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TYPE Study Protocol
PUBLISHED 06 September 2022
DOI 10.3389/fpubh.2022.973721
OPEN ACCESS
EDITED BY
Lucy-Joy Wachira,
Kenyatta University, Kenya
REVIEWED BY
Chiranjivi Adhikari,
Indian Institute of Public Health
Gandhinagar (IIPHG), India
Anand Krishnan,
All India Institute of Medical
Sciences, India
*CORRESPONDENCE
Yogesh Damodar Sabde
sabdeyogesh@gmail.com
Tanwi Trushna
tanwitrushna@gmail.com
SPECIALTY SECTION
This article was submitted to
Environmental Health and Exposome,
a section of the journal
Frontiers in Public Health
RECEIVED 20 June 2022
ACCEPTED 12 August 2022
PUBLISHED 06 September 2022
CITATION
Sabde YD, Trushna T, Mandal UK,
Yadav V, Sarma DK, Aher SB, Singh S,
Tiwari RR and Diwan V (2022)
Evaluation of health impacts of the
improved housing conditions on
under-five children in the
socioeconomically underprivileged
families in central India: A 1-year
follow-up study protocol.
Front. Public Health 10:973721.
doi: 10.3389/fpubh.2022.973721
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Yadav, Sarma, Aher, Singh, Tiwari and
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not comply with these terms.
Evaluation of health impacts of
the improved housing
conditions on under-five
children in the
socioeconomically
underprivileged families in
central India: A 1-year follow-up
study protocol
Yogesh Damodar Sabde1*, Tanwi Trushna1*,
Uday Kumar Mandal1, Vikas Yadav1, Devojit Kumar Sarma2,
Satish Bhagwatrao Aher3, Surya Singh4, Rajnarayan R. Tiwari5
and Vishal Diwan4
1Department of Environmental Health and Epidemiology, ICMR-National Institute for Research in
Environmental Health, Bhopal, Madhya Pradesh, India, 2Department of Molecular Biology,
ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, India,
3Department of Environmental Monitoring and Exposure Assessment (Air), ICMR-National Institute
for Research in Environmental Health, Bhopal, Madhya Pradesh, India, 4Department of
Environmental Monitoring and Exposure Assessment (Water and Soil), ICMR-National Institute for
Research in Environmental Health, Bhopal, Madhya Pradesh, India, 5ICMR-National Institute for
Research in Environmental Health, Bhopal, Madhya Pradesh, India
Unacceptable housing conditions prevalent in Indian urban slums adversely
aect the health of residents. The Government of India initiated the Basic
Services to the Urban Poor (BSUP) as a sub-mission under the Jawaharlal Nehru
National Urban Renewal Mission (JNNURM), to provide basic services to the
urban poor. As per the available scientific literature, the health eects of such
improved housing schemes for the poor have not been studied so far in India,
especially in under-five children (0–5 years old) who spend most of their time
indoors. The present paper describes the protocol for a follow-up research
study proposed to fill this gap. This study, funded by the Indian Council of
Medical Research (Sanction No. 5/8-4/9/Env/2020-NCD-II dated 21.09.2021),
will be conducted in Bhopal in the central Indian province of Madhya Pradesh
for over 2 years. We will recruit 320 under-five children each from Group
1 (Beneficiary families residing in the houses constructed under BSUP) and
Group 2 (Slum dwelling families eligible for improved housing but who did
not avail of benefit). Eligible children will be recruited in the first household
visit. During the same visit, we will record clinical history, examination findings
and take anthropometric measurements of participants. We will also collect
data regarding socio-economic-environmental parameters of the house.
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Sabde et al. 10.3389/fpubh.2022.973721
During subsequent monthly follow-up visits, we will collect primary data
on morbidity profile, anthropometric details and medical history over 1
year. Approval for the study was obtained from the Institutional Ethics
Committee of the National Institute for Research in Environmental Health (No:
NIREH/BPL/IEC/2020-21/198, dated 22/06/2020). This study will evaluate the
impact of dierent housing conditions on the health of under-five children.
Finding of this research will be beneficial in guiding future housing-related
policy decisions in low- and middle-income countries.
KEYWORDS
acute morbidities, built environment, housing scheme, India, under-five children
Introduction
Housing conditions affect human health (1). Research
from developed countries has shown that better housing
conditions can improve health (1–3). Therefore, target 1 of the
United Nations’ Sustainable Development Goal 11 (SDG 11)
emphasized the availability of “safe and affordable housing and
basic services for all and upgrade slums by 2030” (4). Target
3 and 5 of SDG 11 are also related to appropriate planning
of human settlements to reduce the risk of exposure of the
underprivileged population to adverse environmental factors
(4). Following these guidelines, many developing countries have
initiated public housing programs to meet the housing needs of
their poor (5).
In India, a predominantly rural country, research
and administrative attention to housing and other basic
amenities has traditionally focused on human settlements in
underdeveloped rural areas (6). In the meantime, the urban
population, including the migrant rural population, has grown
exponentially, amounting to almost 31 per cent of the country’s
population (7,8). However, urban settlement expansion is often
unplanned, with a large proportion of the urban population
being either houseless (1.77 million) or dwelling in informal
settlements like semi–pucca houses of slums (65–70 million, i.e.
17%) (7).
The improper housing condition prevalent in urban slums
in India has a severe adverse effect on the health of its
residents. Published studies revealed that it is associated with
a higher risk of infections and vector-borne diseases (9).
Children under 5 years of age are especially vulnerable since
they spend most of their time at home (10). Studies have
shown that a higher percentage of slum-dwelling children
suffer from acute respiratory infections (ARIs) than non-slum-
dwelling children in Indore in Central India (11) and in
Gulbarga in South India, where the prevalence of ARIs was
27.25% among under-5 years children (12). Slightly higher
ARI prevalence was seen among under-5 years children in
urban slums of Nagpur and Vishakhapatnam (32.19 and
36.30%, respectively) (13,14). Frequent infections contribute
to the poor nutritional status of children, have long-term
implications on their growth and development (15) and are a
leading cause of infant and childhood mortality in developing
countries (16).
To tackle the adverse health effects of poor urban housing
conditions, the Ministry of Urban Development, Government of
India initiated the Basic Services to the Urban Poor (BSUP) sub-
mission under the Jawaharlal Nehru National Urban Renewal
Mission (JNNURM) in 2005 (8). The primary target of BSUP
was the integrated development of urban slums through
improved housing at a subsidized price and other related
civic amenities (8). Till 2018, under the BSUP submission,
710618 houses have been constructed, 54053 are in progress,
and 788953 are sanctioned (17). Through its BSUP, JNNURM
has the potential to improve housing conditions and, thus,
the health status of the beneficiaries, provided environmental
risks of poor housing are controlled while constructing new
houses (18). The BSUP model is also likely to be adapted for
the projected Housing for All (Urban) mission under Pradhan
Mantri Awas Yojana (PMAY) or the Prime Minister Housing
Scheme, which is proposed to be implemented from 2015 to
2022 for in-situ Rehabilitation of urban slum dwellers (19).
Therefore, at this juncture, it is essential to explore the possible
health impact of changing housing conditions under BSUP (20).
Under-five children (children aged 0–5 years) spend most of
their time in and around the home. Their health status can be a
sensitive indicator of the built-in environment of their dwellings
(10,21). However, as per the available scientific literature, the
effect of subsidized housing schemes on health (especially on
children under 5 years of age) has not been studied so far
in India. With this background, this study aims to evaluate
the impact of different housing conditions on the health of
under-five children.
Specifically, it aims to achieve the following objectives:
i. To compare the 1-year incidence of acute
morbidities between under-five children of, BSUP
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beneficiary families and slum-dwelling families
of Bhopal.
ii. To explore the association between incidences of acute
morbidities and housing conditions while adjusting for
other known confounders such as socioeconomic and
environmental factors.
Materials and methods
Design and duration
This manuscript describes the protocol for a 1-year
follow-up study to employ questionnaire-based data collection,
biological sampling, and environmental monitoring to ascertain
objective achievement. Figure 1 describes schedule of various
study methods of this protocol.
Setting
We will conduct the study in Bhopal city of Bhopal District
in the central Indian province of Madhya Pradesh (MP) India
(Figure 2). According to the 2011 census of India, MP has a
population of almost 72 million (22). The provincial capital,
Bhopal city, has a total population of almost 1.8 million (23),
of which almost 0.4 million live in slums (24). Under-five
children population in Bhopal city is almost 0.2 million (23).
Government of India published a status report of BSUP in 2019
titled ‘state wise monitoring report’. The report stated that, 13
projects of BSUP were completed, till January 2019 in the city
of Bhopal (25). We have selected the project with the highest
number of completed houses (N=3,248) for the current study
(Figure 2).
Study participant groups
Under-five children will be recruited for participation in the
current study from the following two groups:
1. Group 1: Beneficiary families residing in the houses
constructed under BSUP of JNNURM in the urban areas
of Bhopal, MP. The study will be performed in the selected
slum resettlement project of BSUP.
2. Group 2: Slum dwelling families of two slum areas located
near selected BSUP project mentioned above (Slum dweller
families are eligible for the subsidized housing benefits
under BSUP of JNNURM scheme. But some dewllers who
do not avail/get the scheme continue to dwell in the
slum areas).
The following eligibility criteria will be used for
recruiting participants:
Inclusion criteria
1. The family should be a resident of the said household for
1 year.
Exclusion criteria
1. Known cases of congenital anomalies and moderate or
severe “intellectual disability.”
2. Single parenting.
3. Children from families who are migrants, tenants, and
paying guests.
4. Family size more than 6.
Sample size calculation
Previous studies reported that ARI prevalence for under-five
children in urban areas ranges from 16.6 to 19.9% (26,27). In
comparison, the ARI prevalence among the under-five children
in the slum population ranges from 27.3 to 36.3% (12–14). In
this study, we expect that the improved housing conditions
offered by BSUP, JNNURM, should reduce the prevalence of
ARI from 30 (equivalent to that of slums) to 20% (equal to that
of non-slums) according to the available literature. Therefore,
to establish a 10% difference in ARI prevalence considering
confidence level of 95% (i.e., αerror: 5%) and power of 80% (β
being 0.2), required sample size was estimated to be 290.5 using
following formula:
Sample size for the difference in prevalence (N)=
z(α/2)+z(β)2(P1(1−P1)+P2(1−P2))
(P1∼P2)2(1)
Where P1is the expected population proportion in Group 1
(i.e., 0.2); P2is the expected population proportion in Group 2
(i.e., 0.3); Z(α/2) is the critical value of the normal distribution at
α, (i.e., 1.96 for α=0.05), Zβis the critical value of the normal
distribution at β, i.e., 0.842 for β=0.2. An additional 10% of
participants will be enrolled to account for non-response and
loss to follow up. Thus, we will enroll 320 children in each group.
Sampling strategy
We will retrieve the list of children residing in study areas
from their respective anganwadis. Anganwadis are community
outreach centers under the Integrated Child Development
Scheme (ICDS) in India (28), which maintain a list of under-five
children for providing nutritional and educational services. We
will recruit the eligible children after obtaining written informed
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FIGURE 1
Gantt chart of the project timeline.
parental consent in selected areas of Bhopal city to cover both the
participant groups. If two children are selected from the same
house, the child selected first will be retained, and the second
child will be dropped and replaced by another child with the
following random number.
Data collection
Cross-sectional phase (phase 1)
During the initial household visit to recruit eligible children,
basic clinical history taking and general physical examination
of the children, including anthropometry and detailed
household socioeconomic and environmental assessment, will
be conducted.
Clinical history and examination
The child’s anthropometric details (height, weight, skinfold
thickness and mid-arm circumference) will be collected
following standard guidelines (29). The growth parameters
(height, weight, skinfold thickness and mid-arm circumference)
will be compared to the WHO growth standards according
to age (30). The growth and development of the child
will be assessed by estimating age as per achievement of
milestones in five different domains, which include gross motor,
fine motor, adaptive/cognitive, language and personal—social
developmental milestones (31). Immunization status of the child
will be recorded and compared with National Immunization
Schedule (NIS) under Universal Immunization Programme
(UIP) (32). Relevant medical history to assess for the presence
of comorbidities and current health ailments, including acute
morbidities (respiratory, gastrointestinal and mosquito-borne
infections) among under-five children during the last month will
be recorded by trained pediatricians. The case definitions laid
down by the Integrated Disease Surveillance Project (IDSP) of
the Government of India to categorize the morbidities (33) (See
Supplementary Annexure 1).
Family history
Relevant family history will be collected, such as the
number of members in the household and medical illnesses
prevalent in the family (for example, history of congenital
diseases known to increase the rate of ARI (congenital heart
disease) in family members). We will also collect parents’
detailed occupational history and tobacco/alcohol consumption
(Supplementary Annexure 1).
Socioeconomic assessment of household
We will use the 2020 revision of the original Kuppuswamy
Scale developed in 1976, a commonly used composite scoring
system to assess the household’s socioeconomic status (SES) (34).
This scale categorizes households into five SES groups, “upper
class, upper-middle-class, lower middle class, upper lower and
lower socioeconomic class,” based on scores assigned to the
household ranging from 3 to 29 according to responses obtained
for education and occupation of the head of the household along
with total family income per month (34).
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FIGURE 2
Study area showing the location of Group 1 and Group 2
settings (Note: The image was created by researchers using
QGIS Version 3.20, and the open-access image downloaded
from Google Earth https://earth.google.com/web/ was used for
illustrative purposes).
Environmental assessment
To gather information on the environmental factors that
might act as confounding variables in our study, we will conduct
a series of assessments listed subsequently (Table 1).
Household-built environmental assessment
Details such as the number of rooms, the total area of the
house, water supply, sanitation, ventilation, the material used
in flooring/walls/roofs, and the fuel used for cooking/heating
will be recorded using a predesigned pilot-tested questionnaire
prepared for the study. To allow comparison of the study results
with national data, relevant questions were adapted from the
’household questionnaire’ of the National Family Health Survey,
India 2019–2020 (NFHS – 5) (Supplementary Annexure 2).
Ambient air pollution assessment
Ambient air pollution data for last year for study area will
be retrieved from CBCB (Central Pollution Control Board,
India) in the form of daily mean values of particulate matter
(PM10 and PM2.5) and gaseous pollutants (SO2and NO2) (35).
The obtained data will be compiled and statistically analyzed
by comparing it with existing National Ambient Air Quality
Standards (NAAQS) (36).
Indoor air pollution assessment
To assess indoor air pollution, monitoring of PM10, PM2.5,
PM1and gaseous pollutants will be carried out for 24 h
in each representative (10%) household twice a year (once
each in pre and post-monsoon seasons). The particulate
monitoring will be carried out using a sophisticated dust
monitor (Make- TSI Incorporated, USA; Model- DustTrak
8530). Similarly, the indoor air gaseous pollutants, viz., SO2
and NO2, will be monitored using a multigas monitor
(Make- Swan Environmental Pvt. Ltd.; Model: GRI-IAT; Sensor
make: Membrapor R
, Switzerland). The calibration of both
monitoring instruments will be ensured before measurement.
After successfully monitoring selected households, the recorded
data will be retrieved, tabulated and statistically analyzed using
the IBM-SPSS-24 statistical package.
Water quality assessment
Basic physicochemical parameters of drinking water quality,
such as color, odor, taste, pH, electrical conductivity, hardness,
turbidity, total dissolved solids (TDS), chloride, fluoride, and
nitrates, shall be analyzed at the household level. Bacteriological
tests for total and fecal coliform will be performed for a
representative number of samples (10%) of different drinking
water sources. Sensor-based instruments shall be used for water
analysis in the field, and measurements will be conducted
four times during the study period. Laboratory experiments
shall follow the standard American Public Health Association
(APHA) guidelines for determining various water quality
parameters (37). Sampling, transportation, and storage of water
samples shall also be done per the defined guidelines. Drinking
water quality guidelines laid down by the WHO and Bureau
of Indian Standards (BIS) will be used to define normal values
(38,39).
Prevalence of mosquito vector assessment
Prevalence of potential mosquito vectors of malaria
(Anopheles stephensi and Anopheles culicifacies s.l.) and
Dengue/Chikungunya (Aedes aegypti and Aedes albopictus) will
be monitored using standard mosquito collection techniques
in four houses (two indexed and two random) in each study
groups. Anopheles mosquitoes will be collected using CDC
light trap installed inside the human dwellings from dusk
to dawn. Aedes mosquitoes will be collected from inside the
houses in the morning and the evening using a mechanical
aspirator. All the collected mosquitoes will be identified up to
species level using appropriate keys (40,41). Potential breeding
sites for Anopheles and Aedes mosquitoes will be surveyed in
each locality to understand the mosquitogenic potential of the
locality. In addition, notified malaria and dengue fever cases
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TABLE 1 Proposed sampling frequency of environmental exposure assessment.
SN Environmental exposure assessment Proposed sampling
frequency/number of samples
Timeline
1Household- built environmental assessment Once Will be conducted before health assessment starts
2Ambient air quality assessment For each locality, daily mean values for pollutants
over the previous year
Will be retrieved from Central Air pollution
control board
3Indoor air quality assessment 64 (32 from each group) households Will be started after rainy season as per
recommended norms
4 Water quality assessment 4 rounds each for 64 (32 from each group)
households (Total 256 samples)
First two rounds will be done in pre-monsoon
period and next two in post-monsoon period
5 Prevalence of mosquito vector assessment 4 catching stations (2 fixed and 2 random) in each
locality for 12 months
Will be conducted throughout the study period
will be collected from the district malaria office, Bhopal, for
the study period to correlate with vector density and its role in
disease transmission.
Follow-up phase (phase 2)
The recruited children will be followed-up monthly for 1
year to collect primary data on morbidity profile and growth
patterns. In addition, in the past month, anthropometric
details and medical history of the child and their family
will be recorded in the proforma created for this study
(Supplementary Annexure 3).
Quality control
Necessary precautions will be adopted to maintain the
quality of the collected data at a high level. Equipment used
in the environmental assessment will be calibrated, and high-
quality reagents will be used. Adequate training will be provided
to research staff. Questionnaire-based field data collection will
be done through standardized tools wherever possible, and
author-developed tools will be validated before use.
Data management and analysis
The principal investigator will be responsible for data
management, ensuring that all data generated during this project
is stored safely with timely creation and maintenance of backups.
Hard copies will be held in a secure archive in the institute,
whereas all computer-based data will be kept under password
protection to be handled by research staff alone.
Unique identifying code numbers will be assigned to all
filled questionnaires, and data from these will be entered into
the latest version of Microsoft Excel spreadsheets. During data
entry, all morbidities recorded will be coded as per the latest
edition of the International Classification of Disease (ICD). In
addition, environmental assessment data will be linked to the
questionnaire-based socioeconomic, demographic and clinical
data. Data entry will be done by junior research team members.
It will be supervised by senior researchers who verify at least ten
per cent of the entered data for quality assurance.
Statistical analysis
Our input variables will include duration of stay in improved
houses, details of confounders including age, gender, family
size, socioeconomic status, family medical history and data
of environmental assessment of the households (ambient and
indoor air pollution level, type of cooking fuel used, drinking
water quality and mosquito vector density). The outcome
variables that will be used in the analysis include the incidence
rate of acute morbidities (respiratory, gastrointestinal and
mosquito-borne) and the growth and development of the child.
The data analysis will be done using SPSS statistics software
(Version 26). The analysis will be done using the Intention-to-
treat method. If a participant changes his/ her house during
the course of follow-up, we will treat the participant as per the
original group allotted.
Descriptive statistics such as mean/SD or
median/Interquartile range will be presented for continuous
variables depending on the data distribution. The normal
distribution assumption will be tested using the Kolmogorov
Smirnov test. Categorical variables will be summarized
using frequency with percentages. The incidence rate will
be calculated as the number of ARI episodes divided by the
number of children followed over 1 year. Relative risk (RR)
for ARI will be calculated as ARI incidence among the BSUP
beneficiaries group divided by ARI incidence among the slum
dwellers group. Similar calculations will be done for acute
gastrointestinal infections and mosquito-borne infections. The
RR with 95% CI will also be presented for different factors,
such as the gender of the child, socioeconomic status of the
family, etc. Finally, univariate and multivariate analyses will
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compare ARI episodes among the two groups after adjusting for
other confounding factors. A multilevel regression modeling
analyse is chosen to analyse relative importance of housing
characteristics on variation in the incidence of acute morbidities.
Individual and housing characteristics that have a significant
association with the incidence of acute morbidities in bivariate
analysis will be included in multilevel models. The multilevel
analysis will conducted at three levels i.e. study groups, housing
characteristics and individual characteristics.
Ethical considerations
Ethics approval has been obtained from the Institutional
Ethics Committee (Human), National Institute for Research
in Environmental Health (NIREH/BPL/IEC/2020-21/198 date
22nd June 2020). Before the initiation of research activities,
written informed consent (Supplementary Annexure 4) for data
collection and dissemination through scientific publication
will be obtained from the parents or guardians of every
study participant. The study findings will be disseminated
to benefit the study participants and their families. We will
help the children with known cases of congenital anomalies
and moderate or severe “intellectual disability” by providing
appropriate advice and referral services. However, as these
children are more prone to acute infections because of their
poor health conditions/underlying comorbidities and this extra
burden may mask the effect of housing conditions, data from
these children will be excluded from the analysis process.
Further, the children found morbid during the survey will be
referred to a government hospital located near the study setting.
Discussion
This protocol describes a prospective study to evaluate the
impacts of the different housing conditions on the health of the
under-five children while adjusting for the known confounders.
Most research on improved housing conditions’ health
benefits originates from developed countries. However, an equal
number of studies from low and middle-income countries
(LMICs) like India is still lacking. Moreover, the presence of
environmental risk factors like urban air pollution, solid fuel use
for cooking contributing to indoor air pollution, unsafe water
and lead exposure is higher in developing countries than in
developed ones (42). Thus, a higher burden of infectious disease
morbidity is documented among the pediatric population of
developing countries (43,44). Housing benefits estimated by
research in high-income countries cannot be extrapolated to
LMICs. So the impact of housing conditions on public health
needs to be explored in LMICs, especially considering the debate
regarding the timing of adoption of housing programs that will
prove most beneficial to a developing economy (45). If such
research proves that housing improvement can result in a net
gain in health outcomes, then additional investment on housing
programs like BSUP (India) could be further advocated.
Basic Services to the Urban Poor beneficiaries are expected
to have a lower burden of acute morbidities as compared to
slum dwellers by virtue of their improved housing conditions.
However, few studies have attempted to validate this hypothesis
scientifically. Kumar and Singh (46) qualitatively explored the
fulfillment of BSUP objectives in Bhopal, India. Similarly, the
qualitative impact of slum rehabilitation on household decision-
making and energy use from a gender-based perspective
has been explored by Sunikka-Blank et al. (47), whereas
Kshetrimayum et al. (48), investigated residential satisfaction
in association with slum rehabilitation. Furthermore, Gupta
and Kavit (49) and Desai et al. (50) analyzed the success
and failures of the BSUP implementation in Chandigarh
and Nanded, respectively. Quantitative assessment of indoor
air quality (51,52), socio-physical liveability, and built-
environment (53) in slums vs. rehabilitated settlements have
been conducted in Mumbai, India. Vaid and Evans (54),
through their quasi-experimental study, concluded that housing
quality could potentially improve women’s health and subjective
wellbeing. Nevertheless, few of these studies have quantitatively
documented the difference in housing environments and its
consequent health impacts, especially on vulnerable populations
such as children, the elderly, and pregnant women. The
current protocol, when implemented, will fill this critical gap
in information.
The proposed study will be conducted on under-five
children who spend most of their time in their homes and
are most susceptible to environmental challenges making
them the most sensitive indicator of potential environmental
health challenges. The study also engages a comparable
control group that will enable investigators to determine
whether there are any changes due to the intervention
introduced in the form of the housing scheme. The protocol
comprehensively explores participants’ home environment that
will yield baseline information on various environmental factors
affecting inhabitants’ health. This will be possible through a
multidisciplinary research team with expertise ranging from
medical disciplines such as public health/epidemiology and
pediatrics to environmental sciences, a significant strength of
this protocol. Though the BSUP scheme was implemented pan
India, the present study protocol will be implemented in a
limited geographical area of Bhopal city. However, lessons learnt
during this study will aid in conducting similar research in
other communities.
Ethics statement
The studies involving human participants were reviewed and
approved by Institutional Ethics Committee (Human), National
Institute for Research in Environmental Health, Bhopal, Madhya
Pradesh, India (Approval No: NIREH/BPL/IEC/2020-21/198,
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Sabde et al. 10.3389/fpubh.2022.973721
22nd June 2020). Written informed consent to participate in
this study was provided by the participants’ legal guardian/next
of kin.
Author contributions
Conceptualization and funding acquisition: YS. Formal
analysis: YS and VY [analysis not yet started]. Methodology and
investigation: YS, VD, VY, DS, TT, SA, SS, and UM. Project
administration: YS and RT. Visualization and writing—original
draft: YS and TT. Writing—review and editing: VD, VY, DS, TT,
SA, SS, UM, and RT. All authors met the authorship criteria
set forth by the International Committee for Medical Journal
Editors and read and approved the final manuscript.
Funding
This study, on which this protocol is based, was funded
by the Indian Council of Medical Research (Extramural
funding Sanction letter No. 5/8-4/9/Env/2020-NCD-II dated
21.09.2021). However, the funder had no role in designing the
study, decision to publish, or manuscript preparation.
Acknowledgments
We acknowledge the support of the authorities of the
Municipal Corporation of Bhopal and ICDS, Bhopal, for
providing us with permission to conduct this study and
their staff for aiding in site selection. Furthermore, we
acknowledge the support of Gandhi Medical College and
Hospital Bhopal for their consent for referral services in
this project.
Conflict of interest
The authors declare that the research was conducted in
the absence of any commercial or financial relationships
that could be construed as a potential conflict
of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpubh.
2022.973721/full#supplementary-material
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