for all indicators. Discussion: The authors' findings do not suggest that any of the indicators used is substantially better than the other or better than the Official Economic Classification made by local authority. The results also show that no indicator is particularly useful to predict the values of any other indicator and different poverty indicators may classify different socioeconomic groups as poor.

Association of household and community socioeconomic position and urbanicity with underweight and overweight among women in Pakistan

Background

Similar to other developing countries, Pakistan is going through a rapid nutrition transition where shift from underweight to overweight and obesity is occurring. In this paper, we report on the relationship of household socioeconomic position (SEP), community SEP and urbanicity with under- and over-weight categories of BMI among Pakistani women.

Methods

We analyzed data on 4,767 women ages 15-49 years enrolled in a nationally representative Pakistan Demographic Health Survey (PDHS) conducted in 2012-13 that employed a multistage, stratified cluster sampling design. We assessed the association of urbanicity, household and community SEP derived from household assets and utilities, with categories of body mass index (BMI) using multinomial regression analysis where normal weight (BMI 18.6-22.5) was the reference category.

Results

Thirteen percent of women were underweight (BMI <18.5), 15% pre-overweight (BMI: 22.6-24.9), 25% overweight (BMI: 25.0–29.9) and 14% were obese (BMI≥30). Pre-overweight, overweight and obesity among women increased across household wealth quintiles (HWQs) in a graded fashion whereas there was no significant difference in underweight by household wealth. Women in urban areas were more likely to be obese. There was a pronounced increase in adjusted odds ratios (aORs) for overweight/obesity across HWQs within urban areas compared to rural areas. There was a steeper gradient in aORs for obesity from 1st to 5th HWQs in high income communities compared to the middle- and low income communities. In community-level analyses, communities in urban areas were more likely to have higher levels of obesity while in rural areas, especially in Sindh, more communities were more likely to have a higher level of underweight.

Conclusion

A shift to higher overweight and obesity than underweight in Pakistan is associated with high household and community wealth as well as living in urban areas. Clustering of obesity and underweight in distinct communities afford opportunity for tailored intervention programs.

Novel Risk Factors for Allergic Rhinitis in Korean Elementary School Children: ARCO-kids Phase II in a Community

Purpose

Allergic rhinitis (AR) is a multifactorial disease whose genetic and environmental risk factors have been studied for decades. Many pediatric studies have pointed out the familial history of allergy, hygiene hypothesis, breast-feeding, pet ownership, and diets as risk factors of AR. However, most of factors are still up for debate. This preliminary report aimed to confirm the known risk factors and find the novel risk factors for AR in the Korean pediatric population.

Methods

A bi-seasonal, winter and summer, study in 2 elementary schools included all students whose parents completed the questionnaire of medical and social histories, quality of life, infant and early-childhood history, and the living styles. Skin prick tests and endoscopic examinations were conducted on all participants.

Results

Among total 1,020 children, 338 participants had AR. The multivariate logistic regression analysis highlighted 6 factors: male gender (OR, 2.10; 95% CI, 1.32-3.33), older age (1.65; 1.03-2.65), previous history of allergic conjunctivitis (14.25; 4.99-40.74), asthma (2.73; 0.96-7.76) and pneumonia (0.39; 0.19-0.82), and an hour increase in daily playing time (0.90; 0.80-1.00).

Conclusions

Lack of pneumonia in early childhood and short playing time are newly found risk factors for Korean pediatric AR in this study confirming male gender, older age and previous history of allergic conjunctivitis and asthma as the risk factors.

Associations between child disabilities and caregiver discipline and violence in low- and middle-income countries

Using nationally representative samples of 45,964 two- to nine-year-old children and their primary caregivers in 17 developing countries, this study examined the relations between children's cognitive, language, sensory, and motor disabilities and caregivers' use of discipline and violence. Primary caregivers reported on their child's disabilities and whether they or anyone in their household had used nonviolent discipline, psychological aggression, and physical violence toward the target child and believed that using corporal punishment is necessary. Logistic regression analyses supported the hypothesis that children with disabilities are treated more harshly than children without disabilities. The findings suggest that policies and interventions are needed to work toward the United Nations' goals of ensuring that children with disabilities are protected from abuse and violence.

Screening for developmental disabilities in developing countries

Despite waxing international interest in child disability, little information exists about the situation of children with disabilities in developing countries. Using a culture-free screen for child disability from the 2005-2007 Multiple Indicator Cluster Survey, this study reports percentages of children in 16 developing countries who screened positive for cognitive, language, sensory, and motor disabilities, covariation among disabilities, deviation contrasts that compare each country to the overall effect of country (including effects of age and gender and their interactions), and associations of disabilities with the Human Development Index. Developmental disabilities vary by child age and country, and younger children in developing countries with lower standards of living are more likely to screen positive for disabilities. The discussion of these findings revolves around research and policy implications.

Effects of dietary habits and risk factors on allergic rhinitis prevalence among Turkish adolescents

BACKGROUND

Allergic rhinitis (AR) is a global health problem affecting many people from childhood to adulthood. The aim of this study was to evaluate the prevalence of AR and related symptoms, and to assess the risk factors, dietary habits and the Mediterranean diet affecting AR.

METHODS

In a cross-sectional study design, 9991 children, aged 13-14 years in 61 primary schools in 32 districts of Istanbul were evaluated. The prevalence of AR symptoms among the children was evaluated using the ISAAC protocol.

RESULTS

In our study, total of 10,984 questionnaires were distributed to 13-14yr-old schoolchildren to 61 schools in 32 district of Istanbul and 9991 questionnaires were suitable for analysis with an overall response of 91.7%. The rates of lifetime rhinitis, rhinitis in last 12 months and lifetime doctor diagnosed AR prevalence were 53.5%, 38.3% and 4.5%, respectively. The variation among districts in the prevalence of doctor diagnosed AR was very high. The highest prevalence was about 10 times higher than in the district with the lowest prevalence (range: 1.4-14.5) of Istanbul. A family history of atopy, mother with a university degree, presence of cat at home during last 12 months and adenoidectomy were significant for increased doctor diagnosed AR risk. Additionally, although fish and other sea foods, fermented drinks made from millets and various seeds, animal fats and butter were independent risk factors for doctor diagnosed AR, fish oil and hamburger were protective foods for doctor diagnosed AR. The MD was not associated with the prevalence of doctor diagnosed AR.

CONCLUSIONS

This study shows that that there are wide variations for the prevalence of AR related symptoms in 13-14yr-old schoolchildren among districts of Istanbul in Turkey. Socio-economical, environmental factors, some dietary habits, but not Mediterranean diet may affect the prevalence of AR.

Comprehensive assessment of metabolic syndrome among rural Bangladeshi women

BACKGROUND

Metabolic syndrome (MS), defined as a constellation of cardiovascular disease (CVD) risk factors, is one of the fastest growing public health burdens in the Asia-Pacific region. This trend is despite the fact that people in this region are no more overweight than Europeans and Americans. Unfortunately, in South Asia, MS screening has only been performed in a few countries other than Bangladesh. Therefore the present study is designed to conduct a comprehensive screening of MS in Bangladeshi rural women, which includes estimation of prevalence and assessment of risk factor.

METHODS

A total of 1535 rural Bangladesh women aged ≥ 15 years were studied using a population based cross-sectional survey. The prevalence of MS was estimated using NCEP ATP III, modified NCEP ATP III and IDF criteria.

RESULTS

The prevalence rates of MS were 25.60% (NCEP ATP III), 36.68% (modified NCEP ATP III), and 19.80% (IDF), as revealed by the present study. Furthermore, based on the NCEP ATP III criteria, 11.60% of the subjects were found to have excess waist circumference; 29.12% had elevated blood pressure, 30.42% had elevated fasting plasma glucose level, 85.47% had low HDL values and 26.91% had increased triglyceride values. Low plasma HDL level was found to be the most common abnormality in the target population and elevated waist circumference was the least frequent component.

CONCLUSIONS

The present study reveals a high prevalence of MS and its associated risk factors in rural Bangladeshi women. These findings are important in that they provide insights that will be helpful in formulating effective public health policy, notably the development of future health prevention strategies in Bangladesh.

Family-based factors associated with overweight and obesity among Pakistani primary school children

BACKGROUND

Childhood obesity epidemic is now penetrating the developing countries including Pakistan, especially in the affluent urban population. There is no data on association of family-based factors with overweight and obesity among school-aged children in Pakistan. The study aimed to explore the family-based factors associated with overweight and obesity among Pakistani primary school children.

METHODS

A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (> +1SD BMI-for-age z-score) and obesity (> +2SD BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to BMI. Logistic regression was used to quantify the independent predictors of overweight and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. All regression analyses were controlled for age and gender and statistical significance was considered at P < 0.05.

RESULTS

Significant family-based correlates of overweight and obesity included higher parental education (P < 0.001), both parents working (P = 0.002), fewer siblings (P < 0.001), fewer persons in child's living room (P < 0.001) and residence in high-income neighborhoods (P < 0.001). Smoking in living place was not associated with overweight and obesity. Higher parental education (P < 0.001) and living in high-income neighborhoods (P < 0.001) showed a significant independent positive association with BMI while greater number of siblings (P = 0.001) and persons in child's living room (P = 0.022) showed a significant independent inverse association. College-level or higher parental education as compared to high school-level or lower parental education (aOR 2.54, 95% CI 1.76-3.67), living in high-income neighborhoods as compared to low-income neighborhoods (aOR 2.13, 95% CI 1.31-3.46) and three or less siblings as compared to more than three siblings (aOR 1.75, 95% CI 1.26-2.42) were significant independent predictors of overweight.

CONCLUSION

Family-based factors were significantly associated with overweight and obesity among school-aged children in Pakistan. Higher parental education, living in high-income neighborhoods and fewer siblings were independent predictors of overweight. These findings support the need to design evidence-based child health policy and implement targeted interventions, considering the impact of family-based factors and involving communities.

Dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children

Background

There is no data on diet- and activity-related behaviors associated with overweight and obesity among Pakistani school-aged children. The study aimed to explore dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children.

Methods

A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (> +1 SD) and obesity (> +2 SD) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to body mass index (BMI). Logistic regression was used to quantify the independent predictors and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. Statistical significance was considered at P < 0.05.

Results

Children skipping breakfast (8%), eating fast food and snacks ≥ once a week (43%) and being involved in sedentary lifestyle > one hour a day (49%) were significantly more likely to be overweight and obese while those participating in physical activity > twice a week (53%) were significantly less likely to be overweight and obese (all P < 0.01). Skipping breakfast (P < 0.001), eating fast food and snacks (P = 0.001) and sedentary lifestyle (P < 0.001) showed an independent positive association with BMI while physical activity showed an independent inverse association (P = 0.001). Skipping breakfast (aOR 1.82, 95% CI 1.22-2.71), eating fast food and snacks ≥ once a week (OR 1.41, 95% CI 1.07-1.86), physical activity > twice a week (aOR 0.49, 95% CI 0.34-0.70) and sedentary lifestyle > one hour a day (aOR 1.56, 95% CI 1.19-2.03) were independent predictors of being overweight. Skipping breakfast had independent inverse association with physical activity (aOR 0.63, 95% CI 0.45-0.89) and eating fast food and snacks had independent positive association with sedentary lifestyle (aOR 1.79, 95% CI 1.49-2.16). Female gender was independently associated with skipping breakfast (aOR 1.50, 95% CI 1.04-2.16). Male gender (aOR 1.64, 95% CI 1.33-2.02), urban area with high SES (aOR 5.09, 95% CI 3.02-8.60) and higher parental education (aOR 1.74, 95% CI 1.12-2.68) were significant independent predictors of eating fast food and snacks ≥ once a week. Living in the rural area was independently associated (aOR 2.51, 95% CI 1.71-3.68) with physical activity > twice a week. Male gender (aOR 1.60, 95% CI 1.31-1.95), urban area with low SES (aOR 1.46, 95% CI 1.02-2.09), high-income neighborhoods (aOR 1.52, 95% CI 1.02-2.25), higher parental education (aOR 1.55, 95% CI 1.03-2.34) and fewer siblings (aOR 1.38, 95% CI 1.10-1.73) were independent predictors of sedentary lifestyle > one hour a day.

Conclusions

Dietary behaviors, physical activity and sedentary lifestyle are independent predictors of overweight and higher BMI among Pakistani primary school children, and are significantly affected by the child's socio-demographic characteristics. These findings support the urgent need to develop a National strategy for diet and physical activity and to implement culturally relevant behavioral interventions in the resource-poor developing country settings.

Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children

Background

Child growth is internationally recognized as an important indicator of nutritional status and health in populations. Child under-nutrition is estimated to be the largest contributor to global burden of disease, and it clusters in South Asia but literature on under-nutrition among school-aged children is difficult to find in this region. The study aimed to assess the prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children.

Methods

A population-based cross-sectional study was conducted with a representative multistage cluster sample of 1860 children aged 5-12 years in Lahore, Pakistan. Stunting (< -2 SD of height-for-age z-score) and thinness (< -2 SD of BMI-for-age z-score) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Logistic regression was used to quantify the independent predictors of stunting and thinness and adjusted odds ratios (aOR) with 95% confidence interval (CI) were obtained. Linear regression was used to explore the independent determinants of height- and BMI-for-age z-scores. Statistical significance was considered at P < 0.05.

Results

Eight percent (95% CI 6.9-9.4) children were stunted and 10% (95% CI 8.7-11.5) children were thin. Stunting and thinness were not significantly associated with gender. Prevalence of stunting significantly increased with age among both boys and girls (both P < 0.001) while thinness showed significant increasing trend with age among boys only (P = 0.034). Significant correlates of stunting included age > 8 years, rural area and urban area with low SES, low-income neighborhoods, lower parental education, more siblings, crowded housing and smoking in living place (all P < 0.001). Significant correlates of thinness included rural area and urban area with low SES, low-income neighborhoods and lower parental education (all P < 0.001), and age > 10 years (P = 0.003), more siblings (P = 0.016) and crowded housing (P = 0.006). In multivariate logistic regression analyses adjusted simultaneously for all factors, older age (aOR 3.60, 95% CI 1.89-6.88), urban area with low SES (aOR 2.58, 95% CI 1.15-5.81) and low-income neighborhoods (aOR 4.62, 95% CI 1.63-13.10) were associated with stunting while urban area with low SES (aOR 2.28, 95% CI 1.21-4.30) was associated with thinness. In linear regression analyses adjusted for all factors, low-income neighborhoods and older age were associated with lower height-for-age z-score while rural area with low/disadvantaged SES was associated with lower BMI-for-age z-score.

Conclusions

Relatively low prevalence of stunting and thinness depicted an improvement in the nutritional status of school-aged children in Pakistan. However, the inequities between the poorest and the richest population groups were marked with significantly higher prevalence of stunting and thinness among the rural and the urban poor, the least educated, the residents of low-income neighborhoods and those having crowded houses. An increasing trend with age was observed in prevalence of stunting and thinness. Smoking in living place was associated with stunting. Findings suggest the need to implement evidence-based child health policy and strategies, prioritizing the poor and socially disadvantaged population.

Association of socioeconomic position with under- and overnutrition in Pakistan

OBJECTIVE

We assessed the relationship between socioeconomic position (SEP) and under- and overnutrition in Pakistani adults.

METHODS

In 2006, we conducted a cross-sectional study including adult participants ≥20 years of age (n = 3500) residing in district Khairpur in Sindh province of Pakistan. We categorized body mass index (BMI) into <18.5 (underweight), 18.6-22.5 (normal BMI), 23-24.9 (preoverweight), 25-29.9 (overweight), and ≥30 (obese). We assessed the association of SEP based on wealth index measured as quintiles of a linear index derived from household assets and utilities score with categories of BMI through multinomial regression with the use of normal BMI as reference category while accounting for sampling design.

RESULTS

After adjusting for age, sex, education level, and occupation, there was no significant association of SEP and underweight, whereas SEP was positively associated with the categories of preoverweight, overweight, and obesity. In comparison with the 1st quintile, those in upper wealth quintiles had significantly greater odds of being preoverweight (4th quintile: adjusted odds ratio [adjOR], 1.47; 95% confidence interval [95% CI], 1.04-2.08; 5th quintile: adjOR, 1.57; 95% CI, 1.12-2.21), overweight (4th quintile; adjOR, 1.97; 95% CI, 1.43-2.72; 5th quintile: adjOR, 2.66; 95% CI, 1.91-3.69) and obese (4th quintile: adjOR, 2.24; 95% CI, 1.37-3.69; 5th quintile: adjOR, 3.65; 95% CI, 2.14-6.22).

CONCLUSION

Shift from under- to overnutrition across SEP groups is occurring in Pakistan. There is a need for re-evaluating national policies and programs to tackle the growing burden of emerging over-nutrition along with rampant under-nutrition.

Do agreements between adolescent and parent reports on family socioeconomic status vary with household financial stress?

BACKGROUND

Many studies compared the degree of concordance between adolescents' and parents' reports on family socioeconomic status (SES). However, none of these studies analyzed whether the degree of concordance varies by different levels of household financial stress. This research examines whether the degree of concordance between adolescents' and parent reports for the three traditional SES measures (parental education, parental occupation and household income) varied with parent-reported household financial stress and relative standard of living.

METHODS

2,593 adolescents with a mean age of 13 years, and one of their corresponding parents from the Taiwan Longitudinal Youth Project conducted in 2000 were analyzed. Consistency of adolescents' and parents' reports on parental educational attainment, parental occupation and household income were examined by parent-reported household financial stress and relative standard of living.

RESULTS

Parent-reported SES variables are closely associated with family financial stress. For all levels of household financial stress, the degree of concordance between adolescent's and parent's reports are highest for parental education (κ ranging from 0.87 to 0.71) followed by parental occupation (κ ranging from 0.50 to 0.34) and household income (κ ranging from 0.43 to 0.31). Concordance for father's education and parental occupation decreases with higher parent-reported financial stress. This phenomenon was less significant for parent-reported relative standard of living.

CONCLUSIONS

Though the agreement between adolescents' and parents' reports on the three SES measures is generally judged to be good in most cases, using adolescents reports for family SES may still be biased if analysis is not stratified by family financial stress.

Communicative actions, women's degree of social connectedness and child mortality in rural Bangladesh

BACKGROUND

Child deaths are decreasing throughout South East Asia, yet the rate remains high and is a cause of considerable anguish. In Bangladesh, there is also a great deal of variation in child mortality between different regions.

METHOD

Reported in this paper is the analysis of a survey of 613 Bangladeshi women who live in six rural villages and have reported on their experience of child death. Factors obtained from an interview based questionnaire were investigated to ascertain their association with child death. Multilevel Poison regression models were developed to relate these factors to the number and proportion of child deaths to children ever born while allowing for variation between the villages.

RESULTS

It was found that communicative action, especially women's power as the degree of social connectedness, is important in reducing child mortality. Also important in reducing child mortality is the level of women's education. No evidence could be found of sex preference when comparing male and female child deaths.

Indicators for Measuring Material Affluence of Adolescents in Health Inequality Research in Developing Countries

The aim of the present study was to (i) develop a material affluence scale (MAS) for measuring adolescent SES in health inequality research in developing countries, (ii) compare the association of the MAS with the parental SES measures (parental occupation and education), and (iii) evaluate the association of parental SES and MAS with key health and health behaviour indicators. We used school-based cross-sectional survey conducted in thirty districts within three administrative regions in southern Ghana (a West African country) among adolescents ages 12-18-year old (N = 1,195) as an example. Principal Component Analysis (PCA) was used as the main statistical technique. MAS categorised adolescents into material affluence groups (MAS scores for the poorest, poor, average, affluent and most affluent were-1.679, -0.355, 0.354, 0.725 and 1.022 from the first principal component quintile respectively), it has adequate internal coherence (alpha = 0.622) and moderately correlates with parental SES (r = 0.39, p < 0.001). MAS and parental SES showed similar pattern of strength and direction of association with selected health and health behaviour indicators. MAS presents a viable alternative method for measuring adolescent's SES in health inequality research in developing countries and could be useful as well in western countries.

Missed opportunities in surveillance and screening systems to detect developmental delay: A developing country perspective

The future of human societies depends on children being able to achieve their optimal physical and psychological development. Developmental delay is failure to acquire age-appropriate functionality. It may involve one or more streams of development. Responsive parenting has potential to promote better development. Primary health physicians are in the best arrangement to provide this assistance as they can monitor child's development longitudinally and understand the child's developmental trajectory better. Current strategy employed by majority of primary-care providers to monitor the trajectory is termed 'developmental surveillance'. It is "a flexible, continuous process whereby knowledgeable professionals perform skilled observations of children during the provision of health care". Age-appropriate developmental checklists are also used to record milestones as part of surveillance. Both, the American Academy of Pediatrics and the British Joint Working Party on Child Health Services, recommend developmental surveillance by physicians as a method of identification of developmental delays. Developmental screening, however, improves the accuracy of identifying children with delay, compared with surveillance. Primary health physicians should consider using developmental screening tools that are standardized, reliable, valid and practical in the office setting, be familiar with screening techniques which should be incorporated into ongoing care, and keep abreast of current literature. Pakistan, as a developing country, needs specific strategies to ensure that we seize all the chances to detect this delay at an earlier age and introduce intervention, in order to lessen the burden of the disability on child, family and society.

Behaviour problems in young children in rural Bangladesh

OBJECTIVE

To determine the prevalence of child behaviour problems reported by parents in rural Bangladesh.

METHODS

A total of 4,003 children aged 2-9 years were identified during a population-based survey of 2,231 households. A predetermined sample of 499 was selected, of which health professionals saw 453 (90.8%) for structured physical and neurological examination, standardized testing of cognition and adaptive behaviour and parent report of developmental history and behaviour problems.

RESULTS

The prevalence of behaviour impairments was 14.6% (95% CI 11.4, 17.9). The majority involved somatic complaints, including nocturnal enuresis and pica. Problems such as aggression or restlessness were infrequently reported. Behaviour impairments were significantly associated with malnutrition (prevalence ratio 2.1, 95% CI 1.2, 3.6, p < 0.01) and cognitive, motor or seizure disabilities (prevalence ratio 1.8, 95% CI 1.1, 2.9, p < 0.05).

CONCLUSIONS

The prevalence and nature of reported behaviour impairments in rural Bangladesh have implications for public health planning and delivery of health services.

Prevalence of obesity in school-going children of Karachi

Background

Obesity is an emerging problem in Pakistan. The authors sought to determine prevalence of obesity and malnutrition in school-going children, from grades 6^th to 8^th of different schools of Karachi and assess associations that affect the weight of the children.

Methodology/Principal Findings

A cross sectional study design with children studying in grades 6^th to 8^th grade, in different schools of Karachi. We visited 10 schools of which 4 consented; two subsidized government schools and two private schools. A questionnaire was developed in consultation with a qualified nutritionist. Height and weight were measured on calibrated scales. A modified BMI criterion for Asian populations was used. Data was collected from 284 students. Of our sample, 52% were found to be underweight whereas 34% of all the children were normal. Of the population, 6% was obese and 8% overweight. Of all obese children, 70% belonged to the higher socio-economic status (SES) group, while of the underweight children, 63.3% were in the lower SES. Amongst obese children in our study, 65% ate meat every day, compared to 33% of normal kids.

Conclusion

Obesity and undernutrition co-exist in Pakistani school-children. Our study shows that socio-economic factors are important since obesity and overweight increase with SES. Higher SES groups should be targeted for overweight while underweight is a problem of lower SES. Meat intake and lack of physical activity are some of the other factors that have been highlighted in our study.

Approaches for assessing the role of household socioeconomic status on child anthropometric measures in urban South Africa

The objectives of this article were to compare the variance explained in anthropometric outcomes when using individual measures of socioeconomic status (SES) versus different approaches to create SES indices within the urban African context, and to examine the influence of SES measured during infancy on child anthropometric outcomes at 7/8 years. Data from the 1990 Birth-to-Twenty cohort study set in Johannesburg-Soweto, South Africa, were used (n = 888). Linear regression models were used to investigate the association between SES (individual and index measures) during infancy and anthropometric measures at age 7/8 years, controlling for sex, age, and population group. Both individual and index measures of SES explained similar proportions of the variance for each anthropometric outcome. SES measured during infancy influenced weight more than height at age 7/8 years in Johannesburg-Soweto. Positive associations were found between SES and the anthropometric measures--ownership of a car, telephone, and having an inside flush toilet were the most significant SES variables. The similarities observed in the variance explained relating to the anthropometric outcomes suggest that researchers who want to adjust for SES in analyses could use an SES index to make statistical models more parsimonious. However, using such indices loses information relating to the specific socioeconomic factors that are important for explaining child anthropometrics. If the purpose of the research is to make policy recommendations for the improvement of child growth, individual SES variables would provide more specific information to target interventions.

Maternal nutritional status during pregnancy and surma use determine cord lead levels in Karachi, Pakistan

OBJECTIVES

To estimate the umbilical cord blood lead levels (BLLs) of Pakistani neonates and to identify determinants for umbilical BLLs.

METHODS

We conducted a cross-sectional study of mothers and infants at one of the two obstetric units of two tertiary care hospitals in Karachi during January-August 2005. Information from 540 mothers selected randomly from those registered for delivery was obtained about their pregnancy, diet, and current and past lead exposures. We collected umbilical cord blood for lead levels analyzed using graphite furnace atomic absorption spectrophotometry. We computed geometric and arithmetic means. We performed multiple linear regression analysis to identify factors associated with log-transformed umbilical cord BLLs. We also performed logistic regression analysis to identify determinants of high lead cord BLLs (10 microg/dl).

RESULTS

The geometric mean cord BLL of the neonates was 9.6 microg/dl; arithmetic mean (S.D.) was 10.8 microg/dl (5.7) with a median of 9.7 microg/dl and a range of 1.8-48.9 microg/dl. Women who reported intake of less than 58.5mg of elemental iron supplement per day during pregnancy had cord BLL of 10.0 microg/dl; in comparison those women who had higher iron intake had lower cord BLL (8.4 microg/dl). Those who used surma (an eye cosmetic) daily had higher cord BLL (11.5 microg/dl) as compared to those who used it less frequently (9.4 microg/dl). In multivariable linear regression model, higher iron intake, owning a car, and being in 2nd quartile of mid-arm circumference were associated with low lead levels while father's occupation in lead-based industry was associated with significantly higher umbilical cord BLLs. There was interaction of daily surma use and ethnicity. Geometric mean BLLs were varied among surma users by ethnicity.

CONCLUSIONS

Umbilical cord BLLs are high in Karachi, Pakistan, in comparison to those in developed countries such as United States. Measures are needed to reduce fetal lead exposure to prevent adverse affect on neurocognitive development. Association of low iron (below RDA of 60 mg per day) with high umbilical cord has implications for strengthening iron supplement intake during pregnancy. Umbilical cord BLLs differed among surma users by ethnicity.

Factors associated with severe disease in a population of asthmatic children of Bogota, Colombia

BACKGROUND

There is evidence that prevalence and severity of asthma in children has risen. Risk factors for severe asthma have been studied extensively in children living in developed countries, but little is known about factors determining the severity of asthma in Latin American countries. The aim of this study was to investigate the role of suspected, potential risk factors for asthma severity in a population of children living in urban Bogota.

METHODS

We studied 175 children, 2 to 16 years old, with asthma attending an asthma clinic. Severe cases and nonsevere asthmatic subjects were compared regarding suspected, potential pre-, peri-, and postnatal risk factors.

RESULTS

After controlling for asthma duration, we found that children never breast fed (OR, 11.53; 95% CI, 2.35-56.50; p = 0.003), mothers 30 years or younger at the child's birth (OR, 3.44; 95% CI, 1.23-9.63; p = 0.019), usual use of acetaminophen for fever in the child in the 12 months previous to the survey application (OR, 3.13; 95% CI, 1.14-8.56; p = 0.026), older siblings at birth (OR, 3.81; 95% CI, 1.28-11.32; p = 0.016), and primary or secondary school as the highest level of education attained by mother (OR, 3.20; 95% CI, 1.01-10.07; p = 0.046) were all independent predictors of severe asthma.

CONCLUSION

No breastfeeding, maternal age at child's birth of less than 30 years, routine use of acetaminophen for fever in the child in the 12 months previous to the survey application, older siblings at birth, and primary or secondary school as the highest level of education attained by mother were independent predictors of severe asthma. Some of these risk factors are clearly modifiable. Further prospective, population-based studies with a bigger sample size and a more representative sample of the general population residing in the city are needed to retest and clarify these associations.

Impact of the health and living conditions of migrant and non-migrant Senegalese adolescent girls on their nutritional status and growth

Objective:

To describe the living conditions of Senegalese adolescent girls according to their migration status, and to define the main socio-economic and biological determinants of their nutritional and growth status.

Design:

Health and living conditions, sexual maturation, and nutritional and growth status of adolescent girls were determined within the framework of a longitudinal study on growth.

Settings:

The capital city of Senegal (Dakar) and a rural community (Niakhar), 120 km south-east of Dakar.

Subjects:

Three hundred and thirty-one girls, 14.5–16.6 years of age, were recruited from the same villages. Thirty-six per cent of the sample remained in the villages to attend school and/or to help with household subsistence tasks (non-migrants). The remaining (64%) migrated to cities to work as maids (migrants) and lived in two different socio-economic environments: at the home of a guardian during the night and in the house of the employer during the daytime.

Results:

Family rural environment and guardian and employer urban environments were socio-economically different (P < 0.001). Living conditions in urban areas were better than in rural areas and the employer's environment was socio-economically more favourable. Migrants had more advanced sexual maturation and higher body mass index (BMI), fat mass index (FMI) and mid-upper arm circumference than non-migrants. However, migrants were smaller than non-migrants. BMI, FMI and weight-for-age were related to socio-economic levels and duration of migration. Schooling was positively related to height and negatively related to BMI.

Conclusions:

Migrants enjoyed better living conditions than non-migrants. This could be partly due to the better socio-economic environment of the employer. It was associated with earlier puberty and better nutritional status, but not with a better growth.

Assessing household wealth in health studies in developing countries: a comparison of participatory wealth ranking and survey techniques from rural South Africa

BACKGROUND

Accurate tools for assessing household wealth are essential for many health studies in developing countries. Household survey and participatory wealth ranking (PWR) are two approaches to generate data for this purpose.

METHODS

A household survey and PWR were conducted among eight villages in rural South Africa. We developed three indicators of household wealth using the data. One indicator used PWR data only, one used principal components analysis to combine data from the survey, while the final indicator used survey data combined in a manner informed by the PWR. We assessed internal consistency of the indices and assessed their level of agreement in ranking household wealth.

RESULTS

Food security, asset ownership, housing quality and employment were important indicators of household wealth. PWR, consisting of three independent rankings of 9671 households, showed a high level of internal consistency (intraclass correlation coefficient 0.81, 95% CI 0.79-0.82). Data on 1429 households were available from all three techniques. There was moderate agreement in ranking households into wealth tertiles between the two indicators based on survey data (spearman rho = 0.69, kappa = 0.43), but only limited agreement between these techniques and the PWR data (spearman rho = 0.38 and 0.31, kappa = 0.20 and 0.17).

CONCLUSION

Both PWR and household survey can provide a rapid assessment of household wealth. Each technique had strengths and weaknesses. Reasons for differences might include data inaccuracies or limitations in the methods by which information was weighted. Alternatively, the techniques may measure different things. More research is needed to increase the validity of measures of socioeconomic position used in health studies in developing countries.

Socioeconomic status and risk for arsenic-related skin lesions in Bangladesh

OBJECTIVES

Arsenic contamination of groundwater is a severe public health crisis in Bangladesh, where the population is exposed to arsenic in drinking water through tube wells used for groundwater collection. In this study, we explored the association between socioeconomic status and arsenic toxicity.

METHODS

We used baseline data from 11438 men and women who were recruited into the Health Effects of Arsenic Longitudinal Study (HEALS), a prospective cohort study on the health effects of arsenic exposure in Bangladesh. We conducted analyses with logistic regression and generalized estimating equations.

RESULTS

We found a strong dose-response association with all measures of arsenic exposure and skin lesions. We also found that the effect of arsenic was modified by land ownership on a multiplicative scale, with an increased risk among non-land owners associated with well water arsenic (P=.04) and urinary total arsenic concentrations (P=.03).

CONCLUSIONS

Our study provides insight into potentially modifiable host characteristics and identifies factors that may effectively target susceptible population subgroups for appropriate interventions.

An evaluation of a micro-credit system to promote health knowledge among poor women in Bangladesh

A Micro-credit system (MCS) is a financial system to support the economic needs of the poor. It is thought of as a community-based method to solve various problems, including the lack of health-related knowledge. Participants are organized in groups that assemble in regular meetings. Hadi (Hadi in Health Promotion International 16, 219-227, 2001) investigated the MCS as a method to solve the lack of health-related knowledge among the poor in Bangladesh. His result among rural MCS participants shows a positive relationship between the duration of membership in a micro-credit group and health knowledge. Further, more knowledge was ascertained among participants than among non-participants. The present research investigated the effectiveness of the MCS in increasing health-related knowledge. Comparisons were made between rural and urban groups on the basis of three different durations of membership and the influence of TV. This three-factorial design shows a significant increase in knowledge in a very short period in rural areas, whereas in urban areas, no systematic increase was found. TV plays a significant roll in increasing knowledge. Different theoretical conclusions are discussed on the basis of the results.

Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population

BACKGROUND

The associations of body mass index (BMI) and chronic disease may differ between Indo-Asian and Western populations. We used Indo-Asian-specific definitions of overweight and obesity to determine the prevalence of these problems in Pakistan and studied the sensitivity and specificity of BMI cutoff values for an association with hypertension and diabetes mellitus.

METHODS

We analyzed data for 8972 people aged 15 years or more from the National Health Survey of Pakistan (1990-1994). People considered overweight or obese were those with a BMI of 23 kg/m2 or greater, and those considered obese as having a BMI of 27 kg/m2 or greater. We built multivariable models and performed logistic regression analysis.

RESULTS

The prevalence of overweight and obesity, weighted to the general Pakistani population, was 25.0% (95% confidence interval [CI] 21.8%-28.2%). The prevalence of obesity was 10.3% (95% CI 7.0%-13.2%). The factors independently and significantly associated with overweight and obesity included greater age, being female, urban residence, being literate, and having a high (v. low) economic status and a high (v. low) intake of meat. With receiver operating characteristic curves, we found that the use of even lower BMI cutoff values (21.2 and 22.1 kg/m2 for men and 21.2 and 22.9 kg/m2 for women) than those recommended for an Indo-Asian population yielded the optimal areas under the curve for an association with hypertension and diabetes, respectively.

INTERPRETATION

A quarter of the population of Pakistan would be classified as overweight or obese with the use of Indo-Asian-specific BMI cutoff values. Optimal identification of those at risk of hypertension and diabetes and healthy targets may require the use of even lower BMI cutoff values than those already proposed for an Indo-Asian population.

Socioeconomic inequalities in early childhood malnutrition and morbidity: modification of the household-level effects by the community SES

This paper examines variations among communities in childhood malnutrition and diarrhea morbidity, explores the influences of socioeconomic status (SES) on child health, and investigates how the SES of families and that of communities interact in this process. Using multilevel modelling and data from Demographic and Health Surveys of five African countries, it shows evidence of contextual effects and a strong patterning in childhood malnutrition and morbidity along SES lines, with community SES having an independent effect in some instances. It also reveals that living in poorest conditions increases the odds of suffering from both malnutrition and diarrhea, as opposed to experiencing only one of the two outcomes. Importantly, community SES significantly modifies the effects of the household SES, suggesting that measures to improve access of mothers and children to basic community resources may be necessary preconditions for higher levels of familial socioeconomic situation to contribute to improved child health.

Socio-demographic differences in food habits and preferences of school adolescents in Jiangsu Province, China

OBJECTIVE

To identify the differences in food habits and preferences among the adolescents according to socio-demographic characteristics.

DESIGN

Cross-sectional, cluster design survey in 2002.

SETTING

Eight middle schools in two distinct socio-economic areas of the Jiangsu province, China.

SUBJECTS

Some 824 young adolescents (12-14 y) attending public schools with a response rate of 99%.

METHODS

A self-administered questionnaire containing questions on food and meal frequencies, food preferences and socio-demographic characteristics was used.

RESULTS

High socio-economic status (SES) and urban residence was positively associated with intake of high-energy foods, such as foods of animal origin, Western style foods and dairy products. In all, 76% of the students had three meals a day regularly , but 8.1% urban students vs 3.4% rural students had breakfast only 1-3 times per week or less often. Daily fruit consumption was fairly common, but with clear differences by SES. Only about 42% of the boys and 55% of the girls from low SES families ate fruit daily, compared with 66% and 72%, respectively in the high SES families. Urban boys had the lowest proportion of daily consumers of vegetables (67.0%). More urban students drank milk daily than the rural students (68.7 vs 38.5%). The frequency of milk drinking also showed a strong positive association with SES. About 10% of the high SES boys consumed hamburgers daily compared with 2.8% of the low SES boys. More than half of the students reported a liking for Western style fast foods including hamburgers, soft drinks and chocolate. Among high SES boys, 21.5% consumed soft drinks on a daily basis; however, as many as 72.3% wanted to drink soft drinks more often if they could afford it.

CONCLUSIONS

SES and urban location were positively associated with frequency of intake of high-energy foods. Reported food preferences may enforce this trend. Nutrition education for adolescents and parents is needed to promote healthy eating. Health Authorities should strengthen the monitoring of food intake and its association with overweight/obesity.

SPONSORSHIP

This study was funded by the Norwegian Directorate of Health and Social affairs under the auspices of the Norway-China Health Agreement.

Prevalence of skin disorders in school children in Ibadan, Nigeria

Although skin diseases are common in children, there are very few population-based studies in West Africa. Recently, there has been considerable emphasis on hygiene and socio-economic impact on the incidence of allergic disorders in children. We determined the prevalence of skin diseases in a public primary school in Ibadan (southwest Nigeria). A questionnaire for assessing factors associated with the prevalence of diseases was completed, and a complete physical examination was carried out on 1066 students. The study included 529 (49.6%) boys and 537 (50.4%) girls with a mean age of 8.8 +/- 2.5 years. The mean family size of the subjects was 6.7 +/- 2.3 while the mean number of rooms in their homes was 2.6 +/- 1.45. Infectious dermatosis was commonly observed. Of 375 children with a skin lesion, 162 (15.2%) had dermatophytosis, most often tinea capitis, 50 (4.7%) had pityriasis versicolor, and 50 (4.7%) had scabies. Other dermatoses observed included papular urticaria in 35 (3.3%) and angular cheilitis in 27 (2.5%) children. One or more melanocytic nevi were found in 40 (3.8%) children while 138 (12.9%) and 77 (7.25%) had tribal and scarification marks, respectively. Atopic eczema and viral warts were virtually absent. We concluded that fungal infections and scabies were the most common skin diseases in our study population, whereas allergic illnesses were nearly absent.

Inequalities in child mortality in Mozambique: differentials by parental socio-economic position

This study investigates the relation between socio-economic parental position (education and occupation) and child death in Mozambique using data from the Mozambican Demographic and Health Survey carried out between March and July 1997. The analysis included 9142 children born within 10 years before the survey. In spite of the Western system of classification used in the study, the results partly showed a parental socio-economic gradient of infant and child mortality in Mozambique. Father's education seemed to reflect the family's social standing in the Mozambique context, showing a strong statistical association with postneonatal and child mortality. However, maternal education as a measure of socio-economic position was not statistically significantly associated with child mortality. This finding may partly be explained by the extreme hardships experienced by the country (civil war and natural disasters) and the implementation of the Economic Structural Adjustment Programme that have also affected the health of women and their children during the years covered by this study. Other measures of socio-economic position applicable to the rural African setting should be investigated.

Prevalence of skin diseases in Ibadan, Nigeria

AIM

To study the pattern of skin diseases in patients attending the skin clinic of the University College Hospital, Ibadan, Nigeria, and to compare our findings with studies performed earlier in the same clinic.

PATIENTS AND METHODS

The study involved 1091 new patients who had attended the skin clinic of the University College Hospital, Ibadan, Nigeria, between January 1994 and December 1998. The patients were examined by the authors, and laboratory investigations were ordered when necessary to make a diagnosis.

RESULTS

An increased prevalence of eczema, idiopathic pruritus, urticaria, connective tissue diseases, and fixed drug eruptions was observed. Infections, such as scabies, candidiasis, and tinea versicolor, had also increased. Pyoderma, leprosy, onchocerciasis, and dermatophytoses showed a decline. Psoriasis was uncommon, although there was a slight increase in prevalence. Vitiligo and alopecia were stable. Cutaneous tuberculosis, such as lupus vulgaris, was rare.

CONCLUSIONS

Allergic conditions have increased; connective tissue disorders, such as systemic lupus erythematosus, scleroderma, and discoid lupus erythematosus, have also increased. Cutaneous disorders associated with human immunodeficiency virus infection, such as seborrheic dermatitis, have increased. Health workers need to be educated on the management and treatment of these conditions, and should be advised to refer patients to appropriate health facilities when necessary.

Social stratification, development and health in Pakistan: an empirical exploration of relationships in population-based national health examination survey data

There is a growing literature on an overall direct relationship between health and social position in developed countries. The relationship, however, is less well documented in developing countries where social hierarchies are changing more rapidly, demographic and health transitions are less advanced, and this topic has received less attention from researchers than in some developed countries. This paper presents an empirical investigation of the relationship between social stratification and social development and population health using data on over 6000 adults from the National Health Survey of Pakistan, a nationally representative health examination survey of people in that country. We analyze four indicators of poor nutrition in adults from this data set. The findings reveal complex relationships among social development, social stratification and the consequences for the health of the people of Pakistan. Underweight is related to economic status, anemia to education and social development, and both severe dental caries and a monotonous diet are related to both development and economic status which interact with each other. These results suggest that continued conceptual refinement and the development of standardized measures of stratification and development would contribute to building cross-nationally comparable data sets addressing issues of the relationship among health and economic development and health transitions.

Ethnic subgroup differences in hypertension in Pakistan

OBJECTIVE

Cardiovascular risks are globally elevated in South Asians, but this masks important ethnic subgroup differences in risk factors, such as hypertension, which have not been fully explored. We conducted this study to explore the variations in hypertension within ethnic subgroups among South Asians.

DESIGN

Cross-sectional survey [National Health Survey of Pakistan (NHSP) (1990-1994)].

SETTING

Population based.

PARTICIPANTS

A total of 9442 individuals aged 15 years or over.

METHODS

Data on sociodemographic and clinical variables were collected. Distinct ethnic subgroups - Muhajir, Punjabi, Sindhi, Pashtun and Baluchi - were defined by mother tongue.

MAIN OUTCOME MEASURE

Hypertension defined as systolic blood pressure >or= 140 mmHg or diastolic blood pressure >or= 90 mmHg, or currently receiving antihypertensive therapy.

RESULTS

The age-standardized prevalence of hypertension was highest among Baluchis (25.3% in men and 41.4% in women), then Pashtuns (23.7% in men and 28.4% in women), Muhajirs (24.1% in men and 24.6% in women), and lowest among Punjabis (17.3% in men and 16.4% in women) and Sindhis (19.0% in men and 9.9% in women) (P = 0.001). While hypertension was more prevalent in urban (22.7%) versus rural dwellers (18.1%) [odds ratio (OR) 1.34; 95% confidence interval (CI), 1.20, 1.49], this difference was no longer significant after adjusting for body mass and waist circumference (OR 1.03; 95% CI, 0.91, 1.16). However, ethnic differences persisted after adjusting for major sociodemographic, dietary and clinical risk factors (unadjusted OR for Baluchi versus Sindhi, 2.92; 95% CI, 2.20-3.89; adjusted OR, 2.71; 95% CI, 1.97-3.75).

CONCLUSIONS

A threefold difference in prevalence of hypertension exists between people of South Asian descent, which, unlike the urban/rural difference, cannot be accounted for by measured risk factors. Further study would provide valuable etiological and therapeutic clues.

Health for All in the Twenty-First Century, World Health Organization renewal, and equity in health: a commentary

Health for All in the Twenty-first Century is the document presenting the global health policy adopted by the World Health Organization (WHO) in 1998, which reaffirms and updates the vision of Alma-Ata. This article provides a synopsis of the document and a commentary, concentrating on the issue of equity, which is central to WHO policy, and discussing cultural differences that underpin the notion of equity. The meaning of "equity" implies measurement, and the authors develop an approach to definitions of social strata and data issues that are used to quantify health differences. Finally, they discuss the way in which policies invoking equity are implemented into programs and present a rights-based approach as a case study of one way in which policy is being translated into action.

[Association between socioeconomic factors and infant deaths due to diarrhea, pneumonia, and malnutrition in a metropolitan area of Southeast Brazil: a case-control study]

A population-based case-control study was carried out to identify determinant factors for post-neonatal infant deaths due to diarrhea, pneumonia, and malnutrition in Greater Metropolitan Belo Horizonte, Southeast Brazil. From May 1, 1991, to April 30, 1992, 511 post-neonatal deaths due to diarrhea, pneumonia, and malnutrition were selected after investigation of medical records to validate cause of death. Of this total, 396 deaths were compared to a neighborhood control group, matched for age. The study was carried out in a low-income area with a high proportion of families living in shantytowns. The article discusses the methodology and selected socioeconomic factors. Logistic regression analysis indicated that number of household appliances, mother's and father's education, and mother's marital and work status were significantly associated with risk of infant death, i.e., they were determinants of infant deaths due to avoidable causes.

Adolescents' proxy reports of parents' socioeconomic status: How valid are they?

STUDY OBJECTIVE

Children's proxy reports on indicators of their parents' socioeconomic status (SES) have either been used uncritically or dismissed as invalid. This paper examines the validity of young adolescents' reports of parental SES by comparing adolescent reports with parents' own reports of SES.

DESIGN, SETTING AND PARTICIPANTS

In 1990, 924 13 year olds, along with 648 of their fathers and 735 of their mothers, participated in the baseline survey of The Norwegian Longitudinal Health Behaviour Study. Data on parental occupation were collected from both adolescents and parents at baseline, while data on parental education were collected at follow up from the adolescents at age 15 and from their parents when the adolescents were 19 years old.

MAIN RESULTS

Three different ways of grouping the SES categories based on occupational data were investigated, and the strength of agreement was good for all three groups, with kappa statistics ranging from 0.65 to 0.86. There were no significant improvements of agreement when comparing adolescent data from age 15 to adolescent data from age 13. The strength of agreements between the adolescents' and parents' reports of parental education were fair; kappa statistics were 0.30 and 0.38 for fathers' and mothers' education, respectively. The proportions of unclassified answers or no responses from the adolescents were similar for questions on occupation and education, and ranged from 11% to 16%.

CONCLUSIONS

The agreement between adolescents' and parents' reports of SES based on occupation was judged to be good, but adding a few specific questions may cue the adolescent to provide more detailed information, thereby reducing the numbers of unclassified answers or non-responders.

Health status of the Pakistani population: a health profile and comparison with the United States

OBJECTIVES

The health status of the Pakistani population was compared with that of the US population to provide a better understanding of the health problems in a developing nation and shed light on the dynamics of selected diseases.

METHODS

Results from the National Health Survey of Pakistan (n = 18,315) and the US National Health and Nutrition Examination Survey (n = 31,311) were compared. Standardized and comparable methods were used in both surveys.

RESULTS

Indicators of undernutrition among children were high throughout Pakistan. Among adults, there were urban-rural differences and economic gradients in indicators of undernutrition and risk factors for heart disease and cancer. In comparison with the US population, the Pakistani population has a higher rate of undernutrition, a lower rate of high cholesterol, and an approximately equal rate of high blood pressure.

CONCLUSIONS

There are major inequalities in health within Pakistan and between Pakistan and the United States. Standardized national health examination survey methodology can be used to monitor health status and plan health transition policy in developing countries.

The health of enrolled and non enrolled children of school age in Tanga, Tanzania

The health of 227 children enrolled at primary school was compared with that of 214 non enrolled children living in rural Tanga, Tanzania. No consistent difference was observed with respect to prevalence and intensity of parasitic infection (hookworm, T. trichiura, A. lumbricoides, S. haematobium and P. falciparum). Since enrolled children were as commonly and as heavily infected as non enrolled children, treatment of enrolled children would be effective in reducing transmission throughout the total population. Non enrolled children were more stunted (P=0.0001) and wasted (P=0.0001) than enrolled children and also tended to be more anaemic (P=0.080) showing that poor nutrition is not only associated with delayed enrolment but continues to be associated with non enrolment throughout the school age years. Given that treatment has the greatest impact on the most malnourished children, additional measures to extend treatment to non enrolled children would be justified.

Socioeconomic status and adolescent injuries

Injuries are the major cause of morbidity among children and adolescents in developed countries, but there is a lack of consensus on the relationship between socioeconomic status and risk of injuries. A self-complete questionnaire survey, to gather information on non-fatal injuries and sociodemographic details, was administered in schools during April-June 1994 to a national sample of 4710 Scottish adolescents aged 11, 13 and 15 years. Although there was no evidence of a socioeconomic gradient in the total incidence of medically attended injuries among adolescents, based on the Registrar General's classifications of paternal occupation and a composite measure of family affluence, marked socioeconomic variation in the circumstances in which injuries occurred was observed. There were also socioeconomic differences in the extent and type of risk behaviours reported by adolescents, indicating differential rates of risk exposure. The finding that socioeconomic status affects the kinds of injury events adolescents experience and levels of risk behaviour has implications for the design of injury prevention strategies.