Volume 4 │ Issue 1 │ Jan-March 2013 │ Page 1-188
www.njcmindia.org
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 NATIONAL JOURNAL OF COMMUNITY MEDICINE
Official Journal of the National Association of Community Medicine
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816
EDITORIAL BOARD
Editor Emeritus:
Dr. R. K. Bansal
Chief Editor
Joint Editor
Dr. S. L. Kantharia
Dr. A. B. Pawar
Executive Editor
Dr. Prakash Patel
Members
Dr. Anupam Verma, Surat
Dr. A. M. Kadri, Rajkot
Dr. Deepak Saxena, Ahmedabad
Dr. Girish Thakar, Surat
Dr. J. K. Kosambiya, Surat
Dr. K. N. Sonaliya, Ahmedabad
Dr. L. B. Chavan, Ahmedabad
Dr. Mitesh Patel, Ahmedabad
Dr. N. B. Dholakia, Gandhinagar
Dr. Rachna Prasad, Surat
Dr. Sunil Nayak, Surat
Ms. Swati Patel, Surat
Editorial Advisors
Dr. A. K. Bhardwaj, Jaipur
Dr. D.V.S.S. Ramavataram, Surat
Dr. Deepak Solanki, Vadodara
Dr. K. N. Trivedi, Bhuj
Dr. M. K. Lala, Ahmedabad
Dr. M. P. Singh, Bhavnagar
Dr. Manoj Bansal, Vadodara
Dr. N. J. Talsania, Ahmedabad
Dr. P. Kumar, Ahmedabad
Dr. Pankaj Jain, Etawah
Dr. S. Bhansali, Jodhpur
Dr. Sanjay Agarwal, Jaipur
Dr. Udai Shankar, Karamsad
All the views expressed in the articles are the personal views of the authors and should not be considered as the
official views of the National Journal of Community Medicine or the Association or the Editors.
The Journal retains the copyrights of all material published in the issue. However, reproduction of the published
material in part or total in any form is permissible with due acknowledgement of the source as per ethical norms.
The journal is indexed in WHO-HINARI, IndMEDICA, EBSCO, CAB Abstract, Index Copernicus International,
DOAJ, Open J-Gate, NewJour, Global Health, Medical Journal Links, etc.
CORRESPONDENCE
Dr. Prakash Patel
The Executive Editor, National Journal of Community Medicine
Mobile: 094260 39663
Website: www.njcmindia.org
Email: contactnjcm@gmail.com
PUBLISHER
National Journal of Community Medicine (Reg No. 24-022-21-39992)
C-104, Teaching Staff Quarters, SMIMER Campus,
Opp. Bombay Market, Umarwada, Surat – 395010.
Email: contactnjcm@gmail.com
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 4 • Issue 1 • Jan - March 2013
www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816 NATIONAL JOURNAL OF COMMUNITY MEDICINE
Volume 4│Issue 1│Pages 1 – 188│Jan - Mar 2013
TABLE OF CONTENT
Editorial
Teaching Community Medicine to Undergraduates, Problems & Solutions: A Loud Thinking
Pradeep Kumar ......................................................................................................................................................
1-3
Original Article
Survival Probabilities of Paediatric Patients Registered in ART Centre at New Civil Hospital, Surat
Sridhar P Ryavanki, Jayendrakumar K Kosambiya, Sonal O Dayama, Alap Mehta, Nitin Solanki,
Sangita S Trivedi ....................................................................................................................................................
4-9
Reproductive and Sexual Tract Infections Among Married Female Youth in an Urban Slum of
Mumbai
Yasmeen K Kazi, Anita G Shenoy, Gajanan Velhal, Sudam R Suryawanshi ............................................... 10 - 14
Evaluation of Vaccine Wastage in Surat
Shreyash Mehta, Pradeep Umrigar, Prakash Patel, R K Bansal ..................................................................... 15 - 19
Screen Out Anaemia Among Adolescent Boys as Well!
Dheeraj Gupta, Bhawana Pant, Ranjeeta Kumari, Monika Gupta................................................................. 20 - 25
A Study of Gender Differences in Treatment of Critically Ill Newborns in NICU of Krishna Hospital,
Karad, Maharashtra
Vinayak Y Kshirsagar, Minhajuddin Ahmed, Sylvia M Colaco .................................................................... 26 - 29
An Epidemiological Study on Association Between Alcohol and Tobacco Use in an Urban Slum of
Meerut
Rashmi Katyal, Rahul Bansal, Kapil Goel, Sachin Sharma ............................................................................. 30 - 34
Nutritional Status and Factors Affecting Nutrition Among Adolescent Girls in Urban Slums of
Dibrugarh, Assam
Himashree Bhattacharyya, Alak Barua .............................................................................................................. 35 - 39
Utilization Assessment of Basic Maternity Health Services Through Mamta Card in Rural
Ahmedabad
Kapil J Govani, Jay K Sheth, D V Bala ................................................................................................................ 40 - 43
Human Resources for Health: Availability and Competencies for Maternal and Newborn Health Care
Services
Prahlad Rai Sodani, Kalpa Sharma ..................................................................................................................... 44 - 49
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013│Pages 1 - 188 www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816 Mental Health Status and Depression Among Medical Students in Mysore, Karnataka – An
Untouched Public Health Issue
Renuka Manjunath, Praveen Kulkarni ............................................................................................................... 50 - 53
Inter-State Variation in Neonatal Mortality Rate Among Indian States
Tushar A Patel, Deepak B Sharma ...................................................................................................................... 54 - 58
A Cross Sectional Study to Understand the Factors Affecting Intake of Supplementary Nutrition
Among Children Registered with ICDS Anganwadis
Mohamedanas M Patni, Abhay Kavishwar, Mohmmedirfan H Momin, S L Kantharia ........................... 59 - 64
Selected Epidemiological Aspects of Schizophrenia: A Cross Sectional Study at Tertiary Care
Hospital in Maharashtra
Madhura D Ashturkar, Jaggnath V Dixit ........................................................................................................... 65 - 69
A Cross Sectional Study on Pattern of Health Care Seeking Behavior and Out-of-Pocket Household
Expenditure on Curative Medical Care in Rural Central India
Najnin Khanam, Gulab Meshram, Arvind Athavale, R C Goyal, Manmohan Gupta, A M Gaidhane ... 70 - 75
An Evaluation of ASHA Worker’s Awareness and Practice of Their Responsibilities in Rural Haryana
P K Garg, Anu Bhardwaj, Abhishek Singh, S. K. Ahluwalia .......................................................................... 76 - 80
Process Evaluation of Immunization Component in Mamta Diwas and Support Services in Kheda
District, Gujarat
Deepak Kumar Sharma, Arun Varun, Rakesh Patel, Uday Shankar Singh ................................................. 81 - 85
Iodine and Thyroid Status in a Tribal Village in Wayanad, Kerala in the Post Iodization Era –
Observations and Implications
Praveen P Valiyaparambil, Usha V Menon, Vivek Lakshmanan, Sanjeev Vasudevan, Ajitha Kumari,
Harish Kumar ......................................................................................................................................................... 86 - 90
Prevalence and Epidemiological Determinants of Malnutrition Among Under-Fives in an Urban
Slum, Nagpur
Poonam P Dhatrak, Smita Pitale, N B Kasturwar, Jaydeep Nayse, Nisha Relwani ................................... 91 - 95
Mortality Pattern of Hospitalized Children in a Tertiary Care Hospital in Latur: A Record Based
Retrospective Analysis
Sachin W Patil, Lata B Godale.............................................................................................................................. 96 - 99
Nutritional Status of the Government School Children of Adolescent Age Group in Urban Areas of
District Gautambudh-Nagar, Uttar Pradesh
Shalini Srivastav, Harsh Mahajan, Vijay L Grover ...........................................................................................100 - 103
Utilization of Antenatal Care Services in the Gandhinagar (Rural) District, Gujarat
Vaibhavi D Patel , Bhavna T Puwar, Jay K Sheth .............................................................................................104 - 108
Future Pharmacological Armamentaria in Management of Alzheimer Disease
Megha H Shah, Hetal D Shah, Vipul P Chaudhari ..........................................................................................109 - 116
A Study of Osteoarticular Tuberculosis in a Tertiary Care Hospital of Bhopal, Madhya Pradesh
Saurabh Sharma, Sanjay Kumar Gupta, Atul Varshney, Archa Sharma, Akhil Bansal, Ashlesh
Choudhary ..............................................................................................................................................................117 - 120
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013│Pages 1 - 188 www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816 Trends of Utilization of Family Planning Methods at District Hospital of Madhya Pradesh: A
Retrospective Study
Garima Namdev, Swarna Likhar, Mahesh Mishra, Arvind Athavale, Umashanker Shukla ...................121 - 124
Adolescence: the Dilemma of Transition
Bhawana Pant, Anuj Vaish, Parul Sharma, Anuradha Davey, Rahul Bansal, Harinder Singh ................125 - 131
An Educational Interventional Programme for Prevention and Management of Needle Stick Injuries
Among Nursing Students at A Tertiary Care Hospital, Jabalpur, Madhya Pradesh
Anshuli Trivedi, Pradeep Kumar Kasar, Rajesh Tiwari, Prashant Verma, Arvind Sharma .....................132 - 136
Refractive Errors in School Going Children – Data from a School Screening Survey Programme
Harpal Singh, V K Saini, Akhilesh Yadav, Bharti Soni....................................................................................137 - 140
Assessment of Knowledge of Mothers of Underfive Children on Nutritional Problems: A Rural
Community Based Study
Divya Shettigar, Ansila M, Maryes George, Jeena Chacko, Reena J Thomas, Shahila Shukoor...............141 - 144
Etiology of Peritonitis and Factors Predicting the Mortality in Peritonitis
Jeetendar J Paryani, Vikas Patel, Gunvant Rathod ...........................................................................................145 - 148
A Study on Obesity in Relation to Socio -Economic Status in Men and Women
Vinod Porwal, Anand Verma, Sameer Inamdar, Pranay Bajpai ....................................................................149 - 152
Epidemiology of Animal Bite Cases Attending Municipal Tertiary Care Centres in Surat City: A
Cross-Sectional Study
Pradeep Umrigar, Gaurang B Parmar, Prakash B Patel, R K Bansal .............................................................153 - 157
An Effort to Determine Blood Group and Gender From Pattern of Finger Prints
Sandip K Raloti, Kalpesh A Shah, Viras C Patel, Anand K Menat, Rakesh N Mori, Nishith K
Chaudhari................................................................................................................................................................158 - 160
The Status of National Programme for Control of Blindness in Madhya Pradesh
Rituja Kaushal, Sanjay Gupta, Neeraj Gaur, A V Athawale, Manmohan Gupta, Najnin Khanam ........161 - 164
Screening of Extrapulmonary Tuberculosis Samples by Zeihl Neelsen Staining in Patients Presenting
at Tertiary Care Hospital Ahmedabad
Lata Patel, Jignesh Panchal, Jayshree Pethani, Sanjay Rathod, Parimal Patel, Parul Shah .......................165 - 167
Death Audit of Leptospirosis Cases in Surat and Navsari District of South Gujarat
Fenil Patel, Kanan Desai, Kallol Mallick, Rachana Prasad, Rajkumar Bansal ..............................................168 - 171
Short Communication
A Study to Assess Genuineness of Obstetrics / Gynecological Patients Coming or Being Referred to
Medical College Hospital in Southern District of Rajasthan
C P Sharma, Shalabh Sharma, Arun Kumar, Chetan K Jain ...........................................................................172 - 174
Generation of Hospital Waste: An Awareness Impact on Health and Environmental Protection
Deepak Sharma ......................................................................................................................................................185 - 188
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013│Pages 1 - 188 www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816 A
Current Topic
Is 30 the Magic Number? Issues in Sample Size Estimation
Sitanshu Sekhar Kar, Archana Ramalingam .....................................................................................................175 - 179
Case Report
Investigation and Control of Scabies in Shelter Homes of Mandya City
Poornima Sadashivaiah, Raghini Ranganathan, Vinay M, Shreedhara Chikkade, Mahendra B J...........180 - 181
Herpes Zoster in Children and Adolescents: Case Series of 8 Patients
Pragya A Nair, Pankil H Patel .............................................................................................................................182 - 184
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013│Pages 1 - 188 Open Access Article│www.njcmindia.org
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Guest Editorial ▌
TEACHING COMMUNITY MEDICINE TO
UNDERGRADUATES, PROBLEMS & SOLUTIONS: A LOUD
THINKING
Pradeep Kumar
Affiliation: Professor & Head, Community Medicine Department, GMERS Medical College, Sola, Ahmedabad
Correspondence: E mail: drpkumar_55@yahoo.com
Subject of Community medicine is considered a
game changer in improving the community
health. It is lauded universally but receives only
a lip service– be the political leaders, health
planners or the administrators. Most of the
medical students also neither perceive it
important nor find it interesting and find it one
of the least liked subjects during entire MBBS.
Students read it just to clear the university exam
or acquire factual knowledge needed to clear
postgraduate (PG) entrance exams. All this
necessitates taking stock of the situation and
coming out with actions to make the subject
popular amongst students, meaningful and
addressing the community needs.
Before going any further let me put a disclaimer
that the views expressed herein are purely mine
and everyone has right to agree or disagree with
them. Hence this article has been aptly titled as
loud thinking. Target audience of this journal is
the public health professionals, mostly the
teachers in medical colleges making this issue
very topical and relevant.
One of a good definition of Community
Medicine as given by the WHO is “the study of
health and disease in the population of defined
communities or groups in order to identify their
health needs, and to plan, implement and
evaluate health programs to effectively meet
these needs.” What does MCI say about MBBS
curriculum?
“Undergraduate
medical
curriculum (shall be) oriented towards training
students to undertake the responsibility of a
physician of first contact, capable of looking after
preventive, promotive, curative & rehabilitative
aspects of medicine.” Please note that it is the
curriculum of MBBS and not of Community
Medicine alone. WHO endorses for a “Five Star
Doctors” who shall bear essential skills of (i)
Care provider, (ii) Decision maker,(iii)
Communicator, (iv) Community leader, and/or
(v) Manager. Which subject in entire MBBS
enables students to acquire these skills?
The past 30 years of this subject witnessed
several changes as its nomenclature, contents,
teaching methods, teachers profile and
importance accorded to this subject by the
government, MCI and the students. Some of
these changes are as follows
1. Increase in contents: Taking the text book of
PSM by Dr. K Park (followed religiously by
most colleges in India) as a yardstick and
based on the increase in number of its
chapters, pages and the size of each page,
contents have increased by some 165 percent
since 7th edition to the current 21st edition.
Addition of new contents in chapters such as
Health Economics, Epidemiology, Non
Communicable
illnesses,
Planning
&
Management without proportionate removal
of dead wood.
2. Introduction of 3 community postings: of
total 12 weeks duration (225 hours) by MCI is
an opportunity though elsewhere perceived
as a burden to keep the students engaged.
3. Teaching during I MBBS: Thanks to MCI, 60
hours teaching has been added during 1st
MBBS when the minds of students are fully
occupied with Anatomy, Physiology and
Biochemistry, it is difficult to make them to
learn a subject where they will be assessed
after three and half years; in between they
will learn and will be evaluated for seven
other subjects.
4. Extension of learning phase: Similar to the
health services rendered to community “from
womb to tomb”, teaching of Community
Medicine is also given during entire first,
second and part of third (final) MBBS. Further
the 2 months internship posting in the current
format may lead to boredom and aversion.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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5. Field based training and inclusion of
preventive, promotive and rehabilitative
skills: This requires the development of Rural
and Urban Health Training Centers. This in
itself is resource intensive and authorities at
most colleges are reluctant to provide this
unless the MCI pushes them to do so.
6. Shortage of Teachers/Faculty members:
Doubling of medical colleges in past 20 years
has resulted in a demand– supply gap of
teaching faculty members. This has led to a
shortage of teachers in medical colleges in
terms of quality as well as quantity.
Some of the things which have not changed
1.
2.
Continued emphasis on cognitive learning:
Lectures a vehicle largely meant for transfer
of cognitive learning, are still the most
preferred teaching methods. Lectures are
important hence are taken by senior persons.
Tutorials, group discussion and field visits
are treated as inferior modes of teaching
hence are taken by junior and inexperienced
faculty. Unlike “breast feeding is the best” in
maternal and child health, here students feel
that “spoon feeding is the best feeding”
Reliance on a single text book for both
under and post graduate learning: As
mentioned earlier textbook of PSM by Dr. K
Park provides exhaustive details of the
subject with reliance at most of the colleges
for both undergraduate (UG) and PG
learning. This has been most damaging to
the subject where for last 30 years; teachers
have relied solely on one text book alone for
both UG and PG learning. Ours is probably
the only subject where the same book is read
and considered adequate for teachers, PG
and UG students. The dependence is so
heavy that if this book does not cover say
statistics strongly so it becomes a weakness
of most of our teachers and students. If it
does not include anything it is neither taught
nor asked (during evaluation) in many
colleges. Generally we start teaching/ asking
particular aspects once included in this book.
How students feel?
1. Lack of relevance: Adult learning has a
principle that people learn what they want to.
Most students when join MBBS view
themselves either as surgeons or physicians.
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Learning of Community Medicine does not fit
in their dreams. Questions often asked are How I am concerned? Why should I learn
statistics or entomology or occupational
health?
2. Uninteresting subject Textbook (I am
referring the same) has been written in a
boring way with no stories and hardly any
photographs. This book provides excellent
information to teachers but is definitely not
written in a student friendly manner.
3. Too vast subject Along with increase in
contents, students perceive that the subject
has a very wide range from dimensions of a
borehole latrine to clinical features of
metabolic syndrome. Students feel that
learning this subject lead to their becoming
jack of all trade and master of none (not a bad
idea altogether!). Overlapping areas such as
research designs with pharmacology, agent
characteristics in communicable diseases with
microbiology, vaccination with pediatrics,
certain treatment guidelines with Medicine
often leave the students confused as different
things are taught for the same problems.
4. No attitude/ skill building: The subject is full
of facts meant for cramming. While other
subjects if clinical, provide some skill
development and if non clinical, support the
learning of major clinical subjects (Anatomy
to Surgery & Physiology to Medicine), our
subject does not have any such feature. One
can become a successful (money making?)
clinician or super specialist without learning
this subject. Though touted as a clinical
subject, skills as clinical examination and
communication (with patients) are lacking.
5. Least priority by students in I & II MBBS:
Students have short term goals and initially
they are focused more on the subjects of I and
II MBBS. Community Medicine comes under
focus only during 6th & 7th semester (1 year
before university exams) and by that time our
major teaching is already over.
6. Unsatisfactory training of interns: An
internship posting of 2 months in Community
Medicine is the weakest links in the teaching
program and is considered by some as “paid
holiday” or vacations. With stiff entrance tests
competitions, interns in this department
spend time in preparing for entrance exams.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Some solutions
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(overused
&
most
technology today).
abused
teaching
Currently teaching in Community Medicine is
lecture based in the Ivory towers of medical 10. Reprioritizing contents for learning in terms
colleges with little interaction with community
of essential/ desirable/ good to know and
and public health services, while ideally it
same must be followed in evaluation as well.
should be student centered, evidence based and
11. Evaluation: More importance is attached to
problem solving type of active learning and
end evaluation than concurrent evaluation.
capable of addressing to the community needs.
Students are evaluated in “cognitive” domain
1. Motivate students by marketing the subject in
(domain of intellectual activities), rather than
terms of expanding horizons & job avenues.
in terms of the psychomotor (acquisition of
motor skills) and affective domain (domain of
2. Make it relevant and interesting by linking
communication skills). In other words, they
with current events generating interest and
are evaluated more for theoretical knowledge
inclusions of ice breaking, brain storming and
than practical skills. Introduction of multiple
news/ video clip as preludes.
choice/ short questions and assessment
3. Use multiple text books for learning.
techniques such as OSCE / OSPE in teaching
/ evaluation can be helpful in evaluating
4. Provide for computer skills for literature
more areas in less time in more objective
search,
data
entry/
analysis
and
manner. An evaluation should be a perfect
presentations. I am not aware that under any
blend of carrot and stick whereby
subject students are provided these skills
appreciation, awards (for contest, activities),
though every college has a computer lab. We
publications/ presentations of reports can be
can do this during community postings as by
introduced as carrot part of evaluation. It is
assigning projects to students in small
also worth to do occasional evaluation of our
groups.
teachers and their teaching/ evaluation
5. More participatory and interactive teaching
methods - best achieved by students’
during community posting by taking students
feedback (anonymous).
in small groups for Role play for attitude
Community Medicine education in India is
building; Mini projects for skill development;
facing a number of challenges. However, with
Group based activities like discussions &
concerted and proactive efforts, these challenges
presentations.
can be overcome. Bringing its teaching from the
6. Use real life examples & success stories - A classroom to the community would help to
major criticism made against most of the PSM provide a realistic picture to the subject and act
departments across the country is that they as a stimulus to learning and an active
work in isolation from health system. involvement
in
its
application
and
Teaching departments need to be active implementation.
participants in health programs citing real life
examples rather quoting bookish examples.
Acknowledgement
7. Development of urban and rural training
centres for imparting field based training and
clinical skills to students in community
settings. Adoption of centres will help
teachers to update their knowledge and skills
as well and reaching to the solutions
mentioned above as 6 and 7.
8. Integrate teaching with other subjects
vertically or horizontly. A case presentation
covering various subjects by a group of
students in front of panel of teachers from
different subjects is also helpful.
9. Use of multiple teaching methods/
technologies and avoid too much emphasis
on didactic learning and use of PowerPoint
I am grateful to my colleagues, UG and PG
students, for giving me this insight and
particularly my friend Prof. Rahul Bansal,
Professor & Head of Community Medicine at
Subharti Medical College, Meerut, whose
presentation at state chapter conference of
IAPSM (UP & UK) at Jhansi and his informal
interactions have inspired me. I have quoted
extensively from his work and gratefully
acknowledge the same.
(Based on a guest lecture delivered during conference
of IAPSM (GC) at GCS Medical College, Ahmedabad
on 9th March 2013)
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original article ▌
SURVIVAL PROBABILITIES OF PAEDIATRIC PATIENTS
REGISTERED IN ART CENTRE AT NEW CIVIL HOSPITAL,
SURAT
Sridhar P Ryavanki1, Jayendrakumar K Kosambiya2, Sonal O Dayama3, Alap Mehta4, Nitin
Solanki5, Sangita S Trivedi6
Financial Support: None declared
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Ryavanki SP, Kosambiya JK,
Dayama SO, Mehta A, Solanki N,
Trivedi SS. Survival Probabilities of
Paediatric Patients Registered in
ART Centre at New Civil Hospital,
Surat. Natl J Community Med 2013;
4(1): 4-9.
Author’s Affiliation:
1State Health Consultant,
Commissionerate of Health,
Gandhinagar; 2Professor
(Additional); 3Post Graduate
Student, Department of
Community Medicine, Government
Medical College, Surat; 4Senior
Medical Officer, ART Centre, New
Civil Hospital Surat, Surat;
5Assistant Professor, Department of
Community Medicine, NHL
Medical College, Ahmedabad;
6Professor (Additional),
Department of Pediatrics,
Government Medical College,
Surat, Surat
Correspondence:
Dr Sridhar R.P.,
Email: sridhar.ryavanki@gmail.com
Date of Submission: 19-02-12
ABSTRACT
Aims and Objectives: To study the profile of paediatric HIV
patients registered in ART centre of New Civil Hospital, Surat,
Gujarat (India) and provide an estimate of 3 years survival
probabilities of paediatric HIV patients on ART.
Material and methods: Data of 175 paediatric patients (of age less
than 15 years), registered from 2007 to 2010 was collected and
analyzed. Kaplan Meir method for survival analysis and Log rank
test to test statistical significance were used.
Observations: Survival analysis of 161 patients could be done
(registered from Oct 2006 to Oct 2010). The survival probability
after 8 years of diagnosis of HIV is 91.7 %. After 3 year of start of
ART according to WHO criteria survival probability is 85.7 %.
The 3-year survival rate of paediatric HIV patients with WHO
Stage 1 is 100%, Stage 2 is 75%, Stage 3 is 61.9% and Stage 4 is
40.8% which was statistically significant (p < 0.001).
Conclusions: The survival probability was 91% after 3 years of
diagnosis of HIV and remained same till 8 years and the
probability was independent of age groups and sex. The survival
probability was 85.7 % after 3 years of start of ART. There was no
difference in survival probability with different baseline CD4
counts but was significantly low in patients who were in WHO
stage 3 and 4 at the time of registration.
Recommendations: With ART definitely proving increase in
survival probability, it is now time to study different drug
regimens and their respective survival probabilities. There are
many studies on adverse effects of the ART drugs but there is
need for research on their effect on survival. There is a scope for
continuing of this study further with at least median follow up of
5 years. Larger sample and regression model can be used to
understand more precisely the predictors of survival.
Key words: Paediatric HIV, Survival probability, Kaplan-Meier,
WHO staging, India,
Date of Acceptance: 05-03-13
Date of Publication: 31-03-13
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Open Access Article│www.njcmindia.org
INTRODUCTION
The number of annual AIDS-related deaths
worldwide is steadily decreasing from the peak
of 2.1 million in 2004 to an estimated 1.8 million
in 2009. The decline reflects the increased
availability of antiretroviral therapy, as well as
care and support, to people living with HIV,
particularly in middle- and low-income
countries; it is also a result of decreasing
incidence starting in the late 1990s. Globally,
death among children younger than 15 years of
age is also declining. The estimated 260000
children, who died from AIDS-related illnesses
in 2009 were 19% fewer than the estimated 320
000, who died in 2004.This trend reflects the
steady expansion of services to prevent
transmission of HIV to infants and an increase
(albeit slow) in access to treatment for children. 1
In India, Care Support Treatment programme as
per the objectives under National AIDS Control
Programme -3 provides prevention and
treatment of opportunistic infections, AntiRetroviral Therapy (ART), psychosocial support,
home-based care, positive prevention and impact
mitigation. Around 3.84 lakh PLHA including
22,837 children are receiving free ART through
292 ART centres and 550 Link ART Centres.
2 Early Infant Diagnosis programme to closely
monitor HIV-exposed infants, identify their HIV
status and provide them appropriate treatment
to reduce HIV related mortality and morbidity,
has been rolled out through 766 ICTCs and 181
ART centres; 9,016 infants and children under 18
months of age were tested under this
programme till January 2011.2
Out of the total paediatric HIV positive patients
in India, 4.3% have been reported from Gujarat.
That amounts to 979 patients. In Gujarat there
were 18 ART centres in 2010 catering a load of
18,754 HIV patients out of which 17,775 were
Adult and 979 were Paediatric HIV patients.
Gujarat had 4.9 percent of country’s HIV patients
and 4.3 percent of Paediatric HIV patients.
Survival probabilities of these patients have not
been studied yet in India. The following study
was done with objective of estimating survival
probabilities of Paediatric HIV patients on Anti
Retroviral Therapy.
METHODOLOGY
Study setting: The ART centre at New Civil
Hospital, Surat (NCHS) was established in the
year 2006, under National Aids Control Program
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III (NACP-III), funded by National Aids Control
Organization (NACO). 5,422 HIV-infected
individuals are registered with the ART Centre
since September 2006 until December 2010, out
of which, 192 were paediatric patients. The
patient flow of paediatric patient is through
Paediatrics Department of NCHS, PPTCT
(Prevention of Parent to Child Transmission)
program, other departments of NCHS, various
other government health and private clinics. The
patients are first counselled then consent is taken
and tests for HIV are done. The positive patients
are then examined; their CD4 cell counts are
recorded and they are registered at ART centre.
Baseline clinical and demographic data are
recorded for all enrolled patients. Demographic
data include gender, age, residence, status of
parents. Clinical data include baseline CD4+ cell
counts ,WHO staging, weight at registration,
initial ART regimen, change in ART regimen,
recent WHO staging, HIV sero status of parent,
Data of 162* Pediatric HIV
patients was analyzed for
Probability of Survival after
start of ART
Total 192 Pediatric
Patients were enrolled
between Oct 2006 - Oct
2010
*Others excluded as per the exclusion criteria
Data of 132* Pediatric HIV
patients was analyzed for
Probability of Survival as
per baseline CD4 count
Data of 68* Pediatric HIV
patients was analyzed for
Probability of Survival as
per WHO staging
Data of 117* Pediatric HIV
patients was analyzed for
Probability of Survival from
time since diagnosis
mode of transmission of HIV, CD4 count at
regular visit, or period of illness ,etc. All HIVpositive children who meet the standard WHO
clinical and immunological criteria for starting
ART in children are considered eligible to receive
ART.
Selection Criteria: Retrospective and prospective
data collected from October 2006 until October
2010 of children enrolled in ART centre was
analysed. For general profile, all the individuals
with age 1-15 years were included. Survival
probabilities
were
analyzed
with
epidemiological factors including gender, age,
immune status (CD4 count) at HIV diagnosis,
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and baseline WHO staging of those individuals
whose first centre of registration (or first centre
of treatment) was ART centre, NCHS.
Exclusion Criteria: Those patients who were
transferred to the ART centre in study period
were not included. Data cleaning was done
accordingly and those data that were available
for all years uniformly were analysed.
Outcome Measure: Death of a HIV patient was
taken as the primary end point.
Statistical Analysis: Descriptive statistics for
general profile of the patients was carried out.
While Kaplan-Meier analysis and log-rank tests
were used to compare survival curves stratified
by epidemiological group, SPSS version 16 was
used to analyze the data.
OBSERVATIONS
During the time of retrieving the data 192
paediatric age group patients were enrolled at
ART. There were 77 females and 115 males. Out
of these 192 patients, 162 had directly enrolled
and 30 were referred to the ART centre. There
was uncertainty of the data being reliable
regarding the date of HIV diagnosis and start of
ART of patients who were referred. Number of
patients lost to follow up, transferred in and out
of ART centre was 30, which were excluded from
the further data analysis. The mean age of
patients was 7.5 years with SD of 3.7 years. The
proportion of patients in the age group 1-4 years,
5-8 years and 9-12 years was similar of about
27%. Only 5% and 12% of the patients were in
age group <1year and 13-15 years respectively.
Mean CD4 cell count at time of enrolment was
159 cells/µL, median 237 cells/µL, SD 291
cells/µL. The patients with CD 4 count less than
200 were 48% .Twelve percent patients had s CD
4 counts between 200-250 and fifteen percent had
CD 4 counts between. Only 5% had CD 4 count
between 350-500 while there were 20% patients
having CD 4 count >500. According to WHO
staging done at registration, approximately 50 %
of patients were in Stage 3 and 4 and about 50%
were in State 1 and 2. Most common route of
transmission was perinatal. (Table 1)
Table 1: Profile of HIV positive paediatric patients at NCHS
Categories
Total (%)
Deaths (%)
Person years
Total Individuals
192(100)
19(10)
240
Mortality density
(per 100 person years)
7.9
Referral
Direct
Indirect
162(84)
30(16)
18(9.3)
1(0.7)
185
55
9.7
1.8
Sex(n=162)
Male
Female
96(59)
66(41)
12(7.4)
6(3.7)
111.2
73.4
10.8
8.2
8(5)
45(27.7)
44(27.2)
45(27.7)
20(12.4)
0
9(5.5)
2(1.3)
3(1.8)
4(2.5)
2.4
46.6
63.2
55.6
17.1
0
19.3
3.2
5.4
23.4
CD4+ T cell counts (n=132)
<200
200-250
250-350
350-500
>500
63(48)
16(12)
20(15)
7(5)
26(20)
8(6)
1(0.8)
2(1.5)
2(1.5)
3(2.3)
95.1
21
22.9
7.5
31.2
8.4
4.8
8.7
26.7
9.6
WHO Staging(n=68)
1
2
3
4
11(16)
24(35)
23(34)
10(15)
1(1.5)
2(2.9)
4(5.9)
5(7.4)
23.1
50.1
36.6
13.5
4.3
3.9
10.9
37
Age (yrs)(n=162)
<1
1-4
5-8
9-12
13-15
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Males had higher mortality density (10.8 per 100
person years) than females (8.2 per 100 person
years). Mortality density was highest in age
group of 13-15 years (23.4 per 100 person years).
Mortality density was highest in patients with
CD 4 count 350-500 and those who were initially
classified in WHO stage 4. (Table 1)
Among the data of 162 patients only 117 had
reliable date of diagnosed to be having HIV. The
survival probability once the patient is
diagnosed as HIV of 162 patients was calculated.
Survival probability of patients after 8 years of
diagnosis of HIV was found to be 91.7 %. It was
similar in all age groups and, males and females.
(Figure 1)
* Median days of follow up 21.3 months (25th percentile: 9.7
months; 75th percentile: 37.3 months)
Figure 1: Survival probability after HIV
diagnosis (n=117*)
*Median days of follow up 10.6 months (25th percentile: 3.7
months; 75th percentile: 22 months)
Figure 2: Survival probability after start of ART
(n=162*)
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After 3 years of start of ART, survival probability
is 85.7 %. (Figure 2) When survival probability
was seen among patients with different baseline
CD4 counts, no significant difference was seen.
But survival probability was significantly low in
patients who were in WHO stage 3 and 4 at the
time of registration. So, the role of gender, age
and CD4 count as predictor of survival of
children on ART could not established. (Figure 3)
DISCUSSION
The number of people dying of AIDS-related
causes fell to 1.8 million [1.6 million–1.9 million]
in 2010, down from a peak of 2.2 million [2.1
million–2.5 million] in the mid-2000s. A total of
2.5 million deaths have been averted in low- and
middle-income countries since 1995 due to
antiretroviral
therapy
being
introduced,
according to new calculations by UNAIDS. Much
of that success has come in the past two years
when rapid scale-up of access to treatment
occurred; in 2010 alone, 700 000 AIDS related
deaths were averted.3 Without ARV treatment,
half of all children infected with HIV at birth die
from AIDS before their second birthday.4 Early
HIV diagnosis and early ARV treatment lower
infant mortality by 76 percent and the rate of
progression to AIDS by 75 percent.5 Survival
probability was 0.93 (95% CI: 0.91-0.95) and 0.91
(95% CI: 0.88-0.93) at 24 and 36 months after ART
initiation, respectively reported by Issakidis P et
al
in
their
study.6 In
our
study
survival probability, was 0.91 and 0.86 at 12 and
24 months after ART initiation, respectively. In a
study by Alibhai A, Kipp W et al, mortality in
female patients (9.0%) was lower than mortality
in males (13.5%), with the difference being
almost statistically significant (adjusted hazard
ratio for females 0.55; 95% confidence interval
[CI]: 0.28–1.07; P = 0.08). In our study, the
mortality in males is 12.5 % and in females it is
9.1 % which is not found to be statistically
significant after applying log rank test. In their
study, at baseline, female patients had a
significantly higher CD4+ cell count than male
patients (median 147 cells/µL vs 120 cells/µL; P0.01). 7 Whereas in our study, females and males
had similar median of baseline CD4 count.
Antiretroviral treatment reduces illness and
mortality among children living with HIV in
much the same way that it does among adults. In
one study in Brazil by Matida, L.H. et al (2004),
three-quarters of HIV-positive children receiving
ART were alive after a four-year follow-up
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period.8 A study released by O'Brien D.P. et al in
2007, which monitored 586 HIV-positive children
receiving antiretroviral treatment in 14 countries
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in Africa and Asia, found that 82 percent were
still alive after two years. 9
Fig. 3: Survival after start of ART stratified by various characteristics A. Age; B. Sex; C. CD4+
count; D. WHO staging
CONCLUSIONS
The mortality density was higher among males,
age group of 13-15 years, patients with baseline
CD 4 count 350-500 and who were initially
classified in WHO stage 4. The survival
probability was 91% after 3 years of diagnosis of
HIV and remained same till 8 years and the
probability was independent of age groups and
sex. The survival probability was 85.7 % after 3
years of start of ART. There was no difference in
survival probability with different baseline CD4
counts but was significantly low in patients who
were in WHO stage 3 and 4 at the time of
registration. So, the role of gender, age and CD4
count as predictor of survival of children on ART
could not established but WHO staging had
significant role.
Limitations: There can be many factors that
affect survival status of a child like nutrition
status, socio-economic status of parents, type of
ART regimen started, etc which have not been
explored in this study.
Recommendations: With ART definitely proving
increase in survival probability, it is now time to
study different drug regimens and their
respective survival probabilities. There are many
studies on adverse effects of the ART drugs but
there is need for research on their effect on
survival. There is a scope for continuing of this
study further with at least median follow up of 5
years. Larger sample and regression model can
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be used to understand more precisely the
predictors of survival.
Acknowledgement: The authors would like to
acknowledge Gujarat State AIDS Control Society
(GSACS), the Nodal officer of ART centre, the
Medical Superintendent, NCHS, the Dean of
Government Medical College, Surat and
Department of Statistics, Veer Narmad South
Gujarat University for SPSS software support.
REFERENCES
1.
UNAIDS. Report On The Global AIDS Epidemic.
Geneva, Switzerland 2010, p8
2.
NACO, Department of AIDS Control, Ministry of
Health & Family Welfare Annual Report 2009-2010,
Janpath, New Delhi: NACO 2009-10, p1.
3.
UNAIDS. UNAIDS World AIDS Day Report 2011 - How
to get zero: Faster. Smarter. Better. 2011. Geneva,
Switzerland: UNAIDS 2011, p6.
4.
UNICEF Eastern and Southern Africa - HIV and AIDS Preventing mother-to-child transmission (PMTCT) of
HIV - Providing Paediatric Treatment cited on 12, Dec
2012.
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5.
Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J,
Madhi S a, et al. Early antiretroviral therapy and
mortality among HIV-infected infants. The New
England journal of medicine [Internet]. 2008 Nov 20;359
(21):2233–44.
6.
Isaakidis P, Raguenaud M-E, Te V, Tray CS, Akao K,
Kumar V, et al. High survival and treatment success
sustained after two and three years of first-line ART for
children in Cambodia. Journal of the International AIDS
Society [Internet]. 2010 Jan;13:11.
7.
Alibhai A, Kipp W, Saunders LD, Senthilselvan A, Kaler
A, Houston S, et al. Gender-related mortality for HIVinfected patients on highly active antiretroviral therapy
(HAART) in rural Uganda. International journal of
women’s health [Internet]. 2010 Jan;2:45–52.
8.
Novaes A, Jr R. Improving survival in children with
AIDS in Brazil : results of the second national
Ampliação da sobrevida em crianças com AIDS no
Brasil : resultados do segundo estudo nacional de 1999
a 2002. Social Sciences. 2011;1999–2002.
9.
O’Brien DP, Sauvageot D, Olson D, Schaeffer M,
Humblet P, Pudjades M, et al. Treatment outcomes
stratified by baseline immunological status among
young children receiving non-nucleoside reversetranscriptase inhibitor-based antiretroviral therapy in
resource-limited settings. Clinical infectious diseases :
an official publication of the Infectious Diseases Society
of America [Internet]. 2007 May 1 [cited 2012 Apr 21];
44(9):1245–8.
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Original Article ▌
REPRODUCTIVE AND SEXUAL TRACT INFECTIONS
AMONG MARRIED FEMALE YOUTH IN AN URBAN SLUM
OF MUMBAI
Yasmeen K Kazi1, Anita G Shenoy2, Gajanan Velhal2, Sudam R Suryawanshi3
ABSTRACT
Financial Support: None declared
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Kazi YK, Shenoy AG, Velhal G,
Suryawanshi SR. Reproductive and
Sexual Tract Infections among
Married Female Youth an an Urban
Slum of Mumbai. Natl J
Community Med 2013; 4(1): 10-4.
Author’s Affiliation:
1Assistant Professor; 2Professor
(Additional); 3Professor & Head,
Preventive & Social Medicine, TN
Medical College & BYL Nair Ch.
Hospital., Mumbai
Correspondence:
Dr. Yasmeen Kazi,
Email: dryasmeen@hotmail.com
Date of Submission: 17-12-12
Introduction: The issues faced by the youth (15 – 24 years) today
like illiteracy, unemployment, high risky behavior can result in
adverse economic, social and political consequences. Young
women face additional problems, like malnutrition, anemia. They
are forced into early marriage and child bearing. Hence, this
study was carried out to study the Sexual & Reproductive Tract
Infections among the Married Female Youth, in an Urban Slum of
Mumbai.
Methodology: Married Female Youth in the age group 15 – 24
who attended the Out Patient Department at the Urban Health
Centre, Shivaji Nagar during the period from October to
December 2011 were included in the study ( n= 192). Women
were enquired about their socioeconomic status, including their
age at marriage, age at 1st childbirth, number of children, spacing
between children and history of Reproductive Tract Infection/
Sexually Transmitted Infection with the help of pretested,
preformed, semi structured interview questionnaire.
Results: It was found that women were married early (mean =
16.90, S.D=2.37) & even had their 1st child at an earlier age (mean
18.43, S.D=1.94).
Factors, such as early age at marriage ( p= 0.059), early age at 1st
childbirth ( p = 0.038), & less spacing between children ( p =
0.0316) was seen to have an influence on the Reproductive health
of the women.
Date of Acceptance: 04-03-13
Date of Publication: 31-03-13
Keywords: Reproductive Tract Infection, Sexually Tract Infection,
Urban Health Centre, Youth
INTRODUCTION
One fifth of the population in India (18.4%) is
youth between the ages 15 – 24 years, according
to the 2011 Census1. They represent the country’s
future and shape subsequent generations. The
Youth undergo a period of development when
biological, physical, cognitive, and social traits
mature from childhood to adulthood. During
this stage, the challenges that youth face and the
decisions they make can have a tremendous
impact on the quality and length of their lives.
Many important life events and health-damaging
behaviors start during the youth years. As a
result, youth is a time of both risk and
opportunity. Common problems faced by this
group are illiteracy, unemployment, practice of
high risk behavior etc2. Young women face
additional problems, like malnutrition, anemia.
Social pressures force young women into early
marriage and child bearing2. Hence this study
was carried out to assess the various aspects &
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study factors associated with reproductive &
sexual tract infections in the young women.
OBJECTIVES
•
To study the socio demographic profile
of the married female youth attending
the Urban Health Centre.
•
To know the prevalence of symptomatic
reproductive tract infection.
•
To find the practices related to marriage
& child bearing among them.
METHODOLOGY
A cross sectional study was carried out at the
Urban Health Centre, Govandi, affiliated to the
Department of Preventive & Social Medicine,
T.N. Medical College, Mumbai. There were total
of 4895 patients attending the Urban Health
Centre during the period October to December
2011. Out of which 495 were young females
between the age group 15 – 24 & 220 were
married among them. 28 females did not agree to
participate in the study. So, the total sample for
this study was 192.Consent was taken from all
the women.
Data was collected with the help of a Pretested,
preformed, semi structured interview schedule
by the author & Post graduate residents in the
department. Details regarding their age,
socioeconomic status, educational , family &
marital status including the number of children
& the spacing between them were all enquired
into. Women were also enquired about their
history of daily bath & change of clothes
especially during their menstrual cycle to assess
for hygiene. The women were also asked if they
suffered from any of the symptoms of the
Reproductive Tract Infection (RTI). Screening
was based on only questionnaire following the
syndromic approach.
Data was analyzed using the SPSS package
version 15. Analysis was done using the Pearson
Chi Square Test for trend & Logistic Regression.
Enter method was used for Logistic Regression,
thus all variables were assessed at the same time.
The variables included in the Logistic Regression
were Education, type of family, number of
family members, socioeconomic status, age at
marriage, age at childbirth. The reference group
for each of these variables were higher secondary
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& above, extended family, family members> 10,
lower socioeconomic status, age at marriage > 18
years and age at childbirth > 20 years,
respectively. All the variables were included as
categorical variable.
Results
Women interviewed were 192 during the study
period. 57.3% (110) of the women belonged to
the age group 22 – 24 years with the mean age of
the women being 21.51 years(S.D = 2.237) ( Table
1). 65.6% (126) of the women had education level
up to Secondary. (Table 1)
According to the type of family distribution, 41.1
% (79) women belonged to Nuclear family (Table
1). The number of family members were less
than 5 in 44.8% (86) of the women
interviewed.(Table 1).
58.9 % (113) of the women belonged to the Poor
socioeconomic status according to Kuppuswamy
Classification9 (Table 1).
Table 1: Distribution of study subjects
according to their Demogrphic Profile
Patients (%)
Age
15 – 18
19 – 21
22 – 24
Education
Primary & Below
Secondary
Higher Secondary & above
Type of family
Nuclear
Joint
Extended
No. of family members
<5
5 – 10
>10
Socioeconomic Status
Lower Middle
Upper Lower
Lower
Age at marriage
<15
15 – 18
>18
Age at 1st Childbirth
15 – 18
18 – 20
>20
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13 (6.8)
69 (35.9)
110 (57.3)
44 (22.9)
126 (65.6)
22 (11.5)
79 (41.1)
54 (28.1)
59 (30.7)
86 (44.8)
67 (34.9)
39 (20.3)
57 (29.7)
113 (58.9)
22 (11.5)
26 (13.5)
100 (52.1)
66 (34.4)
57 (36.77)
44 (28.39)
54 (34.84)
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The women were married at an early age with
52.1% (100) of women being married between the
age group 15 – 18 years and 13.5% (26) of them
being married even before 15 years of age. The
mean age of marriage of these females was 16. 90
years (S.D = 2.37) (Table 1).
The age at first childbirth was also early with
29.7% (57) delivering their first child between the
age group 15 – 18 years. The mean age at first
childbirth was 18.43 years (S.D= 1.94) (Table 1).
69.03% (107) had <= 2 children and the spacing
between 2 children in 58.70% (91) women was <=
3years 19.27% (37) of these women did not have
any children.
Table 2: Distribution of RTI / STI Symptoms* &
Their Treatment Seeking Behavior
Patients (%)
RTI/STI Symptoms
Genital Ulcers
Burning Micturation
Itching in vulva
Pain in abdomen
Backache
White discharge
Treatment Taken
Yes
No
14 (7.3)
33 (17.2)
49 (25.5)
56 (29.2)
109 (56.8)
126 (65.6)
66 (61.11)
42 (38.89)
* Multiple Responses
Table 3: Factors associated with RTI in the study group. (n=192)
Variables
Age
15 – 18
19 – 21
22 – 24
Education
Primary & below
Secondary
Higher Sec
Socio EconomicStatus
Lower Middle
Upper Lower
Lower
Type of family
Nuclear
Joint
Extended
No. of family members
<5
5 – 10
> 10
Age at marriage
< 15 years
15 – 18
> 18 years
Age at 1st childbirth
15 – 18
18 – 20
> 20 years
No. of children
<=2
>2
Spacing between children
< = 3 years
> 3years
Hygiene
Bad
Good
Abortion
Yes
No
Reproductive Tract Infection
Yes
No
Chi Square
P value
9 ( 69.23)
34( 49.27)
65 (59.09)
4 (30.76)
35 ( 50.72)
45 ( 40.90)
0.1135*
0.7362
31 ( 70.45)
70 ( 55.55)
7 ( 31.81)
13 (29.54)
56 ( 44.44)
15 ( 68.18)
8.651*
0.0033
37 ( 64.91)
59 (52.21)
12 ( 54.54)
20 ( 35.08)
54 ( 47.78)
10 ( 45.45)
1.579*
0.2089
51 ( 64.55)
24 ( 44.44)
33 ( 55.93)
28 ( 35.44)
30 ( 55.55)
26 ( 44.06)
1.362*
0.2432
52 ( 60. 46)
34 ( 50.74)
22 ( 56.41)
34 ( 39.53)
33 ( 49.25)
17 ( 43.58)
0.4544*
0.5003
18 ( 69.23)
62 ( 62)
28 ( 42.42)
8 ( 30.76)
38 ( 38)
38 ( 57.57)
7.589*
0.0059
37 ( 64.91)
24 ( 54.44)
22 ( 40.74)
20 ( 35.08)
20 ( 45.45)
32 ( 59.25)
6.501*
0.038
57 ( 52.29)
26 ( 54.16)
50 ( 47.70)
22 ( 45.83)
0.01069
0.917
66 ( 72.52)
5 ( 35.71)
25 ( 27.47)
8 ( 57.14)
4.623
0.0316
67 (56.30)
41 (56.16)
52 (43.69)
32 (43.83)
0.0003
0.985
14 (12.96)
94 (87.04)
10 (11.90)
74 (88.10)
0.048
0.8259
*Chi Square for linear trend.
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The women were enquired about their
reproductive health & 56.3% (108) had history of
any of the symptoms of Reproductive Tract
Infection with maximum of them having white
discharge, Backache & pain in abdomen (Table
2). For this question, there were multiple
responses from the females. Out of all those who
had the infection, only 61.11 % (66) had taken
any form of treatment. Others 38.89% (42) had
not taken any treatment (Table 2).
Various factors associated with Reproductive
Tract Infection/ Sexually Transmitted Infection
(RTI/STI) were analyzed and it was seen that
education of the women had a significant
relation with the presence of Reproductive Tract
Infection/ Sexually Transmitted Infection
(RTI/STI). Those women with Primary & lesser
education had more chances of getting infected
with Reproductive Tract Infection/ Sexually
Transmitted Infection ( p= 0.0033). The other
socio
demographic
factors
like
age,
socioeconomic status, type of family & no. of
family members did not show any statistical
significance with the presence of Reproductive
Tract Infection/ Sexually Transmitted Infection
(RTI/STI).
Women who got married even before the age of
15 years had more prevalence of Reproductive
Tract Infection/ Sexually Transmitted Infection
18 ( 69.23%) and this was seen to be statistically
significant (p= 0.0059).
Those women who had their first child between
15 – 18 years of age had higher rate of infection
37 (64.91%) with a statistical significance level
(p= 0.0108).
Women who had more children (>2) had more
infection 26 (54.16%) as compared to those with
less children ( <=2) , but there is no statistical
significance between them ( p= 0.917).
Spacing between children had a significant
relation with presence of Reproductive Tract
Infection/ Sexually Transmitted Infection
(p=0.0316) . Those women who had the spacing
between children as < = 3 years had the rate of
infection to be more (66) (72.52%) as compared to
those who had more than 3 years of spacing
between children( 5) ( 35.71%).
Out of those women who had ever done
abortion, 12.96% (14) had Reproductive Tract
Infection. But the relation was not statistically
significant.
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56.3% (67) of women who had Reproductive
Tract Infection had bad menstrual hygiene, but
the relation was not statistically significant.
(Table.3)
Logistic Regression was applied using the
ENTER Method. All the variables were assessed
at the same time. According to the Logistic
Regression, it was seen in this study that those
females who were educated up to primary or
below had more chance of getting Reproductive
Tract Infection/ Sexually Transmitted Infection (
p= 0.002) after adjusting for all the other
variables.
Women who were married at an earlier age i.e at
< 15 years of age are at a higher risk of getting
infected (p= 0.03), after adjusting for all the other
variables.
Table 4: Logistic regression of Reproductive
tract Infection with associated factors
Age 19-21years
Education
Primary & below
Secondary
Higher secondary & above
Type of family
Nuclear
Joint
Extended
No of family members
<5
5 to 10
>10
Socioeconomic status
Lower Middle
Upper Lower
Lower
Hygiene
Abortion
Age at marriage
< 15
15 - 18
> 18
Age at childbirth
15 - 18
18 - 20
> 20
No. of children
Spacing between children
Constant
OR (95% CI)
pvalue
0.038 0.19 (0.04 - 0.91)
0.002
0.029
0.005
51.09 (4.19 - 623.35)
11.88 (1.29 - 109.43)
0.930
0.404
0.626
0.94 (0.22 - 4.03)
0.57 (0.15 - 2.15)
0.968
0.904
0.980
0.97 (0.18 - 5.05)
1.10 (0.25 - 4.86)
0.762
0.039
0.032
0.836
0.924
0.77 (0.14 - 4.23)
0.22 (0.05 - 0.93)
1.12 (0.38 - 3.33)
0.93 (0.22 - 3.98)
0.030
0.906
0.062
7.14 (1.21 - 42.24)
1.07 (0.33 - 3.45)
0.096
0.081
0.174
0.006
0.006
0.187
3.51 (0.80 - 15.42)
4.27 (0.83 - 21.85)
0.12 (0.03 - 0.55)
0.56 (0.37 - 0.84)
11.84
Spacing between 2 children if < = 3years had
more chance of getting infected (p= 0.006)
(Table.4), after adjusting for all the other
variables.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Validity of the model is assessed with Hosmer
Lemslow and found to be good (p= 0.517) with
R2 value as 0.349 (Cox and Snell).
DISCUSSION
Prevalence of RTI/STI in this study was (108)
56.3%, which is comparable to other studies3,4,5.
The prevalence of RTI in the study was 64.55% in
nuclear families and 44.44% in joint families as
seen in study done by Manisha Rathore et. al.6.
RTI was seen more in age group between 15 - 18
( 69.23%). Reproductive Tract infection was also
seen more among those who had their education
level of Primary or below (70.45%) as seen in
study done by B. Sri devi et. al.3.Also more
common among those who were married at age
less than 18 as seen in study done by A. Parasher
et. al.8. It was seen more in those who had their
1st child even before 20 years of age as seen in
studies done by B. Sri Devi et al & Savita Sharma
et. al.3,7. Spacing between 2 children also was a
factor influencing RTI. No. of children also has
an influence on the prevalence of RTI in contrast
to study carried by B Sri Devi et. al.3. Menstrual
hygiene (56.30%) and history of abortion
(12.96%) had no influence on Reproductive tract
infection in this study. Out of those who had
infection only 61.11% (66) had taken any form of
treatment.
CONCLUSIONS
Observed prevalence of Reproductive Tract
Infection/ Sexually Transmitted Infection in
present study is 56.3 % among married female
youth. Women < 18 years of age were mostly
affected. Age at marriage, age at childbirth and
less interval between childbirth have shown
significant
influence
on
prevalence
of
Reproductive
Tract
Infection/
Sexually
Transmitted Infection. Age, socio economic
status , type of family, No. of family members,
no. of children, history of abortion or hygiene
have not shown statistically significant influence
on Reproductive Tract Infection/ Sexually
Transmitted Infection.
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RECOMMENDATIONS
Awareness regarding ill-health effects of early
marriage & early child bearing should be given
wide publicity in the study area. Spacing
between children should be emphasised. Health
education & promotion of hygienic practices &
appropriate treatment seeking behaviour should
form the key strategies towards safe guarding
their health. Detailed community based study to
be carried out.
REFERENCES
1.
Census 2011.Office of the Registrar General & Census
Commisioner, India. Available at
http://censusindia.gov.in/Census_And_You/age_struc
ture_and_marital_status.aspx. Accessed on 16th August
2011.
2.
Some Key Statistics on Youth in South Asia. World
Bank. Available at
http://qo.worldbank.org/7QM6YCSWOO.html.
Accessed on 20th August 2011.
3.
Sri devi B, Swarnalatha N. Prevalence of RTI/STI
among reproductive age women (15-49 years) in urban
slums of Tirupati town, Andhra Pradesh. Health and
Population - Perspectives and Issues 2007;30(1): 56-70.
4.
Ranjan R, Sharma AK, Mehta G. Evaluation of WHO
Diagnostic Algorithm for Reproductive Tract Infections
among Married Women. Indian J of Comm Med 2003;
28(2): 81- 4.
5.
Thakur JS, Swami H M, Bhatia SPS. Efficacy of
Syndromic Approach in management of Reproductive
tract infections and associated difficulties in a rural area
of Chandigarh. Indian J of Comm Med 2002; 27(2): 77- 9.
6.
Rathore M, Swami SS, Gupta BL, Sen V, Vyas BL,
Bhargav A, Vyas R. Community-based study of selfreported morbidity of reproductive tract among women
of reproductive age in rural area of Rajasthan. Indian J
of Comm Medi 2003; 28(3): 117-21.
7.
Sharma S, Gupta BP. The prevalence of reproductive
tract infections and sexually transmitted diseases among
married women in the reproductive age group in a rural
area. Indian J of Comm Med 2009;34(1):62 – 4.
8.
Parashar A, Gupta BP, Bhardwaj AK, Sarin R. The
prevalence of reproductive tract infections and sexually
transmitted diseases among women of reproductive age
group in Shimla City. Indian J of Comm Med
2006;31(1):15 - 7.
9.
Park K. Park’s Textbook of Preventive and Social
Medicine,21st ed.Jabalpur:Bhanot publishers;2011. p 639.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original article ▌
EVALUATION OF VACCINE WASTAGE IN SURAT
Shreyash Mehta1, Pradeep Umrigar1, Prakash Patel2, R K Bansal3
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Mehta S, Umrigar P, Patel PB,
Bansal RK. Evaluation of Vaccine
Wastage in Surat. Natl J
Community Med 2013; 4(1): 15-9.
Author’s Affiliation:
1Resident, 2Assistant Professor,
3Professor & Head, Department of
Community Medicine, SMIMER,
Surat
Correspondence:
Dr. Shreyash Mehta,
Email: shreyash111@gmail.com
Date of Submission: 19-01-13
Date of Acceptance: 27-03-13
Date of Publication: 31-03-13
Introduction: Vaccine wastage is one of the key factors to be
considered with regards to vaccine forecasting and need
estimation.
Objective: This study was conducted to assess the amount of
vaccine wastage; its correlation with type of vaccine and place of
vaccination; with route of administration and wastage and with
beneficiaries per session and wastage factor (WF).
Methods and Materials: Session wise data on vaccine usage and
its beneficiaries were collected from 36 Urban health centre
(UHC) of Surat Municipal Corporation (SMC). Vaccine wastage
rate ,vaccine wastage factor were calculated for each type of
vaccine and each site of session and correlation analysis was done
between the variables beneficiaries per session and wastage factor
per session.
Results: The overall wastage factor for BCG vaccine was 1.83, for
OPV was 1.33, for DPT was 1.19, for Hepatitis B vaccine was 1.26
and for Measles vaccine was 1.39. The WF was highest for
sessions held at ICDS for BCG vaccination (3.38) followed by
sessions held at mobile sites for BCG vaccination (2.50). The WF
was lowest for sessions held at UHC for DPT vaccination (1.11)
followed by sessions held at subcentres for DPT vaccination (1.13)
and sessions held at UHC for Hepatitis vaccination (1.13).
Conclusions: BCG vaccine and Measles vaccine had WF greater
than the allowable WF 1.33, OPV had WF of 1.33, DPT vaccine
and Hepatitis vaccine had WF less than 1.33. WF was less for
fixed sites of vaccination like the UHCs and subcentres while the
WF was more ICDS and mobile sites.
Keywords: Vaccine wastage, Vaccine wastage rate, Wastage
factor, UHC, ICDS, SMC
INTRODUCTION
India has one of the largest Universal
Immunization Programs in the world. The
program budgets more than US$ 500 million
every year for immunizing children against
vaccine preventable diseases, including the polio
eradication program1. Wastage is defined as loss
by use, decay, erosion or leakage or through
wastefulness. The World Health Organization
reports over 50% vaccine wastage around the
world2. Many tools are available for reducing
vaccine wastage but high rates of wastage are
still prevalent across the globe. Vaccine wastage
can be classified as occurring “in unopened
vials” and “in opened vials”. Expiry, VVM
indication, heat exposure, freezing, breakage,
missing inventory and theft are the forms of
vaccine wastage affecting unopened vials.
Vaccine wastage in opened vials may also occur
because doses remaining in an opened vial at the
end of a session are discarded, the number of
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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doses drawn from a vial is not the same as that
indicated on the label, reconstitution practices
are poor, opened vials are submerged in water,
and contamination is suspected.
Vaccine wastage is an important factor in
forecasting vaccine needs. In the absence of local
or national data on wastage rates, if incorrect
figures are used, the country concerned may face
serious vaccine shortages or be unable to
consume received quantities, leading to
increased wastage through expiry. Such
monitoring can provide programme managers
with good guidance on the introduction of
corrective actions to reduce wastage whenever
necessary. With the introduction of new vaccine
management policies such as the application of
multidose vial policy (MDVP), the effective use
of vaccine vial monitors (VVMs), and improved
immunization strategies and practices, vaccine
wastage is expected to decrease. There is lack of
comprehensive study done in India to validate
the wastage rate recommended by WHO and
Ministry of Health and Family Welfare. Very few
published studies in India have studied the
wastage rate of vaccines1,3,4,5,6. This article
attempts to calculate the vaccine wastage rates in
an urban setting in Surat Municipal Corporation.
MATERIALS AND METHODS
This was a record based descriptive study to be
carried out in 36 urban health centres of Surat
Municipal Corporation. There is a dedicated
team of field workers consisting of four
Multipurpose Health workers (2 male and 2
female) and one Public Health Nurse (PHN) who
conduct immunization sessions at a fixed site on
fixed days. National Immunization Schedule
recommended by Ministry of health and family
welfare was followed7. BCG, DPT and HBV
vaccines vials used were 10 dose preparations,
Measles vials were 5 dose preparations and OPV
vials were 20 dose preparations.
Study population &Study period: All children
who got vaccinated between 1st January 2012
and 31st March 2012 were included in the study.
Data retrieval and analysis: The information of
vaccine vials used during immunization sessions
and children vaccinated were retrieved from the
immunization registers for the period of 1st
January 2012 and 31st March 2012 maintained by
the public health nurse. The no. of doses wasted
was calculated using the formula (No. of doses
issued- no. of children benefitted) Vaccine
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wastage rate was calculated using formula [(No.
of doses wasted/ No. of doses issued) X 100]
Vaccine Wastage Factor was calculated by using
the formula [100/ (100-vaccine wastage rate)]8.
Data were entered into Microsoft Excel spread
sheet and descriptive analysis was done.
RESULTS
Due to other important ongoing national
programmes,
Intensive
Pulse
Polio
Immunization (IPPI), incomplete data entry and
feasibility issues data from 24 UHC out of 36
UHC could only be taken for analysis of vaccine
wastage. A total of 2399 immunization sessions
were conducted during the study period. A total
of 5 vaccines (BCG, OPV, DPT, HBV and
Measles) had been given to children. The
information regarding the no. of vaccine vials
and doses used for vaccination, children
vaccinated, the wastage rate and wastage factor
(WF) for each vaccine are provided in table 1.
Table 1: Wastage rate and wastage factor (WF)
for different vaccine
Vaccine
Doses
Children
Wastage
consumed vaccinated
rate
BCG*
16532
9032
45%
OPV@
42290
31732
25%
DPT*
52180
43854
16%
HBV*
39069
31029
21%
Measles# 12941
9312
28%
# 5 dose vial vaccine; *10 dose vial vaccine; @20
vial vaccine
WF
1.83
1.33
1.19
1.26
1.39
dose
Among individual vaccines, wastage factor is
highest for BCG and lowest for DPT (Table-1).
Vial size: The vaccines are supplied in 3
different sizes of vials; 5 doses (Measles), 10
(BCG, DPT, HBV) and 20 (OPV) per vial.
For vaccines of 5 dose preparations (Measles),
the wastage rate was 28% and wastage factor
was 1.39. For vaccines of 10 dose preparations
(BCG, DPT, HBV) the wastage rate was 22% and
wastage factor was 1.28. For vaccines of 20 dose
preparations (OPV), the wastage rate was 25%
and wastage factor was 1.33.
Liquid and Lyophilized vaccine: The vaccine
vials come in liquid and lyophilized forms. Three
vaccines namely OPV, DPT and HBV are
supplied in liquid form and 2 vaccines; BCG and
Measles are freeze dried or lyophilized vaccines.
Among these, wastage factor and wastage rate
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were higher in lyophilized vaccines (1.61) and
(37.8%) compared to that of liquid vaccines i.e.
(1.25) and (20.16%).
were found to be 1.33 and 25% respectively.
Thus, there is negligible difference in wastage
between the two modes of administration.
Mode of Administration: All the vaccines except
for OPV are administered through injection. The
wastage factor and wastage rate for injectable
vaccines (BCG, DPT, HBV and Measles) were
found to be 1.29 and 22% and for oral (OPV)
A correlation between the number of
beneficiaries per session and WF per session was
calculated. The value of correlation coefficient (r)
and P-value was calculated.
Table 2: Correlation of vaccine beneficiary and wastage factor (WF)
variables
BCG beneficiary per session and its WF per session
OPV beneficiary per session and its WF per session
DPT beneficiary per session and its WF per session
HBV beneficiary per session and its WF per session
Measles beneficiary per session and WF per session
DISCUSSION
The Ministry of Health and Family Welfare,
Government of India has recommended that
wastage rate of all vaccines should not be higher
than 25% (Wastage factor of 1.33)9. The World
Health Organization has also projected vaccine
wastage rate in order to help in calculating
vaccine needs8 According to the WHO, projected
vaccine wastage rate for lyophilized vaccines is
expected to be 50% wastage rate for 10-20 dose
vials, and for liquid vaccines 25% wastage rate
for 10-20 dose vials8. The present study showed
that the vaccine wastage for OPV was higher
than the limits given by the Ministry of Health
and Family Welfare, Government of India9, as
well as by WHO8. The wastage rate of BCG,
Measles exceeded the recommendation limit set
by the national government, were above the
recommended wastage rate by the WHO. A field
based assessment and observation done by
National Rural Health Mission (NRHM) and
UNICEF1 documented the vaccine wastage rate
for vaccines under Universal Immunization
Programme (UIP) at session sites to be 61% for
BCG, 47% for OPV, 27% for DPT, 33% for HBV
and 35% for Measles vaccine which more than
the wastage rate obtained from our study.
The wastage rate for 5 dose vaccine vial(
Measles) was 28% , for 10 dose vaccine vial
(BCG, DPT, HBV) was 22% and for 20 dose
vaccine vial (OPV) was 25% which are lower
than the wastage rate obtained by Palanivel C. et
al3 and a field based assessment and observation
done by National Rural Health Mission (NRHM)
and UNICEF1. However, the wastage rate
Correlation Coefficient (r)
-0.046
0.048
-0.029
-0.068
0.035
P- value
0.019
0.015
0.145
0.01
0.170
deduced is more than the vaccine wastage rate
recommended by WHO.
The wastage rate were higher in lyophilized
vaccines (37.8%) compared to that of liquid
vaccines (20.16%). This is similar to the findings
from other studies6,7. This may be due to the fact
that the lyophilized vaccines need to be
discarded within 4 hours after reconstitution9.
The wastage rate for injectable vaccines (BCG,
DPT, HBV and Measles) were found to be 22%
and for oral (OPV) were found to be 25%. Thus
there is negligible difference in vaccine wastage
between oral and injectable route of
administration of vaccines. This is similar to the
findings by Palanivel C et al3 but differs from the
findings by a field based assessment and
observation done by National Rural Health
Mission (NRHM) and UNICEF1.
The value of correlation coefficient (r) calculated
for the correlation between variables BCG
beneficiary/session and WF for BCG/session
was -0.046 and P-value calculated was 0.019 i.e.
less than 0.05 which means that both variables
are negatively correlated. This can be interpreted
as for 95% of cases, as the no. beneficiaries per
session decrease the WF per session increase.
This may be due to the fact that BCG being a
lyophilized vaccine is to be discarded within 4
hours of constitution9 and no. of beneficiaries per
session is less. The wastage rate for BCG
obtained for other studies1,3,10 was found to be
much higher than our study.
The value of correlation coefficient (r) calculated
for the correlation between variables OPV
beneficiary per session and WF for OPV per
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session was 0.048 and P-value calculated was
0.015 i.e. less than 0.05 which means that both
variables are positively correlated. This can be
interpreted as for 95% of cases, as the no.
beneficiaries per session increase the WF per
session increase. This may be due to the fact that
there might be wastage of OPV at time of
administering of vaccine e.g. administering more
drops than that are required to be given per dose
due to faulty vaccinating technique of
vaccinators, child moving the head at the time of
ingestion of vaccine etc. The wastage rate for
OPV obtained from some studies1,3 were higher
than that obtained from our study. But in a study
by Mukherjee et al4 to assess wastage factor of
oral polio vaccine (OPV) in the Pulse Polio
Immunization (PPI) programme of the
Government of India at approximately 31,000
immunization booths all over the country
estimated that wastage at the point of
administration of OPV was 14.5% with a wastage
factor of 1.17. Though the wastage rates are less
compared with the present study, this study
cannot be compared with the present study as
Pulse Polio program involves mass mobilization
and it is not a routine immunization program.
Studies by Jain et al5 and Samant et al6 were
assessing the wastage due to cold chain failure
and didn’t attempt to estimate the wastage rates
of OPV.
The wastage rate calculated for DPT was 16%
which is less than the wastage rate calculated by
other studies1,3,10. This may be due to fact that
more number of DPT doses (3 or 4 doses of DPT
for single child versus single dose of BCG)
required and hence number of eligible children
available per vaccination session will be more.
The value of correlation coefficient (r) calculated
for the correlation between variables HBV
beneficiaries per session and WF for HBV per
session was -0.068 and P-value calculated was
0.01 i.e. less than 0.05 which means that both
variables are negatively correlated. This can be
interpreted as for 99% of cases, as the no.
beneficiaries per session decrease the WF per
session increase. The wastage rate at session sites
obtained by NRHM and UNICEF report1 was
33% which is higher than that calculated from
our study i.e. 21%.
The wastage rate calculated for Measles vaccine
was 28% which is lower than the wastage rate
obtained by other studies1,3,10 but higher than the
recommended wastage rate by the Ministry of
Health and Family Welfare, Government of
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India9, as well as by WHO8. This may be due to
the fact that measles is a lyophilized vaccine and
is to be discarded within 4 hours of constitution8
and no. of beneficiaries per session is less.
Deficiencies in vaccine management and high
wastage increase vaccine demand and inflate
overall program cost. Lower demand for vaccine
favors the way for fewer dose preparations. The
cost of fewer dose preparations is higher as
vaccine filling in vials is expensive, but cost to
the programme may be less even if some vaccine
remaining in multi-dose vials must be thrown
away. Vaccine wastage can be expected in all
programmes and there should be acceptable
limit of wastage. This might differ from location
to location depending on many factors like urban
or rural setting, immunization coverage etc. The
questions arise as to whether the wastage is
preventable and, if so, how to prevent it. It is also
important to know the type of vaccine wastage.
A high wastage rate attributable to opening a
multidose vial for a small session size in order to
avoid missed opportunities is more acceptable
than wastage attributable to freezing or expiry.
Higher wastage rates are acceptable to increase
vaccine coverage in a low vaccine coverage
setting 11.
CONCLUSION
Vaccine wastage rates are higher than expected
in urban setting at the delivery level. Further
details of the vaccine wastage can be obtained by
actual monitoring of the vaccination session.
Monitoring vaccine wastage is useful as a
programme monitoring tool to improve
programme quality and increase the efficiency of
the programme.
RECOMMENDATIONS
Vaccine wastage calculations should be done
routinely to assess the loss due to wastage. This
can save significant funds for an immunization
programme if wastage can be reduced without
affecting the coverage. In rural areas of India
there are grass root level health workers for
every 1000 population, (known as Accredited
Social Health Activists and Anganwadi workers)
who help in identifying the unimmunized and
mobilizing the eligible children but in urban
areas there is a shortage of grass root level
workers. Mobilizing the eligible children with
the help of community mobilizers and
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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organizing the immunization sessions in
collaboration with government, private clinics in
the locality will help to reduce the wastage.
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6.
Samant Y, Lanjewar H, Parker D, Block L, Tomar GS, et
al. Evaluation of the cold-chain for oral polio vaccine in
a rural district of India. Public Health Rep. 2007;122:112–
121.
7.
National Immunization Schedule for Infants, Children
and Pregnant Women. Revised IPHS guidelines
(2010).Directorate General of Health Services. Ministry
of Health & Family Welfare. Government of India.
8.
Immunization service delivery and accelerated disease
control, World Health Organization. Available at
http://www.who.int/immunization_delivery/vaccine_
managementlogistics/logistics/expected_wastage/en/i
ndex.html. Accessed on 10th March 2013
9.
Immunization
Handbook
for
Medical
Officers.Department of Health and Family Welfare,
Ministry of Health and Family Welfare, Government of
India 2008. Page 31-32.
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1.
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3.
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5.
Vaccine Wastage Assessment, April 2010. Field
assessment and observations from National stores and
five selected states of India. UNICEF. Available at
http://www.unicef.org/india/Vaccine_Wastage_Asses
sment_India.pdf. Accessed on 10th March 2013
Monitoring vaccine wastage at country level. Guidelines
for programme managers. Vaccines and Biologicals.
World
Health
Organization.
Available
at
www.who.int/vaccines-documents/. Accessed on 10th
March 2013.
Palanivel C, Kulkarni V, Kalaiselvi S, Baridalyne N.
Vaccine wastage assessment in a primary care setting in
urban India. Journal of Pediatric Sciences. 2012;4(1):e119
Mukherjee A, Ahluwalia TP, Gaur LN, Mittal R, Kambo
I, Saxena NC, Singh P. Assessment of Vaccine Wastage
during a Pulse Polio Immunization Programme in India.
J Health Popul Nutr 2004 Mar; 22(1):13-18.
Jain R, Sahu AK, Tewari S, Malik N, Singh S, Khare S,
Bhatia R. Cold chain monitoring of OPV at transit levels
in India: correlation of VVM and potency status.
Biologicals. 2003 Dec; 31(4):237-44.
10. Guichard S, Hymbaugh K, Burkholder B, Diorditsa
S,Navarro C, Ahmed S, Rahman MM. Vaccine wastage
in Bangladesh.Vaccine. 2010 Jan 8; 28(3):858-63. Epub
2009Aug 27.
11. Richard Duncan, Global Alliance for Vaccines and
Immunization support to introduce hepatitis B vaccine,
Lao People’s Democratic Republic, 26 February to 11
May 2002, MR/2002/0066, WHO WPRO.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original article ▌
SCREEN OUT ANAEMIA AMONG ADOLESCENT BOYS AS
WELL!
Dheeraj Gupta1, Bhawana Pant2, Ranjeeta Kumari3, Monika Gupta4
Financial Support: None declared
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Gupta D, Pant B, Kumari R, Gupta
M. Screen Out Anaemia among
Adolescent Boys as Well!. Natl J
Community Med 2013; 4(1): 20-5.
Author’s Affiliation:
1Assistant Professor, Department of
Community Medicine, VCSG Govt.
Medical College, Srinagar;
2Professor, Department of
Community Medicine, Subharti
Medical College, Meerut; 3Assistant
Professor, Department of
Community Medicine, AIIMS,
Rishikesh; 4Assistant Professor,
Department of Community
Medicine, Subharti Medical
College, Meerut
Correspondence:
Dr. Dheeraj Gupta,
Email: guptadheeru@yahoo.co.in
Date of Submission: 07-05-12
Date of Acceptance: 21-02-13
Date of Publication: 31-03-13
ABSTRACT
Background: Adolescence – a period of transition between
childhood and adulthood is a significant period of human growth
and maturation. Adolescents represent about a fifth of India’s
population. Many studies in recent times have highlighted the
high prevalence of anaemia among adolescent girls in India;
however, there is limited published literature on prevalence of
anaemia among adolescent boys.
Aims: To find out the prevalence of anaemia among adolescent
(10-19 years) boys and girls in the urban slum of Meerut and to
study socio-demographic and other determinants in relation to
anaemia.
Material and Methods: A Community based cross sectional study
was conducted in urban slum, Multan nagar, catchment area of
UHTC, Department of Community Medicine, Subharti Medical
College, Meerut. A total of 406 (216 females and 190 males)
adolescents were included in this study. Haemoglobin estimation
was done using Direct Cyanmethaemoglobin method. Statistical
analysis were done using Microsoft excel 2007 and Epi info
version 3.5.3.
Results: The prevalence of anaemia among adolescent males and
females was found to be 31.6% and 52.8% respectively. Statistical
significant association (p< 0.05) of anaemia among boys were
found with type of family, socio-economic status, educational
status, academic performance, hand washing before eating main
meal, daily frequency of main meals, daily consumption of
lemon/sour fruits and BMI.
Conclusions: A high prevalence of anaemia was found among
adolescent males and females. So there is the need for routine iron
supplementation even among adolescent boys.
Keywords:
Adolescent
cyanmethaemoglobin
INTRODUCTION
Adolescence – a period of transition between
childhood and adulthood is a significant period
of human growth and maturation. The term
“adolescence” has been defined by WHO as
those including between 10 to 19 years.1 The
health of adolescents attracted global attention in
boys,
anaemia,
urban,
slum,
the past decade beginning with the International
Year of Youth in 1985 and the World Health
Assembly in 1989, when discussions were
focused on the health of youth. Though the
issues like sexually transmitted diseases,
reproductive health, etc have been given due
importance, limited work has been done on their
nutritional status especially anaemia among
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adolescent boys. There are 1.2 billion adolescents
in the world, 85% of them live in developing
countries.2 The adolescent population constitutes
about 18 to 25% of the total population of the
South East Asia Region.3 Adolescents represent
about a fifth of India’s population.4
confidence interval and absolute precision of 5%.
So minimum required sample size was 384 and
adding 10% for incomplete responses to it, the
total sample size came out to be 422. Finally,
analysis was done on 406 adolescents (190 males
and 216 females).
During this period, more than 20% of the total
growth in stature and 50% of adult bone mass
are achieved5 and iron requirement increases
dramatically in both adolescent boys and girls,
from preadolescent level of 0.7-0.9 mg Fe/day to
as much as 2.2 mg Fe/day. This increase in iron
requirement is the result of expansion of total
blood volume, increase in lean body mass and
the onset of menstruation in adolescent females.6
Iron needs are highest in males during peak
pubertal development because of a greater
increase in blood volume, muscle mass and
myoglobin.7
Selection of study participants: From the 2112
registered families, 422 families were selected
randomly by lottery method and if there were
more than one adolescent in the selected family,
one adolescent was randomly selected from each
family.
Globally, according to WHO, a total of 1.62
billion people are anaemic.8 Every 9 out of 10
persons affected by anaemia live in developing
world.9 WHO also estimates the benefits of
anaemia correction and suggests that timely
treatment can restore personal health and raise
national productivity levels by as much as 20%.10
Available literature from India confirms that
anaemia is common among adolescent girls but
there is a paucity of information on status of
anaemia among adolescent boys and most of the
studies are based on school – going population
and are not from community. So the community
based study was planned to highlight the
problem of anaemia in adolescent males and
females and to study socio-demographic factors
and other determinants related to anaemia.
MATERIAL AND METHODS
Study population: Adolescents aged 10 to 19
years residing in the registered families in urban
slum, Multan nagar, catchment area of urban
health and training centre, department of
Community Medicine, Subharti Medical College,
Meerut were included for the study.
Study period: The period of study was from
September 2010 to September 2011 which was
used for data collection, compilation and
presentation of findings.
Sample size: Since prevalence (p) of anaemia in
adolescents (both males and females taken
together) was not known, a prevalence of 50%
was taken11 to calculate the sample size with 95%
Data collection: Initially, a pilot testing was done
on 50 adolescents in the study area to assess the
validity of research tool. A pre designed semi
structured schedule was used to elicit the
necessary information from participants.
Hemoglobin estimation: For hemoglobin
estimation, Direct cyanmethaemoglobin method
was used using Photochem-Micro digital 5
calorimeter.
Ethical approval: First approval from the
institutional ethical committee was obtained.
Informed written consent was obtained from
each participant after explaining about the study.
Statistical analysis: Data was analyzed using
Microsoft excel 2007 and Epi info version 3.5.3
software. Proportions were calculated and Chi
square test was used as a test for significance. A
p value of less than 0.05 was considered
significant.
RESULTS
The prevalence of anaemia in adolescent males
aged 10 to 19 years was found to be 31.6%, with
30% of the boys had mild anaemia. (Table-1)
Table 1: Distribution of prevalence of anaemia
in adolescent males according to its severity
(DeMeyer, 1989)12 [n=60]
Severity (Hb g/dl)
Mild (>10 – cut-off)
Moderate (7 – 10)
Severe (< 7)
Total
Male adolescents
57 (95.0)
02 (3.3)
01 (1.7)
60 (100.0)
Prevalence (%)
30.0
1.1
0.5
31.6
In the present study, total 114 (52.8%) females
were found to be anaemic, with 44.9% of the
females had mild anaemia and 7.9% of the
females had moderate to severe anaemia. (Table2)
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Table 2: Distribution of prevalence of anaemia
in adolescent females according to its severity
(De Maeyer., 1989)12 [n=114]
Severity (Hbg/dl) Female AdolescentsPrevalence (%)
Mild (>10–cut-off)
97 (85.1)
44.9
Moderate (7 – 10)
15 (13.2)
6.9
Severe (< 7)
02 (1.7)
1.0
Total
114 (100.0)
52.8
Table 3 and 4 shows the various sociodemographic determinants which were found to
be statistically significant in both males and
females and includes socio-economic status (the
prevalence of anaemia decreased with increase
in socio-economic status) and adolescents
educational status (prevalence of anaemia was
maximum in those who were illiterate/just
literate and minimum in those who had
completed intermediate class).
Table 3: Prevalence of anaemia in males according to socio-demographic determinants (n=190)
Socio-demographic determinants
Type of family
Nuclear
Joint
Males (%)
Anaemic males
Prevalence (%)
159 (83.7)
31 (16.3)
56
04
35.22
12.90
Socio-economic Status
Upper (I)/ Upper middle (II)
Lower middle (III)
Upper lower (IV)/ Lower (V)
42 (22.1)
79 (41.6)
69 (36.3)
05
27
28
11.90
34.18
40.58
10.36, 2, 0.005
Educational Status
Illiterate/ Just literate
Primary
Middle
High school
Intermediate
06 (3.2)
47 (24.7)
80 (42.1)
43 (22.6)
14 (7.4)
03
15
32
09
01
50.0
31.91
40.0
20.93
7.14
9.70, 4, 0.046
46.15
37.80
18.46
14.29
8.95, 3, 0.03
Academic performance*
Below average (≤ 40%)
13 (7.8)
06
Average (> 40 to 60%)
82 (49.1)
31
Above average (> 60 to 80%)
65 (38.9)
12
Topper (>80%)
07 (4.2)
01
* 23 male adolescents had left school and were therefore excluded from analysis
χ2, df, p- value
4.99, 1, 0.02
Table 4: Prevalence of anaemia in females according to socio-demographic determinants (n=216)
Socio-demographic determinants
Socio-economic Status
Upper (I)/Upper middle (II)
Lower middle (III)
Upper lower (IV)/Lower (V)
Females (%)
Anaemic females
Prevalence (%)
χ2, df, p- value
32 (14.9)
96 (44.4)
88 (40.7)
07
53
54
21.90
55.21
61.36
15.09, 2, 0.001
Mother’s working status*
Housewife
Working
177 (83.1)
36 (16.9)
90
11
50.85
30.56
4.94, 1, 0.03
Educational Status
Illiterate/ Just literate
Primary
Middle
High school
Intermediate
08 (3.8)
50 (23.1)
84 (38.9)
42 (19.4)
32 (14.8)
05
30
48
22
09
62.5
60.0
57.14
52.38
23.68
9.80, 4, 0.044
Occupation
80
47.62
Student
168 (77.8)
Employed
09 (4.1)
08
88.89
Unemployed
39 (18.1)
26
66.67
*Mother of 3 female adolescents had died and were therefore excluded from analysis
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The determinants which were found to be
statistically significant only in males include type
of family (prevalence of anaemia was more
(35.22%) in those belonging to nuclear families in
comparison to 12.90% in joint families) & their
academic performance.
The statistically significant determinants for
anaemia among adolescent girls include their
occupation (prevalence of anaemia was least
among students and more among employed and
unemployed female adolescents) and their
mother’s occupation (prevalence of anaemia was
maximum (50.85%) among adolescent females
whose mother’s were housewife and 30.56% in
those whose mother’s were working)
The determinants which were not found to be
statistically significant include age, religion,
caste, father’s education, father’s occupation,
mother’s education and birth order.
Table 5: Prevalence of anaemia in males according to other determinants (n=190)
Determinants
Males (%)
Hand washing before eating main meal
Every time with soap & water
104 (54.7)
Sometimes with soap & water
27 (14.2)
With water only
30 (15.8)
Never
29 (15.3)
Anaemic males
Prevalence (%)
χ2, df, p- value
25
08
12
15
24.04
29.63
40.0
51.72
9.22, 3, 0.03
History of malarial infection
Yes
No
17 (8.9)
173 (91.1)
10
50
58.82
28.90
6.41, 1, 0.01
Frequency of main meals (daily)
Once
Twice
Thrice
11 (5.8)
128 (67.4)
51 (26.8)
10
38
12
90.91
29.69
23.53
19.66, 2, 0.001
Daily consumption of lemon/sour fruits
Yes
43 (22.6)
No
147 (77.4)
06
54
13.95
36.73
7.99, 1, 0.005
Body Mass index
< 5th percentile
67 (35.3)
30
44.78
5-85th percentile
121 (63.7)
29
23.97
>85th percentile*
02 (1.0)
01
50.00
*Category of overweight males were excluded from the analysis for the calculation of χ2 value
8.67, 1, 0.003
Table 6: Prevalence of anaemia in females according to other determinants (n=216)
Determinants
Females (%)
Hand washing before eating main meals
Every time with soap & water
97 (44.9)
Sometimes with soap & water
35 (16.2)
With water only
54 (25.0)
Never
30 (13.9)
Anaemic females
Prevalence (%)
χ2, df, p- value
39
23
33
19
40.21
65.71
61.11
63.33
11.35, 3, 0.01
Nail Cutting
Regular
Irregular
140 (64.8)
76 (35.2)
65
49
46.43
64.47
6.44, 1, 0.01
History of malarial infection
Yes
No
13 (6.0)
203 (94.0)
11
103
84.61
50.74
4.35, 1, 0.04
Body Mass index
< 5th percentile
76 (35.2)
47
61.84
5-85th percentile
138 (63.9)
66
47.83
>85th percentile*
02 (0.9)
01
50.0
*Category of overweight females were excluded from the analysis for the calculation of χ 2 value.
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Table 5 and 6 shows the various other
determinants which were found to be
statistically significant in both males and females
& includes practice of hand washing before
eating main meals (the prevalence of anaemia
was maximum in those who never washed their
hands before eating main meal and minimum in
those who always washed their hands every time
with soap and water before eating main meal),
history of malarial infection (prevalence of
anaemia was more in those who had positive
history of malarial infection) and BMI status of
adolescents (prevalence of anaemia was more
among those who had BMI less than 5th
percentile).
The determinants which were found to be
statistically significant only in males include
daily frequency of main meals (anaemia was
more prevalent among those who were having
their main meals once daily (90.91%) than among
those who were having their meals twice
(29.69%) or thrice daily (23.53%) and daily
consumption of lemon/sour fruits.
The statistically significant determinants for
anaemia among adolescent girls include their
habit of cutting nail (prevalence of anaemia was
maximum (64.47%) in those who had irregular
nail cutting habit in comparison to 46.43% in
those who cut their nails regularly).
The determinants which were not found to be
statistically significant include history of pica,
type of diet, frequency of non-vegetarian diet,
intake of junk food, post meal habit of
consuming
tea/coffee
and
pattern
of
menstruation.
DISCUSSION
The present study yielded relatively low
prevalence (31.6%) of anaemia among adolescent
boys when compared to studies conducted by
Jain et al13 in Urban Meerut, Hyder et al14 in
Bangladesh and Hettiarchi et al15 in Sri Lanka
who found prevalence of anaemia to be 42.8%,
69%, and 49.5% respectively. Basu et al16,
however, reported the prevalence of anaemia
among school going adolescent boys of
Chandigarh to be 7.7%. These differences may be
due to difference in age groups studied, different
study settings and difference in cut-off values for
diagnosis of anaemia.
Adolescent boys who scored below average (≤
40% marks) academic performance were more
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anaemic in comparison to toppers (
80%
marks). Abalkhail et al17 also showed that
anaemics scored lower rank significantly than
non-anaemics.
Daily frequency of main meals influence
anaemia to a large extent as it was very high
(90.91%) among those boys who had their main
meals once daily when compared to 23.53% in
those who had their main meals thrice daily.
ICRW18 and Jain et al13 also documented that
anaemia to be significantly more in those who
eat two or fewer meals in a day.
In this study, the prevalence of anaemia was
significantly more (44.78%) among those
adolescent boys who had their BMI less than 5th
percentile as compared to those who had their
BMI between 5th and 85th percentile. Other
researchers13,19,20 also documented similar
findings.
In the present study, determinants which were
found to be not significantly related with
anaemia among adolescent boys include their
age, religion, caste, father’s education, father’s
occupation, mother’s education, mother’s
working status, their occupation, birth order,
habit of cutting nail, history of pica, type of diet,
frequency of non-vegetarian diet, intake of junk
food, post meal habit of consuming tea/coffee.
Jain et al13 also reported that age is not a
significant correlate of anaemia.
CONCLUSIONS & RECOMMENDATIONS
The present study highlights the high prevalence
of anaemia among adolescent boys in the urban
slum population of Uttar Pradesh, thus
indicating that the problem of anaemia was
related to a wider population than the traditional
groups of the adolescent, pregnant and lactating
females and children. We suggest that there is a
need for well planned, systematic and large-scale
studies by using standardized methodologies to
estimate the prevalence of anaemia as well as the
causes of anaemia at the community level among
males in all the age groups, with the
representation of the different regions of India.
It is seen that anemia affects the overall
nutritional status of adolescent males as well as
females. So iron supplements have to be
provided to the adolescent boys also as in our
country, most of the National programmes
related to supplementary nutrition are focusing
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only on adolescent girls, but none of the
programmes include adolescent boys.
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11.
Lwanga SK, Lemeshow S. Sample size determination in
health studies: A Practical Manual. Geneva: WHO;1991.
12.
DeMeyer EM. Preventing and controlling iron
deficiency anemia through primary health care: a guide
for health administrators and programme managers.
Geneva: WHO;1989.
13.
Jain T, Chopra H, Mohan Y, Rao S. Prevalence of anemia
and its relation to socio-demographic factors: crosssectional study among adolescent boys in urban Meerut,
India. Biology and Medicine. 2011;3(5):01-05.
14.
Hyder SMZ, Chowdhury SA, Chowdhury AMR.
Prevalence of anaemia and intestinal parasites in a rural
community of Bangladesh. Bangladesh: Research and
Evaluation Division, BRAC;1998.
15.
Hettiarachchi M, Liyanage C, Wickremasinghe R,
Hilmers DC, Abrahams SA. Prevalence and severity of
micronutrient deficiency: a cross-sectional study among
adolescents in Sri Lanka. Asia Pac J Clin Nutr.
2006;15(1):56-63.
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WHO. The second decade: Improving adolescent health
and development. Geneva: WHO;2001.
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WHO. Adolescent Nutrition: A Review of the Situation
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WHO. Improving Maternal, Newborn and Child Health
in the South-East Asia Region. New Delhi: WHO;2005.
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Garn SM, Wagner B. The adolescent growth of the
skeletal mass and its implications to mineral
requirements. In: Heald FP, editor. Adolescent Nutrition
and Growth. New York: Meredith; 1969. p. 139−162.
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Beard JL. Iron status before childbearing, iron
requirements in adolescent females. Journal of
Nutrition. 2000; 130: 440S–442S.
Basu S, Basu S, Hazarika R, Parmar V. Prevalence of
anemia among school going adolescents of Chandigarh.
Indian Paediatrics. 2005;42:593-597.
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7.
Hyder SM, Haseen F, Khan M, Schaetzel T, Jalal CS,
Rahman M, et al. Multiple-micronutrient fortified
beverage affects hemoglobin, iron, and vitamin A status
and growth in adolescent girls in rural Bangladesh.
Journal of Nutrition. 2007; 137(9): 2147-53.
Abalkhail B, Shawky S. Prevalence of daily breakfast
intake, iron deficiency anaemia and awareness of being
anaemic among Saudi school students. Int J Food Sci
Nutr. 2002 Nov;53(6):519-28.
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8.
World Health Organization. Worldwide prevalence of
anemia 1993–2005: WHO Global Database on Anaemia.
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ICRW. Youth, gender, well-being and society: emerging
themes from adolescent reproductive health
intervention research in India. Washington, DC:
ICRW;2004.
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World Health Organisation. Turning the tide of
malnutrition: responding to the challenge of the 21st
century. Geneva: WHO;2000.
Ahmed F, Rahman A, Noor AN, Akhtaruzzaman M,
Hughes R. Anaemia and vitamin A status among
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Al-Sharbatti SS, Al-Ward NJ, Al-Timimi DJ. Anemia
among adolescents. Saudi Medical Journal.
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December 2011.
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Original Article ▌
A STUDY OF GENDER DIFFERENCES IN TREATMENT OF
CRITICALLY ILL NEWBORNS IN NICU OF KRISHNA
HOSPITAL, KARAD, MAHARASHTRA
Vinayak Y Kshirsagar1, Minhajuddin Ahmed2, Sylvia M Colaco2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Kshirsagar VY, Ahmed M, Colaco
SM. A Study of Gender Differences
in Treatment of Critically Ill
Newborns In NICU of Krishna
Hospital, Karad, Maharashtra. Natl
J Community Med 2013; 4(1):26-9.
Author’s Affiliation:
1Head of the Department,
2Resident, Department of
Pediatrics, KIMS, Karad,
Maharashtra, India
Correspondence:
Dr. Vinayak Y Kshirsagar
Email: drkshirsagarvy@yahoo.com
Date of Submission: 22-08-12
Introduction: Sex ratio in India is adverse for girl. Gender-based
health disparities are prevalent in India but very little data are
available on care-seeking patterns for newborns. An attempt had
been made to study gender differences in treatment of critically ill
newborns in tertiary hospital.
Methods: Study includes total deliveries, NICU admissions and
patients leaving against medical advice in NICU and neonates
who were not admitted in spite of need for NICU admission. A
study of various socio-demographic parameters and its
correlation to denial of health care were also studied.
Result: A total of 191 babies were taken against medical advice,
134 (70.15%) females and 57 (29.84%) males. 141 babies in the
NICU of which 94 (65.27%) were girls and 50 (34.72%) were boys.
Families of 47 babies who needed NICU admission refused of
which 40 (85.10%) were girls and 7 (14.89%) were boys. The odds
ratio calculated is 3.448 which signify that chances of health care
denial are 3.448 times greater for a female child. Various sociodemographic parameters were studied and significance of each
parameter was determined.
Conclusion: Factors like previous girl child, literacy of mother
and socioeconomic status play an important role in seeking health
care facilities.
Date of Acceptance: 07-01-13
Date of Publication: 31-03-13
Key-words- Gender bias; Neonates; Health care
INTRODUCTION
Worldwide, the ratio of girls to boys is 1,000 for
every 1,005 1. In India, there are only 914 girls for
every 1,000 boys, and often far fewer 2 .The
NFHS survey reflects the female disadvantage is
much more severe in rural than in urban areas.
The disadvantage to the rural child is evident in
the higher infant and neonatal mortality rates in
rural than in urban areas in either sex 3.
Discrimination against the girl child occurs in
every strata of society, having different forms of
manifestation, but is more visible especially in
poverty stricken families or in families under
financial stress. Although gender-based health
disparities are prevalent in India, very little data
are available on care-seeking patterns for
newborns 4. This study gives a clear view about
the gender bias in rural Maharashtra and the
biased society giving more health care facilities
to boys than girls.
METHODOLOGY
This study includes the total number of
deliveries conducted in our hospital, a trust-run
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hospital between May 2009 to May 2012, and the
neonates who were admitted to the NICU in this
period.
Association of Various Socio-demographic
Characteristic of Factors Associated with
Denial of Treatment
The main focus of the study was on the neonates
who were taken from hospital against medical
advice in spite of needing continuation of
treatment in the NICU and also neonates of
families who denied admission in the NICU in
spite of proper counseling about the need for
NICU treatment to save the life of the baby. The
NICU admissions were grouped into male and
female and so were other data collected.
Percentage wise details were obtained and data
was compared. The families were interviewed
about the reasons for discontinuation of
treatment and the significance of these various
sociodemographic factors was determined.
Some sociodemographic factors associated with
denial of health care were studied in the 191
patients and correlation amongst them was
found. Table 3 gives the parameters and
characteristics of the study population. Among
the factors other than private income that have a
strong influence on fertility and mortality, basic
education-especially female education-is now
widely considered one of the most powerful.
Other factors inquired were previous girl child,
socioeconomic status, decision making power in
the household, caste and previous living issues.
It was also observed that parents of neonates
with any congenital anomaly or inherited
syndromes refused any further intervention if
they were not going to have a normal child.
RESULT
The total deliveries conducted in the study
period were 12440, out of these there were 1606
(12.90%) babies requiring NICU admissions. But
only 1559 (97.07%) babies were admitted to the
NICU, 927 (59.46%) being boys and 632 (40.53%)
girls. There were 47 (2.92%) babies who needed
NICU admission but the family refused of which
40 (85.10%) were girls and only 7 (14.89%) were
boys. Of the 1559 admissions, 144 babies were
taken against medical advice of which 94
(65.27%) were girls and 50 (34.72%) were boys.
Table 1: Gender wise distribution of babies
taken against medical advice
Leave against medical advice
Refusing admission
Total
Girls (%) Boys (%)
94 (65.27) 50 (34.72)
40 (85.10) 7 (14.89)
134 (70.15) 57 (29.84)
Table 2: Referred and reached boys and girls
Referred
Boys
Girls
Required NICU services
Reached (%)
Dropout* (%)
927 (59.46)
57 (29.84)
632 (40.53)
134 (70.15)
Odds Ratio (95% CI) = 3.45 (2.49-4.78)
* Sum of left against medical advice and denied treatment
So a total of 191 babies were denied treatment in
which there were 134 (70.15%) girls and 57
(29.84%) boys (Table 1). The Odds ratio is 3.448
which signify that the chances of health care
denial towards girl babies are 3.448 times higher
as compared to boys (Table 2).
Table 3: Comparison of Socio-demographic
characteristic of factors associated with denial
of treatment
Variable
Literacy
Literate =132 (69.10)
Illiterate = 59 (30.89)
Previous girl child
Yes = 177 (92.67)
No = 14 (7.32 )
Boys
Girls
65 (49.24)
10 (16.94)
67 (50.75)
49 (83.05)
43 (24.29)
134 (75.70)
Socio-economic status
Low = 167 (87.43)
Middle/high =24 (12.56)
19 (11.37 ) 148 (88.62)
11 (45.83) 13 (54.16)
Decision maker
Mother =30 (15.70)
Others = 161 (84.29)
2 (6.66)
33 (20.49)
28 (93.33)
128 (79.50)
Religion
Hindu = 167 (87.43)
Non-Hindu = 24 (12.56)
57 (34.13)
9 (37.5)
110 (65.86)
15 (62.5)
No. of living children
0 = none
1 = 17 (8.90)
2 = 24 (12.56)
>2 = 150 (78.53)
0
5 (29.41)
9 (37.50)
31 (20.66)
none
12 (70.58)
15 (62.50)
119 (79.33)
Figure in parenthesis indicate percentage
Table 4 gives the odds ratio and 95% confidence
interval of all the demographic parameters
which shows that previous girl child, literacy
and socioeconomic factors play a very important
role in determining whether families want to
continue health care treatment.
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Table 4: Significance of various parameters
between neonates taken left against medical
advice (LAMA) to those continued treatment
Parameters
Literacy
Literate
Illiterate
LAMA Continued
treatment
OR (CI)*
132
59
429
986
5.14 (3.71-7.13)
Previous girl child
Yes
177
No
14
755
660
11.05 (6.35-19.23)
Socioeconomic status
Low
167
High/middle
24
862
553
4.46 ( 2.87-6.94)
Decision maker
Mother
30
Others
161
393
1022
0.48 (0.32-0.73)
Religion
Hindu
Non-Hindu
167
24
908
507
3.88 (2.50 - 6.04)
Children
One
>one
17
174
356
1059
0.29 (0.17 - 0.48)
*Odds ratio (Confidence Interval)
DISCUSSION
Gender
discrimination
against
females
particularly, girl child has emerged as issue of
vital concern in India, where sons are preferred
over daughters for a number of economic, social
and religious reasons, including financial
support, old age security, property inheritance,
dowry, death rituals, beliefs and faith about
salvation 5,6,7 . Gender inequalities prevail in
work, education, allocation of food, health care
and fertility choice 8 . Certain social trends have
in fact made the situation worse, as borne out by
the fact that the girl child is discriminated even
before her birth in the form of foeticide and after
birth in the form of infanticide, and other forms
of violence and neglect.
Health care is a multi-dimensional activity
related to child development. In health care, girls
are frequently neglected during the care seeking
process, and they experience relatively poorer
nutrition, greater delays in receiving care, and
lower access to preventive and curative care 9,1012.
For the most part, researchers and bodies such
as the United Nations and the Government of
India have stated that this deliberate genderbased neglect, and other acts against girl children
by their own families. This study projects
towards gender bias in delivering medical help
to girl child especially in times like the neonatal
period, when the body is susceptible to illness
and consequences of late or inappropriate health
services 13-15.
We observed that families do not want to treat
the girl child requiring NICU admission in spite
of appropriate counseling by the psychologist of
our institute. Various reasons were given by the
relatives for denying medical treatment like
financial issues, large families, multiple female
siblings, improper support for the mother and
patient being a girl child. The education of the
mother,
previous
girl
child
and
the
socioeconomic status of the family played an
important role. Many families agreed to give the
child intensive care only till mother is admitted
for post- partum care. And others left against
medical advice when a longer duration of NICU
stay was required. When a male neonate
required a longer NICU stay the families agreed
and financial arrangements were made by
methods like taking loans or selling lands. But no
such observations were made in case of a female
neonate.
Various studies have been carried out pointing
toward gender bias Indian society where
discrimination is done on basis of health care
facilities, education, immunization measures,
nutrition and food. A study by Walia and Kumar
found that the proportion of sick female and
male newborn infants receiving any treatment
was 28.8% and 63.1% respectively 12. In a study
by Srivastav and Nayak states the bias towards
male sex in hospitalizations and immunizations
16 .Hospital based studies documented by NNF
in 2004 states that, for every two sick male
newborn male infants using hospital care, there
may be only one sick female counterpart brought
for care 14 . A study carried out in rural Uttar
Pradesh by Wills et al suggest that, during
neonatal period, care seeking for girls is
neglected compared to boys 4 . Similarly our
study also points towards preference towards
boys and discrimination towards the girls in
such crucial period of life. Here in spite of our
country progressing in various fields the cultural
framework of male biased Indian society has not
changed.
CONCLUSION
In our study we found a clear picture of male
biased society in areas like health care in crucial
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period of life like the neonatal period. It may be
attributed to various factors but is more evident
when the neonate is a girl child. The
Government of India has taken many steps in
preventing sex discriminations. But they are
ineffectual at its best. Steps to overcome this
problem may be achieved through education and
exposure of the masses to consequences of
declining sex ratios. Steps like rigorously enforce
the existing laws and formation and
implementation of a law against people
declining health care services to girl child may
improve the state of health care in India.
ACKNOWLEDGEMENT
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5.
Dyson T, Moore M. On kinship structure, female
autonomy, and demographic behaviour in India. Pop.
Dev. Rev., 9: 35 (1983).
6.
Kishor, Sunita. "May God give sons to all": gender and
child mortality in India. American Sociological Review
1993; 58(2):247-65.
7.
Arnold F, Choe MK, Roy TK. Son preference, the familybuilding process and child mortality in India. Popul
Stud 1998;52: 301-15.
8.
Arokiasamy P. Gender Preference, Contraceptive use
and fertility in India. Regional and development
influences. Int J Population Geography 2002; 8: 49-67.
9.
Borooah VK. Gender bias among children in India in
their diet and immunisation against disease. Soc Sci
Med. 2004;58:1719–31.
10.
Pandey A, Sengupta PG, Mondal SK, Gupta DN, Manna
B, Ghosh S et al. Gender differences in healthcareseeking during common illnesses in a rural community
of West Bengal, India. J Health PopulNutr2002;20:30611.
11.
Pande RP. Selective gender differences in childhood
nutrition and immunization in rural India: the role of
siblings. Demography. 2003;40:395–418.
12.
Walia I, Kumar V. Utilization of neonatal health care in
a community. Indian Pediatr1984;21:925-31.
13.
World Health Organization. WHO gender policy:
integrating gender perspective in the work of WHO.
Geneva: World Health Organization, 2002. p6.
14.
National Neonatalogy Forum. Save the Children. The
state of India’s newborns. Washington, DC:
NationalNeonatologForum,2004. Available on
http://www.savethechildren.org/publications/india_p
df/SOIN_Document.pdf. Accessed on 21st June 2012.
15.
de Zoysa I, Bhandari N, Akhtari N, Bhan MK.
Careseeking for illness in young infants in an urban
slum in India. SocSci Med 1998;47:2101-11.
16.
Srivastava SP, Nayak NP. The disadvantaged girl child
in Bihar: Study of health care practices and selected
nutritional indices. Indian Pediatr1995;32:911-13.
The authors are thankful to Dr Manal Ahmed for
immense help and technical support.
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1.
Society For Protection Of Girl Child. An Overview of
Gendericide And Daughter Abuse In India. Available: at
http://www.protectgirls.org. Accessed on June 2,2012.
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The National, “Female foeticide continues in India as
new law falters,” May 20,2010. Available at:
http://www.thenational.ae/news/world/south-asia/
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IIPS National Family Health Survey 1998-99 (NFHS-2)
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AH, Awasthi S, Singh JV, Santosham M, Darmstadt GL:
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Original Article ▌
AN EPIDEMIOLOGICAL STUDY ON ASSOCIATION
BETWEEN ALCOHOL AND TOBACCO USE IN AN URBAN
SLUM OF MEERUT
Rashmi Katyal1, Rahul Bansal2, Kapil Goel3, Sachin Sharma4
Financial Support: None declared
Conflict of interest: None declared
ABSTRACT
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
Introduction: Alcohol consumption and problems related to
alcohol vary widely around the world, but the burden of disease
and death remains significant in most countries. Though there are
studies indicating co-occurrence of alcohol use with tobacco, not
much work is done on association of alcohol and tobacco use in
India.
How to cite this article:
Katyal R, Bansal R, Goel K, Sharma
S. An Epidemiological Study on
Association between Alcohol and
Tobacco Use in an Urban Slum of
Meerut. Natl J Community Med
2013; 4(1): 30-4.
Methods: A cross-sectional study was conducted in the catchment
area of UHTC (Urban Health and training Centre) among 324
males aged > 15 years. Data was collected by home visit using
WHO questionnaire (AUDIT: Alcohol use disorder identification
test) Modified Kuppuswamy scale was used to assess the socioeconomic status of the families. Also, data was collected to know
the association of alcohol use with tobacco. Data was analyzed by
chisquare test using SPSS 20.0 version.
Author’s Affiliation:
1Asst. Professor, Department of
Community Medicine, Rohilkhand
Medical College, Bareilly, UP;
2Professor and Head; 3Assistant
Professor, Department of
Community Medicine; 4Associate
Professor, Department of
Psychiatry, Subharti Medical
College, Meerut, UP
Correspondence:
Dr.Rashmi Katyal,
E mail: rashmikatyal@gmail.com
Results: Among current drinkers, 56.2% used smoked tobacco
while 11.8% of the teetotallers were smokers. Similarly, smokeless
tobacco was used by 48.9% of current drinkers and 2.6% of the
teetotallers. A highly statistically significant association was
found between tobacco use and alcohol use (p value<0.001).
Conclusions: It can be very well concluded that alcohol users are
more indulged into tobacco use as compared to teetotalers.
Therefore, high risk screening for tobacco use among the
alcoholics can be a vital step in the prevention of addiction, which
is emerging as one of the major risk factor for non-communicable
diseases.
Date of Submission: 06-09-12
Date of Acceptance: 08-01-13
Key words: AUDIT, tobacco use, smokeless tobacco, WHO
Date of Publication: 31-03-13
INTRODUCTION
Alcohol has been consumed in India at least
since the Vedic period of 2000–800 BC1. It was
allowed in Hinduism, particularly among the
ruling classes. However, Buddhism, Jainism, and
Islam did not allow their followers to drink.
Although alcohol became more freely available
in the Indian subcontinent under British rule,
Indians did not generally incorporate drinking
alcohol into their social or religious activities2.
When India became independent in 1947,
Mahatma Gandhi and the Indian National
Congress Party campaigned against liquor
production and sales on the grounds that it was
injurious to health.1
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Alcohol consumption and problems related to
alcohol vary widely around the world, but the
burden of disease and death remains significant
in most countries. Approximately 4.5% of the
global burden of disease and injury is
attributable to alcohol. Alcohol consumption is
the world’s third largest risk factor for disease
and disability; in middle-income countries, it is
the greatest risk. Alcohol is a causal factor in 60
types of diseases and injuries and a component
cause in 200 others. Almost 4% of all deaths
worldwide are attributed to alcohol, greater than
deaths caused by HIV/AIDS, violence or
tuberculosis. Alcohol consumption is estimated
to cause from 20% to 50% of cirrhosis of the liver,
epilepsy, poisonings, road traffic accidents,
violence and several types of cancer. Alcohol is
also associated with many serious social issues,
including violence, child neglect and abuse, and
absenteeism in the workplace.3
Alcohol is
attributed to nearly 3.2% of all deaths and results
in a loss of 4% of total DALYs (58 million).4
The economic cost involved in this affair is
massive. To these relatively tangible costs, must
be added, the heavy toll of unhappiness
represented by broken marriages, ruined careers
and neglected children. Increased percentages of
young people have indulged in drinking alcohol
in increased frequency and quantity thus
constitutes serious hazards to health, welfare and
life.5
The rationale of this study is that though there
are studies indicating co-occurrence of alcohol
use with tobacco, there is no such study in this
part of the region. Thus, it reinforces on the
findings of the very few studies and that too in
different part of the country showing the
existence of association between alcohol and
tobacco use.
MATERIAL & METHOD
The indexed study was conducted in Meerut
which is an ancient city located 70 km (43 miles)
northeast of the national capital New Delhi and
453 km North West of the state capital, Lucknow.
It is a part of the National Capital Region of
India.
Community based cross- sectional study was
conducted in an Urban Slum, Multan Nagar in
the field practice area of the department of
Community Medicine, SMC (Subharti Medical
College), Meerut among males aged ≥15 years
during September 2010 to October 2011.
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Inclusion criteria: Males aged ≥15 years, which
had completed 15 years of age at the time of data
collection, residing in the study area have been
included in the sampling universe.
Exclusion criteria: Males staying in the study
area of Meerut for less than 6 months and all the
mentally challenged males were excluded from
the study.
Sample size: Sample size for the proposed study
was calculated according to National Family
Health Survey-36 where prevalence of alcohol
use in U.P. was given as 25.3% in males,
therefore the adequate sample size calculated
was approximately 324 assuming 10% nonresponse and considering 5% absolute error.
Sampling technique: Simple Random Sampling
Technique
Methodology: The proposed study was
conducted in the Urban slum of Multan Nagar in
the field practice area of the Department of
Community Medicine, SMC, Meerut after taking
clearance from ethical committee. Sampling
universe was 2112 registered families in the
study area and the sampling unit was a family in
this study. All male members aged >15 years
were taken from each household, where on an
average there were 2 males aged >15 years based
on the demographic profile of the area, therefore
324/2=162 households were taken in order to
cover the required sample size.
Individual unit (family) constituting the sample
was randomly selected by Random number table
method. All the male members aged ≥15 years
were taken from each family after taking their
written consent. If male aged ≥15 years were not
found in a family then the next family was
visited. If the selected subject was not found at
the first interview, date and time was taken from
their family members for revisit.
The purpose of screening was clearly stated in
terms of its relevance to the individual’s health
status
assuring
the
maintenance
of
confidentiality.
Research tool: Data was collected by home visit
using WHO questionnaire (AUDIT: Alcohol Use
Disorder Identification Test) as study tool by
interviewing each study subject 7.Additional
information was obtained on the sociodemographic determinants of alcohol use.The
AUDIT is a 10-question alcohol screening
instrument developed by W.H.O. and validated
in six-country sample from four industrialized
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and two developing countries. Questions
included in the instrument showed reliability
across a wide range of cultural settings. The
AUDIT has been shown to be highly sensitive
(80%) and specific (89%) screening instrument8.
Flemming (1996) allows the classification of
problem drinkers into more specific subgroups
as hazardous, dependent and harmful drinkers24.
Questions 1-3 assess the quantity and frequency
of drinking and are used to detect ‘at risk’
alcohol consumption. A combined AUDIT score
≥ 4 classifies drinking as hazardous.
Questions 4-6 screen for signs and symptoms of
alcohol dependence.
A combined AUDIT score ≥ 4 indicates the
emergence of alcohol dependence.
Questions 7-10 enquire about the problems
caused by alcohol consumption and adverse
consequences of drinking. A combined AUDIT
score ≥ 4 indicates the existence of harmful
drinking.
Modified Kuppuswamy scale was used to assess
the socio-economic status of the families.
Data was analysed by using chi square test by
SPSS 20.0 version and the results were expressed
in proportions. If the cell frequency was less than
5, the result was obtained by Fischer’s Exact test.
All the alcohol users were motivated to visit the
Mental Health Clinic at Urban Health & Training
Centre, Multan Nagar being run with the help of
the department of Psychiatry, Subharti Medical
College, Meerut.
RESULTS
Majority of the study subjects were seen in 15-24
years of age group (34.9%) with least (10.5%)
being above 55 years. There is a decreasing trend
observed in the age wise distribution of the
study population. Mean age was 36.85+14.53
years.
As far as the marital status is concerned, 68.2%
study subjects were married while 31.8% were
unmarried; all the study subjects were Hindu by
religion; majority (48.1%) belonged to the O.B.C.
category while only 22.5% belonged to the
S.C./S.T. category. Almost half (51.9%) were
having nuclear type of family while 48.1% were
having joint family. Majority of the study
subjects (61.4%) had family size of 5-9 persons
while only 12% were having the family size of 10
and above.
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Table 1: Distribution of the socio-demographic
characteristics of the study population
Socio-demographic
Characteristics
Age (Years)
15-24
25-34
35-44
45-54
≥55
Educational Status
Professional or Honours
Graduate or post Graduate
Intermediate or post high
school diploma
High school certificate
Middle school certificate
Primary school certificate
Illiterate
Occupation
Profession
Semi-Profession
Clerical/shop-owner/farmer
Skilled worker
Semi-skilled
Unskilled
Unemployed
Income(Rs.)
0-9999
10000-19999
20000-29999
≥30000
Marital status
Unmarried
Married
Religion - Hindu
Caste
OBC (Other Backward Class)
S.C./S.T.(Scheduled
Caste/Scheduled Tribes)
Others
Family Type
Nuclear
Joint
Family Size
1-4
5-9
≥10
Study Population
(n=324) (%)
113 (34.9)
77 (23.8)
62 (19.1)
38 (11.7)
34 (10.5)
7 (2.2)
51 (15.7)
63 (19.4)
85 (26.2)
64 (19.8)
24 (7.4)
30 (9.3)
4 (1.2)
2 (0.6)
75 (23.1)
48 (14.8)
52 (16.0)
53 (16.4)
90 (27.7)
260 (80.2)
51 (15.7)
7 (2.2)
6 (1.9)
103 (31.8)
221 (68.2)
324 (100)
156 (48.1)
73 (22.5)
95 (29.3)
168 (51.9)
156 (48.1)
86 (26.5)
199 (61.4)
39 (12.0)
Education wise, 26.2% were educated up to high
school followed by intermediate (19.4%) and
middle school (19.8%) and 9.3% being illiterate.
As far as the occupational classification is
concerned, around one fourth (23.1%) of the
study subjects belonged to the category of
clerical/shop-owner/farmer while only (0.6%)
were semi-professional and more than a quarter
(27.7%) being unemployed. Skilled workers
were 14.8%, 16% being semi-skilled with
unskilled being 16.4%. Majority of the subjects
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(80.2%) had income in the range of Rs. (0-9999),
out of which 78.8% had income below Rs.5000
and those with income above Rs.5000 were only
21.2% while 19.8% had income above Rs.10000.
Table 2: Distribution of the Socio-economic
status (Kuppuswamy scale) of the study
population
Socio-demographic
Participants
Characteristics
(n=324) (%)
Educational Status (Head of the Family)
Professional or Honours
9 (2.8)
Graduate or post Graduate
54 (16.7)
Intermediate or post high
42 (13.0)
school diploma
High school certificate
87 (26.9)
Middle school certificate
49 (15.1)
Primary school certificate
23 (7.1)
Illiterate
60 (18.5)
Occupation (Head of the Family)
Profession
9 (2.8)
Semi-Profession
1 (0.3)
Clerical/shop-owner/farmer
84 (25.9)
Skilled worker
62 (19.1)
Semi-skilled
61 (18.8)
Unskilled
71 (21.9)
Unemployed
36 (11.1)
Income(Rs.) (Head of the Family)
<1290
2 (0.6)
1291-3866
49 (15.1)
3867-6445
63 (19.4)
6446-9644
43 (13.3)
9645-12891
73 (22.5)
12892-25784
64 (19.8)
>25785
30 (9.3)
Socio-economic status
Lower
5 (1.5)
Upper Lower
124 (38.3)
Lower Middle
97 (29.9)
Upper Middle
94 (29.0)
Upper
4 (1.2)
According to the Kuppuswamy classification,
about two fifth (38.3%) of the study subjects
belonged to the upper lower class (II) with least
being 1.2% in the upper class (V). Also, 1.5% of
the subjects belonged to the lower class, 29.9% to
the lower middle class and 29% being in the
upper middle class.
As is evident in table-3(i), among current
drinkers, 56.2% used smoked tobacco while
11.8% of the teetotallers were smokers. Similarly,
smokeless tobacco was used by 48.9% of current
drinkers and 2.6% of the teetotallers. At the same
time, 85.6% of the teetotalers were not addicted
while 15.6% of the current drinkers were not
addicted to alcohol use. A highly statistically
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significant association was found between
tobacco use and alcohol use (p-value<0.001).
Table 3(i): Association of tobacco use with
alcohol use
Type of addictions
Teetotallers
(Audit score-0)
n=228 (%)
Smoked tobacco
27 (11.8)
Smokeless tobacco
6 (2.6)
No addiction
195 (85.6)
χ2 =131.47, df =2, p-value=0.0001
Current
Drinkers
(Audit score >0)
n=96 (%)
54 (56.2)
47 (48.9)
15 (15.6)
Table 3(ii): Association of tobacco use with
alcohol use
Type of addictions
Teetotallers
(Audit score-0)
Current
Drinkers
(Audit score >0)
Tobacco users
No addiction
33
195
101*
15
χ2 =167.35, df =2, p-value=0.0001, OR-0.03(<0.05)
*Includes both smokeless and smoked tobacco users
Table 4: Distribution of tobacco use in the
study population
Type of addiction
Smoked tobacco
Bidi
Smokeless tobacco
Gutka
Pan masala
Tobacco
Smoker and smokeless
tobacco user
None
Respondents (n=324)
(%)
71 (21.9)
25 (7.7)
2 (0.6)
16 (4.9)
10 (3.08)
210 (64.8)
On comparing tobacco users with no addiction,
there was statistically significant association
between tobacco users and those which had no
addiction with chi square value being167.35, pvalue-0.0001 and df-2. The Odd’s ratio is being
0.03 (<0.05) at 95% CI [Table-3(ii)].
21.9% of the study population was bidi smokers
while 13.2% used smokeless tobacco with
majority being gutka users (7.7%) and least using
pan masala (0.6%). Only 3.08% were indulged
into both forms of addiction (Table-4).
DISCUSSION
In the present study, 324 subjects were analysed
to assess the prevalence of alcohol use and its
association with smoking habit.
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Bobak M. et al (1999)9 in their study in Russia
reported that among men smokers consumed
more alcohol; women non smoking consumed
less alcohol.
Meena et al (2002)10 in their study in Rohtak city
reported that 16.81% were current smokers
among alcohol users which were 56.25% in the
indexed study. 6.89% had the habit of taking
pan-masala which were just 0.65 in the present
study. 57.69% took 1-4 cigarrettes/day, 35.89%
took 5-8 cigarrettes /day while 6.42 took 9-15
cigarrettes/day.
Dhupdale N. et al (2006)11 in their study in rural
Goa stated that the alcoholics were 1.9 times
more likely to consume tobacco than nonconsumers (O.R.-1.9).
Sampath S.K. et al (2007)12 in their study in
Kolar in Southern India declared that smokers
were more likely to drink than non-smokers and
they were more problem drinkers than
dependent drinkers.
Gupta P.C. et al (2005)13 in their study reported
that among alcohol users, 51.1% smoked tobacco
and 35.6% used smokeless tobacco which is
different in our study showing 21.9% of smokers
while 13.2% were using smokeless form of
tobacco.
Mohan D. et al (2002)14 in their study reported
that the prevalence of the use of “only tobacco
use; only alcohol use” and concurrent smoking
and drinking was 18.1%, 3.3% and 9.6%
respectively. Alternatively, 56.2% of the current
drinkers were tobacco users and 11.8% of the
teetotalers were smokers.
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REFERENCES
1.
Isaac M. Contemporary trends: India. In: Grant M. ed.
Alcohol and emerging markets, patterns, problems and
responses. Philadelphia: Taylor & Francis, 1998: 145–
176.
2.
Bennett, L. A., Campillo, C., Chandrashekar, Gureje O.
Alcoholic beverage consumption in India, Mexico, and
Nigeria: a cross-cultural comparison. Alcohol Health
and Research World; 22: 243–252.
3.
World Health Organization (WHO), Global status report
on alcohol, Department of Mental Health and Substance
Abuse, Geneva, 2011.
4.
World Health Organization (WHO), World health
report 2002 – reducing risks, promoting healthy Life,
Geneva, 2002.
5.
WHO Expert committee on Problems related to alcohol
consumption. Second Report WHO Technical Report
Series 2007; 944:10-16. Available on URL:
http://www.who.int/entity/substance_abuse/expert_c
ommittee_alcohol_trs944.pdf (assessed on 15.9.2009).
6.
Subramanian S. V., Nandy S., Irving M, Gordon D.,
Smith GD. Role of socioeconomic markers and state
prohibition policy in predicting alcohol consumption
amongst men and women in India: a multi level
statistical analysis. Bulletin of the World Health
Organization, 2005; 83(11): 829–836.
7.
Park K. Medicine and social sciences. Park’s textbook of
preventive and social Medicine, 20th ed., Jabalpur,
Banarsidas Bhanot Publishers, 2009: 609.
8.
World Health Organization (WHO), Global status report
on alcohol, Department of Mental Health and Substance
Abuse, Geneva, 2004.
9.
Bobak M., McKee M., Rose R., Marmot M. Alcohol
consumption in a national sample of the Russian
population: Addiction. 1999 Jun; 94 (6):857-66.
10.
Meena, Khanna P., Vohra A.K., Rajput R. Prevalence
and pattern of alcohol and substance abuse in urban
areas of Rohtak city. Indian J. Psychiatry. 2002; 44(4):
348-352.
11.
Dhupdale N.Y., Motghare D.D., Ferreira A.M.A., Prasad
Y.D. Prevalence and pattern of alcohol consumption in
rural Goa: Indian Journal of Community Medicine. 2006
April-June; 31(2).
12.
Sampath S.K., Chand P.K., Murthy P. Problem Drinking
among Male inpatients in a Rural General Hospital:
Indian Journal of Community Medicine. 2007 Jan; 1 (1).
13.
Gupta P.C., Pednekar M.S., Maulik P.K., Saxena S.
Concurrent alcohol and tobacco use among a middleaged and elderly population in Mumbai Natl Med J
India. 2005 Mar-Apr; 18(2): 88-91.
14.
Mohan D., Chopra A., Sethi H. The co-occurrence of
tobacco & alcohol in general population of Metropolis
Delhi. Indian J Med Res. 2002 Oct; 116: 150-4.
CONCLUSIONS
This study is an important step towards the
public health problem of alcohol use and its cooccurrence with tobacco use. Most important
conclusion is the reinforcement of the association
between the two addictions of alcohol and
tobacco use which indicates the need of stringent
measures towards imparting health education
among the alcoholics on tobacco use as well.
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Original Article ▌
NUTRITIONAL STATUS AND FACTORS AFFECTING
NUTRITION AMONG ADOLESCENT GIRLS IN URBAN
SLUMS OF DIBRUGARH, ASSAM
Himashree Bhattacharyya1, Alak Barua2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Bhattacharyya H, Barua A.
Nutritional Status and Factors
Affecting Nutrition among
Adolescent Girls in Urban Slums of
Dibrugarh, Assam. Natl J
Community Med 2013; 4(1): 35-9.
Author’s Affiliation:
1Senior Resident Doctor,
Department of Community
Medicine, North East Indira Gandhi
Regional Institue of Health &
Medical Sciences, Shillong,
Meghalaya; 2Professor & Former
Head, Department of Community
Medicine, Assam Medical College,
Dibrugarh, Assam
Objective: To assess the nutritional status and and factors
affecting nutrition of adolescent girls residing in urban slums of
Dibrugarh town.
Methods-A community based cross sectional study of 284
adolescent females in the age group 10-19 years was conducted in
all the 10 slums in Dibrugarh town . The BMI for age <5th
percentile and height for age< 3rd percentile or <-2 Z scoresof
NCHS reference standard were used as criteria for thinness and
stunting respectively.
Results: The overall prevalence of thinness was 25.70% and the
prevalence of stunting was 31.33%. A significant association was
observed between the nutritional status of adolescents and the
mother’s literacy level and family size. The various morbidities
prevalent amongst the adolescent girls were found to be pallor
(93.30%); menstrual problems (83.09%); dentalcaries (42.25%);
angular stomatitis (35.56%); glossitis (34.15%); Skin problems
(20.07 %); lymphadenopathy (10.21%) diarrhoea (7.04%), Goitre
(4.22%) and bitots spots (0.35%).
Key words: Adolescent, nutritional, anthropometry, stunting,
thinness.
Correspondence:
Dr. Himashree Bhattacharyya,
Email: bhimashre@yahoo.co.in
Date of Submission: 26-09-12
Date of Acceptance: 04-02-13
Date of Publication: 31-03-13
INTRODUCTION
The entire period of transition from childhood to
adulthood is considered as adolescence.
Adolescence begins with pubescence – the
earliest signs of development of secondary
sexual characteristics and continues until
morphological and psychological changes
approximate adult status. 1It is the period when
35% of the adult weight and 11-18% of the adult
height is acquired. 2This crucial period of
transition is identified by a range of age of 10-19
years by the World Health Organization.3
The adolescents are generally expected to enjoy
good health being less vulnerable than the very
young or very old. But the actual picture is
somewhat different. Inadequate diet and
unfavourable environments in developing
countries may adversely influence the growth
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and nutrition of the adolescents.4Adolescent girls
are particularly at high risk of malnutrition
because of gender discrimination in distribution
of, and access to, food within the family. The
needs of these adolescent girls are often ignored
and they remain a largely neglected population
of our society.3The present study was therefore
conducted to assess the nutritional status of
adolescent girls residing in the urban slums.
MATERIALS AND METHODS
This community based cross sectional study was
conducted from June – December, 2008 in the
urban slums of Dibrugarh ,Assam. The study
population comprised of adolescent girls in the
age group 10-19 years residing in the study area.
There are 10 slums in Dibrugarh district. All the
slums were included for the study. The sample
size was calculated by the formula 4PQ/ L2 ,
where P=58.5% ( Positive character), Q=1-P, L=
Allowable error. Considering the prevalence of
under nutrition among adolescents as 58.5%
from a previous study conducted by National
Institute of Nutrition, Hyderabad and taking
10% as allowable error the sample size was
calculated to be 284. In the slums, the systematic
random sampling was used to select the
individual subjects .The total number of
adolescent girls in all the slums was found out to
be 1487. From this sampling interval was
calculated to be 5. The first adolescent girl was
selected at random by lottery method by
choosing any number between 1 and5.
Thereafter the other subjects were interviewed
by adding every 5th adolescent girl consecutively
starting from the first adolescent girl till the
required sample size was fulfilled.
The data was collected using pre tested and pre
designed proforma. Verbal informed consent
was obtained from every adolescent and their
guardian present and the subjects were informed
of confidentiality of their data. Nutritional status
was assessed by anthropometry along with
general clinical examination and history taking
to look for any signs of vitamin deficiency
Statistics:
Height for age < 3rd percentile or < -2 Z scores of
NCHS reference standard and BMI for age < 5th
percentile of NCHS reference standard were the
indices used for assessing nutritional status.4 The
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data were analyzed using the descriptive
statistics and Chi- Square test.
RESULTS
A total of 288 households were visited to meet
the required sample size of 284.There were only
two non respondents in the study. In the selected
household all the adolescent girls in the age
group 10-19 years were included in the study.
Among the 284 adolescent girls studied, 54.57%
belonged to early adolescence (10-14 years) and
45.42% girls belonged to late adolescence (15-19
years).84.50 %of adolescent girls were found to
be literate and 15.50% were found to be illiterate.
42.95% of the mothers and 30.28% of the fathers
of the study subjects were illiterate.[Table1]
Table-1: Socio-Demographic Characteristics of
the Study Population
Characteristics
Age Group
10-14
15-19
Literacy
Literate
Illiterate
Socio Economic Status
(Kuppuswami’s classification)
Class I
Class II
Class III
Class IV
Class V
Family Size
<5
≥5
Father’s Literacy
Literate
Illiterate
Mother’s Literacy
Literate
Illiterate
Adolescent (%)
155(54.57)
129 (45.43)
240(84.51)
44(15.49)
3(1.04)
51(17.93)
108(38.01)
122(43.02)
Nil
98(34.51)
186(65.49)
198(69.72)
86(30.28)
162(57.04)
122(42.96)
The overall prevalence of stunting was 31.33%
(95% CI= 25.83-36.83%).Though the prevalence
of stunting was higher among early adolescents
than late adolescents, but it was not statistically
significant (p=0.255).The overall prevalence of
thinness was found to be25.70%.( 95% CI= 20.5230.88%) There was also no statistically significant
difference between prevalence of thinness
among
early
and
late
adolescents
(p=0.556)[Table2].
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Table 2: Nutritional Status of Adolescents by Age
Nutritional Status
Total (n= 284)
10-14yr (n=155)
Stunting
89 (31.33)
53(34.19)
Thinness
73 (25.70)
42 (27.09)
*P value<0.05 is considered as significant
15-19 yr (n=129)
36 (27.90)
31(24.03)
P value
0.255
0.556
OR
1.342
1.175
CI (95%)
0.807-2.231
0.686-2.011
Both the prevalence of stunting (36.06%) and
thinness (27.09%) was highest in Socio-economic
class IV. In the present study, however no
significant association was found between
socioeconomic status and prevalence of stunting
(p=0.201)or thinness (p=0.831).The prevalence of
both stunting (38.37%) and thinness(31.39%) was
high among girls whose father’s were illiterate.
But, the present study showed no significant
association between prevalence of stunting
(p=0.092) and thinness (p=0.1481) and literacy
status of father. The prevalence of both stunting
(41.80) and thinness (44.26%) was much higher
among girls who cameform families whose
mother’s were illiterate. In the present study a
significant association was found between the
prevalence of both stunting (p= 0.001) and
thinness (p<.001) with the literacy status of the
mother. In the study, we found that 34.09%of
illiterate girls were found to have stunting
(p=0.668) whereas 25.00% of illiterate girls were
found to have wasting (p=0.907) but it was not
statistically significant.It was observed that
36.5% of girls with stunting belonged to families
with ≥ 5 members. (p=0.009).A statistically
significant difference was also observed with
respect to thinness, where 31.72% of girls
belonged to families with ≥5 members.(p=0.001)
[Table3].
The commonly prevalent nutritional disorders
among girls were found to be Pallor (93.30%),
menstrual problems (83.09%), Dental caries
(42.25%), Angular stomatitis (35.56%), Glossitis
(34.15
%),
Skin
problems
(20.07
%),
Lymphadenopathy (10.21%), Diarrhoea (7.04%),
Goitre (4.22%) and bitot’s spots (0.35%).
Table 3: Stunting and Wasting as per Socio
Demographic Variables
DISCUSSION
In the present study, no significant association
was observed between prevalence of stunting or
thinness with socio economic status of the
family. No association was also observed
between nutritional status and per capita family
income. A study in Rural Wardha observed a
significantly higher prevalence of stunting
among adolescents from the lower family income
group.10Das DK and Biswas R 11 in their study
also did not find any association between socioeconomic status and prevalence of thinness or
stunting.
The present study shows that the prevalence of
stunting was 31.33%. Similarly, a report on diet
and nutritional status by National Nutrition
Monitoring Bureau also showed the prevalence
of stunting to be 39.1%.5A study conducted in
rural West Bengal showed the of prevalence of
stunting to be 52.45%.6
Characteristics
Stunting
(n=89) (%)
Socio economic status
Class I (n=3)
0
Class II (n=51)
16 (31.37)
Class III (n=108)
29 (26.85)
Class IV (n=122)
44 (36.06)
Class V (n=0)
0
P value
0.201
OR (95% CI)
0.71 (0.42-1.20)
Literacy Status-Father
literate (n=198)
56 (28.28)
illiterate (n=86)
33 (38.37)
P value
0.0921
OR (95% CI)
0.63 (0.37-1.08)
Literacy Status-Mother
Literate (n=162)
38 (23.45)
Illiterate (n=122)
51 (41.80)
P value
0.001
OR (95% CI)
0.43 (0.25-0.71)
Literacy status-Adolescent
Literate (n= 240)
74 (30.83)
Illiterate (n= 44)
15 (34.09)
P value
0.668
OR (95% CI)
1.04 (0.5-2.19)
Family size
21(21.42)
<5 (n=98)
≥5 (n=186)
68(36.55)
P value
0.009
OR (95% CI)
0.47 (0.27-0.83)
Thinness
(n=73) (%)
0
13 (25.49)
27 (25.00)
33 (27.09)
0
0.831
0.94 (0.54-1.63)
46 (23.23)
27 (31.39)
0.648
0.66 (0.37-1.16)
19 (11.72)
54 (44.26)
<0.001
0.167 (0.09-0.30)
62 (25.83)
11 (25.00)
0.907
0.86 (0.44-1.7)
14 (14.28)
59(31.72)
0.001
0.36 (0.19-0.68
* P value<0.05 is considered as significant
The prevalence of thinness in the present study
was found to be 25.70%.This is almost consistent
with other studies which had reported
prevalence of 35.5% and 30.1% respectively.7,8
NFHS-2 reported a higher rate of 38.8% among
ever married adolescent girls of 15-19 years of
age.
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The present study did not find any association
between the nutritional status of adolescent girl
with the father’s literacy status. However, a
significant association was found between
stunting and thinness and mother’s literacy
status. Das DK and Biswas R 11 in their study
also reported no association between nutritional
status of adolescent girls with father’s literacy
status. However, they found a significant
association between thinness and mother’s
literacy status. Thus, a mother’s literacy level is a
better determinant than Socio economic status as
it affects the type of food prepared, distributed
including the type of care received by the girls in
a particular family. In a study conducted in Gaza
by Abudayya A it was observed that in
adolescent girls’ mothers’ education was
negatively associated with stunting.12The present
study showed no significant association between
literacy and nutritional status of the adolescent
girls. Deshmukh PR et al in his study observed
that prevalence of thinness was significantly
higher in those having education less than 8th
standard than those educated at least up to 8th
standard.
In the present study, a significant association
was found between both stunting and wasting
with respect to family size. A study of nutritional
status of rural adolescents found a significant
association between underweight /Chronic
Energy deficiency and family size.13Factors such
as family composition and distribution of food in
the family may play a role in this association.
However, in the present study no analysis was
done to individually predict the indicators for
stunting and thinness. Inability to adjust for
these confounding factors can be considered to
be a limitation in this study.
The present study has revealed a high
prevalence of pallor (93.30%) in the study
population. Other important causes of morbidity
were menstrual problems (83.09%) ,dental caries
( 42.25%), Angular stomatitis ( 35.56%), Glossitis
(
34.15%),
Skin
problems
(20.07%),
Lymphadenopathy ( 10.21%), Diarrhoea (7.04%),
Goitre ( 4.22%) and bitot’s spots( 0.35%)
respectively.Singh.J.et al in a study reported that
deficiency signs of vitamins were found in 28.7%
of girls; a majority of them (22.2%) showed signs
of Iron deficiency and 3% of girls showed signs
of signs of Vitamin A deficiency.14Das K.D. and
Biswas. R in their study conducted in rural West
Bengal showed that the common prevalent
nutritional
deficiency
disorders
among
adolescent girls were Anemia (44.8%) followed
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by Dental Caries (25.9%) and Angular Stomatitis
(15.4%).Goiter was found only in 1.4% of
girls.11A study on health problems of adolescents
in an urban field practice area of Nagpur
observed that the major problems were acute
nasopharyngitis/ tonsillitis (62.7%), anemia
(57.28%), dental caries (37%), menstrual
problems (30%), Vitamin B complex deficiency
(26.28%), history of passing worms in stool
(19.42%), scabies (6.43%, and pediculosis
(7.43%).15
CONCLUSION
Improvement of the nutritional status of
adolescent girls requires a multi-sectoral
approach in order to ensure adequate food
supply, maintain equity in food distribution and
promote improved knowledge about nutrition
and healthy eating habits 3. Low level of literacy
and higher family size has been the major factors
contributing to the poor health status of the
adolescent girls. Thus, health and nutrition
education especially of the mothers can play a
vital role in improving the nutritional status of
these adolescent girls.
REFERENCES
1.
Chapter in the book: Ghai O P, Gupta P. Adolescent
Health: Social and Health issues. Ghai OP, Paul VK, Bagga
A, Editors. Textbook of Preventive and Social Medicine.
Ghai O.P, Gupta P-2007.CBS Publishers and Distributors:
p428-433.
2.
Chapter in the book: Sharma S, Nutrition in Adolescent
Girls: Possible role of Calcium and other minerals; Sachdev
HPS, Choudhury P, Editors. Nutrition in Children:
Developing Country Concerns. 2ndEdition.Sachdev HPS,
Choudhury P. B I Publications, New Delhi: p 272-273.
3.
World Health Organization-10 facts on adolescent health.
Available At www.who.int/features/facilities/adolescenthealth/en/; Accessed on 18.7.2011.
4.
World Health Organization-Physical status: The use and
interpretation of Anthropometry Report of a WHO Expert
Committee-TRS 854. Geneva, WHO: 1995.p-271. Available
at www.who.int/child growth/publications/physical
_status/.../index.html; Accessed on 18.7.2011
5.
National Nutrition Monitoring Bureau. Report on Diet and
Nutrition Status of Adolescents. NNMB Technical Report
No 20, National Institute of Nutrition, ICMR, Hyderabad
2000.
6.
Das P, Ray SK, Joardar GK, Dasgupta A. Nutritional
Profiles of Adolescents in A Rural Community of
Hooghly District in West Bengal. Indian Journal of
Public Health 2007; 51 (2):120-121.
7.
Kapoor G, Aneja S- Nutritional Disorders in Adolescent
Girls- Ind Ped 1992; 29(2) : 969-973.
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8.
Anand K. Nutritional status of Adolescent school
children in rural north India. Ind Ped. 1999; 36 (2): 810815.
9.
National Family Health Survey (NFHS-2) (1998-1999):
Mumbai; International Institute of Population Sciences
and Macro; 2000.
10. Deshmukh PR, Gupta SS, Bharambe MS, DongreAR,
Maliye C, Kaur S, Garg BS. Nutritional status of
adolescents in rural Wardha. Indian Journal of Ped.
2006; 73(2):139-141.
11. Das D Kumar, Biswas R. Nutritional Status of
Adolescent Girls In A Rural Area Of North 24 Parganas
District, West Bengal. Indian Journal of Public Health
2005; 49(1): 18-21.
12. Abudayya A, Thoresen M, Abed Y, Ottesen GH.
Overweight, stunting and anemia are public health
problems among low socio-economic goups in school
adolescents in North Gaza strip. Nutrition
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Research.2003; 27 (12):762-771.Available at
http://linkinghub.elsever.com/ retrieve/pil; Accessed
on 6/7/08.
13.
Venkiah K et al: Diet and nutritional status of rural
adolescents in India. European Journal of Clinical
Nutrition. 2002; 56(11): 1119-1125. Available at
www.nature.com/ejcn/journal/V 56/n 11/Full/
1601457 a.html.; Accessed on 12/7/2011.
14.
Singh J Singh JV, Srivastava AK, Suryakant ; Health status
of Adolescent Girls in Slums of Lucknow. Indian Journal
of Community Medicine. 2006; 31(2): 102-103.
15.
Kalamka HS. Study of Health Problems of Adolescents in
Urban Field Practice Area. Dept. of Preventive & Social
Medicine, Indira Gandhi Medical College, Nagpur
2001.Studies on Adolescent girls: An Analytical Review;
Published by National Institute of Public Co operation and
Child Development, New Delhi,2008 Available at
www.nipccd.nic.in/reports/eag.pdf; Accessed on 6/7/08
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Original Article ▌
UTILIZATION ASSESSMENT OF BASIC MATERNITY
HEALTH SERVICES THROUGH MAMTA CARD IN RURAL
AHMEDABAD
Kapil J Govani1, Jay K Sheth2, D V Bala3
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Govani KJ, Sheth JK, Bala DV.
Utilization Assessment of Basic
Maternity Health Services through
Mamta card in Rural Ahmedabad.
Natl J Community Med 2013; 4(1):
40-3.
Author’s Affiliation:
1Third year Resident; 2Assistant
Professor; 3Professor & Head,
Community Medicine Department,
Smt. NHL Municipal Medical
College, Ahmedabad
Correspondence:
Dr. Kapil J. Govani,
Email: kapilgovani@gmail.com
Date of Submission: 30-10-12
Date of Acceptance: 15-03-13
Date of Publication: 31-03-13
Introduction: Mamta card is a comprehensive MCH card as it
provides the information of pregnant / lactating women and 0-3
years of Children.
Objectives: To find the utilization of antenatal, Intranatal and
postnatal health services by rural mothers and to assess
completeness of records in the Mamta card.
Methodology: Community based cross sectional study was
conducted at nine villages of seven sub centres under two PHCs
of rural Ahmedabad district during October-2011 to January-2012.
Proforma was prepared covering various components of Mamta
card. Total 130 mothers having infants (<1 year) were
interviewed. Information was assessed primarily from the Mamta
card or by directly asking the mother whenever the card was
unavailable.
Result: Out of total 130 mothers, 103 (79%) having mamta card.
Majority (52%) were educated up to primary level.
Documentation of treatment and advice was 82.5% for antenatal
and only 3.9% for postnatal details. Date of birth was noted in
78.6%, birth weight in 67% and Growth chart mapping in 44.6% of
mamta cards. Majority (76.9%) had taken at least 3 ANC visits.
Around 95% mothers were fully immunized for TT, as per
requirement. 52% mothers had taken IFA for at least 3 months.
Majority (53%) delivered at private hospital. Beneficiaries of
Janani-Suraksha Yojna were 32%. Preferable contraception was
condom (16%) followed by Cu-T(7%), whereas majority(67%)
were not using or did not reply.
Conclusion: The coverage of basic maternity health services is
unsatisfactory. Documentation was satisfactory only for antenatal
details but not for rest of the services. Relevant steps are required
to improve services and its documentation.
Key words: Basic Maternity Health Services, Mamta card,
Documentation.
INTRODUCTION
A Mamta card or mother and child care booklet
designed for providing information and
guidance to caregivers about care for pregnant,
lactating women and 0-3 years of Children.1,2
Mamta card is more comprehensive than MCH
card as it includes various details like complete
family details, birth details, Health organization
details, various ANC record and notes on
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treatment, follow up and referral advice during
antenatal, intra natal and post natal period by
doctors or health workers.3 For growth
monitoring of child, gender wise Growth chart is
also available in card. Thus it covers almost all
Maternal and Child components e.g. ante-natal,
intranatal, new born care, post natal, exclusive
breastfeeding, infant and young child feeding,
immunization, regular weight and growth
monitoring of Children (0-3 years). Mamta card
also serves as a very good tool for evaluating the
service delivery by various health workers.4,5
OBJECTIVES
Objectives of the study are to find the utilization
of antenatal, Intranatal and postnatal health
services by rural mothers and to assess
completeness of records in the Mamta card.
MATERIALS AND METHODS
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education status, 32 (25%) mothers were
illiterate. Majority 68 (52%) of mothers studied
up to primary level; followed by 19 (14%)
secondary level; 6 (5%) higher secondary level;
and 5 (4%) up to graduate level. Various sections
of the Mamta Card were checked for the
documentation status (Table-1). In the available
103 mamta cards, documentation in birth detail
section showed, birth date in 81(78.64%), birth
weight in 69 (66.99%) and birth registration in 19
(18.45%). Among those 69 babies whose birth
weight was recorded, 17 (24%) babies had
weight less than 2.5 kg. Growth chart mapping
was done in only 46 (44.66%) of mamta cards.
Complete documentation for family details
(including mother’s name, age, ID No., address
etc.) was seen in 24 (23.3%). Health facilities’
details (including name of PHC, sub centre,
Anganwadi etc.) were found to be completed in
31(30.09%).
Out of total 43 PHCs in rural Ahmedabad, 2
PHCs were selected from one block of Table 1: Status of documentation of various
components in Mamta card (N=103)
Ahmedabad district. Using the purposive
sampling method, a cross sectional community Documentation Details
Mamta cards
having
based study was conducted in nine villages of
details (%)
seven sub centres of these PHCs during October
24 (23.30)
2011 to January 2012. Proforma was prepared Complete Family details
16 (15.53)
taking various components of Mamta card which Complete Birth details
a. Date of Birth detail
81 (78.64)
includes family details; birth details and growth
b. Birth Weight detail
69 (66.99)
chart status of baby; health organization details;
c. Birth Registration detail
19 (18.45)
various ANC record details; etc. It also has notes
31 (30.09)
on treatment, follow up and referral advice Complete Health facilities’ details
Ante natal Weight detail
92 (89.32)
during antenatal, intra natal and post natal
Ante natal Blood Pressure detail
86 (83.49)
period by doctors or health workers. As the
Treatment, advice, follow up and
85 (82.52)
Proforma was specially prepared for the study,
Referral notes for Antenatal
field testing was done and necessary Treatment, advice, follow up and
4 (3.88)
modifications were applied to make it Referral notes for Post natal
standardized. Those mothers with <1 year old Treatment, advice, follow up and
0 (0)
children were selected and interviewed for the Referral notes for New born care
study after their informed consent. As the data Growth chart mapping
46 (44.66)
was collected within limited time, only 130
mothers were taken for study purpose. Record of ANC services in the mamta card
Regarding basic maternity health services, showed documentation of weight in 92 (89.32%)
information was assessed primarily from mamta and
blood
pressure
in
86
(83.49%).
card. If mamta card was not available, Documentation of treatment, advice & follow up
Information was obtained by asking the mothers notes in mamta card were found in 85 (82.52%)
after informed verbal consent. Analysis of study for antenatal details, in 4 (3.88%) for postnatal
was done by using appropriate statistical details and in none for new born care details.
software applying suitable statistical tests.
Assessment of ANC visits showed that 30 (23%)
mothers had <3 ANC visits; 34 (26%) mothers
had 3 ANC visits while the remaining 66 (51%)
RESULTS
mothers had >3 ANC visits. Assessment of ANC
Out of total 130 mothers, mamta card was services revealed that 124/130 (95%) mothers
available with 103 (79%) mothers. Regarding the had complete TT coverage (TT1 & TT2 or TT
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Booster according to their requirement) and 117
(90%) mothers had received IFA tablets. Out of
117 mothers 68 (58%) mothers had continued
IFA tablets for at least 3 months and 26 (22%)
mothers had taken tablets before meal.
Table 2: Comparison of Maternal Health indicators of present study (n=130) with DLHS3.6
Indicators
At least 3 ANC visits
At least 1 TT inj. in antenatal
BP noted in antenatal period
Consume 100 IFA tablets
Institutional delivery
Home delivery by
skilled health personnel
Beneficiaries of JSY
Female sterilization (TL)
Copper –T (IUD)
O.C. – pills
Condoms
Present study
(Ahmedabad
Rural) (%)
76.9
100.0
83.0
58.0
98.5
0.0
32.0
5.0
8.0
3.0
16.0
Ahmedabad
Rural
Total
47.9
79.9
37.3
80.3
13.3
9.7
50.0
1.8
3.1
2.8
36.6
4.9
5.1
6.6
DLHS3 (2007-08)
Gujarat
Rural Total
48.0
54.9
63.1
68.6
44.8
51.0
52.3
50.7
48.1
56.5
6.4
5.6
10.4
43.7
2.5
2.4
3.0
9.5
41.5
3.5
3.0
4.5
India
Rural Total
44.1
49.8
68.7
73.4
38.0
45.7
47.3
46.6
37.9
47.0
5.7
5.7
13.6
34.1
1.4
4.1
3.8
13.3
34
1.9
4.2
5.9
‘-’indicates ‘Data Not Available’
The commonest place of delivery was private
hospitals (69, 53.1%) followed by Government
hospitals (43, 33%) & municipal hospitals (16,
12.3%). Home deliveries were reported to be 2
(1.5%). Normal deliveries were 112 (86%) and the
rest were by caesarian section. Majority of
deliveries were conducted by doctors (80, 61.5%)
followed by nursing staff (48, 37%) and trained
dais (2, 1.5%). Gender distribution of babies
showed, 69 (53%) males and 61 (47%) females.
Beneficiaries of Janani Suraksha Yojna were 42
(32%) and Chiranjeevi yojna were 4 (3.07%). For
birth spacing, preferred method of contraception
was condom (16%), followed by copper T (8%),
tubal ligation (5%) and oral contraceptive pills
(3%). However, majority (68%) women were
either not using any method or preferred not to
answer.
Table 3: Comparison of Maternal Health indicators of present study (n=130) with NFHS 3.6,7
indicators
At least 3 ANC visits
Consume 100 IFA tablets
Institutional delivery
Female sterilization (TL)
Copper –T (IUD)
O.C. – pills
Condoms
Present study 2011-12
(Ahmedabad Rural) (%)
76.9
58
98.5
5
8
3
16
The results was compared with the latest District
Level Health Survey (DLHS3) (Table-2).6 for the
district, state and national level for total as well
as rural components. The results were also
compared with the latest National Family Health
Survey (NFHS3) (Table-3).6,7 It was compared
with the state and national level data for total as
well as rural components of NFHS3.
DISCUSSION
Mamta card is important documentary evidence
as well as a unique tool for assessing the
NFHS 3 (2005-06)
Gujarat
India
Rural
Total
Rural
Total
55.8
64.9
42.8
50.7
28.9
35.7
18.1
22.3
42.2
54.6
31.1
40.8
47.0
42.9
37.1
37.3
2.7
4.4
1.1
1.7
1.5
2.6
2.8
3.1
3.7
5.8
3.2
5.2
utilization of basic maternity services.1 Current
study showed availability of mamta card to be
79%. Reasons for unavailability of mamta card
were misplace, torn, card not available at home
etc. Even when the cards were available, the
overall condition of the mamta card was poor.
This shows the need to emphasize the 4 key
messages during service delivery particularly
vaccination which includes preserving the card
and keeping it safe for documentation. Female
literacy is an important indicator as well as a
factor affecting health. Even though, the female
literacy in the current study is higher than the
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national (65.46%) and state (70.7%) female
literacy rate (census 2011)8, it needs to be
improved further as the current study showed
female illiteracy rate to be 25%. Documentation
of birth weight, which was average (66.9%), is
very helpful for identification of LBW babies. In
the present study, 24% Low birth weight (LBW)
babies were documented, which is less than the
incidence of LBW babies (28%) of India 2008.6
Growth chart is very important tool for
monitoring the growth and nutritional status of
baby.1 Result shows that growth chart mapping
was done in 45% mamta cards, which needs
improvement for early identification of
malnourished children and for tracking the
growth of the baby.
Complete documentation for family details was
23% and for Health organization details was
30%, as E-mamta ID no. in family detail and First
Referral Unit (FRU) information in Health
organization details were not documented by
majority of health workers. The study showed
there was drastic difference in documentation of
antenatal components (maternal weight-89%,
blood pressure-83% and treatment, advice &
follow up notes-82.5% etc.) and Intra & postnatal
components (treatment, advice & follow up
notes for post natal details (3.9%) and none for
newborn care details). This shows higher
weightage for documentation was given only up
to antenatal details.
Mamta cards reveal that 23% mothers had taken
<3 ANC visits. Although majority of women had
started IFA tablets, the continuation of at least 3
months was 58% and only 22% mothers had
taken IFA tablets before meals as per ideal
recommendation. More efforts are still required
for full coverage of antenatal Tetanus
immunization. It reiterates the need to put equal
and higher emphasis on all components of ANC
during follow up and mamta day sessions.
Improved rate of tetanus immunization and
institutional deliveries in current study were
might be due to small sample size. Among the
institutional delivery, majority were private
hospitals deliveries (53%) as compare to
government institutions. This could be due to
unawareness of various government schemes,
poor compliance due to low quality of care at
government Health facilities, inadequate referral
services, availability of private services at
reasonable cost in rural areas etc.
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Regarding birth spacing information, majority
(68%) women were either not using any method
or preferred not to answer. This has not only
made the direct comparison difficult but also
reflects social stigma, customs, beliefs or even
lack of knowledge regarding contraceptive
methods. Effective counseling of women for
family planning and birth spacing is still a major
felt-need in the community. As the target
population is women having <1 year old child,
the permanent method of contraception (e.g. TL)
is not reflected accurately in the comparison with
the district and national level data.
CONCLUSION
Higher emphasis needs to be given for better
coverage of all RCH services including ANC
services. Currently the mamta card is primarily
used for documentation of ANC details only,
which shows documentation in mamta card is
still very poor & requires radical improvement.
REFERENCES
1.
Park’s text book of Preventive and Social medicine, K.
PARK, 21st edition, M/s Banarsidas Bhanot, Jabalpur,
India.
2.
Ministry of Health and Family Welfare (MOHFW). 2006.
National Rural Health Mission (2005-2012), Mission
Document. New Delhi: MOHFW.
3.
World Health Organization (WHO). 1998. Postpartum
care of the mother and newborn: A practical guide.
Geneva:
Maternal
and
Newborn
Health/Safe
Motherhood Unit, Division of Reproductive Health
(Technical Support), WHO.
4.
Ministry of Women and Child Development (MOWCD).
National guidelines on infant and young child feeding.
New Delhi: MOWCD (Food and Nutrition Board),
Government of India.
5.
Ministry of Health & Family Welfare, Government of
India. Immunization Handbook for Medical Officers.
New Delhi: Dept. Health & Family Welfare, Govt. of
India, 2009.
6.
International Institute for Population Sciences (IIPS),
World Health Organization (WHO) and World Health
Organization (WHO) - India – WR Office. 2006. Health
System Performance Assessment: World Health Survey
2003 India. Mumbai: IIPS.
7.
Directorate General of Health Services (DGHS), Ministry
of Health and Family Welfare (MOHFW) in
collaboration with WHO India Country Office. 2005.
National Health Profile 2005. New Delhi: Central
Bureau of Health Intelligence, DGHS, MOHFW, Govt.
of India.
8.
Census of India 2011, Ministry of Home affairs,
Government of India, New Delhi.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
HUMAN RESOURCES FOR HEALTH: AVAILABILITY AND
COMPETENCIES FOR MATERNAL AND NEWBORN
HEALTH CARE SERVICES
Prahlad Rai Sodani1, Kalpa Sharma2
Financial Support: WHO Country
Office, India
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Sodani PR, Sharma K. Human
Resources for Health: Availability
and Competencies for Maternal and
Newborn Health Care Service. Natl
J Community Med 2013; 4(1): 44-9.
Author’s Affiliation:
1Dean; 2Research Officer, Institute
of Health Management Research,
Jaipur
Correspondence:
Dr. P.R. Sodani,
Email: prsodani@gmail.com
Date of Submission: 10-11-12
Date of Acceptance: 05-03-13
Date of Publication: 31-03-13
ABSTRACT
Background: Human resources are the largest component of
health care delivery system in India and motivated health
workers are essential for improving health outcomes.
Objectives: The objective of this paper is to study the availability
and competency of staff at community health centers (CHCs) and
24X7 primary health centers (PHCs) and compare these with the
Indian Public Health Standards (IPHS).
Materials and Methods: Data were collected from various health
service providers and managers at district, block and community
level through well structured questionnaire.
Results: Shortage of manpower especially specialists were
observed at CHCs whereas at 24*7 PHC shortage of laboratory
technician and pharmacist were observed. More than 75 percent
medical officers were competent in history taking and physical
examination during ANC followed by antenatal counseling and
interventions (71.4%), health education and counseling (66.7%)
and providing newborn care (61.9%) whereas nearly 70 percent of
the nursing staff were competent in ANC history taking, establish
I/V line and give fluid and conduct normal delivery. Fourteen
programme managers found themselves competent in monitoring
and evaluation followed by implementation planning (76.5%),
managing
training
programmes
(76.5%),
programme
management and review (58.8%), quality management (58.8%),
essential computer skills (58.8%), developing action plan (58.8%)
and managing contracts (58.8%).
Conclusions: Important deficiencies were revealed in the studied
CHCs and 24X7 PHCs of Bharatpur district and by additional
inputs such as recruiting staff health facilities can be upgraded.
Training is essential for enhancing the competencies which
should be addressed on the priority basis.
Key words: Human Resources, Indian Public Health Standards,
Clinical Competency, Techno-managerial Competency, Maternal
and Newborn Care
BACKGROUND
Human resources are the largest component of
health care delivery system in India and defined
as “all people engaged in actions whose primary
intent is to enhance health”. Human resource for
health (HRH) encompass all of the men and
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women who work in the health field including
clinical staff such as physicians, nurses,
pharmacists and dentists, as well as management
and support staff, those who do not deliver
services directly but are essential to the
performance of health systems, such as health
workers, policy makers, educators, clerical staff,
scientists, pharmacists, managers, ambulance
drivers and accountants. It has been estimated,
however, that countries with fewer than 23
physicians, nurses and midwives per 10 000
population generally fail to achieve adequate
coverage rates for selected primary health-care
interventions, as prioritized by the Millennium
Development Goals. 1, 2
One major challenge in health care delivery
system is the availability of non competent staff.
A competency need exists when there is a gap
between what is required of a person to perform
efficiently and what he actual knows and this
can be reduced or eliminated by training and
development. To assess the competency need
little efforts have been made. However, there are
studies conducted for training needs assessment
such as those of Christiane Brems et al (2010) and
Reena Isaac (2011) both of which have been
conducted among health care providers. 9, 10 Very
few studies such as Michael Nash (2002);
Markaki A (2009) carried out to assess the
training needs of nursing staff. 11, 12
Health care delivery in India has been envisaged
at three levels namely primary, secondary and
tertiary. The primary and secondary level of
health care essentially includes Primary Health
Centers (PHCs) and Community Health Centers
(CHCs) respectively. CHCs are public health
facility, designed to provide referral health care
for cases from the primary level and for cases in
need of specialist care approaching the CHC
directly whereas PHCs are the cornerstone of
rural health services; a first port of call to a
qualified doctor of the public sector in rural areas
for the sick and those who directly report or
referred from Sub-centers for curative,
preventive and promotive health care. Some
PHCs has been selected which provide round the
clock services by increasing the number of
medical officers and staff nurses and called as
24X7 PHCs. 3, 4
The objective of the present paper are as follows:
a) to study the availability of human resources at
CHCs and 24X7 PHCs and compare these with
the Indian Public Health Standards; b) to assess
the clinical competencies required by health care
providers (i.e. Medical Officers and Nursing
Staff) on the core skills of maternal and newborn
care at various public health facilities i.e. CHCs
and 24*7 PHCs; and c) to assess the technomanagerial
competencies
required
by
programme managers at district and block levels
as well as medical officer in charge (MOIC) at
various public health facilities i.e. CHCs and 24*7
PHCs in the Bharatpur District of State of
Rajasthan.
According to Rural Health Statistics Bulletin
(2011) of Ministry of Health and Family Welfare,
Government of India, there are 4809 CHCs and
23887 PHCs are functioning in India. 5 However,
the density of health workforce was found pity.
According to the World health Statistics (2012),
6.5 physician, 10 nursing and midwife personnel
and 0.5 community health worker per 10,000
population are available in India. 6
Indian Public Health Standards (IPHS) are the
set of standards formed to provide optimal level
of quality health care, with the aim to deliver
high quality services which are fair and
responsive to client’s needs, which should
provide
equitably
and
which
deliver
improvements in the health and wellbeing of the
population. Draft guidelines for Indian Public
Health Standards for PHCs and CHCs were
published in 2006 which were then modified in
2010. 7, 8
MATERIALS AND METHODS
The present paper is based on a study conducted
in Bharatpur district of the State of Rajasthan,
India. There are thirteen CHCs and nineteen 24*7
PHCs in the study district. As we know,
Rajasthan is one of the 18 special focused states
identified by the National Rural Health Mission
(NRHM) to provide effective healthcare, because
of weak public health indicators. 13 From the
State of Rajasthan, Bharatpur district is identified
purposively for the present study because of
weak health outcomes.
To assess the availability of human resources at
CHCs and 24*7 PHCs with respect to Indian
Public Health Standards (IPHS), a facility
assessment tool was developed referring the
Revised Draft of Indian Public Health Standards
(IPHS) for Community Health Centers and
Primary Health Centers (2010) developed by the
Ministry of Health and Family Welfare,
Government of India. 7, 8 To assess the clinical
and managerial competencies required, two
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separate checklists were developed by referring
various guidelines regarding maternal and
neonatal care developed by Ministry of Health
and Family Welfare (MoHFW), Government of
India. 14, 15
To assess the clinical competencies required by
the health providers such as Medical Officers
(MOs) and Nursing Staff including Staff Nurses,
Auxiliary Nurse Midwives (ANMs), General
Nurse Midwives (GNMs) and Lady Health
Visitors (LHVs) to provide maternal and
newborn health care services at CHCs and 24*7
PHCs, 89 health providers including 21 medical
officers and 68 nursing staff were interviewed.
Similarly, to assess the techno-managerial
competencies required to perform better, 3
district level officials [Chief Medical and Health
Officer (CMHO), District Programme Manager
(DPM), and District Maternal and Child Health
Consultant (DMCHC)], 14 block level officials [6
Block Chief Medical Officers (BCMO) and 8
Block Programme Managers (BPMs)], eight CHC
Medical Officers In-charge, and nine 2*7 PHC
Medical Officers In-charge were interviewed.
Data were collected through interviews at public
health facilities including district hospital, CHCs
and 24*7 PHCs during the months of September
and October 2010. Written consent was obtained
from all the participants. Clinical competencies
were assessed on core skills of maternal and
newborn care including : a) ante-natal care such
as antenatal history taking, antenatal physical
examination and antenatal counseling and
interventions; b) intra-natal care such as basic
emergency obstetric care (BeMOC), emergency
obstetric care (EmOC), manual removal of
placenta, identification of danger signs during
pregnancy, labor, delivery and postpartum
period, giving deep intramuscular injections,
establish I/V line and give fluids, fill client care
and referral slip, use of partograph during
labour , conducting normal delivery, and
application of forceps and vacuum; and c) postnatal care such as family planning, abortions,
providing newborn care, providing postpartum
care to normal mothers and newborns and health
education and counseling. However, technomanagerial competencies were assessed on the
following skills such as leadership, hospital
management, programme management and
review; procurement, logistic and inventory
management, quality management, budgeting
and finance, fund management, monitoring and
evaluation,
essential
computer
skills,
implementation planning, developing district
action plan, managing training programmes,
developing terms of references and managing
contracts.
RESULTS AND DISCUSSION
Availability of Human Resource
In order to provide round the clock services,
appropriate human resources including both
medical and support should be made available at
health facility. According to the Indian Public
Health Standards (IPHS) from revised draft
(2010) for CHCs, five specialists such as one
general surgeon, one physician, one obstetric and
gynecologist (OBG), one pediatrics and one
anesthetist; six medical officers; sixteen nursing
staffs (including ANM and staff nurses); three
pharmacists; three laboratory technicians and
two radiographers should be made available at
CHC.
Table 1: Availability of Human Resources at Community Health Centers in Bharatpur District,
Rajasthan
Human Resources
General Surgeon
Physician
OBG
Pediatrics
Anesthetist
Medical Officers
Nursing Staff (SN+ANM)
Pharmacist/Compounder
Lab Technician
Radiographer
IPHS (Revised
Draft)-2010
1
1
1
1
1
6
16
3
3
2
Human Resource at all 13 CHCs
Required
Availability
% availability
13
4
30.8
13
5
38.5
13
5
38.5
13
4
30.8
13
1
7.7
78
32
41
208
163
78.4
39
12
30.8
39
26
66.7
26
13
50
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Existing
Gap (%)
69.2
61.5
61.5
69.2
92.3
59
21.6
69.2
33.3
50
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The study shows that around 31 percent general
surgeon and pediatrics are available as per the
requirement. However, out of the 13 CHCs in the
study district, only one had the availability of
Anesthetist. Only four CHCs have general
surgeon in place. However, only five CHCs have
physician. Table 1 depicts that only five CHCs
were functioning with OBG and four CHCs were
functioning with a pediatrics. The above finding
shows that the availability of specialists to
provide various specialist services at CHCs was
found to be very poor in the study district. As far
as medical officers are concerned, data shows
that only 32 medical officers are there at the CHC
level. Data depicts that only 163 (78.4%) nursing
staff are available at CHCs. However, 12 (30.8%)
pharmacists/compounders and 26 (66.7%)
laboratory technicians were available at CHC
level in the study district. It was observed that
only 13 (50%) radiographers were available at
CHC level in the study district.
According to the IPHS (2010) for primary health
centers, two medical officers, five staff nurses,
two
pharmacist/compounder
and
two
laboratory technicians should be available at 24*7
PHCs. Table 2 shows the availability of human
resources at 24*7 PHC in the study district. Data
depict that only 23 (60.5%) medical officers were
available at 24*7 PHCs. However 79 (83.2%) staff
nurses are available in all the study 24*7 PHCs. It
was
observed
that
only
4(10.5%)
pharmacists/compounders and 18 (47.4%)
laboratory technicians were available at 24*7
PHC level.
Table 2: Availability of Human Resources at 24*7 Primary Health Centers in Bharatpur District,
Rajasthan
Human Resources
IPHS (Revised
Draft) -2010
Medical Officer
2
Staff Nurses
5
Pharmacist/ Compounder
2
Laboratory Technician
2
Human Resources at all nineteen 24*7 PHC
Required
Availability
% availability
38
23
60.5
95
79
83.2
38
4
10.5
38
18
47.4
Competencies Found
Competencies among medical officers and
nursing staff were identified on two aspects:
clinical skills and techno-managerial skills. In
clinical skills, focus was on maternal and
newborn care.
Clinical Competencies found in Medical
Officers (MOs): Data depicts that more than 75
percent medical officers were competent in
history taking and physical examination during
ANC followed by antenatal counseling and
interventions (71.4%), health education and
counseling (66.7%) and providing newborn care
(61.9%). Only one MO found to be competent in
EmOC followed by application of forceps and
vacuum (4 MOs)) and abortion (6 MOs).
Clinical Competencies found in Nursing Staff:
Data depict that nearly 70 percent of the nursing
staff were competent in ANC history taking,
establish I/V line and give fluid and conduct
normal delivery. It was found that 46 nursing
staff out of 68 were competent in ANC
counseling and intervention, providing newborn
care and health education and counseling
followed by antenatal physical examination
(64.7%), give deep intramuscular injections
Existing Gap
(%)
39.5
16.8
89.5
52.6
(61.8%) and providing postpartum care to
normal mothers and newborns (61.8%). Only 23
nursing staff reported the use of partograph
during labour. Competency regarding abortion,
BeMOC and manual removal of placenta was
found to be poor.
Techno-Managerial Competencies Found
Programme Managers at District and Block
Level: Programme managers in public health are
responsible for successful management of public
health facilities. This responsibility requires a lot
of technological and managerial skills which are
assessed in programme managers at study
district. Findings depict that 14 programme
managers found themselves competent in
monitoring and evaluation followed by
implementation planning (76.5%), managing
training programmes (76.5%), programme
management and review (58.8%), quality
management (58.8%), essential computer skills
(58.8%), developing action plan (58.8%) and
managing contracts (58.8%). Only 5 programme
managers out of 17 were competent in
procurement followed by budgeting and finance
(7) and fund management (9).
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Table 3: Clinical Competency found in Medical Officers and Nursing staff in Core Skills of
Maternal and Newborn Care
Core Skills
Competent Medical
Officers (N=21) (%)
Competent Nursing
Staff (N=68) (%)
16 (76.2)
16 (76.2)
15 (71.4)
48 (70.6)
44 (64.7)
46 (67.6)
7 (33.3)
1 (4.7)
8 (38.1)
11 (52.4)
- (- (12 (57.1)
4 (19.0)
-
33 (48.5)
34 (50.0)
42 (61.8)
48 (70.6)
38 (55.9)
23 (33.8)
38 (55.9)
-
48 (70.6)
11 (52.4)
6 (28.6)
13 (61.9)
8 (38.1)
14 (66.7)
41 (60.3)
32 (47.0)
46 (67.6)
42 (61.8)
46 (67.6)
Ante-natal Care
Antenatal history taking
Antenatal physical examination
Antenatal counseling and interventions
Intra-natal Care
Basic emergency obstetric care (BeMOC)
Emergency obstetric care (EmOC )
Manual removal of Placenta
Give deep intramuscular injections
Establish I/V line and give fluids
Client care and referral slip
Use of partograph during labour
Application of forceps and vacuum
Identification of danger signs during pregnancy, labor, delivery
and postpartum period
Conducting normal delivery
Post-natal Care
IUCD insertion
Abortion
Providing newborn care
Providing postpartum care to normal mothers and newborns
Health education and counseling
Medical Officer In-Charge (MOIC) at CHC/24*7
PHC: MOIC is overall in-charge of the public
health facility i.e. CHCs and PHCs. MOIC at
CHCs and 24*7 PHCs are engaged in clinical
services as well as in the management of public
health
institutions.
To
fulfill
these
responsibilities, they should have technomanagerial needs, which are assessed and
presented in table 4. Data depict that ten MOIC
were competent in quality management,
monitoring and evaluation, implementation
planning, developing TOR and managing
contracts. However, only 5 MOIC were
competent in essential computer followed by
hospital management (6), procurement (8) and
budgeting and finance (8).
Table 4: Techno–Managerial Competencies found in Programme Managers and Medical Officer
In-Charge (MOIC) in Bharatpur District, Rajasthan
Techno-managerial Skills
Leadership
Hospital management
Programme management and review
Procurement
Logistics and inventory management
Quality management
Budgeting and finance
Fund management
Monitoring and evaluation
Essential computer skills
Implementation planning
Developing action plan
Managing training programmes
Developing terms of reference (TOR)
Managing contracts
Competent
Programme
Managers
(N=17)
13
7
10
5
8
10
7
9
14
10
13
10
13
9
10
Percentage of
competent
programme
managers
76.5
41.2
58.8
29.4
47.0
58.8
41.2
52.9
82.3
58.8
76.5
58.8
76.5
52.9
58.8
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Competent
MOIC
(N=17)
Percentage of
competent
MOIC
9
6
9
8
9
10
8
9
10
5
10
9
9
10
10
52.9
35.3
52.9
47.0
52.9
58.8
47.0
52.9
58.8
29.4
58.8
52.9
52.9
58.8
58.8
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CONCLUSION
REFERENCES
Findings shows that there is vast shortage of
manpower at studied public health facilities and
available human resource are not competent to
provide quality services to the beneficiaries as
they reported several clinical and technomanagerial competency needs. Vacant posts
should be filled and efforts should be put to
place human resource as per the IPHS.
1.
World Health Organization, The World Health Report
2006- Working together for health. Geneva, 2006: WHO;
2006. p1.
2.
World Health Organization, Not Enough Here… Too
Many There… Health workforce in India. Country
Office for India, 2007. p1.
3.
Ministry of Health and Family Welfare, Government of
India. Indian Public Health Standards for Community
Health Centers (Draft Guidelines). New Delhi: 2006. p4.
4.
Ministry of Health and Family Welfare, Government of
India. Indian Public Health Standards for Primary
Health Centers (Draft Guidelines). New Delhi: 2006. p5
5.
Ministry of Health and Family Welfare (2011). Rural
Health Statistics in India. New Delhi: Ministry of Health
and Family Welfare. p 39-40
6.
World Health Organization (WHO). World Health
Statistics, 2012. p 124-125
7.
Ministry of Health and Family Welfare. Government of
India. Indian Public Health Standards for Primary
Health Centers (Revised Draft 2010). New Delhi: 2010. p
6
8.
Ministry of Health and Family Welfare. Government of
India. Indian Public Health Standards for Community
Health Centers (Revised Draft 2010). New Delhi: 2010. p
6
9.
Christiane Brems, Rachel V Boschma-Wynn, Sarah L
Dewane, Alexandra E Edwards, Rebecca V Robinson.
Training Needs of Healthcare Providers related to
Centers for Disease Control and Prevention core
competencies for Fetal Alcohol Spectrum Disorders.
Journal of Population Therapeutics and Clinical
Pharmacology 2010; 17: 405-417
10.
Reena Isaac, Jennifer Solak, Angelo P. Giardino. Health
Care Providers' Training Needs Related to Human
Trafficking: Maximizing the Opportunity to Effectively
Screen and Intervene. Journal of Applied Research on
Children: Informing Policy for Children at Risk 2011; 2:
1-32
11.
Michael Nash. The training need of primary care nurses
in relation to mental health. Nursing times. 2002; 98(16).
p 42
12.
Markaki A, Alegakis A, Antonakis N, KalokerinouAnagnostopoulou A, Lionis C. Exploring training needs
of nursing staff in rural Cretan primary care settings.
Applied Nursing Research. Vol. 22, No. 2. May 2009.
13.
Ministry of Health and Family Welfare, Government of
India. National Rural Health Mission (2005-2012):
Mission Document. 2005.
14.
Ministry of Health and Family Welfare (2009). Trainees’
Handbook for Training of Medical Officers in
Pregnancy Care and Management of Common Obstetric
Complications Maternal Health Division. New Delhi:
Ministry of Health and Family Welfare. Government of
India
15.
Ministry of Health and Family Welfare. Government of
India/National Health Systems Resource Center (2010).
Trainer’s Guide for Conducting Training of
ANMs/LHVs & SNs: New Delhi: Ministry of Health
and Family Welfare. Government of India.
District hospital should be identified as “District
Health Training Center” and a separate
committee should be formed, which should be
responsible to deliver competent health staff to
the district. Committees should be responsible to
identify the training needs of health service
providers working at different levels of health
system at regular intervals, organize training
programmes and prepare training material as
per the need. District hospital, civil hospitals and
first referral units (FRUs)/community health
centers (CHCs) should be identified as training
sites on the basis of patients load and
convenience of the trainees, where trainees can
learn and use their skills at the same place which
can be cost effective too.
Training is an effective way to enhance the
competencies of health providers which
ultimately results in overall improvement in
health indicators.
Acknowledgments
Data used for this research paper was gathered
from the study “Baseline Studies for Developing
Implementation Model for Strengthening Maternal
and Newborn Health Services in district Bharatpur,
Rajasthan using Health Systems Approach under
NRHM” project which was supported by WHO
India Country Office. Thanks are due to WHO
India Country Office for providing financial
support in conducting the study. We also express
our gratitude to Directorate of Medical, Health
and Family Welfare Services, Government of
Rajasthan for facilitating to conduct the study.
Thanks are also due to Director, Institute of
Health Management Research, Jaipur for
providing an opportunity to conduct the study.
We also acknowledge the contribution of
district/block and facility level officials in
providing the required data.
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Original Article ▌
MENTAL HEALTH STATUS AND DEPRESSION AMONG
MEDICAL STUDENTS IN MYSORE, KARNATAKA – AN
UNTOUCHED PUBLIC HEALTH ISSUE
Renuka Manjunath1, Praveen Kulkarni2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Manjunath R, Kulkarni P. Mental
Health Status and Depression
among Medical Students in Mysore,
Karnataka – An Untouched Public
Health Issue. Natl J Community
Med 2013; 4(1): 50-3.
Author’s Affiliation:
1Professor, 2Assistant Professor,
Community Medicine, JSS Medical
College, Mysore
Correspondence:
Dr Renuka M,
Email: dr.renuka.m@gmail.com
Date of Submission: 05-12-12
Date of Acceptance: 11-03-13
Date of Publication: 31-03-13
Background: Medical education across the globe is perceived as
being inherently stressful. Studies on psychological problems
such as stress, depression and anxiety among medical students
have found that these disorders are under diagnosed and under
treated. In this background the present study was undertaken
with the objectives to assess the overall mental health status and
magnitude of depression of medical students
Methods: This Cross sectional study was undertaken in a private
medical college in Mysore city for a period of three months
involving all 211 students studying in I (first term) and II year
(third term) MBBS. Goldberg’s General Health Questionnaire
(GHQ-28) and Center for Epidemiological studies- Depression
scale (CES-D) were used for assessing general mental health
status and depression respectively.
Results: Among 211 students included in the study, poor mental
health status and depression was found in 25.1% and 40.8% of
subjects. There was statistically significant association between
poor mental health status and depression with age group of 17-18
years and year of study (1st year MBBS).
Conclusion: Poor mental health status and depression was found
to be high among medical students. This call for in-house
counseling services and mentorship programme at medical
colleges for early detection and treatment of these problems that
will intern help in academic and curricular improvements.
Keywords: Mental health status, depression, medical students,
GHQ-28, CES-D
INTRODUCTION
Medical education across the globe is perceived
as being inherently stressful.1-4 Over burden of
information provides a reduced opportunity to
relax and recreate and leads to serious sleep
deprivation, impaired judgment, reduced
concentration, loss of self-esteem, along with
mental health status like increased anxiety and
depression. A medico encounters various
stressors in terms of academic pressures and its
resultant outcome measured in terms of success
in the evaluation process and long term objective
to settle down in the coming future as well as
adjustment to the new environ in the medical
school. These students face social, emotional and
physical and family problems which may affect
their
learning
ability
and
academic
performance.1 Studies on psychological problems
such as stress, depression and anxiety among
medical students have found that these disorders
are under diagnosed and under treated. Failure
to detect these disorders unfortunately leads to
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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increased
psychological
morbidity
with
unwanted effects throughout their careers and
lives.3 Therefore it becomes imperative to study
the overall mental health status and particularly
prevalence of depression among medical
students as these constitute neglected public
health problems in India. It is very important to
prevent the ill effects of depression on one’s
academic attainment and carrier through early
identification
and
effective
intervention
measures.5 In this background the present study
was undertaken with the objectives to assess the
overall mental health status and magnitude of
depression of medical students and to describe
the factors influencing mental status and
depression among medical students in a private
medical college at Mysore City.
Materials and Methods
This Cross sectional study was undertaken in a
private medical college in Mysore city for a
period of three months (January to March 2012)
involving all 211 students studying in I (first
term) and II year (third term) Bachelor of
Medicine and Bachelor of Surgery (MBBS). These
two terms were selected purposively for the
reason that students in first term are those who
had just now entered into new environment of
medical college and medical curriculum. The
other group consisting of second year MBBS
would have already been accustomed for the
college as well as curriculum. Thus comparing
the mental health status and depression among
these two groups would give a better idea
regarding influence of academic environment
and medical curriculum on mental health.
Details
regarding
Sociodemographic
characteristics and factors influencing mental
health status were collected in an anonymous
pre- tested structured proforma. Overall mental
health status was assessed using self reported
Goldberg’s General Health Questionnaire (GHQ28) 6 which is developed by David Goldberg at
Institute of psychiatry London, as a screening
instrument in community. This scale consists of
four set of questions (A,B,C,D) each having
seven items related to Somatic symptoms,
Anxiety/insomnia, Social dysfunction, Severe
depression experienced in last 2 weeks.
Magnitude of depression was assessed using a
self reported Center for Epidemiological studiesDepression scale (CES-D) derived from five
validated depression scales including the Beck
Depression Inventory (BDI).7 This is a widely
used 20 item scale that measures the current
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level of depressive symptomatology in the
general population, with an emphasis on
depressed mood during the past one week.
Confidentiality of data was strictly maintained.
Statistical analysis
Data obtained was entered in MS excel-07 spread
sheet, analyzed and interpreted using descriptive
statistical measures like mean, SD and
percentages as appropriate. SPSS version 16 was
used for Chi-square test to find out the
association between mental health status
depression and various factors under study.
RESULTS
General characteristics:
Among 211 students included in the study, 85
(40.3%) were in I (first term) and 126 (59.7%) and
II year (third term) MBBS. Majority 122 (57.8%)
were in the age group of 19 and above. 98
(46.5%) were males and 113 (53.5%) were
females. Majority 171 (81%) of the students were
localites /staying with parents and 181 (85%)
were belonging to nuclear families.
Table1: Distribution of study subjects based on
presence of poor mental health status and
depression (n=211)
Screening tool
GHQ-28 (Scores >23)
Poor mental health
CES-D (Scores >15)
Depression
Number (%)
53 (25.1)
95% CI
19.2 - 30.9
96 (45.5)
38.7 - 52.2
General Mental health status:
General mental health status as per Goldberg ‘s
General Health Status Questionnaire, was found
to be poor in 53(25.1%) students. (Table 1) As
indicated in (Table 2), there was statistically
significant association between poor mental
health status and age group 17 - 18 years (χ2 =
4.66, P= 0.003) and year of study (first term
MBBS) (χ2 = 5.6, P= 0.017). There was no
significant association between general mental
health status and sex, father’s education,
residence, type of family, presence of siblings.
Depression
Magnitude of depression as assessed by Center
for Epidemiological studies- Depression scale
(CES-D), was found to be 96 (40.8%) students
(Table 1). As indicated in table – 2, the state of
depression was significantly associated with age
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group of less 17-18 years (χ2 =8.16, P= 0.004) and
year of MBBS (first term MBBS) (χ2 = 11.04, P=
0.001). There was no significant association
between depression and sex, father’s education,
residence, type of family, presence of siblings.
Table 2: Distribution of study subjects based on factors influencing poor mental health status and
depression (N=211)
Variable
Age
17-18
19 and above
Total
89 (42.2)
122 (57.8)
Sex
Males
Females
GHQ-28 (>23)
OR (95% CI)
P*
30 (33.7)
25 (20.5)
1.97 (1.05 -3.67)
0.030
98 (46.4)
113 (53.6)
25 (25.5)
28 (24.8)
1.20 (0.64- 2.26)
Fathers education
<degree
122 (57.8)
PG
89 (42.2)
59 (44.3)
29 (58.2)
Residence
Localite
Non localite
174 (82.5)
37 (17.5)
Family type
Nuclear
Joint
CES-D (>15)
OR (95% CI)
P*
44 (49.3)
43 (35.2)
1.79 (1.02- 3.13)
0.039
0.562
47 (48.0)
39 (34.5)
1.74 (1.04 - 3.04)
0.048
1.93 (1.09- 3.41)
0.022
55 (82.0)
31 (78.8)
1.53 (0.87-2.69)
0.135
42 (24.1)
11 (29.7)
0.75 (0.34-1.65)
0.477
74 (42.6)
10 (27.0)
1.99 (0.91- 4.38)
0.084
180 (85.3)
31 (14.7)
44(24.4)
9 (29.9)
0.79 (0.33- 1.84)
0.587
71 (39.4)
15 (48.4)
0.69 (0.32 -1.49)
0.351
Sibling
Present
Absent
181 (85.8)
30 (14.2)
47 (26)
6 (20)
1.40 (0.54-3.64)
0.48
75 (41.4)
11 (36.7)
1.22 (0.54- 2.71)
0.622
Year of study
1st year
2nd year
126 (59.7)
85 (40.3)
39 (31)
14 (16.5)
2.27 (1.14- 4.51)
0.019
63 (50)
23 (27.1)
2.69 (1.49-4.87)
0.001
Note: Figures in parenthesis indicate percentages, NS: P >0.05
DISCUSSION
MBBS study is the toughest course among all the
study courses including, Bachelor of Computer
Administration (BCA), Indian Administrative
Services (IAS), Engineering, or any other
technical courses as quoted in the Guinness Book
of World Records in May 2011.8 Medical school
is recognized as a stressful environment that
often exerts a negative effect on the academic
performance, physical health and psychological
wellbeing of the student. The personal and social
sacrifice that the students have to make in order
to maintain good academic results in a highly
competitive environment puts them under a lot
of stress which may end up in wide spectrum of
psychological disorders like depression, anxiety,
stress etc. 3
In the present study, general mental health status
was found to be poor among 25.1% of the
students. This is in line with the findings of M.
Nojomi et al and Liselotte N. Dyrbye et al at Iran,
using SCL-90-R questionnaire, where 19.4% and
25% of medical students were having poor
mental health status respectively. 4,9 This is
almost half of the burden that is reported by Rael
D. Strous et al using DSM-IV criteria in Israel,
where 55.5% of students had reported poor
mental health status.10 A study on three
generations of Iranian medical students and
doctors found that 44% of participants scored
above
the
threshold
of
the
GHQ-28
questionnaire, indicating probable psychiatric
disorders.11 There was a significant association
between lower age as well as 1st year of MBBS
with the poor mental health status. This is
attributed to the higher academic and intellectual
burden that is disproportionate to the age and
capability of the student. The mental health
status of students in higher age group and
studying in third term MBBS was better
compared to their juniors as they would have
already acclimatised to the academic and social
environment of medical school. This implies that
the stressors precipitating poor mental health
status taper as the student accustoms himself to
the environmental influences. These findings
were similar to the observations made by Marie
Dahlin et al where students in 1st year of
Medicine had higher burden of stressors
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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compared to
curriculum.12
those
in
later
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phases
of
Various studies conducted at different parts of
world reported the prevalence of depression
among medical students to be 15-65%.5 In the
present study the magnitude of depression
among medical students was found to be 40.8%.
This is consistent with the findings of M S
Sherina et al from Malaysia where the prevalence
of depression was 33.6% using the CES-D scale.3
In a study conducted by Thomas H et al among
3rd year medical students of University of
Mississippi school of Medicine, United States
and Marie Dahlin et al at Sweden, where
prevalence was as low as 23% and 12.%
respectively.2,12 On the other hand Ganesh
Kumar et al. reported the prevalence of
depression using Beck depression inventory
among medical students in Southern India, to be
as high as 71.25%.5 This wide range in the
magnitude of depression can be attributed to
variations in the types of scales used in the
screening and different socio-demographic,
geographic backgrounds of students under
study.
Interestingly, depression was significantly high
among students in the lower age group and
those studying in the first year of MBBS. Even
though this is in consistent with the findings of
Inam SNB et al, in Pakistan, reported higher
rates of depression among students in earlier
phases of medical carrier,13 most of the available
literature gives contrasting picture of increase in
the rates of depression as the student moves
towards higher level of academics in
medicine.2,3,4 The lower burden of depression
among third term students in the present study
can be attributed to good academic and student
friendly atmosphere in the institution that helps
the students to cope with factors precipitating
depression.
CONCLUSION
Poor mental health status and depression was
found to be high among medical students. Both
poor mental health status and depression were
significantly associated with the lower age and
year of the study. It has been stated that young
doctors should be given the same care and
support that we expect them to provide to their
patients. The same should be extended to
medical students in order to promote resilience
and personal fulfilment, and for enhancement of
professionalism and patient care. This call for inhouse counseling services and mentorship
programme at medical colleges for early
detection and treatment of these problems so
that for budding doctors can concentrate on their
studies resulting in better academic and
curricular outcomes.
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Sherina MS, Med M, Rampal L, Kaneson N.
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M. Nojomi M, Gharayee B. Medical students and mental
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Ganesh SK, Jain A, Supriya H. Prevalence of depression
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Goldberg DP. The General Health Questionnaire
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Radloff LS. The CES-D Scale: A self report depressive
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Dr. Shah Navas P. Stress among Medical Students.
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Rael D. Strous, Shoenfeld N, Lehman A, Aharon W,
Leah S, Barzilai O. Medical students self-report of
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Assadi SM, Nakhaei MR, Najafi F, Fazel S. Mental
health in three generations of Iranian medical students
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Dahlin M, Joneborg N, Runeson B. Stress and
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Inam SNB, Saquib A, Alam E. Prevalence of anxiety and
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National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
INTER-STATE VARIATION IN NEONATAL MORTALITY
RATE AMONG INDIAN STATES
Tushar A Patel1, Deepak B Sharma2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patel TA, Sharma DB. Inter-state
variation in Neonatal Mortality
Rate among Indian states. Natl J
Community Med 2013; 4(1): 54-8.
Author’s Affiliation:
1Assistant Professor; 2Associate
Professor, PSM Department, PSMC,
Karamsad, Gujarat
Correspondence:
Dr. Tushar Patel
Email: trushar_9@yahoo.com
Date of Submission: 31-12-12
Date of Acceptance: 11-03-13
Date of Publication: 31-03-13
Background: Infant Mortality Rate has been accepted as an
important indicator of overall health status of community and has
also been included in millennium development goal indicators.
The study was conducted to find the: Association of neonatal
mortality rate with different risk factors
and association of neonatal mortality rate with various
interventional variables
Methods: This study uses data from Indian National Family
Health Survey -3 (NFHS-3). Sample for analysis includes all 29
states of India in which third round of National Family Health
Survey were conducted and reports for the same were available.
Data was obtained from state reports of National Family Health
Survey -3.Neonatal mortality rates of different states were taken
as dependent variable.
Results: Bi-variate regression showing influence of percentage of
women age 15-19 years who have begun childbearing and
percentage of women with BMI < 17 on neonatal mortality was
confounding effect of socio-economic status. Bi-variate regression
showing influence of ante-natal check up, iron-folic acid
supplementation and post natal check up on neonatal mortality
was confounding effect of socio-economic status.
Conclusions and Recommendations: The only variable other
than socio-economic condition which was having association with
neonatal mortality rate was percentage of hospital delivery.
Government of India should take all possible measures to make
health care services particularly facility based services available,
accessible and affordable.
Keywords-Neonatal mortality rate, Risk
Regression analysis, interventional variables
INTRODUCTION
Infant Mortality Rate has been accepted as an
important indicator of overall health status of
community and has also been included in
millennium development goal indicators.
According to MDG4 Infant mortality rate should
decline by two-thirds between 1990(84/1000 live
births) and 2015(28/1000 live births).1 However
factors,
NFHS-3,
from 2000 to 2010 IMR in India has declined
from 68/1000 live births to 47/1000 live births
with average annual decline of only 2.1/1000 live
births.2 IMR has departed from the longer term
trend since 1994. In 1997 IMR was 71/1000 live
births against predicted value of 63.5/1000 live
births based on longer term trend. Recent data is
clearly indicating that rate of decline in IMR is
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slowing down and at the current rate of decline
it will be difficult for India to achieve
millennium development goal.3, 4
Two-thirds of infant deaths occur during first
month of life. Out of all neonatal deaths three
quarter happens within first week of life.5 Home
delivery contributes to half of neonatal deaths.6
Most important determinant of neonatal
mortality and morbidity is Low birth weight.
Low birth weight contributes to three-fourth of
neonatal deaths and half of infant deaths.
Principal risk factors for low birth weight are
poor maternal nutrition and too early, too
frequent and too many pregnancies.7
Out of all neonatal deaths one third are due to
infections. Pre-term birth complications are
second major cause of death among neonates
which is followed by Birth asphyxia.8 Neonatal
sepsis is primary cause of death in 20% of
neonatal deaths.9 A study in Uganda on three
delay model to understand neonatal deaths has
identified that among 50% cases delay was due
to failure in problem recognition or in deciding
to seek care. 30% cases received delayed care at
health facility.10
To accelerate the pace of decline of IMR it is
essential that important risk factors for infant
death among several are identified and also
more effective interventions among all are
selected.
METHODS
Data sources: This study uses data from Indian
National Family Health Survey -3 (NFHS-3).11
The International Institute for Population
Sciences coordinated the survey with support
from several international organizations. The
large-scale cross-sectional survey was conducted
in a representative sample of households
throughout India during 2005-06. A summary of
the coverage and target population is presented
in Table 1. The sampling, questionnaire
structure, and content of the NFHS surveys
follow what has been adopted by the
Demographic Health Surveys (DHS) in other
developing countries. The NFHS uses nationally
representative area-based sampling frames in
each survey. During Nov. 2005 to Aug. 2006
1,24,385 women age 15-49 and 74,369 women age
15-54 were interviewed by eighteen research
organizations. Sample size was calculated in
terms of ever-married women in the
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reproductive age group. Initial target was set to
interview 1,500 ever married women in states
with less than 5 million population, 3,000 women
in states with a population between 5 and 30
million, and 4000 women in states with more
than 30 million populations according to 2001
census. In each state urban and rural samples
were drawn separately. Within each state,
villages were selected with probability
proportional to population size followed by
random selection of households within each
village. In urban areas, wards were selected with
PPs sampling. Within wards census enumeration
block (CEB) were randomly selected. Selection of
households within CEB was done by random
method. Interviewer team was trained with eight
different manuals to maintain standardized
survey procedures across states and to minimize
non-sampling
errors.
Manuals
described
procedures for drawing location and layout
maps of sample areas, listing households and
selecting household for surveys as well as
standard
interviewing
techniques
and
procedures, field procedures to be followed in
the process of measurement of bio-markers.
Height and weight of women was measured by
two health investigators on each survey team.
Health investigators took blood samples of
women and measured hemoglobin level in the
field using portable HemoCue instruments. The
NFHS produced high response rates in all states
ranging from 90% in Maharashtra and
Meghalaya to 99% in Madhya Pradesh and
Chhattisgarh. Details of the survey methodology
and response rates have been published.11
Our sample for analysis includes all 29 states of
India in which third round of National Family
Health Survey were conducted and reports for
the same were available. Data was obtained from
state reports of National Family Health Survey 3.
Indicators and measures: Neonatal mortality
rates of different states were taken as dependent
variable. Independent variables were following
percentages/proportions of
different states:
proportion of the population in lowest quintile of
wealth index, percentage of women in age 15-49
having BMI < 17, percentage of women age 15-19
years who have begun childbearing, percentage
of pregnant women with moderate(7.0-9.9g/dl)
anaemia, percentage of live births delivered at
home, Percentage of live births delivered with
assistance from non-health professionals (other
than doctor, ANM, Nurse, Mid-wife, LHV),
Percentage of higher birth order (4th or above)
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among total births during last three years,
percentage of births having interval < 2 years
since the preceding birth.
Data analysis: The analyses in this paper are
primarily descriptive and present regression of
neonatal mortality rate by proportion of various
risk factors. In first step bi-variate linear
regression was done followed by multiple linear
regression was done with three variables. As
numbers of states were only twenty nine,
regression analysis with more than three
variables was not done. Regression of neonatal
mortality rate by selected interventional
variables was done in similar manner. Data were
managed and analyzed using SPSS (version)
software which usually reveals F statistic
(ANOVA) for relationship between two
variables, un-standardized regression co-efficient
and t statistics for comparing un-standardized
coefficients.
RESULTS
Table -1 shows the bi-variate linear regression of
neonatal mortality rate by prevalence of different
risk factors. Relationship of Neonatal mortality
rate with percentage of births having interval
less than two years since preceding birth was not
significant (F-0.26, p-0.61). There was no strong
linear relationship between two variables with
coefficient of determination only 0.01. On
comparing the t value with one another it is
clearly evident that percentage of the population
in lowest quintile of wealth index has highest
influence on neonatal mortality rate (t-7.48, p0.00). Other risk factors showing major influence
on neonatal mortality rate were percentage of
women age 15-19 who have begun childbearing
(t-4.60,p-0.000), percentage of live births
delivered at home (t-4.40,p-0.00) and percentage
of women in age 15-49 with BMI < 17 (t-4.36,p0.00).
Table-1 Univariate Regression analysis of Neonatal mortality rate with different risk factors
Variables
Lowest
BMI
Anaemia
Teenage pregnancy
Home delivery
Assistance by non-professional
Percentage of birth before two years
Higher birth order
R square
0.68
0.41
0.21
0.44
0.42
0.35
0.01
0.21
F
55.97
19.03
6.88
21.20
19.43
14.19
0.27
6.95
P value
0.00
0.00
0.01
0.00
0.00
0.00
0.61
0.01
B
0.65
1.34
0.61
1.17
0.32
0.33
0.26
0.49
SE
0.09
0.31
0.23
0.25
0.08
0.09
0.50
0.18
t
7.48
4.36
2.62
4.60
4.41
3.77
0.51
2.63
P value
0.00
0.00
0.01
0.00
0.00
0.00
0.61
0.01
Table-2 Mutivariate Regression analysis of Neonatal mortality rate with selected risk factors
Variables
BMI
Anaemia
Teenage preg
Home delivery
Assistance by non-professional
Higher birth order
R square
0.68
0.65
0.66
0.70
0.70
0.65
Table-2 shows the multiple linear regressions of
neonatal mortality rate by percentage of
population in lowest quintile of wealth index
and other risk factors. Suggested by F test all six
variables were having significant relationship
with neonatal mortality rate. Controlling for the
percentage of population in lowest quintile of
wealth index, only two variables were reliably
predicting neonatal mortality rate – percentage
of deliveries assisted by non-health professional
(t-2.09, p-0.046) and percentage of births
delivered at home (t-2.09, p-0.046). Bi-variate
F
30.87
26.06
28.71
33.69
33.71
27.00
P value
0.00
0.00
0.00
0.00
0.00
0.00
B
0.45
0.07
0.29
0.13
0.14
0.04
SE
0.28
0.18
0.27
0.06
0.06
0.14
t
1.60
0.40
1.07
2.09
2.10
0.25
P value
0.12
0.69
0.29
0.05
0.05
0.80
regression showing influence of percentage of
women age 15-19 years who have begun
childbearing and percentage of women with BMI
< 17 was confounding effect of socio-economic
status.
Table -3 shows the bi-variate linear regression of
neonatal mortality rate by prevalence of different
interventional
variables.
Relationship
of
Neonatal mortality rate with percentage of
mothers who received supplementary food
during pregnancy was not significant (F-0.0, p0.98).
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Table-3 Univariate Regression analysis of Neonatal mortality rate with possible interventional
variables
Variables
Supplementary food taken
Antenatal care by health professional
IFA for 90 days
> 3 ANC taken
Post natal check up within 2 days
R square
0.00
0.15
0.28
0.32
0.37
There was no strong linear relationship between
two variables with coefficient of determination
only 0.0. On comparing the t value with one
another it was clearly evident that risk factors
showing major influence on neonatal mortality
rate were percentage of pregnant women who
F
0.00
4.71
10.69
13.28
15.99
P value
0.98
0.03
0.00
0.00
0.00
B
0.00
-0.29
-0.37
-0.32
-0.32
SE
0.13
0.13
0.11
0.08
0.08
t
0.02
-2.17
-3.27
-3.64
-3.99
P value
0.98
0.04
0.00
0.00
0.00
took Iron Folic Acid for more than 90 days (t3.27, p-0.000), percentage of pregnant women
who had at least three antenatal check up (t-3.64,
p-0.00) and percentage of women who had post
natal check up within two days of delivery (t3.99, p-0.00).
Table-4 Multivariate Regression analysis of Neonatal mortality rate with selected interventional
variables
Variable
Antenatal care by health professional
IFA for 90 days
> 3 ANC taken
Post natal check up within 2 days
Supplementary food taken
R square
0.68
0.71
0.70
0.71
0.74
Table -4 shows the multiple linear regressions of
neonatal mortality rate by percentage of
population in lowest quintile of wealth index
and other interventional variables. Suggested by
F test all four variables were having significant
relationship with neonatal mortality rate.
Controlling for the percentage of population in
lowest quintile of wealth index, not a single
variable was reliably predicting neonatal
mortality rate – percentage of pregnant women
who took Iron Folic Acid for more than 90 days
(t-1.75, p-0.09), percentage of pregnant women
who had at least three antenatal check up (t-1.32,
p-0.19) and percentage of women who had post
natal check up within two days of delivery (t1.69, p-0.10). Bi-variate regression showing
influence of ante-natal check up, iron-folic acid
supplementation and post natal check up was
confounding effect of socio-economic status.
DISCUSSION
Our study shows that bi-variate regression
showing influence of percentage of women age
15-19 years who have begun childbearing and
percentage of women with BMI < 17 on neonatal
mortality rate was confounding effect of socioeconomic status. Influence of ante-natal check
up, iron folic acid supplementation and post
natal check on neonatal mortality rate was also
confounded by socio-economic status. The only
F
27.21
31.67
29.65
31.35
36.45
P value
0.00
0.00
0.00
0.00
0.00
B
-0.04
-0.15
-0.10
-0.12
-0.18
SE
0.09
0.08
0.07
0.07
0.07
t
-0.41
-1.75
-1.32
-1.69
-2.49
P value
0.68
0.09
0.20
0.10
0.02
variable other than socio-economic condition
which was having association with neonatal
mortality rate was percentage of hospital
delivery. Thus variation in neonatal mortality
rate among Indian states can be attributed to
percentage of population in lowest quartile of
wealth index and percentage of hospital
delivery.
Infant Mortality rate is not only used for
measurement of health status but also as a part
of standard of living evaluations in economics.12
The infant mortality rate correlates very strongly
with, and is among the best predictors of state
failure.13
Rationale for selecting the infant mortality rate as
an health indicator was not only to measure
health status of children but was to measure
health status of total population. It also reflects
the socio-economic condition in which children
live and also availability, accessibility and
affordability of health care services particularly
peri-natal and neonatal care.14,15
For more than 20 years India emphasized on
“Dai” training (TBA) to reduce maternal
mortality rate. Ultimately some reduction in
maternal mortality rate was achieved in recent
years by promoting hospital delivery and
providing transport facility.
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A review of potential interventions to reduce
neonatal mortality rate has suggested that at 90%
coverage family-community based interventions
along with outreach services can reduce neonatal
deaths by 18-37%. Settings with very high
neonatal mortality rate will show greater effect.
For more than 50% reduction in neonatal
mortality rate simultaneous expansion of facility
based clinical services which make up 62% of
total programme cost is needed.16
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accessible and affordable. As well as it should
adopt economic policies that can reduce
economic disparity rather than wasting scarce
resources on other interventions to reduce infant
and neonatal mortality rate.
REFERENCES
1.
Official list of MDG indicators: Available at
http://mdgs.un.org/unsd/mdg/Host.aspx?Content=In
dicators/OfficialList.htm Accessed on 20th December
2012.
2.
http://www.censusindia.gov.in/vital_statistics/SRS_B
ulletins/Bulletins.aspx
3.
Mariam Claeson, Eduard Bos and Indra Pathmanathan.
Reducing Child Mortality in India: Keeping up the Pace,
HNP Discussion Paper. The International Bank for
Reconstruction and Development / The World Bank.
November 1999; Page 12.
4.
Mariam Claeson, Eduard R. Bos, Tazim Mawji, et al.
Reducing child mortality in India in new millennium.
Bulletin of the World Health Organization, 2000, 78
(10):1192-1199
5.
Dr Josephine Sauvarin. Maternal and Neonatal Health
in East and South-East Asia. UNFPA Country Technical
Services Team for East and South-East Asia, Bangkok,
Thailand. March 2006. Page 4.
6.
Joy E Lawn, Simon Cousens, Jelka Zupan, et al. 4
million neonatal deaths: When? Where? Why? Lancet
March, 2005. Page 9-18.
7.
National Neonatology Forum & Save the Children/US.
State of India’s newborns. New Delhi / Washington,
DC. November 2004. Page-58-60.
The main limitations of this study are those
associated with all ecologic studies. Data were
collected at the community level; therefore, it is
not possible to infer individual-level risk from
the results. However, Indian institute of
population science can conduct further analysis
with individual data. As number of states were
limited it was not possible to conduct multiple
regressions with more variables.
8.
Newborn health Epidemiology. Available at http://
www.who.int/maternal_child_adolescent/epidemiolog
y/newborn/en/index.html. Accessed on 21st Dec 2012.
9.
S.P. Shrivastava, Anjani Kumar, Arvind Kumar Ojha.
Verbal Autopsy Determined Causes of Neonatal Deaths.
Indian Pediatrics 2001; 38: 1022-1025.
10.
Waiswa P, Kallander K, Peterson S, et al. Using the
three delays model to understand why newborn babies
die in eastern Uganda. Trop Med Int Health. 2010 Aug;
15 (8):964-72.
Another limitation of our study is that we have
tested only limited number of variables and not
all. It does not include variables like availability,
accessibility and affordability of neonatal care
services, three delays, etc. as data for same was
not available. District level health surveys have
included certain variables pertaining to health
services but they have surveyed only
government facilities and not private. DLHS can
expand their survey to private sector for the
measurement of availability, accessibility and
affordability.
11.
International Institute for Population Sciences and
Macro International 2007: National Family Health
Survey (NFHS-3) 2005-06, India.
12.
Sullivan, Arthur; Steven M. Sheffrin (2003). Economics:
Principles in action. Upper Saddle River, New Jersey
07458: Pearson Prentice Hall. pp. 474.
13.
Gary King: Langche Zeng (July 2001). “Improving
forecasts of state failure” .World Politics 53 (4): 623–658
14.
Infant Mortality Rate: Available at http://apps.who.int
/gho/indicatorregistry/App_Main/view_indicator.asp
x?iid=1 Accessed on 21st December 2012.
15.
Reidpath DD, Allotey P: Infant mortality rate as an
indicator of population health. J Epidemiol Community
Health 2003, 57(5):344-6
16.
Gary L Darmstadt, Zulfiquar A Bhutta, Simon Cousens,
et al. Evidence based, Cost effective interventions: how
many newborn babies can we save? Lancet March 2005
Page 19-30
Facility based neonatal care might be available
up to district level in India but availability at
sub-district level is questionable. Even if
neonatal care is available at district and higher
level, its affordability is also questionable.
Government of India has regulated the petrol
price since several years but cost of medical
services is not under any regulation and
escalating day by day.
If we will reduce neonatal mortality rate without
reducing economic disparity and making
healthcare (neonatal care) services available,
accessible and affordable, question will still
remain whether we have treated an indicator or
underlying cause for which an indicator was
selected. In the race of reducing infant mortality
rate, have we forgotten the purposes for which
an indicator has been selected?
Government of India should take all possible
measures to make health care services
particularly facility based services available,
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Original Article ▌
A CROSS SECTIONAL STUDY TO UNDERSTAND THE
FACTORS AFFECTING INTAKE OF SUPPLEMENTARY
NUTRITION AMONG CHILDREN REGISTERED WITH ICDS
ANGANWADIS
MohamedAnas M Patni1, Abhay Kavishwar2, Mohmmedirfan H Momin3, S L Kantharia4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patni MM, Kavishwar K, Momin
MH, Kantharia SL. A Cross
Sectional Study to Understand the
Factors Affecting Intake of
Supplementary Nutrition among
Children Registered with ICDS
Anganwadis. Natl J Community
Med 2013; 4(1): 59-64.
Author’s Affiliation:
1Tutor; 2Associate Professor;
3Assistant Professor; 4Professor &
Head, Preventive and Social
Medicine Department, Government
Medical College, Surat
Correspondence:
Dr. Patni MohamedAnas M,
Email: dr.anas1985@gmail.com
Date of Submission: 22-01-13
Date of Acceptance: 27-03-13
Date of Publication: 31-03-13
Introduction: Malnutrition a serious problem in India. ICDS
anganwadis provide supplementary nutrition to its children
beneficiaries.
Aims and objectives: 1) To study various factors affecting the
intake of supplementary nutrition by children registered with
anganwadis.2) To understand the mother’s perception about
supplementary nutrition provided at anganwadi centers.
Methods: It was a cross sectional study done during January and
February 2011. All children of three to five years of 6 randomly
selected anganwadis of Jhagadia block of Bharuch district were
selected for study. The pretested and predesigned questionnaire
was used for collection of data from the mother of the children at
their home. Data for availing of supplementary nutrition by child
was obtained from anganwadis.
Results: Out of 104 children, 70 (67.3%) received adequate and 34
(32.7) did not receive adequate supplementary nutrition. Among
various factors, complementary feeding after 6 months of birth,
birth weight, Vitamin A intake, diet at home, variety of food in
diet at home and illness were found to have significant effect on
attainment of supplementary nutrition by children from
anganwadi. Also, mothers of children had good perception about
supplementary nutrition in anganwadi, but considered it to be
insignificant for growth of their child.
Conclusion: Illness of child, diet at home, birth weight was few of
the many factors found to have impact on intake of
supplementary nutrition by child at anganwadi.
Keywords: Supplementary nutrition, ICDS, Cross sectional study
INTRODUCTION
Protein energy malnutrtion is an important
nutritional problem among preschool age
children. This leads to various degrees of growth
retardation. Many factors can cause malnutrition,
most of which relate to poor diet or severe and
repeated
infections,
particularly
in
underprivileged populations. Inadequate diet
and disease, in turn, are closely linked to the
general standard of living, the environmental
conditions, and whether a population is able to
meet its basic needs such as food, housing and
health care. Malnutrition is thus a health
outcome as well as a risk factor for certain
diseases and exacerbated malnutrition and these
diseases can increase the risk both of morbidity
and mortality1.
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According to the National Family Health Survey
(NFHS-3) carried out in 2005-061, Almost half of
children under five years of age (48 percent) are
stunted and 43 percent are underweight.
Wasting is also quite a serious problem in India,
affecting 20 percent of children under five years
of age1.
Launched on 2nd October 1975, today, ICDS
Scheme represents one of the world’s largest and
most unique programmes for early childhood
development. ICDS provides supplementary
feeding
through
anganwadis.
Children
beneficiaries avail supplementary feeding
support for 300 days in a year2.
However, in spite of the expansion of ICDS,
evaluation studies done by FORCES indicate that
ICDS reaches out to only 30% of the children.
Children from remote scattered hamlets and
children living in new slum clusters are often out
of the ambit of ICDS services3. Malnutrition has
decreased only marginally from 47% in 1998-99
to 46% in 2005-06, as was revealed in the
National Family Health Survey III (2006)1.
So there is need to study factors affecting reach
of ICDS services especially supplementary
nutrition.
OBJECTIVES
Objectives of this study were to study factors
affecting intake of supplementary nutrition by
children registered with anganwadi centers and
to understand the mother’s perception about
supplementary food provided at anganwadis.
MATERIAL & METHODS
It was a Cross sectional study conducted from
January to February 2011. Verbal consent of
mothers of all the children was taken prior to
study. All children in the age group of three to
five years in the six randomly selected
anganwadis of Jhagadia block of Bharuch district
during the period of January-February 2011 were
included in the study. These age groups of three
to five years were selected because; these were
the children who came to anganwadi for availing
supplementary nutrition.
As malnutrition is homogenously distributed,
Jhagadia block is purposively selected for study.
Jhagadia block is divided in to 2 units. 1st unit
has 125 anganwadis and 2nd has 103 anganwadis.
Three anganwadis from both units have been
randomly selected by random table number
method. All the children in these six anganwadis
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aged between three to five years were enrolled in
this study.
The total number of children aged between three
to five years in all these six anganwadis came out
to be 111. But 104 children were recruited in the
study due to absence of seven children at the
time of data collection. Confirmation of their age
was done by their birth certificates, and if their
birth certificates were not available, then through
the records from the anganwadi.
The pretested and predesigned questionnaire
was used. The Performa had questions regarding
child’s
socio-demographic
profile
which
included his name, age, type of family, social
status, expenditure per month, education of
parents, illness in past few months, occupation of
parents etc which was taken from the mother of
each child at home. The children were
considered
to
have
received
adequate
supplementary nutrition if they attended
anganwadi on an average for more than 14 days
per month over last six months. This information
was collected from anganwadi register which is
compiled by anganwadi worker.
RESULTS
It was observed that about 70 children (67.3%)
received adequate supplementary nutrition from
the anganwadis (on an average more than 14
days per month over last six months). 34 children
(32.7 %) did not receive adequate supplementary
nutrition from the anganwadis (on an average up
to 14 days per month over last six months).
Further results are described by dividing the
children in these two groups.
Table 1: Basic characteristics of children in
Anganwadis
Characteristic
Supplementary Nutrition
(sample size)
up to 14 days
> 14 days
Caste
SEBC(n=15)
4 (26.7)
11 (73.3)
ST(n=89)
30 (33.7)
59 (66.3)
Religion
Hindu(n=101)
33 (32.6)
68 (67.4)
Muslim(n=3)
1 (33.3)
2 (66.7)
Family Type
Joint(n=5)
3 (60)
2 (40)
Nuclear(n=46)
16 (34.8)
30 (65.2)
3rdgeneration(n=53)
15 (28.3)
38 (71.7)
Family Size
≤4 members (n=20)
6 (30)
14 (70)
>4 members (n=84)
28 (33.3)
56 (66.7)
Vitamin A in last 6 months
Received (n=91)
23 (25.2)
68 (74.8)
Not received (n=13)
11 (84.6)
2 (15.4)
Figure in parenthesis indicate percentage
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p- value
>0.05
>0.05
>0.05
>0.05
<0.05
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The basic characteristics of the children include
caste, religion, family type, family size, and
vitamin A supplementation in last 6 months.
Majority of children belonged to ST class. Most
of the children belonged to Vasava community.
Also, almost all of the children were from Hindu
families.
When family type was considered, it was found
that almost half of all the children belonged to
three generation family. It was observed that
35% of the children from the nuclear family did
not receive adequate supplementary nutrition
which was 28 % in three generation family.
When family size was taken in to account, a large
number of children (80%) came from family
which had more than four members. In the
family which had up to four members in the
family, 30 % children did not receive adequate
supplementary nutrition which was 33 % in the
children of the family which had more than four
members.
In the children who reportedly received vitamin
A in last 6 months, 25 % of them did not receive
adequate supplementary nutrition. While, in the
children who did not report to receive vitamin A
in last 6 months, 85% of them did not receive
adequate supplementary nutrition from the
anganwadi.
It was found that only vitamin A
supplementation had significant effect on intake
of supplementary nutrition by children in
anganwadi.
Table 2: Distribution of study population
according to biological characteristics
Characteristic
Supplementary Nutrition
up to 14 days
> 14 days
(sample size)
Gender
Girl(44)
16 (40.9)
28 (59.1)
Boy(60)
18 (30)
42 (70)
Age(months)
36-41(25)
7 (28)
18 (72)
42-47(18)
7 (36.8)
11 (63.2)
48-53(35)
9 (25.7)
26 (74.3)
≥54 (26)
11 (42.3)
15 (57.7)
Birth order
1(37)
13 (35.1)
24 (64.9)
2(32)
8 (25)
24 (75)
3(26)
9 (34.6)
17 (65.4)
≥4(9)
4 (44.4)
5 (55.6)
Reported age of starting of complementary
feeding at home(months)
≤6(49)
11 (22.4)
38 (77.6)
>6(55)
23 (41.8)
32 (58.2)
Birth weight (BW) (grams )
Low BW (62)
27 (43.5)
35 (56.5)
Normal BW (42)
7 (16.7)
35 (83.3)
Figure in parenthesis indicate percentage
p- value
(p>0.05
p>0.05
The biological characteristics include age, sex,
birth order, reported age of starting
complementary feeding, number of siblings, and
birth weight of the population under study.
The anganwadis had even distribution of boys
and girls with almost 55% constituted by boys
and 45% constituted by girls, which is in
accordance to data of census 2011. It was
observed that 41% of the girls did not receive
adequate supplementary nutrition, which was 30
% for boys. And being boy or girl did not have
any effect on availing supplementary nutrition
from the anganwadi.
When age group was taken into account, there
was no particular age group found to have
majority of children in it. All age groups had
almost even distribution of children. And being
in any age group did not have effect on intake of
supplementary nutrition from anganwadi.
When birth order was considered, it was found
being of any birth order, be it be first or any, did
not have significant effect on intake of
supplementary nutrition from anganwadi.
Table 3: Economic profile of families and
dietary intake of children at home
Characteristics
Supplementary Nutrition
up to 14 days
> 14 days
(sample size)
Economic status
APL(37)
11 (29.7)
26 (70.3)
BPL(64)
22 (34.3)
42 (65.7)
Not known(3)
1 (33.3)
2 (66.7)
Families who reported borrowing money
Yes (52)
18 (34.6)
34 (65.4)
No (52)
16 (30.7)
36 (69.3)
Proportion of families who sold assets
Yes(32)
14 (43.7)
18 (56.3)
No(72)
20 (27.7)
52 (72.3)
Average expenditure (RS)/ month
≤3000(50)
16 (32)
34 (68)
>3000(54)
18 (33.3)
36 (66.7)
Kilocalories per day
≤ 1000 kcal (47)
27 (57.4)
20 (42.6)
> 1000 kcal (57)
7 (12.2)
50 (87.8)
Variety of food in diet
Absent (57)
25 (43.8)
32 (56.2)
Present (47)
9 (19.1)
38 (80.9)
Figure in parenthesis indicate percentage
p- value
p>0.05
p >0 .05
p>0.05
p>0.05
p<0.001
p<0.01
p>0.05
(p<0.05
p<0.05
When complementary feeding was taken into
account, it was seen that in the children who
received complementary feeding within 6
months of birth, 22 % of them did not receive
adequate supplementary nutrition. While, in the
children who received complementary feeding
after 6 months, 42% of them did not receive
adequate supplementary nutrition from the
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anganwadi. And the difference between them
was found to be significant.
It was observed that, in the children who were
low birth weight at birth, 44% of them did not
receive adequate supplementary nutrition. While
in the children who had normal weight at birth,
16 % of them did not receive adequate
supplementary nutrition. And the difference
between them was found to be significant,
though we expect that parents of low birth
weight babies would be conscious enough to
send their child to anganwadis.
The economic characteristics include economic
status, proportion of families who borrow
money, proportion of families who sold assets,
average expenditure of family per year. Families
reported to have BPL card were identified as BPL
families, irrespective of their real economic
status. Also impact of energy intake and variety
of food in diet were checked to assess their
impact on intake of supplementary nutrition in
anganwadi.
More than 60% population in both the groups
was below poverty line. In BPL families, 34 % of
the children did not receive adequate
supplementary nutrition, while in the APL
families, 29% of the children did not receive
adequate supplementary nutrition. But, being in
BPL or APL did not have impact on availing of
supplementary nutrition by children from
anganwadi centers, though one would expect
BPL families to send their children to
anganwadis more because of their economic
condition.
Half of the families of 104 children reported of
borrowing money is past one year due to one or
others reasons. Though it is expected that
families who reported borrowing money would
send their children to anganwadis, as free
supplementary nutrition is provided there, it
was not the case.
The family, which reported selling some of their
assets, among them, 44 % of the children did not
avail adequate supplementary nutrition from the
anganwadi, which was 27 % for the children
coming from the family, which did not report to
sell any of their assets. But, it did not have any
effect on receipt of supplementary nutrition from
anganwadi.
When average expenditure of the families of the
study group was considered, it was seen that
whether the family’s expenditure was up to three
thousand per month or more than three
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thousand per month, about 30 % children in both
the groups did not receive adequate
supplementary nutrition.
Among the children who did not receive
adequate calories at home (<1000 kcal), 57 % of
the children received supplementary nutrition
for only up to 14 days from the anganwadi.
While in the children who received more than
1000 kcal at home, only 12 % of the children were
exposed. And the difference was highly
significant, which mean the children who were
really in need of supplementary nutrition from
anganwadi, did not get it.
When variety of food in the diet was considered,
it was observed that, in 57 children who did not
have variety in diet at home, about 44 % did not
receive
supplementary
nutrition
from
anganwadi. While among 47 children, who had
variety in diet at home, only 19 % of children did
not receive adequate supplementary nutrition
from anganwadi.
Table 4: Mother’s working status, illness of
children and status of availing supplementary
nutrition from anganwadi
Supplementary nutrition
up to 14
> 14
days/month
days/month
(n=34)
(n=70)
Mother’s working status
Working
12
26
Housewife
22
44
Illness of children
Present
24
18
Absent
10
52
χ2 and P
value
χ2=0.03,
p>0.05
χ2=19.14,
p<0.001
The above table shows that even if mother of
child was working, it did not affect a child from
receiving supplementary nutrition from the
anganwadi, contrary to the assumption that if
the mother works as a laborer, it is expected
from her to take child with her at her work place
averting her child from going to anganwadi and
receiving supplementary nutrition.
As one would expect that children who are ill
would not go to anganwadi for receiving
supplementary nutrition, the above table
supported this assumption, with the result
turning out to be highly significant. Out of 42
children who had some illness, 24 did not avail
adequate supplementary nutrition from the
anganwadi. And the out of 62 children, who
were not sick, only 10 of them failed to avail
adequate supplementary nutrition from the
anganwadi.
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Table 6: Perceptions of mother regarding supplementary nutrition at anganwadi
Perceptions
Adequate quantity of supplementary nutrition in anganwadi
Good quality of food in anganwadi
Regular availability of supplementary nutrition in anganwadi
Good hygiene of food supplied in anganwadi
Mother’s were asked a few questions about their
perception of anganwadi. When inquired about
quantity of food provided in anganwadi, 80%
described quantity to be adequate. When asked
about quality, about 63% were satisfied about the
quality of food provided in anganwadi. About
67% told that the food was supplied regularly in
anganwadi to their children. About 78% of
mother told that hygiene is maintained in
anganwadi. Also when asked about what
supplementary nutrition is provided in
anganwadi, there were multiple responses, with
73% mother knowing that sheera is provided at
anganwadi followed by more than 50 % for
Balbhog and fruits. Also, 75 % of the mother
responded that supplementary nutrition has a
positive impact on growth of their child.
DISCUSSION
One of the least talked about issues in the debate
on India's demographic dividend is child
malnutrition. India is home to about a third of
the world's underweight and stunted children
under the age of five. A child under five is
almost twice as likely to be chronically
underweight in India as in sub-Saharan Africa.
Sadly, the impressive economic growth of the
past decade has made only a modest dent into
the obstinately high incidence of severe
underweight and stunting of children in the
country4.
One of the limited programs for combating the
problem of malnutrition in India is ICDS, in
which supplementary nutrition amounting to
provide one third of the energy requirement and
one half of the protein requirement per day for
the child is being provided through anganwadis.
Malnutrition has been determined to a
significant extent by supplementary nutrition
available to pre-school children.
In the study done by Bhasin, Sanjiv K. et al, it
was observed that total attendance at the
anganwadi showed statistically significant
relation with the degree of malnutrition. Overall,
children who attended anganwadis were
nutritionally better than their counterparts who
Yes
85(81.7%)
70(67.3%)
74(71.1%)
84(80.7%)
No
5(4.8%)
19(18.2%)
13(12.5%)
2(1.9%)
Do not know
14(13.5%)
15(14.5%)
17(16.4%)
18(17.4%)
did not attend anganwadi during their
childhood. He pointed by univariate analysis
that attendance in anganwadi is significantly
associated with degree of malnutrition p < 0.0542.
It signifies the impact of supplementary nutrition
on malnutrition status of the child5.
With this background in mind, this study was
done to identify the factors which had impact on
intake of supplementary nutrition provided in
anganwadis. As proportion of malnutrition is
almost similar in all areas of Gujarat, Jhagadia
block of Bharuch district was selected for study.
And six anganwadis were selected for study
randomly. All children from three to five years of
age were included in study from these six
anganwadis. The total came out to be 111
children. Among them, 7 were excluded from
study, as they were not available at the time of
data collection. So, out of 104 children, when
studied, it was found that 34 children did not
receive adequate supplementary nutrition (i.e.
up to 14 days of supplementary nutrition per
month), while 70 children received adequate
supplementary nutrition (i.e. more than 14 days
of supplementary nutrition per month).
Similarly, in study done in Madhya Pradesh by
an NGO on ICDS, about 41 % of the children
utilized supplementary nutrition services8.
Supplementary nutrition can be influenced by
variety of factors. Out of so many factors, this
study could identify a statistically significant
association between age at initiation of
complementary feeding, consumption of vitamin
A dose and birth weight with availing
supplementary nutrition for more than half a
days per month. This study suggested that
earlier is the initiation of complementary
feeding, the more are the chances for obtaining
supplementary nutrition from anganwadi per
month. Similarly, data suggested higher
attendance and hence supplementary nutrition
for more than 14 days a month among children
who also consumed a dose of vitamin A and
normal weight at birth.
The guidelines for ICDS suggest that the food
available at ICDS anganwadi is only
supplementary to a diet consumed by a baby at
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home6. By providing supplementary feeding, the
anganwadi attempts to bridge the caloric gap
between the national recommended and average
intake of children and women in low income and
disadvantaged communities2.
Two by two table has indicated that there is a
statistically significant association between
reported low calorie intake at home and
inadequate
supplementary
nutrition
at
anganwadi. So the philosophy of providing
supplementary nutrition over and above the
routine calorie intake did not work in this study
which means children who were really in need of
supplementary nutrition did not avail this
service to an expected level. Similar point was
indicated by Gragnolati et al in their article that
the states with the worst malnutrition have the
lowest levels of ICDS programme coverage7.
Presence of variety in diet has association with
higher
attendance
at
anganwadi
for
supplementary nutrition.
It is useful to study few variables which reflect
the perception of caretakers about the
supplementary nutrition and its role in the
whole issue of protein energy malnutrition.
Twenty to eighty percent awareness among
mothers regarding variety of recipes served at
anganwadi denotes possibility of extension
education in the field of child nutrition. In a
similar study done by Vinnarasan A. in Chennai,
it was found that about 32 % of the mothers were
about nutrition services provided at anganwadi9.
In another study done by Das NC et al. in Orissa,
It was found that supplementary feeding was
usually given for 25 days in a month and was
considered adequate by over 96% of the mothers
of beneficiary children. 92% mothers mentioned
that the quality of food was good10.
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anganwadi were illness of child, diet of child and
variety of his diet at home, birth weight, age of
complementary feeding and vitamin A intake at
anganwadi.
Also, mothers had positive perception about
supplementary nutrition provided at anganwadi
in growth of their child.
REFERENCES
1.
International Institute for Population Sciences (IIPS) and
Macro International. 2007. National Family Health
Survey (NFHS-3), 2005–06: India: Volume I. Mumbai:
IIPS.
2.
Integrated Child Development services;
http://wcd.nic.in/icds.htm, accessed on 18th February
2011.
3.
FORCES (Forum for Creche and Child Care Services),
The Micro Status of ICDS in Hayatnagar, Andhra
Pradesh: A Study by FORCES, New Delhi (2005)
4.
Kaushal N. India's child malnutrition puzzle. The
Economic Times. Apr 29, 2011;
http://articles.economictimes.indiatimes.com/2011-04
29/news/29487240_1_saharan-child-malnutritionunderweight
5.
Bhasin S, Bhatia V, Kumar P, Agarwal O.P. Long term
nutritional effects of ICDS. Indian Journal of
Pediatrics,2001; 68(3):211-16
6.
Evaluation Report on Integrated Child Development
Scheme (ICDS) Jammu & Kashmir. Programme
Evaluation Organization, Planning Commission,
Government of India. February 2009.page no.4
7.
Gragnolati M, Caryn B, Das Gupta M, Lee Y, Shekar M.
ICDS and Persistent Under nutrition. Strategies to
Enhance the Impact Integrated Child Development
Services programme; Special Articles; Economic and
Political Weekly; March 25, 2006.
8.
Sanket - Center for Budget Studies, Moribund ICDS (a
study on the ICDS and Child Survival issues in Madhya
Pradesh), Published by - Right to Food Campaign
Madhya Pradesh Support Group, pg-30, 2009.
9.
Vinnarasan, A. (2007).A Study on factors influencing
non enrollment of children in the ICDS anganwadi
centers at Chennai Corporation. Chennai: Loyola
College, Dept. of Social Work. 170 p.
10.
Dash, N.C. et al. (2006). Impact assessment/ evaluation
of ICDS programme in the state of Orissa. Bhubaneswar:
Centre for Rural Development. ~170 p.
11.
Blössner, Monika, de Onis, Mercedes. Malnutrition:
quantifying the health impact at national and local
levels. Geneva, World Health Organization, 2005. WHO
Environmental Burden of Disease Series, No. 12.
CONCLUSION
In the present study, more than 30 % of children
did not receive adequate supplementary
nutrition which is quite high as through
supplementary nutrition, a child receives half of
protein and one third of caloric requirements.
Also, factors which hampered intake of
supplementary nutrition by children from
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Original Article ▌
SELECTED EPIDEMIOLOGICAL ASPECTS OF
SCHIZOPHRENIA: A CROSS SECTIONAL STUDY AT
TERTIARY CARE HOSPITAL IN MAHARASHTRA
Madhura D Ashturkar1, Jaggnath V Dixit2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Ashturkar MD, Dixit JV. Selected
Epidemiological Aspects of
Schizophrenia: A Cross Sectional
Study at Tertiary Care Hospital in
Maharashtra. Natl J Community
Med 2013; 4(1): 65-9.
Author’s Affiliation:
1Assistant professor, Community
Medicine, Smt Kashibai Navale
Medical college , Pune; 2Associate
professor, Community Medicine,
Govt. Medical College ,
Aurangabad
Correspondence:
Dr. Madhura D Ashturkar,
Email: madhurapsm@yahoo.co.in
Date of Submission: 30-07-12
Date of Acceptance: 20-01-13
Background: To study epidemiological factors in cases of
schizophrenia, as schizophrenia begins in early age of life and
treatment
includes
pharmacological
and
psychosocial
interventions and rehabilitation of patients.
Objectives: To study agent, host and environmental factors, to
study clinical profile and identify, familial, psycho – social factors
Methods: Diagnosed cases of schizophrenia according to WHO
ICD -10 classification at tertiary care hospital in central
Maharashtra between 1st Jan 2006 to 31st Dec 2006. The data was
collected with pre-tested questionnaire by direct interview
method. Socio- demographic variables were reported using
descriptive statistics and age of onset of first symptom of
schizophrenia were compared across gender by Chi- square test.
Results: There were 48 men and 24 women with mean age of
30.26 years. 44.44% were unmarried, 50% were unemployed and
41.66% were in socio-economic class IV. Substance abuse and
alcohol was found to be 83.33% among males. Age of onset of
symptoms of schizophrenia found at earlier age in males than in
females.
Conclusion: Age of onset of first symptom were at earlier age in
males than in females, this difference is found to be statistically
significant.
Key words: Schizophrenia, substance abuse, Modified BG Prasad
classification, Family history of disease
Date of Publication: 31-03-13
INTRODUCTION
Schizophrenia begins in early age of life; causes
significant & long lasting impairments; makes
heavy demands for hospital care and requires
ongoing clinical care, rehabilitation & support
services and the financial costs. The burden on
patient’s family is heavy & both patient and his
or her relatives are often exposed to the stigma
associated with illness over generation. So
schizophrenia remains major public health
problem 1.
Schizophrenia is a clinical syndrome of variable
but profoundly disruptive psychopathology,
which involves thought, perception, emotion,
movement and behaviour2.
The condition as such causes serious distress,
suffering, decreases the positive strengths of an
individual & affects quality of life. Schizophrenia
affects just under 1% of world’s population
(0.85%). The disease is found in all societies and
geographical areas3.
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In year 1990, it was estimated that 3% Disability
Adjusted Life Years (DALYs) in 15-44 years age
group worldwide were due to schizophrenia. It
is estimated that by 2020, 15% of DALYs lost due
to mental and behavioural disorders 4.
From review of 13 different studies, prevalence
of schizophrenia identified as 2.5/1000
population, this means that, it is estimated that
India has nearly 2.5 million schizophrenics
needing care at any point of time 5.
Emerging evidence has an important implication
for the role of mental health professionals who
need to recognize the bio-psycho-social approach
in practice of psychiatry 6.
Present study is an attempt to study some
epidemiological
aspects
in
patients
of
schizophrenia at Tertiary care hospital in central
Maharashtra.
Aim: To study epidemiological factors in cases of
schizophrenia, at Tertiary care hospital in central
Maharashtra.
Objectives: To study agent, host and
environmental factors; to study age of onset of
symptoms of schizophrenia in males and
females; and to study clinical profile and
identify, familial, psycho – social factors
MATERIAL AND METHODS
Hospital based cross sectional study was carried
out at a tertiary care teaching hospital in
marathwada region of Maharashtra state from 1st
Jan 2006 to 31st Dec 2006.
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organic psychotic disorders and seriously ill
were excluded from study.
Using pre –tested questionnaire, data were
collected by direct interview of the study subjects
who were admitted in psychiatry ward and
outpatient department of psychiatry of teaching
to hospital in central Maharashtra.
In situation where the study subject could not
answer, parents or accompanying relatives were
asked for relative information and then study
subjects were clinically examined.
The Questionnaire includes; socio – demographic
profile, Aetiology of disease in terms of agent
host environmental factors, age of onset of the
disease addictions to the cases of alcohol, tobacco
etc. questionnaire related to patients about the
symptoms, since how long they are suffering,
where they had gone for treatment, taking the
treatment regularly or not, improvement in the
symptoms following the treatment etc.
Clinical profile of all cases recorded which
includes history of presenting complaints,
general examination, height, weight, pulse,
blood pressure, temperature, respiratory rate,
any signs of icterus, clubbing, cyanosis,
lymphadenopathy, examination of respiratory
system, cardio vascular system, Central nervous
system and per abdominal examination.
Drug abuse is defined as self administration of a
drug for non – medical reasons in quantities and
frequencies which may impair individual’s
ability to function effectively and which may
result in social, physical or emotional harm4.
Ethical committee approval of college committee
was taken before starting up the study. Informed
oral consent was taken from cases of
schizophrenia.
Family history of disease – in this first and
second degree relatives were considered
Selection criteria for cases: Confirmed cases of
schizophrenia visiting in psychiatric OPD and
admitted in psychiatric ward of the hospital
during the study period were included cases.
The cases were diagnosed by qualified
psychiatrist according to WHO ICD -10
classification. The purpose and methodology of
study were explained to the psychiatrists for
seeking their active cooperation in selection of
cases.
Second degree relatives – uncles, aunts,
grandparents and cousins were taken as second
degree relatives 9.
Exclusion criteria for cases: Cases with acute
and transient psychotic disorders; persistent
delusional
disorders;
induced
delusional
disorders; organic psychotic disorders; other non
First degree relatives – parents, brother, sister
were taken as first degree relative
Modified BG Prasad classification was used to
classify the socio economic status 4.
RESULTS
Total 72 cases were studied. 33.33% of cases were
in age group of 26-30 years, 66.66% of cases were
male while 33.33% cases were females. No one
out of 72 cases found to have major medical
problem.
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Table 1: Distribution of cases according to
socio- demographic profile
Category
Age wise distribution
15-20
21-25
26-30
31-35
36-40
>40
Education
Illiterate
Primary/ literate
Middle
High school
Intermediate
Degree/diploma
Marital status
Unmarried
Married
Separated
Divorced
Occupation
Employed
Unemployed
Dependent
Housewife
Agricultural labourer
Own business
Socio – economic class
Class I
Class II
Class III
Class IV
Class V
Cases (n=72) (%)
08 (11.11)
13 (18.05)
24 (33.33)
13 (18.05)
05 (6.94)
09 (12.50)
11 (15.27)
03 (4.16)
30 (41.66)
04 (5.55)
08 (11.11)
16 (22.22)
32 (44.44)
28 (38.88)
09 (12.50)
03 (4.16)
05 (6.94)
36 (50.00)
01 (1.38)
12 (16.66)
09 (12.50)
09 (12.50)
08 (11.11)
18 (25.00)
12 (16.66)
30 (41.66)
04 (5.55)
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Table 3: Distribution of cases of schizophrenia
according to the psycho –social risk factors
Psycho – social
factors
Substance abuse
Attempt of suicide
Stressful life events
Male
Female
Total (%)
40
11
20
00
10
10
40 (55.55)
21 (29.16)
30 (41.66)
In the agent factors, history of stressful life
events was asked, 41.66% of the study cases were
found to the stressful life event in the past.
Among the environmental factors, attempt of
suicide was asked, 29.16% were gave history of
attempt of suicide in the past, 55.55% were given
history of substance abuse and all were males.
Other environmental factors as any intra-natal
complications during the birth of the case and
migration of the family of the study case but
both these factors were not found to be
associated with the disease.
Table 4: Distribution of cases of schizophrenia
according to age of onset of first symptom of
schizophrenia
Sex
Age of onset of first symptom
15 – 25 Yrs
>25yrs
Male
39
09
Female
11
13
Total
50
22
X2 =9.33, P value = 0.002
Total
48
24
72
The investigator studied the relation of family
history of the disease with the cases of
schizophrenia; it shows 25 (34.72%) cases having
family history of disease with different degree of
relationships.
Clinical profile of all cases was done. Not a
single case is suffering from any medical
disorder.
Table shows distribution of schizophrenia cases
according to age of onset of first symptom, in
this it has been observed that males were having
earlier age of onset of disease than in females
and this difference is found to be statistically
significant.
To assess the agent, host and environmental
factors, in table 1 the details of host factors is
given.
DISCUSSION
Table 2: Distribution of cases of schizophrenia
according to the type of substance abuse
Type of substance
Tobacco
Cigarette
Alcohol
Tobacco with alcohol
Cannabis with tobacco
Cannabis with alcohol
Number (n=40) (%)
23 (57.5)
07 (17.5)
03 (7.5)
03 (7.5)
02 (5.0)
02 (5.0)
Present study was carried out at GMC & H,
Aurangabad, a tertiary care hospital in
marathwada region of Maharashtra state from 1st
Jan 2006 to 31st Dec 2006. Total 72 cases were
included in the study.
Mean age for the cases was 30.26 years. Sex wise
distribution of the cases shows 66.66% were
males and 33.33% were females. McGrath J et al
(2004) studied the incidence and prevalence of
schizophrenia, the distribution of rates was
significantly higher in males compared to
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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females; the male/female ratio median was 1:0.4
7.
Jablensky et al (1992) 8 studied the incidence of
schizophrenia, in WHO DOSMED study, 6 out of
8 sites reported an excess proportion of males
over females.
Distribution of cases of schizophrenia according
to religion shows, 55.55% cases were Hindus.
Findings are similar to the study which was
conducted by National Institute of Mental Health
9; prevalence of schizophrenia found at similar
rates in all ethnic groups around the world, as in
this study population of Hindus is more than
other religion. According to the place of
residence, 65.27% of cases were from urban area
and 34.73% were from rural area; the findings
are consistent with McGrath et al (2004)7.
Marital status of cases shows 44.44% were
unmarried. Eaton (1985) 10 studied the relation of
marital status with schizophrenia, found that
marital status has been found to be associated
with the risk of schizophrenia; the increased risk
of developing schizophrenia for unmarried as
compared with married people ranges between
2.6 and 7.2. It has been suggested that marriage
exerts a protective effect which delays the onset
of illness in women.
Occupational status of cases of schizophrenia,
50% of cases were unemployed. Carpenter WT et
al (2002) 11 studied the epidemiology of
schizophrenia; the disease is the fourth leading
cause of disability in adults worldwide. In
United States, about 80% of persons with
schizophrenia are unemployed, a third of
homeless persons have schizophrenia.
According to the socio-economic status of
schizophrenia cases, 41.66% of cases from class
IV lower socio- economic class, the similar
findings were observed by Clark et al (1949) 12
and Hollinshead and Redlich (1958) 13.
Distribution of cases of schizophrenia with
family history of disease; 34.72% were found to
have family history of disease. Gottles Mann D
(1991) 14 and Hallmayer J (2000) 15, studied the
familial risk of developing schizophrenia for
people with different degrees of relationship to
someone with schizophrenia. Risk varies with
extent of gene sharing the risk is greatest in
identical twins i.e. 48% and decreased step by
step in children of two schizophrenic parents,
first degree relatives, second degree relative and
third degree relatives and general population
which has risk of 1%.
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Investigator has studied relationship of psychosocial risk factors and schizophrenia, 55.55%
were with substance abuse, 29% were with
attempt of suicide in past, 41% had gone through
stressful life events. The findings are consistent
with studies done by Fenning et al (2005) 16,
Cuffe SP et al (2005) 17. Hafner H et al (1992) 18
studied mean age at different points in the
development of schizophrenia for men, and
women, Germany, found that the earliest signs
of mental disturbance occurred 4.5 years prior to
the first admission in males as compared to
females.
In this study, 57.5% out of 40 male cases showed
abuse to tobacco. Similar findings were observed
in Carpenter WT et al (2002) 11, shows 80%of
schizophrenics smoke cigarettes and nicotine in
patients.
Substance abuse does not cause schizophrenia.
However, people who have schizophrenia are
much more likely to have a substance or alcohol
abuse problem than the general population.
Addiction to nicotine is the most common form
of substance abuse in people with schizophrenia.
They are addicted to nicotine at three times the
rate of the general population (75 to 90 percent
vs. 25 to 30 percent). The relationship between
smoking and schizophrenia is complex. People
with schizophrenia seem to be driven to smoke,
and researchers are exploring whether there is a
biological basis for this need19.
Socio- economic status of cases of schizophrenia
according to Modified B. G. Prasad classification
shows 41.66% of cases from class IV. According
to the literacy status, 41.66% were educated up to
Middle school, 22.22% were educated up to
degree/diploma and 15.27% were illiterate.
REFERENCES
1.
World Health Organization, Epidemiology of Mental
disorders & psychosocial problems, Schizophrenia.
Warner R, Girlamo G; Geneva WHO 1995.
2.
Schizophrenia: Youth’s Greatest Disabler – Some facts
and figures. Internet site www.searo.who.int ; accessed
on 27th Oct 2012
3.
Sadock B, Sadock V; Comprehensive Textbook of
Psychiatry; 7th edition; Philadelphia; Kaplan and
Sadock’s. Lippinkott, Williams & Wilkins publication;
2000, 1096-1231.
4.
Kulkarni AP, Baride JP: 3rd edition Textbook of
Community Medicine; Vora Medical Publication;
Mumbai. 22-35, 666-675
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Open Access Article│www.njcmindia.org
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5.
Ganguli HC; Epidemiological Findings on Prevalence of
Mental Disorders in India; Indian Journal Of Psychiatry,
2000, 42(1); 14-20.
12.
Clark RE et al; Psychoses, Income & Occupational
Prestige; American Journal of Sociology, 1949; 54; 433440.
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Gururaj G, Girish N, Isaac MK; Mental, Neurological
and Substance Abuse Disorders: Strategies towards a
Systems Approach; NCMH- background papers –
burden of disease in India; 226-250.
13.
Hollinshead AB, Redlich FC; Social Class and Mental
Illness. New York, Wiley, 2007.
14.
Gottles Mann D; Schizophrenia Genesis: The Origins of
Madness. 1991, New York, Freeman.
15.
Hallmayer J; the Epidemiology of the Genetic Liability
for Schizophrenia Australian NZ Journal of Psychiatry
2000; 34 suppl: 47-55.
16.
Fenning et al; Life Events and suicidality in adolescents
with schizophrenia Eur child adolescent psychiatry;
2005; 14(8): 454-460.
17.
Cuffe SP, Mckeown RE, Addy CL, Garrison CZ; Family
and Psychosocial Risk Factors in a Longitudinal Study
of Adolescents; Journal of American Academy of child
adolescence psychiatry.2005; 44(2): 121-129.
18.
Hafner H et al; first onset and early symptomatology of
schizophrenia. A chapter of epidemiological and
neurobiological research into age and sex differences.
European archives of psychiatry and clinical
neuroscience, 1992; 242: 109-118.
19.
Schizophrenia – Substance Abuse and Schizophrenia. .
Internet site www.nimh.nih.gov ; Accessed on 27th Oct
2012.
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McGrath J, Saha S, Welham J, Saadi O, Culey CM and
Chant D; A Systematic Review of the Incidence of
Schizophrenia: The Distribution of Rates and Influence
of Sex, Urbanicity, Migrant Status and Methodology;
Biomedcentral Medicine, 2004, 2004,2:13; 1741-7015.
Jablensky et al; Schizophrenia: Manifestations, Incidence
and Course in Different Cultures. A world Health
Organization Ten Country Study Psychological
Medicine, 1992; suppl. 20.
Symptoms of Schizophrenia. Internet site
www.nimh.nih.gov ; Accessed on 27th Oct 2012.
10. Eaton; Epidemiology of Schizophrenia. Epidemiological
Reviews, 1985; 7: 105-126.
11. William T Carpenter, Gunvant K. Thaker; Advances of
Schizophrenia; Epidemiology; Nature medicine
2001;7(6):667-71.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Open Access Article│www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816
Original Article ▌
A CROSS SECTIONAL STUDY ON PATTERN OF HEALTH
CARE SEEKING BEHAVIOR AND OUT-OF-POCKET
HOUSEHOLD EXPENDITURE ON CURATIVE MEDICAL
CARE IN RURAL CENTRAL INDIA
Najnin Khanam1, Gulab D Meshram2, Arvind V Athavale3, R C Goyal4, Manmohan Gupta5, A M
Gaidhane6
Financial Support: None declared
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Khanam N, Meshram GD, Athavale AV,
Goyal RC, Gupta M, Gaidhane AM. A
Cross Sectional Study on Pattern of
Health Care Seeking Behavior and Outof-pocket Household Expenditure on
Curative Medical Care in Rural Central
India. Natl J Community Med 2013; 4(1):
70-5.
Author’s Affiliation:
1Assistant Professor, Community
Medicine, Peoples College of Medical
Science and Research centre, Bhopal;
2City programme manager (URCH
project), Municipal Corporation,
Nagpur; 3Professor & HOD, Community
Medicine, Peoples College of Medical
Science and Research centre, Bhopal;
4Professor, Community Medicine, Datta
Meghe Institute of Medical Sciences’
University, Wardha; 5Associate
professor, Community Medicine,
Peoples College of Medical Science and
Research centre, Bhopal; 6Professor,
Community Medicine, Datta Meghe
Institute of Medical Sciences’
University, Wardha
Correspondence:
Dr. Najnin Khanam,
Email:dr.najninkhanam@yahoo.com
Date of Submission: 09-09-12
Date of Acceptance: 11-02-13
ABSTRACT
Introduction: Effective health care policies and programmes
depend on health care seeking behaviour & out-of-pocket
household expenditure.
Methodology: It is a community based cross-sectional study done
in rural area of Seloo block of Wardha district, Maharashtra.
Multistage sampling technique was adopted to select study
villages. Among the study villages 25% households were selected
by systematic sampling method. Sample size was 300 household
(unit of study) to study the out-of-pocket household expenditure
on curative medical care, in contrast 1319 members (unit of study)
of total household were interviewed to know the pattern of
health care seeking behavior. Data on socio-demographic profile,
morbidity profile, health care seeking behaviors and curative
medical care expenditure were collected. Study period was from
July 2008 to June 2009.
Results: About half (50.13%) of the patients during their illness
gave first preference to private practioners. Significant difference
between variables (age distribution & education) and health care
seeking behavior was noted. More of productive age group
participants prefer to go to Private Practitioners 210 (58.33%),
Chemist shops 110(82.71%), Tertiary hospitals 40 (83.33%) and
Rural hospitals 11(84.62%) than dependents age group. More of
secondary schooled personal preferred to go to Chemist shops
81(60.90%), primary health center 38(74.51%) and tertiary
hospitals 30 (62.50%) than others. From all the Households
average out-of-pocket health care expenditure during last six
month was Rs /- 418.72 ± 933.0 SD.
Conclusion: Reasons for seeking care in private practitioner to be
sorted out so that same or better treatment may be obtained from
public health care system with low expenses from competent and
trained health care provider.
Keywords: Health care seeking behavior,
household expenditure, curative medical care
Out-of-pocket
Date of Publication: 31-03-13
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Page 70
INTRODUCTION
Health expenditure in India is 4.5 to 6.0 % of
Gross Domestic Product (GDP); of this
expenditure nearly 70% comes from household.1
Public financing on health in India is 0.9% of
GDP (2001-2002), while in terms of per capita
expenditure it is Rs. 120.00 (2003-2004).2 Kerala is
the leading state in terms of health indicators
and accounts for the highest household
financing, around Rs. 1700 per annum; while in
Maharashtra it was Rs. 800 / annum on health.1
There are various sources of finance in health
sector in India, the primary source of public
financing is general tax and non tax revenue
while another method are user fees, out-ofpocket expenditure, donation, etc.3 World Bank
study on India concluded that out-of-pocket
healthcare expenditure pushes 2.2% of the
population below poverty line each year.4
Illness has two effects on the household, firstly
the immediate loss of income due to the absence
from work and secondly large out of pocket
expenses to cover the necessary medical care.
Costly health care also deters people from using
the health services thereby prolonging their
health problems.5,6 In rural area, this problem is
further aggravated by poor quality and
accessibility of the Government health services ,
forcing the individuals to visit the private
sector.7,8,9 In fact, in many urban areas of various
districts the large influx of rural population to
the major hospitals, indicates the absence of
similar facilities in the rural areas. Recent
evidence indicates that in rural areas individuals
accessing private practitioners often end up
going to providers who are not legally qualified
to dispense medication10 thus in terms of price,
access and quality, the rural Indians are probably
much worse off than their urban counterparts.
Hence this study was undertaken to know the
pattern of health care seeking behavior of rural
people and also to find out the out-of-pocket
household expenditure on curative medical care.
METHODS:
Study Setting: The study was carried out in a
rural area of Seloo block of Wardha district,
Maharashtra. Study Design: It was a community
based cross-sectional study. Sampling method
and sample size: Multistage sampling technique
was adopted to select study villages. In first
stage: out of eight blocks of Wardha district,
Seloo block was selected by lottery method. In
second stage: Zadasi PHC (primary health
center) was randomly selected out of the five
PHCs in Seloo block. In the third stage: four Subcenters (Takali, Wadgaon, Yelakeli and Surgaon)
out of eight Sub-centers of Zadasi PHC were
randomly selected. In fourth stage: one village
was randomly selected from each Sub-center.
Thus Yelakeli, Wadgaon, Barkhedi and Surgaon
were selected for study. A total 1200 household
were available in four study villages, out of these
25% household were selected by systematic
sampling method for study, thus the final
sample size was 300 household (94 from Yelakeli,
81 from Wadgaon, 73 from Barkhedi and 52 from
Surgaon) to study the out-of-pocket household
expenditure on curative medical care and to
know the pattern of health care seeking behavior
all members of each household were included
(1319 participants, out of 1333). Data collection:
Approval from the Institutional Ethical
Committee was obtained to proceed for the
study and also written consent obtained from
head of the households. Social workers were
trained by supervisor for data collection. For out
of pocket expenditure respondents were head of
the households. For health care seeking behavior
respondents were all participants except children
<15 years and persons > 65 years of age, for
those data was collected from head of the
households. Person not willing, not giving
consent or the selected household found locked
on three consecutive visits were excluded. Data
was collected by using a pre-tested interview
schedule; schedule consists of variables related
to socio-demographic profile, morbidity profile,
health care seeking behaviors and curative
medical care expenditure. Morbidity among any
household member in preceding six months
from the time of data collection was recorded.
Data related to direct cost (Doctor fees, Drug
charges, Hospital charges) and indirect cost
(Transport, Loss of wages) were collected.
Information was collected by interview
techniques in Hindi language. Confidentiality
was maintained. Data quality was checked by
cross checking 5% of total household by
supervisor. Study period: One year from July
2008 to June 2009.
STATISTICS:
Non parametric tests were applied to test for any
statistically significant differences between
variables (gender distribution, age distribution,
social class and education) and health care
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seeking behavior. Average and standard
deviation was calculated for direct and indirect
expenditure of household on curative medical
care. Direct expenditure was calculated by
addingDoctor
consultancy
fees,
Drugs/medicine charges and Hospital charges
(investigation charge, hospital charge, surgery,
special diet). While indirect expenditure was
calculated by adding- transport cost (sick person
+ accompanying person) and loss of wages (sick
person + accompanying person). Total
expenditure was calculated by adding direct and
indirect expenditure.
Morbidity profile: Out of 1319 study
participants, 718(54.43%) had morbidity during
last six months. Among them 241(33.56 %) had
only once, 375(52.23%) had twice, 98(13.65 %)
had three times, 4(0.56%) had four or more than
four times illness during last six months. On an
average, patients experienced 2.5(±1) times
illness in last six months.
Table 1 shows about half 360(50.13%) of the
patients during their illness gave first preference
to private practioners followed by chemist shops
133(18.53%).
Table 1: First visit Preference to health care
provider during illness by patients
RESULT
Socio-demographic profile: Out of 1333
participants from 300 households in study area
we included 1319 participants & 288 households,
of which 674(51.09%) participants were males
and 645(48.91%) females. Majority of participants
867(65.73%) belonged to productive age group
(15-64 year). Total dependency (persons above 65
years of age and children below 15 years of age)
was found to be 452(34.27%). Most of them
1171(88.78%) participants were literate (a
participant age ≥ seven years and he or she can
read and write with understanding in any
language)11 , 112(8.49%) illiterate and 36(2.73%)
were less than seven year of age. {Male literacy
was 661(99.39%) and female literacy was
510(82.52%), 9 males and 27 females were < 7
years of age}. Amongst literate majority
750(64.04%) were educated up to secondary
school. Majority of study households were
belonged to class ІV 140(46.7%), followed by
class III 88(29.3%) socio-economical status as per
Modified Prasad’s classification.12
Health care seeking behavior
Private practitioners
Chemist shops
District hospitals
Primary health centers
Tertiary hospitals
Home treatment
Rural hospitals
Anganwadi workers
Not taken treatment
Total number of patients
Total (%)
360(50.13)
133(18.53)
65(09.06)
51(07.10)
48(06.68)
35(04.87)
13(01.82)
04(00.56)
09(01.25)
718
Table 2 and 3 Shows no statistically significant
difference between gender distribution and
health
care
seeking
behavior.Statistically
significant difference between age distribution
and health care seeking behavior was noted.
More of productive age group participants prefer
to go to Private Practitioners 210(58.33%),
Chemist shops 110(82.71%), Tertiary hospitals
40(83.33%) and Rural hospitals 11(84.62%) than
dependents. Only productive age group
participants prefer to go Anganwadi workers
3(100%).
Table 2: Preference for first visit to health care provider by patients during illness as per their
gender
Health care seeking behavior
Private practitioners
Chemist shops
District hospitals
Primary health center
Tertiary hospitals
Home treatment
Rural hospitals
Anganwadi workers
Not taken treatment
Total (N=718)
360
133
66
51
48
35
13
3
9
Male (n=413) (%)
214(59.44)
77(57.89)
36(54.54)
31(60.78)
24(50)
17(48.57)
9(69.23)
00
5(55.55)
Female (n=305) (%)
146(40.56)
56(42.11)
30(45.46)
20(39.22)
24(50)
18(51.43)
4(30.77)
3(100)
4(44.45)
*P-value
0.297
0.923
0.607
0.624
0.276
0.273
0.388
**0.076
**0.579
*Each row was compared against other rows pulled together; **Fisher exact test was applied
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Page 72
Table 3: Preference for first visit to health care provider by patients during illness as per their age
distribution
Health care seeking behavior
Private practitioners
Chemist shops
District hospitals
Primary health center
Tertiary hospitals
Home treatment
Rural hospitals
Anganwadi workers
Not taken treatment
Total
(N=718)
360
133
66
51
48
35
13
3
9
<15 years
(n=203) (%)
124 (34.45)
16 (12.03)
22 (33.33)
17 (33.33)
8 (16.67)
14 (40)
2 (15.38)
00
00
15 to ≤ 64 years
(n=470) (%)
210 (58.33)
110 (82.71)
41 (62.12)
29 (56.86)
40 (83.33)
17 (48.57)
11 (84.62)
3 (100)
9 (100)
≥ 65 years
(n=45) (%)
26 (7.22)
7 (5.26)
3 (4.55)
5 (9.81)
00
4 (11.43)
00
00
00
*P-value
0.0002
0.00001
0.569
0.330
0.016
0.083
**0.001
**0.0001
**0.001
*Each row was compared against other rows pulled together; **Fisher exact test was applied
Non significant difference between social class
and health care seeking behavior was noted.
Significant difference between education status
and health care seeking behavior was noted for
preference to chemist shops, primary health
center, tertiary hospitals and home treatment.
More of secondary schooled personal preferred
to go to chemist shops 81(60.90%), primary
health center 38(74.51%) and tertiary hospitals
30(62.50%) than others.
Table 4: Preference for first visit to health care provider by patients during illness as per their
social class
Health care
seeking behavior
Private practitioners
Chemist shops
District hospitals
Primary health center
Tertiary hospitals
Home treatment
Rural hospitals
Anganwadi workers
Not taken treatment
Total
(N=718)
360
133
65
51
48
35
13
04
09
SC-I
(n=50)
20 (5.56)
07 (5.26)
06 (9.23)
06 (11.76)
05 (10.42)
02 (5.71)
00
02 (50)
02 (22.22)
SC-II
(n=86)
45 (12.5)
11 (8.27)
06 (9.23)
04 (7.84)
09 (18.75)
06 (17.14)
02 (15.39)
01 (25)
02 (22.22)
SC III
(n=201)
92 (25.56)
36 (27.07)
26 (40)
10 (19.61)
14 (29.16)
10 (28.57)
09 (69.23)
00
4 (44.45)
SC IV
(n=327)
177 (49.16)
68 (51.13)
25 (38.46)
26 (50.98)
15 (31.25)
13 (37.15)
01 (7.69)
01 (25)
01 (11.11)
SC V
(n= 54)
26 (7.22)
11 (8.27)
02 (3.08)
05 (9.81)
05 (10.42)
04 (11.43)
01 (7.69)
00
00
*P-value
0.205
0.428
0.119
0.317
0.218
**1.362
**5.382
**1.439
**1.438
Figure in parenthesis indicated percentage; *Each row was compared against other rows pulled together; **Fisher exact test
was applied
Table 5: Preference for first visit to health care provider by patients during illness as per their
literacy
Health care
seeking behavior
Private practitioners
Chemist shops
District hospitals
Primary health center
Tertiary hospitals
Home treatment
Rural hospitals
Anganwadi workers
Not taken treatment
Total
(N=718) Illiterate
(n=53)(%)
360
25 (6.94)
133
10 (7.52)
65
03 (4.61)
51
05 (9.80)
48
04 (8.33)
35
02 (5.71)
13
00
04
04 (100)
09
00
Secondary
(n=485) (%)
244 (67.78)
81 (60.90)
48 (73.85)
38 (74.51)
30 (62.50)
26 (74.29)
10 (76.92)
00
08 (88.89)
Education
Higher secondary Graduation&above
(n=116) (%)
(n=64) (%)
63 (17.50)
28 (7.78)
21 (15.79)
21 (15.79)
09 (13.85)
05 (7.69)
05 (9.80)
03 (5.89)
09 (18.75)
05 (10.42)
05 (14.29)
02 (5.71)
03 (23.08)
00
00
00
01 (11.11)
00
*P
value
0.563
0.020
0.678
**0.002
**0.0008
**0.0007
**4.393
**3.091
**2.384
*Each row was compared against other rows pulled together; **Fisher exact test was applied
Among the total household average out-ofpocket health care expenditure during last six
month was Rs.418.72, of which Rs.40.94(09.78%)
paid for Doctor Fees, Rs.229.17(54.73%) paid only
for drugs/medicine/consumable items, Rs.17.66
(04.22%) paid for Hospital charges, Rs.45.56
(10.88%) for transport and Rs.85.39(20.39%)
because of loss of wages.
Table 6: Out-of-pocket Health care expenditure at household level
Cost (in Rs.)
Visits to health care provider for curative medical services (Average ()SD), median, Range)
Once
Twice
Thrice
Four or more
For all
*DC: Doctor fees
40.06 (±66.9),
41.15 (±75.6),
55.88 (±95.5),
95 (±73.7),
40.94 (±69.4),
30, 0-600
30, 0-600
30, 0-300
100, 0-180
30, 0-600
DC:(Medicines &CI) 216.61 (±486.0), 243.43 (±639.2),
442.94 (±990.3),
620 (±926.6),
229.17 (±536.5),
60, 0-5000
60, 0-5000
40, 5-3000
225, 30-2000
60, 0-5000
DC: Hospital charges 12.78 (±88.1),
26.13 (±133.3),
118.53 (±331.7),
17.66 (±110.0),
00, 0-1050
00, 0-1000
00, 0-1000
00, 0-1050
Total direct cost
269.45 (±551.8), 310.71 (±766.3),
617.35 (±1405.4), 715 (±941.4),
287.77 (±631.2),
90, 0-5200
90, 0-6200
70, 5-4300
365, 30-2100
90, 0-6200
IC: Transport
41.51 (±140.0),
52.19 (±203.0),
135.88 (±328.7),
15 (±19.1),
45.56 (±159.9),
00, 0-2000
00, 0-2000
10, 0-1000
10, 0-40
00, 0-2000
IC: Loss of wages
66.57 (± 254.8), 153.15 (±591.7),
209.41 (±722.1),
85.39 (±357.5),
00, 0-5000
00, 0-5000
00, 0-3000
00, 0-5000
Total indirect cost
108.08 (±313.6), 205.34 (±687.6),
345.29 (±802.9),
15 (±19.1),
130.95 (± 424.5),
20, 0-5400
10, 0-5400
40, 0-3200
10, 0-40
20, 0-5400
GT(DC + IC)
377.53 (±768.0), 516.05 (±1306.5), 962.64 (±1910.4), 730 (±948.0),
418.72 (± 933.0),
140, 0-8400
140, 0-9700
130, 5-5300
385, 30-2120
140, 0-9700
All figures are * DC: Direct cost, CI: Consumable items, IC: Indirect cost, GT: Grand total; Responses to questions were influenced by level of
understanding and knowledge of the participants
DISCUSSION
In our study half (50.13%) of the patients during
their illness gave first preference to private
practioners
followed
by
chemist
shops(18.53%).Similar finding observed by
future health systems (FHS) research13 reported
majority (64.7%) of the patients who sought
treatment, consulted either a village doctor or a
drug seller at some point of treatment. But
another study conducted by Satyajit C on “health
seeking behavior of aged population of a rural
Block in West Bengal” showed only (13.4%)
sought care from Private providers.14
A study conducted by Vaishnavi D et al on
“health care seeking behavior of elderly in Tamil
Nadu”15 revealed elderly females had better
health care seeking behavior (p<0.05) then men
but in our study no statistically significant
difference observed between gender distribution
and health care seeking behavior. In the same
study Vaishnavi D et al revealed overall (79%) of
the aged persons sought care for their ailments.
In our study 45 (6.27%) were aged ill patients,
amongst them 41(91.11%) sought care for their
ailments and remaining 4(8.89%) have taken
home treatment. Vaishnavi D et al study also
showed fully dependent were less likely to seek
care (p<0.05) similarly in our study dependent
were less likely utilizes the private services
compared to productive age group participants.
Health care seeking is a dynamic process and
determined by certain socio-demographical
factors. These factors influence the decision to
take any action or visiting any health care
providing agency. A study conducted by Grover
et al16 revealed (16.7 %) from class -V, (33.3 %)
from class -IV and (57.9 %) from class-III were
seeking care from Private allopathic practitioner.
Our study shows 26(48.14%) from class-V,
177(54.12%) from class-IV, 92(45.77%) from classIII, 45(52.32%) from class-II and 20(40%) from
class-I seek care from Private practitioners. A
study by Tanimola et al17 revealed that there was
no significant difference across educational
status in the type of health facility [public
{135(44.85%)} and private {166(55.15%)} out of
total 301] patronized. In our study 360(50.13%) of
the patients during their illness gave first
preference to private practioners and we
observed no significant difference across
educational status and preference to private
practioners but we also observed significant
difference across educational status and
preference to Primary health center (public).
Finding observed by Sodani et al18 in rural area
of Rajasthan was that, household spent Rs. 931.7
on health care per year and consumer
expenditure survey shows Indian household
spent Rs. 905/- per annum out-of-pocket on
health which were almost similar with our study
(Rs. 418.72 in six month). Srivastava et al19
reported mean out-of-pocket expenditure on
neonatal illness was Rs.547.5 in urban area of
Lucknow. Average expenditure on health of
household visiting once to health care provider
was Rs. 377.53/-, similarly average expenditure
of household visiting to four or more than four
times to health care facilities was found to be
Rs.730 , it shows visiting once to health care
Open Access Article│www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816
/2544/Financial%20Impact%20of%20HI%20on%20Hou
seholds+Uganda. Accessed on Aug 4th, 2009.
provider spent less money than those visiting to
multiple times.
7.
Whitehead M, Dahlgren G, Evans T. Equity and health
sectors reforms can low income countries escape the
medical poverty trap. Lancet 2001; 358: 833 - 836.
8.
Chaplin R, Earl L. Household spending on health care.
Health reports statistics Canada1998; 12(1): 82-89.
9.
Socio-economic differences and health seeking
behaviour for the diagnosis and treatment of malaria.
Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi
?artid=544024. Accessed on Aug 4th, 2009.
10.
Health seeking behavior in Chakaria 2008. Available at:
http://www.futurehealthsystems.org/publications/po
licy%20briefs/Bangladeshinformalproviderbrief.pdf.
Accessed on Aug 4th,2009.
11.
Michael A, Jamil K, Peter K Shah S, Sabir AA, Shams El,
et al. Maternal health and care-seeking behavior in
Bangladesh. Findings from national survey
international family planning perspectives 2007;
33(2):423-434.
12.
K Park. Park’s textbook of preventive and social
medicine, 20th ed. Jabalpur: Bhanot Publishers; 2009. p
416.
13.
Dr J P Baride, Dr A P Kulkarni. Textbook of community
medicine, 3rd ed. Mumbai: Vora Medical Publications;
2006.p 32.
14.
Health seeking behavior in Chakaria 2006. Available at:
http://www.futurehealthsystems.org/publications/po
licy%20briefs/Bangladeshinformalproviderbrief.pdf.
Accessed on Aug 4th,2009.
15.
Sree Chitra Tirunal Institute for Medical Sciences and
Technology. Health seeking behaviour of aged
population of a rural block in West Bengal, Working
Paper Series no.8. Thiruvananthapuram: Achutha
Menon Centre for Health Science Studies; 2005.
16.
Health care seeking behavior of Elderly in Tamil Nadu
(South India): Implications for health policy,
International health economics association. Available at:
http://ihea2011.abstractsubmit.org/presentations/1856
/. Accessed on Sept 20th,2011.
17.
Grover A, Kumar R, Jindal SK. Socio-demographic
determinants of treatment seeking behaviour among
chest symptomatics. Indian Journal of Community
Medicine 2006; 31(3):145.
18.
National sample survey organization. Morbidity and
treatment of ailments, Report no. 441. New Delhi:
Department of statistics, Central statistics organization,
Government of India; 1998. A-13.
Tanimola, M Akande, Julius O Owoyemi. Health care
seeking behaviour in Anyigba, North-Central, Nigeria.
Research journal of medical sciences 2009;
3(2): 47-51.
19.
World Bank. India policy and finance strategies for
strengthening the primary health care services, Report
No. 13042.Washington, D.C: Population and human
recourse division, World Bank; 1995.chapter 5.
Sodani P R. Health spending by people in underserved
areas- Survey in three district of Rajasthan. Policy
implication for health financing reforms in India,
Demography India 2005; 28:257-271.
20.
Neeraj MS, Shally A, Girdhar GA. Care-seeking
behavior and out-of-pocket expenditure for sick
newborns among urban poor in Lucknow, Northern
India- a prospective follow up study.BMC Health
Services Research 2009; 9:61.
CONCLUSION
Most of the participants gave first preference to
private practitioner irrespective of their social
and education status. But limitation of this study
is that we do not know the reasons for seeking
care in private practitioner. Productive age
group participants utilises both private and
public facilities more. Pattern of care seeking
among the socio-economic classes indicate no
significance differences. Only illiterates seek
treatment from Anganwadi workers. Average
out-of-pocket health care expenditure by
household during last six month was high (Rs /418.72 ± 933.0 SD) because of expenses required
for drugs and consumable items was very high
(contributes 54.73% of total expenses), also
expenses
required
for
indirect
cost
[transportation and loss of wages (contributes
31.27 % of total expenses)]. This excess burden of
health care can also be alleviated to a great extent
by a carefully thought out health insurance
system, though not necessarily only a private
one. The role of private and public sector in
covering the entire population is an area that
needs a lot more thought and research.
REFERENCES
1.
Financing and delivery of health care in India New
Delhi. Available at:
2.
http://www.whoindia.org/LinkFiles/Commision on
Macroeconomic and Health, Health insurance in India.
Accessed on Aug 4th, 2009.
3.
Andhra Pradesh state health accounts 2004. Available
at:
http://www.whoindia.org/LinkFiles/Commision_on_
Macroeconomic_and_Health_Annexure_1_National_He
alth_Accounts_for_India.pdf. Accessed on Aug 4th,
2009.
4.
5.
6.
Ability to pay for health care concept & evidence, health
policy and planning 1996. Available at:
http://www.karmayog.org/communityhealth/upload
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
AN EVALUATION OF ASHA WORKER’S AWARENESS AND
PRACTICE OF THEIR RESPONSIBILITIES IN RURAL
HARYANA
P K Garg1, Anu Bhardwaj2, Abhishek Singh3, S. K. Ahluwalia4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Garg PK, Bhardwaj A, Singh A,
Ahluwalia SK. An Evaluation of
ASHA Worker’s Awareness and
Practice of their Responsibilities in
Rural Haryana. Natl J Community
Med 2013; 4(1): 76-80.
Author’s Affiliation:
1 Associate Professor; 2 Assistant
Professor; 3 Resident; 4 Professor
and Head, Department of
Community Medicine, Maharishi
Markandeshwar Institute of
Medical Sciences, Mullana
Correspondence:
Dr Abhishek Singh,
Email: abhishekparleg@gmail.com
Date of Submission: 14-09-12
Date of Acceptance: 28-01-13
Date of Publication: 31-03-13
Introduction- Currently Government of India is providing
comprehensive integrated health care to the rural people under
the umbrella of National Rural Health Mission (NRHM). A
village level community health worker “Accredited Social Health
Activist” (ASHA)’ acts as an interface between the community
and the public health system. Therefore present study was
conducted to access the socio-demographic profile of ASHA
workers and to assess the knowledge, awareness and practice of
their responsibilities.
Methodology- The study was conducted in the rural field practice
area of the department of community medicine, MMIMSR,
Mullana. All 105 ASHA workers in the area were included in the
study and were interviewed using a self designed semi-structured
questionnaire. Data was analyzed using SPSS and valid
conclusions were drawn.
Results- Majority of ASHA workers were aware about helping in
immunization, accompanying clients for delivery, providing
ANC and family planning services as a part of responsibility.
Only 17-19% of ASHAs knew about registration of births and
deaths, assisting Auxiliary Nurse Midwife (ANM) in village
health planning, creating awareness on basic sanitation and
personal hygiene.
Conclusion- ASHAs do provide constellation of services and play
a potential role in providing primary health care but still they
need to put into practice their knowledge about while providing
services and/or advice to negotiate health care for poor women
and children.
Key words- ASHA, Awareness, Responsibility, Practice
INTRODUCTION
The Government of India launched the National
Rural Health Mission (NRHM) on 12th April
2005, to provide accessible, accountable,
affordable, effective and reliable primary health
care, especially to the poor and vulnerable
sections of the population.1,2 The Mission adopts
a synergistic approach by relating health to
determinants of good health viz. segments of
nutrition, sanitation, hygiene and safe drinking
water.3 One of the key components of the
mission is creating a band of female health
volunteers, appropriately named “Accredited
Social Health Activist” (ASHA) in each village
within the identified States. These village level
community health workers would act as a
‘bridge’ or an interface between the rural people
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and health service outlets and would play a
central role, in achieving national health and
population policy goals.4,5
Framework of the NRHM underlines ASHA as a
health activist in the community.5 She is
expected to Provide primary medical care with
her kit, Control of diseases by information,
education, sanitation and surveillance, antenatal,
natal & postnatal services to women ,
counselling on family planning, safe abortion,
child
Immunization
and
Vitamin
A
supplementations, change in behaviour in breast
feeding, birth spacing, sex discrimination, child
marriage, girls education, care of the child
especially
newborn,
household
survey,
collaborating with health functionaries, working
with community for disease control, to create
awareness on health and its determinants,
mobilize the community towards local health
planning, and increase the utilization of the
existing health services.6,7
The current study has been designed for
ascertaining how efficient the ASHAs are to play
their defined roles effectively. They can play an
important role in identifying problems at the
earliest and help in improving community health
status. Therefore the present study was
undertaken to understand the functioning of the
ASHAs in the community. Objectives of the
study were to assess the socio-demographic
profile of ASHA workers and to study their
knowledge, awareness and practice of their
responsibilities.
MATERIALS AND METHODS
The present cross sectional study was carried out
in the rural field practice area of the department
of
community
medicine,
Maharishi
Markandeshwar Institute of Medical Sciences
And Research (MMIMSR), Mullana (Ambala)
during the period of June 2010 to May 2011. The
Field practice area covers 95 villages covering
population of 135000 and has a total of 105
ASHA workers. All ASHA workers in the area
were included in the study. However, those who
could not be contacted despite three visits were
excluded. Finally data collected from 105 ASHA
workers was included in the study. The Medical
officers In charge of the respective PHC’s were
met and the days of the meeting with ASHA
workers were ascertained. Ethical committee
approved the study. Informed consent was
obtained from the study participants.
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The ASHA workers were interviewed by post
graduate student of Department of Community
Medicine after the meetings using a self designed
semi-structured questionnaire. The questionnaire
was pilot tested on 10 subjects and amended for
clarity with the addition of some answer options
and
was
modified
accordingly.
The
questionnaire was designed in English initially
and later translated in Hindi and back translated
to English to check validity of translated
questionnaire contained. A detailed proforma for
the purpose of recording socio-demographic
profile of ASHA workers, their knowledge and
practices regarding things to be done for
antenatal cases, possible complications during
pregnancy, actions supposed to be taken if
ASHA foresees a complication, possible
complications during delivery, knowledge and
practices regarding immunization, knowledge
and practices about general responsibilities,
knowledge and practices about record keeping
and other relevant data etc was prepared for the
purpose of filling observations of the present
study. The collected data was entered in
Microsoft Excel. Coding of the variables was
done. SPSS version 11.5 was used for analysis.
Interpretation of the collected data was done by
using appropriate statistical methods like
percentage and proportions.
RESULTS
Socio-demographic profile of ASHA
functionaries
Data of 105 ASHA workers was included and
analysed in the study. Majority 41 (39.05%) of the
ASHA workers were in the age group of 20-29
years. Mean age of ASHA workers was 31.36
years. Most 89 (84.76%) of the ASHA workers
were Hindus. Most 101 (96.19%) of ASHA
workers completed 8th std or more of schooling.
Of the 105 ASHAs interviewed 93 were married
accounting for 88.57% of the subjects. 102
(97.14%) of ASHA workers completed training
before working as ASHA. In general ASHA
workers were satisfied and happy with their
training.
Knowledge and awareness of her
responsibilitiesA large proportion of the ASHAs commonly
cited vomiting (80.95 %) and swelling of hands
and feet (69.52 %) as pregnancy complications
that women are likely to experience.
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p
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Table -1: ASHAs’
A
know
wledge abou
ut
complicattions during pregnancy & delivery
and its’ management
m
Study Variiable
Number (%))
Complicattions women ca
an experience during
pregnancy
y*
Vomiting
85 (80.95)
73 (69.52)
Swelling off hands and feeet
Paleness/A
Anaemia
27 (25.71)
Abdominaal pain
25 (23.80)
Excessive bleeding
b
22 (20.95)
Weak or no
o movement off foetus
18 (17.14)
Abnormal position of foeetus
11 (10.47)
Visual distturbance
11 (10.47)
Others
3 (2.85)
upposed to be taken,
t
if ASHA
A recognize
Actions su
signs of co
omplication in a pregnant wo
oman*
Take her to
o the nearest fu
unctional FRU
75 (71.42)
Ask her to consult the AN
NM next day
33 (31.42)
Immediateely refer her to the nearest
48 (45.71)
functional FRU
o government hospital
50 (47.61)
Refer her to
Refer her to
o private accreedited hospital
30 (28.57)
Others
Complicattions during de
elivery *
Excessive bleeding
b
Abnormal position of foeetus
Convulsion
ns/fit
Foetus die in mother’s wo
omb
Placenta prroblem
Others
ow
Do not kno
On the other
o
hand, it was surprisin
ng to hear th
hat
31.42% of
o the ASHAss said that th
hey would assk
the preg
gnant woman
n to consult the ANM th
he
next day. (Table 1)
In orderr to ascertaain knowled
dge of ASH
HA
workers about imm
munization questions were
asked ab
bout when an
nd how man
ny doses to be
b
given? Where
W
to tak
ke the child?? And booster
doses to be given. (Table 2)
Table -2:: Response off ASHAs regaarding their
knowled
dge about imm
munization
Vaccine
Resp
ponse (%)
No
Satisfactory Not satisfacttory response
63 (60.00)
36 (34.28)
6 (5.72)
66 (62.85)
31 (29.53)
8 (7.62)
85 (80.95)
20 (19.05)
0 (0.00)
80 (76.19)
18 (17.14)
7 (6.67)
32 (30.47)
64 (60.95)
9 (8.58)
BCG
DPT
Polio
Measles
Tetanus
ng newborn care, majoriity of ASHA
As
Regardin
rightly saaid that newb
borns are mo
ost likely to d
die
soon afteer birth (67.62%), followed
d by a quarter
of ASHA
As reporting d
deaths in first week of life.
82 (78.09)
59 (56.19)
21 (20.00)
10 (9.52)
15 (14.28)
11 (10.47)
3 (2.85)
The stud
dy explored A
ASHAs familia
arity with theeir
tasks. Very
V
few AS
SHAs mentio
oned assistin
ng
ANM in village h
health plann
ning, creatin
ng
awarenesss on basicc sanitation
n & person
nal
hygiene and registraation of birth
hs & deaths as
a
their resp
ponsibilities. (Figure 1)
* Multiple reesponses
Help in
n immunization
100%
Accompanying
g delivery cases
98%
Fa
amily planning
96.40%
Pro
ovide ANC care
96.10%
Advicce mothers aboutt breast feeding
92.90%
Good health
h
practices
91.10%
Basic cu
urative services
0%
80.40
Reproductive & sexual health
h
problem
66%
Motivatting and mobiliziing community
37%
Basic sanitatio
on and hygiene
26%
Village health
h
planning
%
21%
Registration off birth & deaths
17%
00%
20%
40%
%
60%
80%
100%
%
120%
Figure 1 : AS
SHAs' awaren
ness about heer responsibilities
7.14%) said th
hat they were
Out of tottal 105, 60 (57
provided drug kits at the end of training
g.
Another 27% ASHAss received drrug kit much
h
later afterr their trainin
ng and the rem
maining weree
yet to receeive it. Only 30
3 (28.57%) ASHA
A
workerrs
agreed tha
at they have ever
e
used thiss kit.
Record keeping prractice by ASHAs waas
satisfacto
ory except b
birth & deatth registratio
on
records which weree relatively deficient witth
respect to
t their main
ntenance and completenesss.
The peop
ple primarily
y inspiring th
hem to work as
a
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urnal of Commun
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ASHA were Gram Pradhan (70.47%) and family
members (52.38%). (Table 3)
Table 3: Practice of ASHAs regarding record
keeping and their views about inspirational
force behind them
Study Variable
Number (%)
Various record keeping by ASHA workers *
ANC records
101 (96.19)
Immunization records
98 (93.33)
Delivery records
96 (91.43)
Family planning records
90 (85.71)
Birth & death registration records
73 (69.52)
Household survey records
83 (79.05)
Inspirational Force Behind ASHA workers *
Gram Pradhan
74 (70.47)
family members
55 (52.38)
ANMs
48 (45.71)
Others
25 (23.81)
* Multiple responses
Table 4: Distribution of ASHAs according to
motivational factors to become ASHA, cash
remuneration received and expectations for
better work by them
Study Variable
Number (%)
Motivational factors for ASHA workers*
To provide health services
54 (51.43)
To earn money
85 (80.95)
Doing work gives satisfaction
58 (55.24)
To do something (pass time)
32 (30.48)
Serving/helping the community
65 (61.90)
Hoping for absorption in
21 (20.00)
government job
Amount of monthly cash remuneration
received (in Rupees)
<200
200-500
500-800
>800
Expectations by ASHA for better work*
Better Incentives
Fixed regular monthly payment
Better means of transportation of
patients
Incentive for more work
More medicines
Others
22 (20.95)
35 (33.33)
28 (26.67)
20 (19.05)
89 (84.76)
98 (93.33)
27 (25.71)
35 (33.33)
14 (13.33)
7 (6.67)
* Multiple responses
Major motivating factor for ASHAs were either
financial gain (80.95%) or serving/helping the
community (61.90%). About one-fifth of ASHAs
were earning more than Rs.800 per month
whereas one-fifth were earning less than Rs. 200
per month, showing the varying capability of
ASHAs. Majority of the ASHAs (71.66%) were
not satisfied with their incentives. There was a
general demand from all stakeholders for a
regular monthly payment to each ASHA besides
the job related incentives. For betterment of work
around 84.76% expect better pay. (Table 4)
DISCUSSION
Majority (39.05%) of the ASHA workers were in
the age group of 20-29 years. Similar result was
observed by others.4,8 Thus majority of the
ASHAs may be considered young and this may
be strength for programme as they are energetic
and enthusiastic and may deliver better service
with proper motivation and capacity building.
ASHA envisage a total period of 23 days training
in five episodes. It is said that ASHA training is a
continuous one and that she develops the
necessary skills & expertise through continuous
on the job training.9 Regarding level of
education, most of ASHA workers had
completed minimum 8th std but a few i.e. 4
ASHAs (3.80%) had education less than 8th std.
Another report shows percentage of ASHAs
educated below 8th std as high as 32.8%.2 This
can be explained by the fact that selection criteria
are 8th Class and at some places it has been
reduced to 5 th Class.8 Similar findings were
obtained by others.2,10
Report on assessment of ASHA and Janani
Suraksha Yojana (JSY) in Rajasthan shows that
only 19.7% of ASHAs cited that pregnant women
are likely to experience vomiting.11 This is in
contrast to our finding which shows > 80% of
ASHAs said so. Our findings indicate low
knowledge levels with special reference to direct
Obstetric complications during delivery and post
partum period (Table 1). Prolonged labour as a
complication was not mentioned by ASHAs and
this could be life threatening if not managed in
time.
As
far
as
ASHAs
knowledge
about
immunization was concerned, their overall
response was not satisfactory specifically
regarding tetanus immunization. Most of the
ASHAs preferred helping in delivery and
immunization. These activities are also
associated with financial incentives. But many
other jobs like promotion of awareness on
hygiene and sanitation, counselling on family
planning etc. were drawing lesser attention
probably due to lack of incentives. They were
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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also not very much aware about their role in
birth and death registration. These could be
areas requiring reorientation.
The study revealed that only 57.14% of the
ASHAs received drug kit, immediately after
training. Non-availability of drug kits is a matter
of concern. Not surprisingly, finding of our
study mimics the finding presented by ‘Rapid
appraisal of functioning of ASHA in Orissa’.8
Availability of drug kit helps ASHAs in not only
attending some primary medical care needs, but
also builds confidence of community in ASHAs
as someone available in “ hour of need”.
The present study revealed that the most
important motivational factor for the ASHAs
were the financial gain. Others studies have
observed similar result.4,6,8 ASHA workers
received incentive of Rs. 25/- per ANC for a
maximum of 03 ANC visits for a particular
pregnant woman, Rs. 200/- for facilitating
pregnant women per institutional delivery, Rs.
100/- per case for complete immunization of
children other than routine immunization
coverage, Rs. 50/- per case for birth & death
registration.12
Hope of being absorbed in government job was
least important motivational factor in our study
whereas this factor was ranked second most
important motivational factor in another study
conducted in Uttar Pradesh in 2008.10 This study
contradicts our observation on this aspect.
Initially they had immense hope from
government but hope got blunted with the
passage of time, could be a possible explanation
for the same.
CONCLUSION
In general ASHAs are satisfied and happy with
the training. But their perception about the in job
responsibilities appeared to be incomplete and
improper. Many of them were not aware about
their role in assisting ANM in village health
planning, creating awareness on basic sanitation
& personal hygiene. They were also not very
much aware about their role in birth and death
registration. Incentives in monitory terms and
capacity building in the weak areas of training
can act as driving force in delivering better
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health services. ASHAs do provide constellation
of services and play a potential role in providing
primary health care but still they need to put into
practice their knowledge about while providing
services and/or advice to negotiate health care
for poor women and children.
REFERENCES
1.
Government of India, National Rural Health Mission
(2005 -12), Mission Document. Available at:
http://www.mohfw.nic.in/NRHM/Documents/Missio
n_Document.pdf . Accessed on November 28th, 2012.
2.
Assessment of ASHA and Janani Suraksha Yojana in
Madhya Pradesh. Available at:
www.cortindia.com/RP/RP-2007-0301.pdf. Accessed on
November 7th, 2011.
3.
Namshum N., Maternal and child health. Reading
Material for ASHA. Book Number- 1. 1st ed. New Delhi:
Ministry of Health and Family Welfare, Government of
India; 2006. p 8.
4.
Srivastava DK, Prakash S, Adhish V, Nair KS, Gupta S,
Nandan D. A study of interface of ASHA with the
community and the service providers in Eastern Uttar
Pradesh. Indian J Public Health 2009; 53(3):133-6.
5.
Darshan K. Mahyavanshi, Mitali G. Patel, Girija Kartha,
Shyamal K. Purani, Sunita S. Nagar. A cross sectional
study of the knowledge, attitude and practice of ASHA
workers regarding child health (under five years of age)
in Surendranagar district. Healthline 2011; 2(2): 50-53.
6.
Bhatnagar R, Singh K, Bir T, Datta U, Raj S, Nandan D.
An assessment of performance based incentive system
for ASHA Sahyogini in Udaipur, Rajasthan. Indian J
Public Health 2009; 53(3):166-70.
7.
Factors influencing utilization of ASHA services under
NRHM in relation to maternal health In rural Lucknow.
Indian J Community Med. 2010 July; 35(3): 414–419.
8.
Assessment of ASHA and Janani Suraksha Yojana in
Orissa. Available at: www.cortindia.com/RP%5CRP2007-0303.pdf. Accessed on November 8th, 2011.
9.
Training of ASHA. Available at:
http://www.mohfw.nic.in/NRHM/asha.htm. Accessed
on November 28th, 2012.
10.
Jain N, Srivastava NK, Khan AM, Dhar N, Manon S,
Adhish V, Nandan D. Assessment of functioning of
ASHA under NRHM in Uttar Pradesh. Health and
Population: Perspectives and Issues 2008; 31 (2): 132-40.
11.
Assessment of ASHA and Janani Suraksha Yojana in
Rajasthan. Available at: www.cortindia.com/RP/RP2007-0302.pdf. Accessed on November 8th, 2011.
12.
Mission Flexipool. Available at:
http://nrhmharyana.org/Writereaddata/userfiles/file/
Mission%20Flexipoo1.pdf. Accessed on November 4th,
2012.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
PROCESS EVALUATION OF IMMUNIZATION
COMPONENT IN MAMTA DIWAS AND SUPPORT
SERVICES IN KHEDA DISTRICT, GUJARAT
Deepak Kumar Sharma1, Arun Varun2, Rakesh Patel2, Uday Shankar Singh3
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Sharma DK, Varun A, Patel R,
Singh US. Process Evaluation of
Immunization Component in
Mamta Diwas and Support Services
in Kheda District, Gujarat. Natl J
Community Med 2013; 4(1): 81-5.
Author’s Affiliation:
1Associate Professor; 2Second year
Resident; 3Professor, Department of
Community Medicine, Pramukh
Swami Medical College, Karamsad,
Gujarat
Correspondence:
Dr Deepak Sharma,
Email: drdeepak1105@gmail.com
Date of Submission: 30-10-12
Date of Acceptance: 24-01-13
Date of Publication: 31-03-13
Background: Mama Diwas is a fix day, fix site, preventive,
promotive health care service center for mother and child.
Objectives: The present study is to evaluate the process of Mamta
Diwas in terms of different immunization variables and the
logistic support to Mamta Diwas from Primary Health Centre.
Methods: The present study is a “Descriptive cross sectional
study” encompassing all the PHCs in Kheda district. The Mamta
Diwas checklist is used a tool for the data collection.
Results and: Forty (80%) had calculated the beneficiaries for the
year and based on it only 17(34%) have calculated the logistics
requirement. In 45 PHCs T-series vaccine and Hepatitis- B (HepB) vaccine were not found at the bottom of the Ice lined
Refrigerator(ILR). In 11(22%) PHCs, dropout rate was found to be
more than 10%. Adverse events following immunization (AEFI)
were reported from 20(40%) PHCs and Vaccine Preventable
Diseases (VPD) were reported from 25(50%) PHCs. Information
Education and Communication (IEC) materials were displayed in
38(76%) PHCs. In 41(82%) session sites, time of reconstitution was
mentioned on the vial. Site of vaccination and correct dosage and
technique of vaccination was known to every interviewed Female
Health Worker (FHW) at all the session sites.
Conclusions: Programme management at PHC needs to be
emphasized. Vaccine storage practices and cold chain
maintenance is up to the mark throughout the District.
Keywords: Mamta Diwas, Programme Management, Cold Chain
maintenance, Supplies and Stock, Micro planning, VPD, AEFI
INTRODUCTION
Mama Diwas is a fix day, fix site, preventive,
promotive health care service center for mother
and child population or village per month. All
pregnant women, breast feeding women, under
five children are beneficiaries of this session.
Services provided through this session includes
growth
monitoring,
health
check
up,
immunization, primary treatment, referral and
counseling services.1
During monthly visit weight gain of pregnant
women and children is measured and recorded
in growth chart. This facilitates identification of
defaulters in adequate weight gain for
appropriate intervention and counseling.
General and specific health check up of antenatal
women and children is done for early detecting
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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and prompt treatment with timely referral. Here
integrated management of antenatal, postnatal,
neonatal and child health services is practiced.
Vaccination of mother and child is done for all
vaccines included under National Immunization
Programme. Prophylactic and therapeutic drug
for preventive and primary Reproductive and
Child Health Care are available at the centers
and are provided to the beneficiaries.1
Immunization is one of the most well-known
and effective methods of preventing childhood
diseases. With the implementation of Universal
Immunization Programme (UIP), significant
achievements have been made in preventing and
controlling the vaccine preventable diseases.
Immunization has to be sustained as a high
priority to further reduce the incidence of all
VPDs, control measles, eliminate tetanus and
eradicate poliomyelitis. One of the important
elements for improving the immunization is cold
chain and vaccine logistics management which is
backbone of immunization programme. Cold
Chain and vaccine management are the left and
right hands of immunization programme.2
RESEARCH OBJECTIVES
The present study is an attempt to evaluate the
process of Mamta Diwas in terms of different
immunization variables and to evaluate the
logistic support services for Mamta Diwas (from
PHC)
MATERIALS AND METHODOLOGY
The present study is a “Descriptive cross
sectional study” encompassing all the PHCs in
Kheda district. The Mamta Diwas checklist is
used a tool for the data collection relevant to
Mamta Diwas activities. The supervision
findings are used to prepare manuscript. All the
PHCs in all the blocks are supervised at least
once. During the PHC visit all the necessary
details of the PHC supporting the Mamta Diwas
sessions were taken as per the checklist.
The key points which were taken during the
study were
a.
Programme Management at PHCs for
Mamta Diwas,
b. Cold Chain maintenance
c. Supplies and Stock, Micro planning, reports
and Injection safety
d. Mamta Diwas findings at Session site
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One sub centre was randomly chosen amongst
all the subcentres and subsequently the centre
was visited and the active Mamta Diwas session
was observed. The findings are noted down as
per the checklist. The ANM is interviewed as per
the checklist. The data entry is done in excel
sheet and analyzed by SPSS 15.0
Ethical Clearance and Consent: Data was
gathered as per the routine SRIM visits and so
the ANM were interviewed as per the procedure
and the PHC details were taken accordingly.
Before submission of manuscript, Human
Research Ethics Committee of the college was
informed and one copy was submitted also.
RESULTS
There are total 50 PHCs in 8 blocks in Kheda
district. The distribution is shown below.
Table 1: Distribution of PHCs* of different
Blocks in Kheda District
Blocks in Kheda District
Balasinor
Kapadwanj
Kathlal
Kheda
Mahemdabad
Mahuda
Nadiad
Thasra
Total
PHCs (%)
5(10.0)
6(12.0)
5(10.0)
8(16.0)
6(12.0)
5(10.0)
8(16.0)
7(14.0)
50(100.0)
*PHC Primary Health Center
Programme management at PHCs for Mamta
Diwas is shown in table 2.
Out of 50 PHCs visited, 34(68%) were having the
map of the catchment area. Beneficiaries for the
year were calculated in only 40(80%) PHCs .In
46(92%) PHCs, immunization calendar was
available. Coverage monitoring chart was
available only in 4(8.0%) PHCs.
Particulars regarding cold chain management
are shown in table 3.
In 48(96%) PHCs, ILR and DF were placed on
wooden block. In 42 PHCs (84%) ILR and DF
were connected through individual stabilizer. In
45 PHCs T-series vaccine and Hep B vaccine
were not found at the bottom of the ILR. In
49(98%) PHCs lab reagent and other vaccines
were not placed in ILR.
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Table 2: Programme Management at PHCs for Mamta Diwas
Programme Management at PHCs for Mamta Diwas (n=50)
Catchment area map available
Estimation of beneficiaries calculated
Estimation of logistics calculated
Immunization calendar available at PHC
Immunization calendar displayed at the facility(PHC)
Supervisory field visits details for sessions in a year available
Coverage Monitoring chart available(Drop out chart) at PHC
Meeting conducted with PRI* and ICDS** functionaries about Mamta Diwas
Supervisory visits by District officials on Mamta Diwas
Yes (%)
34(68.0)
40(80.0)
17(34.0)
46(92.0)
32(64.0)
29(58.0)
04(8.0)
31(62.0)
20(40.0)
95% CI
54.2-79.77
67.24-89.37
21.93-47.88
81.82-97.41
50.07-76.35
44.05-71.04
2.59-18.18
48.04-74.60
27.17-53.96
*PRI –Panchayati Raj Institution ICDS** Integrated Child Development Services
Table 3: Cold Chain maintenance
Cold Chain maintenance (Total Observations n=50)
ILR* and DF** placed on wooden block
ILR connected through stabilizer
Functional Thermometer placed inside ILR
DF connected through stabilizer
Functional Thermometer placed inside DF
Twice daily monitoring of temperature
Record of power failures maintained
Periodic check by facility in charge
ILR- Vaccine vials arranged in labeled cartoons
ILR-T series and Hep-B*** vaccine not found at bottom
ILR-Diluent placed within 24 hours
DF icepacks arrangement proper
Lab reagent and other vaccines than RI**** vaccine in ILR
DF and ILR placed 10 cm away from the wall
Yes (%)
48(96.0)
42(84.0)
49(98)
42(84)
41(82)
44(88.0)
49(98.0)
49(98.0)
48(96.0)
45(90.0)
49(98.0)
31(62)
01(2.0)
50(100.0)
95% CI
87.41-99.32
71.87-92.28
90.53-99.90
71.87-92.28
69.53-90.85
76.71-94.99
90.53-99.90
90.53-99.90
87.41-99.32
79.22-96.24
90.53-99.90
48.04-74.60
0.10-9.46
94.18-100.0
*Ice lined Refrigerator; **Deep freezer; ***Hepatitis-B; ****Routine immunization
Table 4 highlights the supplies and stock, micro
planning, reports and Injection safety. In 25(50%)
PHCs stock register tallied with issue register for
BCG/Measles vaccine whereas in 6 (12%) PHCs
it was kept under lock and key which is a wrong
practice. In 11(22%) PHCs stock register tallied
with issue register for BCG diluent/Measles
diluent. In 11(22%) PHCs, dropout rate for DPT-
3 was found to be more than 10%.AEFI was
reported from 20(40%) PHCs and VPD was
reported from 25(50%) PHCs. In 47(94%) PHCs
chemical disinfection was done before final
disposal of immunization waste. In 46(92%)
PHCs disposal pit were available in the
premises.
Table 4: Supplies and Stock, Micro planning, reports and Injection safety
Supplies and Stock, Micro planning, reports and Injection safety (n=50)
Stock register tallied with issue register for BCG/Measles
Stock register tallied with issue register for BCG diluent /Measles diluent
Every session having at least one vial of each antigen
ADS syringe and reconstitution syringe record updated
Planned sessions are conducted
Dropout rate more than 10%
AEFI* or zero report in last 3 calendar months reported
VPD** or zero report in last 3 calendar months reported
Chemically disinfection before final disposal
Disposal pit available in the premises
Yes (%)
25(50.0)
11(22.0)
46(92.0)
27(54.0)
43(86.0)
11(22.0)
20(40)
25(50.0)
47(94.0)
46(92.0)
95% CI
36.34-63.66
12.15-35.01
81.82-97.41
40.15-67.39
74.26-93.67
12.15-35.01
27.17-53.96
36.34-63.66
84.54-98.45
81.82-97.41
*Adverse event following immunization; ** Vaccine preventable diseases
Mamta Diwas findings at Session/Vaccination
site are shown in table 5. IEC material was
displayed in 38(76%) session sites. At 40(80%)
session sites, ice packs were found to be
conditioned. Hub cutter was not available in
11(22%) sites. Due beneficiaries list was available
at 45(90%) session sites. Site of vaccination and
correct dosage and technique of vaccination was
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known to every FHW interviewed at the session
sites. At 47(94%) session sites, four key messages
were told to mother like what is this vaccine for,
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next date for immunization, what needs to be
done after vaccination, nutritional advices for
child and contraceptive advices.
Table 5: Mamta Diwas findings at Session/Vaccination site
Mamta Diwas at Session site (Total Observations n=50)
IEC material displayed properly
Vaccine carrier available at the site
Conditioned of ice pack
Plastic zipper bag to place vaccines available
Expired vaccine found during vaccination
T series vaccine or Hep-B found frozen
Time of reconstitution mentioned on the vial (BCG/Measles)
Due list of beneficiaries available
Administration of vaccines seen correctly
Hub cutter available at the session
Key messages were given to mother
Medical Officer visited the session site within 1 month
DISCUSSION
Coverage monitoring chart was available only in
4(8.0%) PHCs. The coverage monitoring chart is
developed to track the coverage of infants on a
month- by-month basis against the target
population (left outs).It also helps to determine
whether the beneficiaries are completing the
series of vaccines (dropouts).3 All the PHC has
functional ILR and DF. In a study by Rao. S et
al4, ice lined refrigerators and deep freezers were
available in 69 (98.6%) and 67(95.8%) of centers.
In 48(96%) PHCs, ILR and DF were placed on
wooden block. In 42 PHC (84%) ILR and DF
were connected through individual stabilizers.
Rao S et al4 in their study found cold boxes,
frozen packs and automated voltage stabilizers
in 68(97.2%) centers In 49(98%) PHCs functional
thermometer was placed in ILR whereas in
41(82%) PHCs functional thermometer was
placed inside DF. Rao. S et al4 in their study
found dial thermometer in all the centers.
Temperature of ILRs/Freezers used for storage
of vaccines must be recorded twice daily. These
records should be checked during supervisory
visits. A break in the cold chain is indicated if
temperature rises above +80 C or falls below
+2oC in the ILR; and above -15o C in the Deep
Freezer.2 The ILR and Deep freezers each should
have separate thermometer and temperature
record book.2
In 49 PHCs (98%) record of power failures were
maintained and also verified by the facility in
charge. The DPT, DT, TT and BCG vaccines
should never be kept directly on the floor of the
refrigerator as they can freeze and get damaged.
The top section of the ILR maintains the
Yes (%)
38(76.0)
50(100.0)
40(80.0)
48(96.0)
49(98.0)
00(0.0)
41(82.0)
45(90.0)
50(100.0)
39(78.0)
47(94.0)
50(100.0)
95% CI
62.77-86.30
94.18-100.0
67.24-89.37
87.41-99.32
90.53-99.9
0.0-5.81
69.53-90.85
79.22-96.24
94.18-100.0
64.99-87.85
84.54-98.45
94.18-100.0
temperature of +20Cto +80C. All the vaccines
should be kept in the basket provided with the
refrigerator. OPV and Measles can be kept at
bottom of the basket while BCG, DPT, DT and
TT vaccines are kept in upper part of the
baskets.2
In 45(90%) PHCs the vaccine arrangement was
proper as T-series vaccine and Hep B vaccine is
not found at the bottom of the ILR. Rao S et. al4
found improper vaccine storage was observed in
7 (10%) centers. The diluents may be stored
outside the cold chain but diluents should be
kept inside ILR for at least 24 hours before use to
ensure that vaccines and diluents are at +2° to
+8°C when being reconstituted.2 In the present
study we found that diluents were placed within
24 hours in ILR. In all the PHCs, ILR and DF
were placed 10 cm away from the wall. Book on
immunization for medical officers states that all
electrical cold chain equipment should be kept at
least 10 cm away from walls.3
Monthly reporting of immunization data
including vaccine usage, VPD and AEFI cases
must be ensured as per Government of India
(GOI) guidelines.2 AEFI was reported from
20(40%) PHCs and VPD was reported from
25(50%) PHCs. It is important that AEFIs are
detected, investigated, monitored and promptly
responded to for corrective interventions.3 Each
individual case of VPD needs to be recorded and
reported upwards within a comprehensive VPD
surveillance system.3
In 40(80%) session sites, ice packs were found to
be conditioned. An icepack is said to be
adequately conditioned as soon as beads of
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water cover its surface and sound of water is
heard on shaking it. Conditioning prevents
freezing of freeze sensitive vaccines.3 At all the
session sites, respective MO has visited the
session site within previous one month.
Supportive supervision is a process of helping
staff to continuously improve their own work
performance. It is carried out in a respectful and
non-authoritarian way with a focus on using
supervisory visits as an opportunity to improve
the knowledge and skills of health staff.3
CONCLUSIONS AND
RECOMMENDATIONS
Logistic support is not a problem in Kheda
district but Hub cutter was not available in
11(22%) session sites. It should be made available
at all session sites. Programme management at
PHC needs to be emphasized. Vaccine storage
practices and cold chain maintenance is up to the
mark throughout the District. Reporting of AEFI
and VPD needs to be strengthened. Supportive
supervision by the medical officers is very good
in the district.
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Abbreviations used:
PHC-Primary Health Centre,
AEFI-Adverse events following immunization,
VPD-Vaccine preventable diseases,
ILR-Ice lined Refrigerator,
DF-Deep Freezer,
MO-Medical Officer,
GOI-Government of India,
SRIM-State routine Immunization Monitor,
Hep-B- Hepatitis B,
FHW-Female Health worker,
RI-Routine Immunization
REFERENCES:
1.
www.guvhealth.org accessed on 7th June 2012
2.
UNICEF Ministry of Health and Family Welfare,
Department of Health & Family Welfare. Government of
India; 2010. Handbook for Vaccine & Cold Chain
Handlers
3.
Department of health and family welfare, Government
of India; 2008.Immunization handbook for medical
officers.
4.
Rao. S, Naftar S and Baliga S and Unnikrishnana B.
Evaluation, Awareness, Practice and Management of
Cold Chain at the Primary Health Care Centers in
Coastal South India. Journal of Nepal Paediatr. Soc,
2012; 32 (2):19-22
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
IODINE AND THYROID STATUS IN A TRIBAL VILLAGE IN
WAYANAD, KERALA IN THE POST IODIZATION ERA –
OBSERVATIONS AND IMPLICATIONS
Praveen P Valiyaparambil1, Usha V Menon1, Vivek Lakshmanan1, Sanjeev Vasudevan2, Ajitha
Kumari2, Harish Kumar1
Financial Support: Institutional
funding (Amrita Institute of
Medical Sciences)
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Valiyaparambil PP, Menon UV,
Lakshmanan V, Vasudevan S,
Kumari A, Kumar H. Iodine and
Thyroid Status in a Tribal Village in
Wayanad, Kerala in the Post
Iodization Era – Observations and
Implications. Natl J Community
Med 2013; 4(1): 86-90.
Author’s Affiliation:
1Department of Endocrinology;
2Department of Palliative Medicine,
Amrita Institute of Medical
sciences, Cochin
Correspondence:
Dr Praveen V. P.,
Email: praveenvp@aims.amrita.edu
Date of Submission: 20-11-12
Date of Acceptance: 11-02-13
Date of Publication: 31-03-13
ABSTRACT
Background: Data on thyroid and iodine status in tribal
population is scarce. We sought to assess the thyroid and iodine
status in this population, by ascertaining the goitre prevalence,
thyroid function and thyroid autoimmune markers in adults, and
the goitre prevalence and iodine status in school going children
from both tribal and non tribal populations
Methods: Questionnaire survey and physical examination was
done in 50 randomly selected houses from both tribal and nontribal
populations.
Goitre,
thyroid
function,
thyroid
autoimmunity was assessed in 175 adults and goiter and iodine
status were assessed in 83 children.
Results: Goitre prevalence was similar in tribal and non- tribal
adults ( tribal ,45.7% vs. nontribal , 42%,P 0.87) and children
(14.9% and 19.4%, P=0.77) . Goitre prevalence was more in adult
females . Thyroid dysfunction was seen in 3.9% of tribal and 4.2%
of non-tribals. Abnormal thyroid function tests were all in the
thyrotoxic range in tribals whereas they were all in the
hypothyroid range in non-tribal. Thyroid autoimmunity was
more in the non-tribal Compared to tribal population ( 24.7% vs.
10.6% p =0.026).
Conclusions: This is the first data on thyroid status in tribal and
non-tribal population from Wayanad district, which has shown a
high adult prevalence of goitre. However the prevalence of goitre
in children is near the national average, which might indicate an
improvement in the iodization status in the post iodization era.
The higher prevalence of hyperthyroidism in tribals and
significant difference in thyroid autoimmunity between tribals
and non -tribals merit further study.
Keywords: Iodine, thyroid, goiter, tribal
INTRODUCTION
Wayanad is not considered to be an iodine
deficient district. This dubious distinction goes to
idukki, Kottayam and Kasarkod 1. While
conducting medical camps for tribals in Amrita
Kripa Hospital, Kalpetta, high prevalence of
large sized goitres in this population came to our
attention. Significant proportions of these
goitrous subjects develop thyrotoxicosis and
compressive symptoms necessitating either
medical therapy and/or surgery. The reasons for
this
high
prevalence
merited
further
investigation because of indirect implications
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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both for physical and social wellbeing. Such
large size goitres on a community scale are
classically due to the effects of iodine deficiency
or less commonly due to exposure to goitrogens
2,3.
Other factors like autoimmunity may
contribute to goitre formation. Although there is
data pertaining to iodine deficiency disorders in
general population in Wayanad there are no
studies specifically in tribal population. The food
habits of the tribals traditionally included roots
and tubers which may contain goitrogenic
substances similar to that seen in cassava.
However with the rehabilitation processes
initiated by the government significant changes
in life style have taken place. If iodine deficiency
is found to be the main reason then easily
rectifiable measures can be taken which can
improve the welfare of this socially backward
population.
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aspects related to health. Interviewed subjects
were examined for the presence of goitre and
graded as per the standard WHO guidelines.
Information pertaining to goitre such as type of
diet, type of salt used, were observed by the
investigators in the houses visited and recorded
in the questionnaire. Venipuncture was done and
blood was collected from adult participants for
thyroid function tests and anti-thyroid
peroxidase antibody estimation . Blood and
urine sampling was done after obtaining
informed written consent from the adult
participants or adult family members, in case of
children. Urine for iodine estimation was
collected from two children of school going age
(age group 5-18years) randomly selected from
each household. Five representative salts
samples which included powdered salt and rock
salt were analyzed for the iodine content.
Laboratory methods
AIMS AND OBJECTIVES
We sought to answer the questions related to the
iodine and thyroid status by ascertaining goitre
prevalence ,thyroid function and thyroid
autoimmune markers in tribal and non tribal
population . Goitre prevalence and iodine status
of school going children were also assessed in
both groups .
MATERIAL AND METHODS
Wayanad is located in the northern part of
Kerala and is a hill station providing habitat to
majority of tribal population in Kerala state. A
representative area Modakkara, Vellamunda
Panchayat was selected as the study area due to
high level of cooperationfrom the local
authorities and population . This locality had
two tribal groups , Paniya and Kurichiya tribes
living in colonies specially earmarked for them
by the Government of India. Non tribals were
living in adjacent areas. Approval for the study
was obtained from the institutional ethics
committee and also from the district
administrative and health authorities. Among
tribal and non-tribal population, 50 houses were
selected on a random sampling basis. A team of
two doctors and four paramedical staff visited
selected houses and conducted a questionnaire
survey and physical examination ofindividuals
in the age range of 5-65years in the homes
visited. A previously validated thyroid survey
questionnaire 3 in a suitably modified form was
used to assess nutrition, salt intake and other
Serum Thyroid Stimulating Hormone (TSH), free
thyroxine (FT4) and anti-thyroid peroxisome
Antibody (Anti TPO), were measured by Chemi
luminescence Immunoassay (CLIA) using
Abbott Architect 2000SR. Urine iodine was
estimated by simple microplate method using
ammonium persulphite digestion and Sandell
Kolthoffs reaction. Estimation of urine iodine
and iodine salt content was performed in the
ICCIDD cell, department of community
medicine AIIMS, New Delhi.
Statistical analysis
Statistical software SPSS version 17 was used for
analysis. The prevalence of goitre, iodine
deficiency and thyroid autoimmune marker
were calculated. The tribal and nontribal groups
were compared with either chi square test or
Mann Whitney U test as appropriate. Correlation
between goitre and various factors was
calculated. Binary logistic regression was done to
analyze goitre etiology.
RESULTS
In the study, 94 adults (Males 31 and Females 63)
and 47 (Males 29 and Females 18)children from
the tribal population and 81 adults(23 males+ 58
females) and 36(18 males +18 females) children
from the non-tribal population were included
(table 1). Median age of adults in both groups
was similar. Body mass index was 21.5 kg/m2 in
the non-tribal group and 19kg/m2 in the tribal
group(P=0.00). Median age for children was 10.5
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years and 7 years respectively in the non-tribal
and tribal group respectively (P=0.005). Body
mass index was 15.1kg/m2 in the non-tribal and
14.3 kg/m2 in the tribal group(P=0.019)
Table 1: Distribution of common study variable among subjects
Variable
Adults
Children
Median age of adults
Adults with goitre
Children with goitre
Median urine iodine
Homes with adequate urine iodine
Abnormal thyroid function Tests
Anti TPO positivity
Iodized salt use
Tribal
94(31M+63 F)
47(29M+18F)
41
43(45.7%)
7(14.9%)
38 ug/L
21.9%
3(3.2%)
10(10.6%)
48(34%)
Iodine status
The median urine iodine was 26ug/L and 38
ug/L in the non-tribal group and tribal group
respectively (p=0.136). Percentage of household
with adequate urine(>100ug/l) iodine was 16.7
% (21.9% in non- tribals vs 12.5% in tribal, p
=0.35 ).There was no difference in the diet
patterns of the tribals and non -tribals and the
assumption that their diet included lot of tubers
proved to be untrue. Five representative salts
samples were analyzed for the iodine content.
The results showed that none of the rock salt
samples contained iodine. The packed powder
form of salt contained iodine in the
recommended at least 15ppm of salt at the
consumer level. Since all of the salt used in the
region came from two shops it could be
concluded reasonably that the rock salt is devoid
of iodine whereas the powdered salt was indeed
iodized. Iodized salt use was higher in the
nontribal compared to tribals (54.5% vs 34%), but
did not achieve statistical significance (p value
=0.163).
Non tribal
81(23M+58F)
36(18M+18F)
39
34(42%)
7(19.4%)
26.2ug/L
12.5%
4(4.9%)
20(24.7%)
64(47%)
P value
0.87
0.76
0.13
0.35
0.26
0.16
analysis was done to identify the factors
responsible for goitre. The resulting equation
predicted the goitre occurrence poorly (66.9%
prediction). The only two factors which
predicted goitre were advancing age andfemale
sex . The higher prevalence of goitre in
nonsmokers noted in univariate analysis is
probably due to the almost exclusive
composition of smoker group by males and
nonsmoker group by females.
Thyroid dysfunction and autoimmunity
Among adults 3.5% of tribals and 4.9% of
nontribals had abnormal thyroid function tests.
Subclinical thyrotoxicosis constituted all of the
thyroid function abnormalities in tribals whereas
subclinical hypothyroidism was exclusively seen
in nontribals. Thyroid peroxidase antibodies
,which
serve
as
markers
of
thyroid
autoimmunity were significantly higher in
nontribals (24.7%) compared to tribals(10.6%), P
=0.02(figure1). There was no difference in the
anti-thyroid peroxidase antibody prevalence
between smokers and nonsmokers ( P =0.90)
Goitre
In this study 45.7% of adults in tribal group and
42% of adults in non -tribal group had goitre.
The goitre prevalence in children were 14.9%
and 19.4% respectively in the tribal and nontribal
groups . Both in adults and children there was no
statistically significant difference in the
prevalence rates for goitre between the two
groups. Goitre was more in females in adults (p
=0.000) where as such an association was not
apparent in children (p =0.38). 9.5% percentage
of adult participants was smokers. Goitre
prevalence
was
significantly higher
in
nonsmokers
(18.8%
vs
47.4%)
in
univariateanalysis (p=0.03) . Logistic regression
DISCUSSION
Though there had been many studies on iodine
status and goitre among children of Kerala,
studies focusing on tribal populations are rare .
Iodine sufficient status as assessed by urine
iodine excretion of >100ug/l was seen in 54% of
the school children in Wayanad district with a
median iodine urine excretion of 100ug/L1. In
that study 26% of the salt samples subjected to
analysis contained adequate iodine of 15ppm.
The current goitre rate in school going children
in Kerala is 16.6% as per latest reports published
jointly by ICCIDD and IDD cell Kerala
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government4. There were few studies on goitre
prevalence in adults. Endocrine department of
Amrita institute had conducted a study [ADEPS
-Amrita Diabetes and Endocrine Population
Study] 5 among adults above 18yr in three areas
of Ernakulam district with a population of
3,50,000. The study sample was 986 and
prevalence of goitre was 12% (8.5% grade 1 and
3.5% grade 2). The goiter prevalence among
children in the present study is similar to that
reported in the ICCIDD survey as well as that
reported in a recent nationwide study of school
children 6. But the goitre prevalence in the
studied adult population was much higher than
that reported in adults in Ernakulam district,
however the goitre sizes were rather modest.
Grade 2 goitre was seen in 8.5% of the tribal
group and 9.9% of the non tribals.
There were number of problems associated with
trying to ascertain relative contribution of
various studied factors with goitre. The analysis
is likely to be more accurate in children at least
regarding the incident iodine status. Iodine
status of family as extrapolated from urine
iodine values in children and use of iodized salt
is likely to be less accurate as a predictor of
goitre in adults because of lack of information of
past iodization status during their childhood and
youth. However the role of factors like smoking
in goitre causation can be studied only in
adults.The two factors which turned out to be
significant in the regression analysis in adults are
age and sex. In most of the previous studies
goitre is negatively correlated with age. The
higher prevalence of goitre in female population
has been reported in almost all studies
previously. This sex difference was not seen in
children. The studied factors including the
iodine status predicted the goitre poorly in
adults underscoring the importance of looking
for other unidentified factors. Alternately the
current iodine status may not be representative
of the past iodine status which would naturally
have its bearing on the goitre prevalence in
adults. The marked disparity in the goitre
prevalence in adults and children might
represent improved present iodization status
accounting for the lower goitre prevalence in
children, comparable to state and national
average. The households consuming adequate
iodized salt was 48.9% in the ICCIDD survey
which is similar to the rates seen in nontribal. So
probably we are looking at a much improved
iodine status without much disparity between
the tribal and non tribal population. However
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this is still below the target and hence there is a
need to implement corrective measures.
The high prevalence of antibodies in non tribals
was striking but within range for that reported in
adult population from Ernakulam district in
ADEPS study ( TPO positivity - 16.7% in males
and 19.8% in females) as well as that reported
from Caucasian population 5,7 Most of the non
tribals have been living in this region for more
than two generations. There was no significant
difference in the diet patterns or environmental
exposures which are apparent. The effects of
iodine
supplementation
on
thyroid
autoimmunity is controversial 8,9 Except for
probable genetic reasons there is no apparent
reason why thyroid autoimmunity should be
higher in non tribals. Separate binary logistic
regression analysis in non tribals did not reveal
any role for autoimmunity in the causation of
goitre. In view of the relatively modest sample
size this requires further study. Smoking was
found to be a factor associated with lowered
autoimmune markers in some of previous
studies10. However no difference was found in
thyroid autoimmunity between smokers and non
smokers.
Goitre
associated
thyroid
hyperfunction was seen only in tribals. Hypo
function was not seen in any of the tribal subjects
studied. Higher prevalence of thyroid hyper
function is expected in population with iodine
deficiency goitre when iodine deficiency is
corrected. We speculate that this could be due to
the difference in the genetic makeup of the two
groups. It is possible that in tribals iodine
utilization is very efficient as a genetic
adaptation to past deficiency. The current
improved iodine status in the background of
goitre could have resulted in thyrotoxicosis.
These intriguing facts need to confirmed and
studied further in large surveys. This survey
serves to do the ground work needed for
undertaking such large scale studies. We
acknowledge that the use of palpation to identify
goitre may lead to overestimation of goitre
prevalence. This is however more true for
children and may not cause significant problems
in the adult population. Being a pilot study the
sample size is small and this is a limiting factor
in drawing firm conclusions because of the lower
statistical power. The relationship between
autoimmunity and goitre and that between
goitre and iodine status in non tribals may differ
and approach significance with higher sample
size.
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CONCLUSIONS
This pilot study reveals high prevalence of mild
iodine deficiency and goitre in tribal and
nontribal adults. However the goitre prevalence
in children is comparable to that in the rest of
Kerala.
High
prevalence
of
thyroid
autoimmunity was noted in nontribal which is
on the higher side of that reported for general
population. Thyrotoxicosis was more common in
tribals whereas hypothyroidism albeit at a
subclinical level was the commonest abnormality
in non tribals.
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4.
Dennis Moorthy. Tracking progress studies in Kerala,
Tamilnadu ,Orissa , Bihar ICIDD ,Govt of India Data2003
5.
V. Ushamenon , K. Vinod Kumar . Prevalence of known
and undetected diabetes and associated risk factors in
central Kerala — ADEPS - Diabetes Res Clin Pract
7.2006,74 , 289-294
6.
Marwaha R K , Tandon N .Clinical Endocrin ology(oxf)
Thyroid status two decades after salt iodization:
Country-wide data in school children from India. 2011
Dec 5
7.
Kronenberg ,Williams Text book of Endocrinology 12th
Edition Thyroid physiology and diagnostic evaluation
of patients with thyroid disorders
8.
Kahaly GJ, Dienes HP, Beyer J et al. Iodide induces
thyroid autoimmunity in patients with endemic goitre: a
randomized, double-blind, placebo-controlled trial.
European Journal of Endocrinology 1998; 139: 290–297.
9.
Zimmermann MB, Moretti D, Chaouki N et al.
Introduction of iodized salt to severely iodine-deficient
children does not provoke thyroid autoimmunity: a oneyear prospective trial in northern Morocco. Thyroid
2003; 13: 199–203.
10.
Vestergaard P. Smoking and thyroid disorders – a metaanalysis. European Journal of Endocrinology 2002 ;146:
153–161.
REFERENCES
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Kapil U ,Singh P . Status of iodine nutriture and
universal salt iodisation at beneficiaries levels in Kerala
State, India. J Indian Med Assoc. 2006 Apr;104(4):165-7.
Marwaha R.K, Tandon N Residual goitre in the
postiodization phase iodine status thiocyanate exposure
and autoimmunity. Clin Endocrinol (Oxf). 2003
Dec;59(6):672-81
M.B. Zimmerman .Iodine deficiency disorders Lancet
,2008,vol 372,October 4
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Original Article ▌
PREVALENCE AND EPIDEMIOLOGICAL DETERMINANTS
OF MALNUTRITION AMONG UNDER-FIVES IN AN
URBAN SLUM, NAGPUR
Poonam P Dhatrak1, Smita Pitale2, N B Kasturwar3, Jaydeep Nayse4, Nisha Relwani1
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Dhatrak PP, Pitale S, Kasturwar
NB, Nayse J, Relwani N. Prevalence
and Epidemiological Determinants
of Malnutrition among Under-Fives
in an Urban Slum, Nagpur. Natl J
Community Med 2013; 4(1): 91-5.
Author’s Affiliation:
1Post Graduate Student; 2Associate
Professor; 3Professor & Head;
4Assistant Professor, Department of
Community Medicine, NKP Salve
Institute of Medical Sciences and
Research Centre, Nagpur
Correspondence:
Dr. Poonam P. Dhatrak,
Email:drpoonamdhatrak@gmail.com
Date of Submission: 20-11-12
Date of Acceptance: 15-02-13
Date of Publication: 31-03-13
Background: The prevalence of malnutrition among preschool
children can be used to determine the need for nutritional
surveillance, nutritional care, or appropriate nutritional
intervention programmes in a community.
Objectives: To study prevalence of stunting, wasting and
underweight in under fives and to find out epidemiological
determinants associated with malnutrition.
Methodology: A community based cross-sectional study was
carried out to assess prevalence of stunting, wasting, underweight
and epidemiological determinants associated with malnutrition
among under-fives in the field practice area of Urban health
training centre (UHTC), dept. of Community Medicine, NKP
Salve Institute of Medical Sciences and Research Centre, Nagpur.
Data was collected by predesigned, pre-tested questionnaires.
Data analysis was done by using Epi Info software.
Results: Out of the total 150 children 46% were underweight, 52%
were stunted and 20.7% were wasted. The total prevalence of
malnutrition was 63.33%. The factors associated with
malnutrition were low birth weight (85%), mothers literacy
(77.78%), fathers literacy (73.97), lack of exclusive breast feeding
(81.25%), socio-economic-status (74.44%) and incomplete
immunization (76.19%).
Conclusion: The study strongly points toward the importance of
proper infant feeding practises, proper nutrition, parental
education and improved living conditions for reducing
malnutrition among under-five children.
Key words: Prevalence, stunting, wasting,
malnutrition, epidemiological determinants.
INTRODUCTION
Pre-school children constitute the most
vulnerable segment of any community. Their
nutritional status is a sensitive indicator of
community health and nutrition. Undernutrition among them is one of the greatest
public health problems in developing countries.
Attempts to reduce child mortality in developing
countries through selective primary health care
underweight,
have focused primarily on the prevention and
control of specific infectious diseases, with less
effort being directed to improving children’s
underlying nutritional status.1
During 2003-08 more than 23% of worlds
children under five years of age were under
weight for their age. At present in India 48%
children under five years age are under weight.2
This includes 43% moderate to severe cases, 16%
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severe malnutrition, of these, 20% have moderate
to severe wasting and 48% moderate to severe
stunting.2 The global community has set a target
of halving the prevalence of underweight
children by 2015 as a key indicator of progress
towards the Millennium Development Goal
(MDG) of eradicating extreme poverty and
hunger.3
The three main indicators used to define
undernutrition, i.e., underweight, stunting, and
wasting, represent different histories of
nutritional insult to the child. Occurring
primarily in the first 2–3 years of life, linear
growth retardation (stunting) is frequently
associated with repeated exposure to adverse
economic conditions, poor sanitation, and the
interactive effects of poor energy and nutrient
intakes and infection. Low weight-for-age
indicates a history of poor health or nutritional
insult to the child, including recurrent illness
and/or starvation, while a low weight-for-height
is an indicator of wasting (i.e., thinness) and is
generally associated with recent illness and
failure to gain weight or a loss of weight.4
The main and immediate causes of children
growth failure are a lack of adequate food and
the high incidence of infectious disease. Thus,
adequate food and non food input are required
for good nutrition. Poverty is the major cause of
inadequate food intake.5 The aetiology of
malnutrition is complex and multi-factorial. It is
usually a consequence of inadequate dietary
intake and disease. However, this occurs in
combination with multiple social, economic,
cultural and political elements.6
OBJECTIVES
To study prevalence of stunting, wasting and
underweight in under fives and to find out
epidemiological determinants associated with
malnutrition.
MATERIALS AND METHODS
A community based cross sectional study was
carried out in the field practice area of Urban
health training centre (UHTC), dept. of
Community Medicine, NKP Salve Institute of
Medical Sciences and Research Centre, Nagpur.
The total population of the area is around 20,342
having 3188 houses among which under five
children were approximately 2525. Based on
prevalence of 40% (underweight),7 a sample of
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150 was calculated with an allowable error of 8%
by using the formula (1.96)2*pq/L2.
After Ethical Committee approval of our
institution a house to house survey was carried
out selecting every seventeenth house of total
3188 by systematic random sampling. The first
house was selected by lottery method and then
every seventeenth house was surveyed until the
desired sample size was achieved. After visiting
a house, informed consent of the caretaker was
taken and detailed interview of caretaker was
conducted regarding socio-economic status(SES),
feeding of child, immunization status, parental
literacy and was entered in a pre-designed
questionnaire. Age of the child was determined
by
reviewing
the
Birth
certificate.
Anthropometric measurements were carried out
following standard methods. The data included
weight, recumbent length (for children less than
24 months of age) and height (for children more
than 24 months of age). Weight was measured to
the nearest 0.1 Kg and Salter weighing machine
was used for weight measurement. Height was
measured against a non stretchable tape fixed to
a vertical wall, with the participant standing on a
firm/level surface and it was measured to the
nearest 0.5 cm. Recumbent length (for children
less than 24 months of age) was measured by
using an infant measuring board.
Socio-economic status (SES) - was determined by
using Modified Prasad’s scale.8 Data of the
nutritional survey were analyzed using WHO
Anthro for personal computers, version 3.1,
2010.9
Statistical analysis: The data was analysed with
Epi info version 3.4.3. Odds ratio and p value
were used to examine the relation between
variables.
RESULTS
Table 1:- Age & gender distribution of study
population (n=150)
Age (months)
0-12months
13-24months
25-36months
37-48months
49-60months
Total
Males (%)
25(58.14)
11(35.48)
18(60)
13(61.90)
14(56)
81(54)
Females (%)
18(41.86)
20(64.52)
12(40)
8(38.10)
11(44)
69(46)
Total (%)
43(28.67)
31(20.67)
30(20)
21(14)
25(16.66)
150(100)
Table 1 shows age and gender distribution of
study population. It was observed that out of
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total 150 children, 81(54%) were males maximum
being in the age group 37-48 months i.e. (61.90%)
and 69 (46%) were females maximum in the age
group 13-24 months i.e. (64.52%) . There were
43(28.67%) infants and 21(14%) children in the
age group of 37-48 months.
Table 2 shows prevalence of underweight,
stunting and wasting. It was seen that 45(35%)
children were underweight and 24(16%) were
severely underweight, 34(22.7%) children were
stunted and 44(29.3%) were severely stunted,
19(12.7%) were wasted and 12(8%) were severely
wasted.
Table 2:- Prevalence of underweight, stunting
and wasting in study population (n=150)
<-2SD
<-3SD
Normal
Total
Underweight(%) Stunting(%) Wasting(%)
45(30)
34(22.7)
19(12.7)
24(16)
44(29.3)
12(8)
81(54)
72(48)
119(79.3)
150
150
150
A child either underweight, wasted or stunted or
any combination of the three was considered as
having malnutrition which comes to be 63.33%
indicating
prevalence
of
malnutrition.
Malnutrition was prevalent in 56(58.95%) males
and 39(41.05%) females. Malnutrition was
highest amongst infants 26(27.37%) and lowest in
37-48months age group i.e. 14(14.74%). (Table 3)
Table 3:- Age & gender-wise distribution of
malnutrition in study population (n=95)
Age
(months)
0-12months
13-24months
25-36months
37-48months
49-60months
Total
Males (%)
Females (%)
16(61.54)
6(35.29)
13(65)
10(71.43)
11(61.11)
56(58.95)
10(38.46)
11(64.71)
7(35)
4(28.57)
7(38.89)
39(41.05)
Total (%)
26(27.37)
17(17.89)
20(21.05)
14(14.74)
18(18.95)
95(100)
Table 4 shows epidemiological factors of under
five children. It was observed that 21(14%)
children were low birth weight. Parents literacy
profile showed that 72(48%) mothers and
73(48.67%) fathers were educated upto S.S.C.
whereas 78(52%) mothers and 77(51.33%) fathers
were educated above S.S.C. Classification of
socio-economic status according to updated
Prasad Scale showed that maximum i.e. 81(54%)
children belonged to lower middle class families
and minimum 6(4%) belonged to upper class
whereas 35(23.33%) children belonged to middle
class families. Exclusive breast feeding was
present in 118(78.67%) children, 108(72%)
children were fully immunized till date and
42(28%) were partially or non-immunized.
Table 4:- Epidemiological factors of the study
population (n=150)
Factors
Birth weight
<2.5
≥2.5
Frequency (%)
21 (14)
129 (86)
Mothers literacy
Upto S.S.C
Above S.S.C
72 (48)
78 (52)
Fathers literacy
Upto S.S.C
Above S.S.C
73 (48.67)
77 (51.33)
Socio economic status
Class I (Upper)
Class II (Upper Middle)
Class III (Middle)
Class IV (Lower Middle)
Class V (Lower)
6 (4)
19 (12.67)
35 (23.33)
81 (54)
9 (6)
Ex. Breast feeding
Present
Absent
118 (78.67)
32 (21.33)
Immunization status
Fully immunized
Partially/Non-immunized
108 (72)
42 (28)
Table 5 shows associations of certain risk factors
with malnutrition. It was found that low birth
weight 18 (85.71%) (p<0.05), mothers education
below S.S.C. 56(77.78%) (p<0.001), fathers
education below S.S.C. 54 (73.97%) (p<0.05),
lower socio-economic class 67 (74.44%) (p<0.001),
lack of exclusive breast feeding 26 (81.25%)
(p<0.05) and non-immunized children 32 (76.19)
(p<0.05) were statistically associated with
malnutrition. No association was found between
age and gender of the child and malnutrition
(p>0.05).
DISCUSSION
Urban slums in all big cities of India are growing
at an alarming pace and yet, sufficient attention
has not been paid to understand nutritional
problems of slum populations. Problems of
urban slums in India would be of greater
dimensions and that they would need far more
attention than that in the past. Nutritional status
of slum children is even poorer than rural
children.10
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In our study prevalence of underweight, wasting
and stunting was 46%, 20.7% and 52%
respectively giving total prevalence of
malnutrition to be 63.33% which is almost same
with NFHS-37 data (40%, 23%, 45%). This finding
is higher than the studies conducted by Avachat
SS11 (50.46%) and Bloss E4 (30 % underweight,
47% stunted, and 7% wasted) and lower than
studies of Sengupta P3 (74% stunted, 42% wasted
and 29.5% underweight), Biswas T12 (64.9%
stunted, 20.3% wasted and 64.9% underweight)
and Rao VG1 [underweight (61.6%), stunting
(51.6%) and wasting (32.9%)].
Table 5:- Association between risk factors and malnutrition
Risk factors
Age
0-24 months
25-60 months
Malnourished (%)
Normal (%)
Chi-square
Odds ratio
p-value
43 (58.11)
52 (68.42)
31(41.89)
24(31.58)
1.717
0.6402
>0.05
Sex
Female
Male
39 (56.52)
56 (69.14)
30(43.48)
25(30.86)
2.553
0.5804
>0.05
Birth weight
<2.5
≥2.5
18 (85.71)
77 (59.69)
3(14.29)
52(40.31)
5.267
4.052
<0.05*
Mothers literacy
Upto S.S.C
Above S.S.C
56 (77.78)
39 (50)
16(22.22)
39(50)
12.44
3.5
<0.001†
Fathers literacy
Upto S.S.C
Above S.S.C
54 (73.97)
41 (53.25)
19(26.03)
36(46.75)
6.932
2.496
<0.05*
Socio economic status
Class IV & V
Class I, II, III
67 (74.44)
28 (46.67)
23(25.56)
32(53.33)
11.96
3.329
<0.001†
Ex. Breast feeding
Absent
Present
26 (81.25)
69 (58.47)
6(18.75)
49(41.53)
5.623
3.077
<0.05*
Immunization status
Partially/Non-immunized
Fully immunized
32 (76.19)
63 (58.33)
10(23.81)
45(41.67)
4.152
2.286
<0.05*
* - Significant † - Highly significant
In our study no association was found between
age and gender of the child with malnutrition
(p>0.05) which is comparable with the study of
Rao VG1 and contradicts the finding of studies
conducted by Avachat SS11 which founded
association with age (p<0.05), with female
gender by Sharghi13 A(p=0.01) and Sengupta P3
that found association with both age and gender
(p<0.05)
In our study 18 (85.71%) low birth weight
children were found to be malnourished and
showed significant statistical association (p<0.05)
which is similar to the study conducted by
Avachat SS11 (88.98%, p<0.05) and higher than
the study of Nozomi M5 (35.3% LBW in stunted
children and 29.4% in underweight; p < 0.05).
Prevalence of underweight was observed being
significantly higher (p=0.024) in LBW children
by Sengupta P3.
Prevalence of malnutrition was 56(77.78%) in
children having their mothers literacy below
S.S.C (p<0.001). Similar findings were reported
from the studies conducted by Nozomi M5
(15.9%, p < 0.05) and Sengupta P3 (p=0.04)
whereas the study conducted by Harishankar14
observed no association between mothers
literacy and malnutrition (p>0.01).
Prevalence of malnutrition was 54(73.97%) in
children having their fathers literacy below S.S.C
(p<0.05). Md. Israt Rayhan15 also stated an
inverse relation between father’s education and
under-weight whereas studies of Nozomi M5
and Sengupta P3 found no association between
them.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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In our study 67 (74.44%) children from lower
socio-economic class had malnutrition (p<0.001).
Study of Sapkota VP16 reported four times risk of
underweight
in
children
from
poor
socioeconomic class (40.3%) [OR= 4.336]. Similar
findings were reported by Khan Khattak
M.M.A17 (41.05% underweight in lower class).
Prevalence of malnutrition was 26 (81.25%) in
children with lack of exclusive breast feeding
(p<0.05). Sengupta P3 and Biswas T12 also
reported association between lack of exclusive
breast feeding and underweight (p<0.05)
In our study, 32 (76.19%) (p<0.05) nonimmunized children had malnutrition, similar
findings were reported by Biswas T12 (p=0.049)
whereas Sengupta P3 observed no association
between the two.
pISSN 0976 3325│eISSN 2229 6816
3.
Sengupta P, Philip N, Benjamin A I. Epidemiological
correlates of under-nutrition in under-5 years children
in an urban slum of Ludhiana. HPPI. 2010; 33 (1): 1-9.
4.
Bloss E, Wainaina F, Bailey R C. Prevalence and
Predictors of Underweight, Stunting, and Wasting
among Children Aged 5 and Under in Western Kenya.
Journal of Tropical Pediatrics. 2004; 50(5): 260-270.
5.
Nojomi M, Tehrani A, Shahandokht Najm-Abadi MS.
Risk analysis of growth failure in under-5-year children.
Archives of Iranian Medicine. 2004; 7( 3): 195 200.
6.
Syed Farid-ul-Hasnain, Raafay Sophie. Prevalence and
risk factors for Stunting among children under 5 years: a
community based study from Jhangara town, Dadu
Sindh. J Pak Med Assoc. 2010; 60(1): 41-44.
7.
Govt. of India. National family Health survey. NFHS III
(2005-2006). International Institute for Population
Sciences, Ministry of Health & Family Welfare, Mumbai
2007.
8.
Kumar P. Social Classification need for constant
Upgrading. Ind. J Comm Med; 1993: 18(2).
9.
Software for assessing growth and development of the
world’s children. Geneva: WHO, 2010
(http://www.who.int/childgrowth/software/en/).
10.
Rao S, Joshi S B, Kelkar R S. Changes in nutritional
status and morbidity over time among pre-school
children from slums in Pune, India. Indian Pediatrics.
2000; 37: 1060-1071.
11.
Avachat S S, Phalke V D, Phalke D B. Epidemiological
study of malnutrition (undernutrition) among under
five children in a section of rural area. Pravara Med Rev.
2009; 4(2): 20-22.
12.
Biswas T, Mandal P K, Biswas S. Assessment of health,
nutrition and immunization status amongst under- 5
children in migratory brick klin population of periurban
Kolkata, India. Sudanese Journal of Public Health. 2011;
6(1): 7-13.
13.
Sharghi A, Kamran A, Faridan M. Evaluating risk
factors for protein-energy malnutrition in children
under the age of six years: a case-control study from
Iran. Int J Gen Med. 2011; 4: 607-611.
14.
Harishankar, Dwivedi S, Dabral S B, Walia D K.
Nutritional status of children under 6 years of age.
Indian J. Prev. Soc. Med. 2004; 35: 156-162.
15.
Md. Israt Rayhan, Khan S H. Factors causing
malnutrition among under five children in Bangladesh.
Pakistan Journal of Nutrition. 2006; 5(6): 558-562.
16.
Sapkota V P, Gurung CK. Prevalence and predictors of
underweight, stunting and wasting in under five
children. 2009. J Nepal Health Res Counc. 2009; 7(15):
120-126.
17.
Khan Khattak M.M.A, Ali S. Malnutrition and
associated risk factors in pre-school children (2-5 years)
in District Swabi (NWFP)- Pakistan. Journal of Medical
Sciences. 2010; 10: 34-39.
CONCLUSION
We found that more than half of the study
population had malnutrition and the risk factors
associated with malnutrition were parents’
literacy, low birth weight, lack of exclusive
breast feeding, immunization status and socioeconomic status of family. The study strongly
points towards the importance of proper infant
feeding practises, proper nutrition, parental
education and improved living conditions for
reducing
malnutrition
among
under-five
children. The high prevalence of malnutrition in
the
community
requires
that
National
Nutritional Programme should monitor the
growth of the under-five children in terms of
weight for height. Since socioeconomic status, in
terms of food sufficiency was found predicting
nutritional status of under-five children;
coordination with income generation and food
production activities might be an option to make
nutritional interventions more effective.
REFERENCES
1.
2.
Rao V G, Yadav R, Dolla C K, Kumar S, Bhondeley M K,
Ukey M. Undernutrition & childhood morbidities
among tribal preschool children. Indian J. Med. Res.
2005; 122: 43-47.
K. Park. Parks Textbook of Preventive and Social
Medicine- 21st Edition. Jabalpur: Banarsidas Bhanot
Publishers; 2011: 506-507.
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Original Article ▌
MORTALITY PATTERN OF HOSPITALIZED CHILDREN IN
A TERTIARY CARE HOSPITAL IN LATUR: A RECORD
BASED RETROSPECTIVE ANALYSIS
Sachin W Patil1, Lata B Godale2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patil SW, Godale LB. Mortality
Pattern of Hospitalized Children in
a Tertiary Care Hospital in Latur: A
Record Based Retrospective
Analysis. Natl J Community Med
2013; 4(1): 96-9.
Author’s Affiliation:
1Senior Resident; 2Professor &
Head, Department of PSM,
Government Medical College, Latur
Correspondence:
Dr. Sachin W. Patil,
Email: dr_sachin1985@yahoo.in
Date of Submission: 01-12-12
Problem statement: Children mortality is one of very important
indicators which reflect country’s development. In country like
India, causes of children mortality are often poorly documented
in most of the hospitals. The present study aimed at finding the
major causes childhood mortality of inpatients in the Pediatric
Department admitted during September 2011 to august 2012.
Methods: A retrospective analysis was done with the medical
records of Childrens died in the Peadiatric Department of
Government Medical College and Hospital, Latur, from 1
September 2011 to 31 August 2012.
Results- A total of 3910 children were admitted to the Pediatric
Department during study period. Total 176 paediatric deaths,
61.15% males and 38.84% females, were recorded. Out of total 176
pediatric deaths, 57.95 % were Neonatal deaths. Among the 139
infant deaths, neonatal deaths were 74%. Birth Asphyxia was
most common cause for neonatal deaths while sSepticemia was
the leading killer in post neonatal infants.
Conclusion-The childhood mortality pattern in different age
groups suggests that we are in need of an effective and more
comprehensive improvement in maternal health care along with
antenatal and newborn care.
Date of Acceptance: 08-03-13
Date of Publication: 31-03-13
Key Words - Neonate, Medical Records, Paediatric deaths, Birth
Asphyxia.
INTRODUCTION
Children mortality is one of the very important
indicators which reflect country’s development .1
It is estimated that all over the world, more than
26,000 children under the age of five mostly from
developing countries die every day. Causes of
death of these childrens are often preventable in
their early course.2 Childhood deaths have been
reported mostly from the developing countries
where the health facilities are inadequate. Some
sociodemographic factors like poor resources,
poverty, ignorance of female childrens and social
instability are also plays major role in their
mortality. Malnutrition and infection-related
diseases are still the major killers around the
world.2
In India causes of children mortality are often
poorly documented in most of the hospitals. The
Medical Records Department of all teaching
hospitals compile and retain the information
regarding patients diagnosis, treatment, death
records etc, yet the meaningful statistics from
these records for health care planning and
review is lacking.
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Death records preserved by medical record
section contains information regarding the
causes of deaths, age and sex distribution, which
can be used in planning programs of health care
services for prevention of children mortality. A
better understanding of childhood mortality
pattern of a country can enable us for prevention
of loss of these important lives. Such
epidemiological information is very useful in
planning and implementation of public health
programmes.
The present study aimed at finding the major
mortality causes of inpatient childrens in the
Pediatric Department of Government Medical
College.
OBJECTIVE
To study the pattern of peadiatric deaths with
some socio-demographic factors
To find out the major causes of mortality of
Pediatric Patients.
METHOD AND MATERIALS
Latur Government Medical College and Hospital
has 60 beds in the Pediatric Department, out of
which 25 are in Neonatal Intensive care Unit
(NICU). Children under 12 years of age with
illness are admitted in the Pediatric Department
both from the
departments.
outpatient
and
emergency
A retrospective analysis was done with the
medical records of Childrens died in the
Pediatric Department of Government Medical
College and Hospital, Latur over a 12-month
period from 1 September 2011 to 31 August 2012.
Data was collected and analysed regarding age,
gender, cause of death, and duration of
hospitalization of all the childrens from Medical
Record Section attached to PSM department.
Data were analyzed using SPSS 18.0 version and
MS Excel.
RESULTS
A total of 3910 children comprising of 2391 (61.15
%) males and 1519 (38.84 %) of females were
admitted to the Pediatric Department during
September 2011 to August 2012. Out of 1095 total
deaths of all ages in Government Medical
College and hospital, Latur during one year
period, 176 were paediatric death. Proportional
mortality rate of peadiatric age group is 16.07 %.
Out of total 176 paediatric deaths, 98 (61.15 %)
were males and 78 (38.84 %) were females. An
overall proportion of peadiatric deaths to total
number of admissions are 4.57 % and proportion
of deaths in males and females was 4.22 % and
5.13 %, respectively.
Table 1: Important Causes of Mortality in Different Age Groups
Causes of Mortality
Septicemia
Birth Asphyxia
Meningitis/ Encephalitis
Prematurity
ARI
Congenital Anomaly
Hepatic Coma
Miscellaneous*
Total
Neonates
34
40
04
14
00
03
00
07
102 (57.95)
Post-Neonate
Infants
14
00
03
00
10
05
00
05
37 (21.02)
1-4 year
Children
03
00
03
00
01
00
00
03
10 (5.68)
5-12 years
Children
05
00
06
00
00
02
04
10
27 (15.34)
Total (%)
56 (31.82)
40 (22.73)
16 (09.09)
14 (07.95)
11 (06.25)
10 (05.68)
04 (02.27)
25 (14.21)
176 (100)
* no. of death due to Poisoning, Burns, Seizure disorders, surgical causes etc.; Figure in parenthesis indicate percentage
Out of total 176 pediatric deaths, 102 i.e. 57.95 %
were Neonatal deaths and of total 139 infant
deaths, neonatal deaths were 74 %. i.e. ¾ of
infants died in their 1st month of life while post
neonatal , 1-4 years childhood and 5-12 yrs
childhood deaths were 37 (21.02%) , 10 (5.68%)
and 27 (15.34%), respectively (Table 1). Out of
total 102 neonatal deaths, the most common
cause was Birth Asphyxia and Septicemia was
the leading killer in post neonatal infants.
Septicemia 56 (31.82 %) out of 176 deaths was the
leading cause of death among all peadiatric age
groups followed by Birth Asphyxia i.e. 40 (22.73
%). Meningitis/encephalitis and ARI were
responsible for 9.09 % (16) and 6.25 % (11) of
total deaths respectively. Prematurity 14 (7.95 %)
and congenital anomaly 10 (5.68 %) are also
important causes in childhood mortality seen in
this study.
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Table 2: Age & Sex Distribution of Pediatric
Deaths
Age group
Neonates
Post Neonate Infants
1-4 yrs Children
5-12 yrs Children
Total
Male
Deaths
62(63.27)
21(21.43)
03(03.06)
12(12.24)
98 (100)
Female
deaths
40(51.28)
16(20.51)
07(08.97)
15(19.24)
78 (100)
Total
Deaths
102(57.95)
37(21.02)
10(5.68)
27(15.34)
176 (100)
Figure in parenthesis indicate percentage
Table 2 shows that 63.27 % i.e. 62 of male deaths
were neonates as compaired to 51.28 % i.e. 40
female neonatal deaths. The risk of death was
found more in 1-4 yrs and 5-12 yrs female
children’s as compaired to males which is
evident by the figures in table 2.
The mean time interval between admissions and
deaths was around 74.76 hrs (Approximately 3
days) with standard deviation (SD) of about
68.76. 49.43 % i.e. 87 of children deaths occurred
within 24 hrs of admission i.e. nearly 50% of
deaths occurred within 24 hrs of admission
because of late referral of patient and referral in
critical/ moribund condition. The intervals
between admissions and deaths were 24-48 hrs,
49-120 hrs and more than 120 hrs in 28 (15.90 %),
41 (23.29 %) and 20 (11.36 %) of deaths,
respectively (Table 3).
Table 3: Mean time interval between
Admission and Deaths of Children
Time Interval
<24 Hrs
24 – 48 Hrs
48 – 120 Hrs
>120 Hrs
Total
Deaths (%)
87 (49.43)
28 (15.90)
41 (23.29)
20 (11.36)
176 (100)
DISCUSSION
The number of admissions was more in males
(2391) than females (1519), Roy R. Et. al 3 and
Singhi S. Et. al 4 studies reported greater male
admission rate in hospitals than females
children. Afolabi et.al.5 also found same statistics
in their study.
The risk of death in peadiatric age group is
highest during neonatal period.1 In the present
study, approximately 57.95 % neonatal cases
died out of total of 176 deaths in all age groups,
indicating that the risk of death was highest in
the neonatal period followed by deaths in the
post-neonatal period which was around
37(21.02%) of total child deaths. Gulati P. Et. al 6
and Deivanayagam N. Et. al 7 also had similar
finding that children mortality is higher within
one year of age.
In present study, peadiatric deaths (176) in
relation to total pediatric admissions (3910) in
one year period showed overall mortality of
pediatric patient in present study was 4.57 %,
which was higher than that observed in the
Singhi S. Et. al 4 study (2.7%) at PGIMER,
Chandigarh. Higher mortality in the present
study may be due to the large number of
admissions in critical conditions, late referring of
pregnant mothers and children in tertiary care
hospitals. But this statistics was lower than the
Roy R. Et. al 3 study (9.87%) conducted in 2008.
Current study shows that the early neonatal
deaths in males (63.27 %) were more than the
females (51.28 %), this shows biological
vulnerability of males to infection is more than
females as they are biologically stronger in their
early ages. Godale L. Et. al8 reported the same
statistics in their study.
Present study shows that the mortality is
comparatively more in female after 1st year of
their life. This may be due to the gender
discrimination and female child negligence.
Godale L. Et. al 8 in their study also found more
female child mortality but Roy R. Et. al 3 and
Singhi S. Et. al 4 studies show no such significant
difference between two sexes.
About 50% of pediatric deaths occurred within
24 h of admission, which could be attributed to
delay transportation of patients and referral in
critical conditions. Roy R. Et. al 3 and
Deivanayagam N. Et. al 7 supported this finding
in their studies.
In present study, the salient causes of deaths in
different peadiatric age groups were studied and
birth asphyxia and septicaemia were two most
common causes of deaths in 39.22 % and 33.34 %
of all neonatal deaths respectively. Roy R. Et. al 3
study conducted in 2008 shows the same causes
of neonatal mortality. Singh M. Et. al 9 from
hospital-based data shows that bacterial sepsis
was a major cause of neonatal mortality in India.
Acute Respiratory Infections (ARI) proved to be
the leading cause of death in pediatric age group
worldwide but in the present study, septicemia,
birth asphyxia, meningitis and prematurity is
leading causes for children mortality.
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CONCLUSION AND RECOMMENDATIONS
REFERENCES
The pattern of mortality in different peadiatric
age group found in the present study showed
that yet the trend of death in children has not
changed as birth asphyxia, ARI, meningitis,
septicemia were the common causes of deaths in
them which suggests that we are in need of more
comprehensive antenatal and newborn care and
up gradation of facilities in the tertiary care
hospitals for prevention of neonatal deaths and
strengthening of the services given under
National Rural Health Mission (NRHM). There is
need to strengthen Information, Education and
Communication (IEC) activities so that the health
cervices given are fully utilize. The deaths of the
childrens within short duration after admission
in most of the cases high lighten the need of
timely referral and early transportation of cases
for prevention of loss of important lives.
1.
Park K.Park’s Textbook of Preventive and Social
Medicine.21st ed. Jabalpur, India: M/S Banarsidas
Bhanot Publishers. 2011. 24-27.
2.
George I. Alex-Hart B. Frank-Briggs A. Mortality
Pattern in Children: A Hospital Based Study in Nigeria.
International Journal of Biomedical Science. 2009; 5(4):
369-372.
3.
Roy R. Nandy S. Shrivastava P. Chakraborty A.
Mortality pattern of Hospitalized Children in a Tertiary
Care Hospital of Kolkata. Indian J Community Med
2008; 33:187-189.
4.
Singhi S. Gupta G. Jain V. Comparison of Pediatric
emergency patients in a tertiary care hospital vs. a
community hospital. Indian Pediatr 2004; 41:67-72.
5.
Afolabi B.Clement C. Ekundayo A. et.al. A hospitalbased estimate of major causes of death among underfive children from a health facility in Lagos, Southwest
Nigeria: possible indicators of health inequality.
International Journal for Equity in Health 2012; 11:39.
6.
Gulati P. Mortality rate and causes of deaths among
children below five years. Indian Pediatr 1967; 34:235.
7.
Deivanayagam N. Shivarathinam S. sankaranarayanan
V. Mortality and morbidity pattern of the hospitalized
children at madras city. Indian J Pediatr; 1987:733-737.
8.
Godale L. Mulage S. Trend And Pattern Of Paediatric
Deaths In Tertiary Care Hospital Solapur, Maharashtra.
Indian J MCH 2012; 14:2-10.
9.
Singh M. Hospital based data on perinatal and Neonatal
mortality in India. Indian Pediatr 1986; 23:579-84.
ACKNOWLEDGMENT
I am thankful my HOD, Department of PSM for
allowing me to carry out this study and members
of medical record department for their kind
cooperation in collection of data for this work.
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Original Article ▌
NUTRITIONAL STATUS OF THE GOVERNMENT SCHOOL
CHILDREN OF ADOLESCENT AGE GROUP IN URBAN
AREAS OF DISTRICT GAUTAMBUDH-NAGAR, UTTAR
PRADESH
Shalini Srivastav1, Harsh Mahajan1, Vijay L Grover2
Financial Support: None declared
Conflict of interest: None declared
ABSTRACT
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
Introduction: Adolescents are overlooked in most health
programs as they are basically considered healthy population but
the scenario varies. The present study was done with the objective
of assessing the nutritional status of adolescent children attending
a school in urban resettlement colony.
How to cite this article:
Srivastav S, Mahajan H, Grover VL.
Nutritional Status of the
Government School Children of
Adolescent Age Group in Urban
Areas of District Gautambudhnagar, Uttar Pradesh. Natl J
Community Med 2013; 4(1): 100-3.
Author’s Affiliation:
1Assistant Professor; 2Ex-Professor
&
Head,
Department
of
Community Medicine, School of
Medical Sciences and Research,
Sharda University Greater Noida
Correspondence:
Dr. Shalini Srivastav,
Email: gud009@gmail.com
Methodology: A cross-sectional study was done covering 392
children between 10-19 years of age from two government schools
and interviewed and anthropometric measurements taken.
Results: The overall prevalence of thinness was found to be 23.2%
and severe thinness was found to be 7.4%.The prevalence of
thinness and severe thinness in boys was 24.1% and 8.6%
respectively whereas in girls it was comparatively low thinness
20.6 and 3.9%. Overall 12.5% children were found to be suffering
from stunting and 1.5% from severe stunting. Moderate stunting
was found in 13.7% and 12% girls whereas severe stunting was
found in 0.7% boys and 3.9% girls.
Conclusion: Adolescents have the lowest mortality among the
different age groups and have therefore received low priority in
national health programs but considering the high prevalence of
malnutrition in this important transitional phase of human life,
the adolescent nutrition should be given prior importance in
nutritional programs.
Date of Submission: 06-01-13
Date of Acceptance: 11-03-13
Keywords: Adolescence, thinness, stunting
Date of Publication: 31-03-13
INTRODUCTION
Adolescence is defined as a period of life ranging
from 10 to 19 years of age1. Adolescents aged
between 10-19 years account for more than onefifth of the world’s population. In India, this age
group forms 21.4 percent of the total population2
.Malnutrition denotes impairment of health
arising either from deficiency or excess or
imbalance of nutrients in the body3. Inadequate
nutrition in adolescence can put them at high
risk of chronic diseases particularly if combined
with other adverse lifestyle behaviours4. In India,
large
numbers
of
adolescents
are
undernourished and the problem is more among
girls (45%) than boys (20%), primarily due to
deep-rooted gender discrimination2. World
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Health Organization (WHO, 1995) has
recommended various indices based on
anthropometry to evaluate the nutritional status
of the school aged children5. It has now been
established that the Body Mass Index (BMI) is
the most appropriate variable for nutritonal
status among adolescents5,6. There is paucity of
anthropometry based information on nutritional
status of govt school children in Uttar Pradesh.
Moreover, to date there are few studies which
have dealt with sex differences in the level of
malnutrition among govt school children in
Uttar Pradesh. The objective of the present study
was to study the nutritional status of the
government school students of 10-19 years age
group in District Gautambudh-nagar, Uttar
Pradesh.
MATERIALS AND METHODS
The study was cross-sectional (Observational) in
nature. The study was carried out in the
Government schools in Bhangel , the urban field
practice area of Department of Community
Medicine. The study was carried out between
July to September 2012.
Sample Size: By taking the prevalence of
malnutrition ranging from 6-50% in school going
adolescent children in various studies and taking
prevalence (p) of malnutrition as 50% and
relative precision of 10% (d) at 95% confidence
interval , optimal sample size comes out to be
400. (sample size7= 4pq/ d2= 400)
Since there are two government schools in
Bhangel , the study sample was selected from
both the schools. A total of 1200 students from
both the schools were enrolled as primary unit
and every third student was selected as study
unit by systematic random sampling. After
taking prior permission from the principals of
schools, dates of visits to the schools were fixed.
A semi structured, pre-tested questionnaire was
administered to each of the 392 students (290
boys and 102 girls) of 11-18 years age group
studying in VIth-XIIth standard, eight students
did not give consent to fill questionnaire so
excluded from the study. The questionnaire
included socio-demographic data (Age, Sex,
father’s and mother education, occupation and
family income). All the students were subjected
to measurement of height and weight and BMI
was calculated.
Height: Height in centimetres was marked on a
wall with the help of a measuring tape. All
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students were made to stand against the wall
without foot wear and with heels together and
their heads positioned so that the line of vision
was perpendicular to the body. A glass scale was
brought down to the topmost point on the head
and the height was recorded.
Weight: A bathroom scale was used for
recording weight. The zero error was checked for
and removed if present. The clothes of the
students were not removed as adequate privacy
was not available.
Body mass index(BMI) of all the students was
calculated by using the formula:
BMI=Wt (in kg)/ (Ht in mtrs)2
The height, weight and BMI of the students was
then compared with the WHO standards8.
Statistical Analysis: The data thus collected was
entered on Excel master chart and then
statistically analysed. WHO growth reference
2007, for adolescent and older children was used
as reference cut offs for BMI and stunting.
Weight for age has been found to be unreliable
and therefore has not been included in this
analysis.8
Table 1: Distribution of Adolescent Children
according to Age and Sex
Age (in yrs)
11
12
13
14
15
16
17
18
Total
Boys (%)
10 (2.6)
22 (5.6)
32 (8.2)
63 (16.1)
53 (13.5)
64 (16.3)
22 (5.6)
24 (6.1)
290 (73.9)
Girls (%)
5 (1.3)
18 (4.6)
15 (3.8)
19 (4.8)
13 (3.3)
13 (3.3)
12 (3.1)
07 (1.8)
102 (26.0)
Total (%)
15 (3.82)
40 (10.2)
47 (11.9)
82 (20.9)
66 (16.8)
77 (19.6)
34 (8.7)
31 (7.9)
392 (100)
Of the total children studied (73.9%) were boys
and (26.0%) girls. According to WHO cut -off
values of BMI in adolescents , overall 23.2% of
the children were found to be having thinness
and 7.4% having severe thinness . The thinness
was more in boys (24.1%) compared to girls
(20.6%) . Similarly, severe thinness was also
more in boys (8.6%) compared to girls (3.9%). A
total of 2% adolescents were found to be overweight , with 3.9 % over-weight adolescent girls
compared
to
only
1.4%
over-weight
boys.(Table2). However the difference in
prevalence of thinness among the boys and girls
was not found to be statistically significant.
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Table 2: Distribution of Adolescent Children according to Sex and BMI
BMI
Normal
Thinness (<-2SD and ≥ -3SD)
Severe Thinness (<-3SD)
Overweight (>+1SD)
Total
Boys (%)
191 (65.9)
70 (24.1)
25 (8.6)
4 (1.4)
290 (100)
Girls (%)
73 ( 71.6)
21 (20.6)
4 (3.9)
4 (3.9)
102 (100)
Total (%)
264 (67.3)
91 (23.2)
29 (7.4)
8 (2.0)
392(100)
Table 3: Distribution of Adolescent Children according to Sex and Height
Height for Age
Normal
Moderate Stunting (<-2SD and ≥-3SD)
Severe Stunting (<-3SD)
Total
Boys (%)
253 (87.2)
35 (12.0)
2.0 (0.7)
290 (100)
25
15
BMI
Total (%)
337 (85.9)
49 (12.5)
6 (1.5)
392 (100)
Considering the WHO cut-offs for stunting ,
Stunting was found in 12.5% adolescents, and
was more in adolescent girls (13.7%) compared
to boys (12.0%) .Severe stunting was found in
3.9% adolescent girls compared to only 0.7%
boys.
20
10
5
WHO Reference BMI
Study Population BMI
0
11
12
13
14 15 16
Age in Years
17
25
20
15
10
5
WHO Reference BMI
Study Population BMI
0
11
12
13
14 15 16
Age in Years
17
As in Fig.1 &2 , the BMI in all the age groups in
adolescent boys & girls was found to be less
compared to WHO reference cut-offs and the
difference was found to be statistically
significant on applying Z test (p value < .01 in all
the age groups) .
18
Fig.1: Comparison of Study Population
Adolescent Girls BMI with WHO Reference
BMI (Z-Score)
BMI
Girls (%)
84 (82.4)
14 (13.7)
4 (3.9)
102(100)
18
Fig 2: Comparison of Study Population
Adolescent Boys BMI with WHO Reference
BMI (Z-Score)
DISCUSSION
In a recent period anthropometric measurements
have become a popular measure for the
assessment of nutritional status among children
and adolescents. It is well established that among
other anthropometric measures body mass index
(BMI) is not only the single most appropriate,
cost effective and non-invasive tool for the
assessment of the nutritional status of
adolescents and adults (WHO 1995) 5but it is also
the best indicator of thinness during adolescence
. The study thinness is of particular interest
because it is associated with poor school
achievement and work productivity. Thinness is
defined as Body Mass Index (BMI) less than Z
score < -2 SD of the(WHO growth reference for
adolescents 2007) 8. BMI (weight/height2) for age
was recommended as the best indicator for use
in adolescence
In the present study the prevalence of thinness
among the adolescent age group was found to be
30.6% overall with prevalence of 24.1% thinness
and 8.6% severe thinness among boys and 20.6%
thinness and 3.9% severe thinness among girls ,
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this is comparatively less as compared to the
study findings of Anand etal9. in which
prevalence was found to be 30.1% in girls and
43.8% in boys and study by Malhotra and Passi10
which also reported the prevalence of thinness
among adolescent girls as 30.6% however this is
comparatively more when compared with a
study conducted by Kapil et al11 which found the
prevalence of Under nutrition ranging from 6.6%
to 22.5% in urban set-up. Regarding prevalence
of Over-weight only 2% were found to be overweight which is comparatively much less as
compared to findings of other studies as Kapil et.
al. The difference may be because the present
study was done in resettlement colony whereas
previous studies have been carried out in
affluent schools. However the difference in the
prevalence of thinness in boys (24.1%) and girls
(20.6%) and severe thinness (8.6%) in boys and
(3.9%) in girls was not found to be statistically
significant.
The prevalence of stunting was found to be 12%
in boys and 13.3% in girls whereas severe
stunting was 0.7% in boys and 3.9% in girls this
is also comparatively less as compared to the
study findings of Anand et.al9 which found the
prevalence to be 37.2% in boys and 19.9% in
girls.
Acknowledgement: We are grateful for the
sincere efforts by Mr. Bhoop Singh (MSW) in
data collection.
REFERENCES
1.
Edberg M. PART 3: Revised draft UNICEF/LAC core
indicators for MICS4 (and beyond) with rationale and
sample module. UNICEF the Americas and the
Caribbean Regional Office August 2009
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2.
Adolescents in India: A Profile. UNFPA for UN System
in India.
3.
Kishore J. National Health Programs of India. New
Delhi: Century Publications; 2007,p. 441-7
4.
Body Mass Index for Age percentiles (2 – 20 years).
Developed by National Centre for Health Statistics in
collaboration with the National Centre for Chronic
Disease Prevention and Health Promotion 2000, May 30,
2000. Available from:
http://www.cdc.gov/growthcharts. [modified on 2000
Oct 16]; [accessed on 2008 Oct 12]
5.
World Health Organization. Physical status: use and
interpretation of anthropometry; report of a WHO
Expert Committee. Geneva: World Health Organization,
1995. 452. (WHO technical report seriesno.854)
6.
Himes, J.H. and C. Boucher, 1989. Validity of
anthropometry in classifying youths as obese. Int. J.
Obes., 13: 183-193
7.
Fox N., Hunn A., and Mathers N. Sampling and sample
size calculation.The NIHR RDS for the East Midlands /
Yorkshire & the Humber 2007.
8.
Development of a WHO growth reference for schoolaged children and adolescents. Bulletin of the World
Health Organisation, volume 85, No 9, pp 649- 732,
September 2007. Available at
http://www.who.int/bulletin/volumes/85/9/07043497/en/print.html#R18#R18
9.
K.Anand,S.Kant , S.K Kapoor. Nutritional Status of
Adolescent School Children in Rural North India Indian
Pediatr 1999; 36: 810-815
10.
Malhotra A and Jain PS. Diet quality and nutritional
status of rural adolescent girl beneficiaries of ICDS in
North India. Asia Pac J Clin Nutr.2007;16(Suppl 1):8-16.
11.
Kapil et al, 2002. Prevalence of obesity amongst affluent
adolescent school children in Delhi. Indian Pediatrics;
39: 449-452
12.
World Health Organization. Measuring Change in
Nutritional Status. Geneva, World Health Organization
1983; pp 63-74.
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Original Article ▌
UTILIZATION OF ANTENATAL CARE SERVICES IN THE
GANDHINAGAR (RURAL) DISTRICT, GUJARAT
Vaibhavi D Patel 1, Bhavna T Puwar1, Jay K Sheth2
Financial Support: Department of
Health and Family Welfare,
Government of Gujarat
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patel VD, Puwar BT, Sheth JK.
Utilization of Antenatal Care
Services in the Gandhinagar (Rural)
District, Gujarat. Natl J Community
Med 2013; 4(1): 104-8.
Author’s Affiliation:
1Assistant Professor, Department of
Community Medicine, AMCMET
Medical College, Maninagar,
Ahmedabad; 2Assistant Professor,
Department of Community
Medicine, NHL Municipal Medical
College, Ahmedabad, Gujarat,
India.
Correspondence:
Dr. Vaibhavi Patel,
Email:drvaibhavipatel@yahoo.co.in
ABSTRACT
Back ground :Maternal and child health care is one of the eight
essential components of primary health care as per Alma–Ata
Declaration.
Materials & Methods: A Multi-Indicator Cluster Survey (MICS)
was conducted in April 2008 using 30 cluster technique.
Results: 118 (7.82 %) women who were pregnant at the time of
MICS survey were included in this article. More than half of the
women were in 20 to 24 years age group with mean age 23.75
years. At the time survey 83% of the antenatal women had
registered for Antenatal care and about two third of antenatal
women had received IFA tablets, a single dose of TT injection and
undergone BP measurement. About two third of the Antenatal
women had registered for ANC at government health facilities
and about one third at private hospital. Knowledge about the
Chiranjeevi Yojana and JSY was very poor. 61% antenatal women
had registered at Mamta session(VHND). The significant
association was found between availing the ANC services and
planning the institutional delivery.(p-0.009)
Conclusions: Awareness about the government scheme for
delivery was very low. ANC visits are opportunity for counseling
the women for institutional delivery.
Key-words: MICS, ANC, Mamta session (VHND)
Date of Submission: 26-01-13
Date of Acceptance: 20-03-13
Date of Publication: 31-03-13
INTRODUCTION
Antenatal care (ANC) refers to pregnancyrelated health care. 1 Women rarely perceive
childbearing as problematic and therefore do not
seek care. This affects the utilization of ANC
services in regions of the country where poverty
and illiteracy are wide spread. 2 To increase the
number of women for early registration,
consuming IFA tablets, two TT injections and
counseling, and thereby to increase the antenatal
coverage up to 90% is one of the objectives of the
Reproductive and Child Health (RCH) II. Also
under RCH II there is increased emphasis on
mobilization of community for weekly ANC
clinics at health facilities named as Mamta Day
or Village health and Nutrition Day (VHND). 3
Antenatal visits raise awareness and make
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pregnant women and their families familiar with
health facilities, which enable them to seek help
more efficiently during a crisis. Utilization of
antenatal care services promotes the preference
for institutional deliveries. 2 National Family
Health Survey-3 (NFHS-3) reveals just over half
of mothers (52%) had three or more antenatal
care visits. Urban women were much more likely
to have three or more antenatal visits than rural
women. 1 The present study assessed the
utilization of antenatal services in Gandhinagar
(Rural) district.
METHODOLOGY
Gandhinagar is an administrative district in the
central part of Gujarat with its headquarters in
Gandhinagar city, the state capital. It covers an
area of 2163 square kilometers with a total
population of 13,34,731 according to 2001 census.
The district has a population density of 617
persons per sq.km. and sex ratio of 911 females
per 1000 males. The district includes four talukas
with about 35% population living in urban area.4
Department of Health & Family Welfare,
Government of Gujarat planned to carry out
Multi-Indicator Cluster Survey (MICS) in various
districts. Preventive & Social Medicine (P&SM)
departments of various medical colleges who
already had good liaison with the health
department were given the responsibility for
conducting the MICS in one district each. As per
the allocation of district, MICS was planned &
carried out in rural component of Gandhinagar
district from 1st April to 17th April 2008 by
P&SM department of this institute. A total of five
teams, each comprising of four members
(1faculty member, 1 resident from P&SM
department and 2 interns) carried out the survey.
All the 5 teams surveyed 6 clusters each,
completing the survey of 30 clusters. A
structured, pre-tested questionnaire designed by
UNICEF was used after necessary modifications
and approval by the health officials of
government of Gujarat. To minimize errors and
uniform reporting, the survey team members
received training and extensively discussed the
likely problems in filling the format. To reduce
data-entry errors, programming was done using
EPI-Info software and survey team members
were assigned the duties to enter their own
collected data.
Selection of study clusters: Urban areas were
excluded from the list of district population of
2007 and a total of 292 villages/towns with
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10,34,032 total population were selected. Cluster
interval was 34,468. The first cluster was selected
using the random number which was 00092.
Subsequent clusters were selected using the
sampling interval. Thus, 30 clusters were
selected on the basis of systematic random
sampling from the probability of the cluster
selection based on the population size of the
cluster. Details of sampling within a cluster: The
30 cluster technique was used in MICS. The
cluster survey methodology has been criticized
by survey statisticians due to the manner in
which the households are selected within a
cluster.5
Documented techniques to improve the accuracy
of cluster survey method including, segmenting
sample clusters (selecting subsamples of equal
probability from within a cluster) was also
considered.6 To satisfy the objective of studying
multiple indicators, various criteria were
considered for the completion of study in one
cluster. Among these, study of households in
four different quadrants of the village with at
least two children aged 12-23 months in each
quadrant
making a total of minimum 8 children was also
considered. The present article is the part of
MICS survey undertaken during April 2008 and
information about the women who were
antenatal at the time of survey was included in
this article. Those antenatal women who were
not registered at the time of survey were
counseled for ANC services so that women who
were not registered at the time of survey might
get registered later on but as this was the cross
sectional survey follow up was not done. Data
thus gathered was entered and analyzed using
the EPI-INFO software package. Simple
proportions were calculated and appropriate
statistical tests were applied wherever found
necessary.
RESULTS
A total of 1,218 families with 6,366 subjects with
an average family size of 5.22 were studied from
30 clusters. Sex ratio was 964. Out of a total
1508(48.25%) women of reproductive age group,
majority (87%) were married and 118 (7.82 %)
were pregnant at the time of survey.
Mean age of antenatal women was 23.75 years
and median age was 23 years. Age ranged from
18 to 43 years. More than half of the women
(55.1%) were in 20 to 24 years age group while
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2.5% of antenatal women were > 35 years of age
and can be considered for high risk pregnancy.
Five percent of antenatal women were of 18 to 19
years age group. (Table-1)
Table 1: Age wise distribution of Antenatal
women
Age group
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
Frequency (n=118)
6
65
38
6
2
1
Percent
5.1
55.1
32.2
5.1
1.7
0.8
At the time of survey, 83% of the antenatal
women had registered for Antenatal care and
had done at least one ANC visit and about two
third of antenatal women had received Iron and
Folic Acid (IFA) tablets, Tetanus Toxoid (TT)
injection and undergone BP measurement. Out
of 81 women who had taken IFA tablets
71(87.65%) were consuming it regularly while
10(12.35%) were consuming the tablets
irregularly because of side effects. Out of those
antenatal women who had registered for ANC
about two third (68.37%) of Antenatal women
had registered at government health facilities
and about one third (31.63%) had registered at
private hospital (Table 2).
Table-2: Antenatal services received
pregnant women at the time of survey
Services (n=118)
Registered for
ANC
IFA received
TT received
BP measured
by
Total(%)
98 (83.1)
Public(%)
67 (68.4)
Private(%)
31 (31.6)
81 (68.6)
78 (66.1)
78 (66.1)
47 (58.0)
42 (53.8)
46 (58.9)
34 (41.9)
36 (46.2)
32 (41.0)
Table 3: Distribution of pregnant women
according to planned place for delivery
Place of delivery
Home
Govt. Hospital
Private Hospital
Not yet decided
Subjects (n=118) (%)
7 (5.93)
32 (27.12)
40 (33.90)
39 (33.05)
When asked about the choice of place for
delivery, only about one fourth (27.12%) of the
women had selected the government hospital for
delivery and one third (33.90%) had private
hospital. Six percent of women had preferred
home delivery and 33 % of the women had not
yet decided the place of delivery.(Table 3)
The antenatal women were asked about the JSY
and Chiranjeevi Yojana and their benefits. Janani
Suraksha Yojana (JSY) is a safe motherhood
intervention under the National Rural Health
Mission (NRHM) being implemented with the
objective of reducing maternal and neo-natal
mortality by promoting institutional delivery
and it integrates cash assistance with delivery
and post-delivery care among the poor pregnant
women. The Chiranjeevi Yojana implemented by
the Government of Gujarat aims at encouraging
the BPL families to improve access to
institutional delivery by providing financial
protection to these families. Knowledge about
the benefits under Chiranjeevi Yojana and JSY
was very poor, only seven antenatal women had
correct information.
Table 4 Services availed by antenatal women
during Mamta session
Services availed during Mamta
session
Visit Mamta day regularly
Having Mamta card
BP measured at Mamta session
Weight done at Mamta session
Counseled at the session
True understanding about weight
Respondent
(n=72)
52 (72.22)
59 (81.94)
46 (63.88)
61 (84.72)
40 (55.55)
24 (33.33)
On the Mamta day (VHND session) preventive,
promotive health care service are offered to
pregnant/lactating mothers and under 5
children every week on a fix day and at the fix
site. Mamta Day provide an opportunity for
integrated Management of Antenatal, Postnatal,
Neonatal Child Health and nutrition Services
and is a day of counseling for institutional
delivery; diet, IFA and Calcium supplement
compliance, child feeding and care, vaccination,
FP and early detection and timely treatment. Out
of the total antenatal women 61% had registered
at Mamta session and out of them 72.22% had
regularly visited Mamta day, 61 (85%) had
undergone weight measurement and 40(55.55%)
women were counseled about the same. Only
one third of the women visiting Mamta session
had true understanding about weight. The
services availed from the Mamta session are
lesser than beneficiaries registered at Mamta
session. (Table-4)
As per palmer examination 20 (16.95%) antenatal
women were having pallor, and 5(4.24%) women
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had pedal oedema. When asked about current
health status 106(89.83%) of antenatal women
responded that they were healthy and only
10(8.47%) had complained about weakness.
Minor health complains during the pregnancy
were rarely perceived as problematic by
antenatal women and therefore did not seek care.
Table 5: Association of variable of ANC
services with age of antenatal women
Variable
Place for ANC
Govt. sector
Private hospital
Age in years
≤25(n=73)
>25(n=25)
46(63.01)
21(84.00)
27(36.99)
4(16.00)
P
value
0.051
Table 6: Association of variable of ANC
services with planned place of delivery
Place of delivery
decided
Institutional
Not decided/
home delivery
Registration for ANC
Yes (n=98) No (n=20)
65(66.33)
7(35)
33(33.67)
13(65)
P
value
0.009
Among those Antenatal women who had
registered their ANC, place of registration was
associated with age. Among both the groups
(above and below 25 years of age) registration
was higher in government sector. Registration at
government place was slightly higher among
antenatal women above 25 years (84%) then the
antenatal women < 25 years age group (63%),
however the difference was not significant. Out
of 98 women who had registered for ANC,
65(66%) had planned for institutional delivery,
while out of 20 antenatal women who had not
done a single ANC visit, only 7(35%) had
planned their delivery at the institution and this
difference was statistically significant. (p-0.009)
(Table 5 and Table 6).
of women taking ANC from government sector
than private hospital while when planning the
place of delivery, higher percentage of women
had planned it in private hospital compared to
government facilities. Six percent of women had
planned home delivery. In general, women
prefer to deliver at home for reasons such as
support, familiarity, tradition, and belief that
birth is considered a natural phenomenon for
which an institutional delivery is not required.2 .
Sixty one percent of antenatal women found to
be registered at Mamta session while a study in 7
states found 45% of antenatal women used
VHND services.8 The percentage of antenatal
women availing various services from Mamta
session was slightly less than percentage of
women registered at Mamta session indicating
that all the women who had registered at Mamta
day were not given all the services available for
them on the Mamta day. This study did not
observe the significant association of place of
registration and age antenatal women. Majority
of women (66%) with antenatal care observed to
plan an institutional delivery. Similar to a study
by Nomita Chandhiok etal this study also found
significant association of availing the ANC
services and planning the institutional delivery.2
It may therefore, be possible to promote
institutional delivery by promoting antenatal
check-ups and associated counseling.
CONCLUSION
Though the ANC registration among the
antenatal women of rural area in Gandhinagar
was high, the awareness about the benefits under
the government scheme for delivery was very
low so there is a need for enhancing awareness
about the same. Those antenatal women who
had done at least an ANC visit plan institutional
delivery, so ANC visits are opportunity for
counseling the women for institutional delivery.
DISCUSSION
This study was carried out among 1,218 families
with 6,366 subjects. Out of a total 1508(48.25%)
women of reproductive age group, 118 (7.82 %)
women who were pregnant at the time of survey
were included in this article. More than half of
the antenatal women were in 20 to 24 years age
group similar to a study in Karnataka.7 Out of
total antenatal women 2.5% were > 35 years of
age and 5% were at age of 18 to 19 years can be
considered for high risk as they may develop
serious consequences for the health of
themselves and their infant. Higher percentage
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Original Article ▌
FUTURE PHARMACOLOGICAL ARMAMENTARIA IN
MANAGEMENT OF ALZHEIMER DISEASE
Megha H Shah1, Hetal D Shah2, Vipul P Chaudhari3
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Shah MH, Shah HD, Chaudhari VP.
Future Pharmacological
Armamentaria in Management of
Alzheimer Disease. Natl J
Community Med 2013; 4(1): 109-16.
Author’s Affiliation:
1Assistant Professor, Department of
Pharmacology, B.J. Medical
College, Ahemedabad; 2Consultant
Cardiac Anesthetic, Narayana
Hrudalaya, Ahmedabad; 3Assistant
Professor, Department of
Community Medicine, Government
Medical College, Surat.
Correspondence:
Dr. Megha Shah,
Email: mkshah_80@yahoo.com
Date of Submission: 30-05-12
Date of Acceptance: 22-11-12
Date of Publication: 31-03-13
Introduction: Alzheimer’s disease (AD) is a chronic progressive
neurodegenerative disorder and common cause of dementia in
elderly. With advancing age, number of people suffering from AD
is also increased. Exact aetiology of AD was not known and
therapy was focused mainly on increasing central cholinergic
transmission with drugs like donepazil, reivastigmine and
galantamine. With the generation of amyloid hypothesis,
extracellular amyloid plaques, consisting of amorphous extra
cellular deposits of β-amyloid protein (known as Aβ) and
intraneuronal neurofibrillary tangles(Tau) mainly in the
hippocampus and frontal cortex ,altered processing of amyloid
protein from its precursor (amyloid precursor protein, APP)
recognised as the key to the pathogenesis of AD. But, now various
studies have shown that etiology may be multifactorial. Inspite of
having identified many potential targets, currently no drug
modifying disease pathology is available .Advancement of the
early diagnostic methods like positron emission tomography
(PET) scan and measurement of various biomarkers like NO
tagged proteins, ADAM-10 in c.s.f. could potentiate research to
develop disease modifying drugs. Drugs modifying Y secretase,
tyrosine kinase inhibitors, sigma receptor agonists, anti-Aβ
monoclonal Abs are in the various stages of drug development
and could become the cornerstone in the management of AD in
future.
Methods: Reviews from index journals and books were taken in
this study. In this process, we identified 276 possible sources of
information which, upon further scrutiny, were eventually
reduced to 30 appropriate studies for inclusion in the review.
Conclusion: Understanding the role and extent of factors causing
AD, robust designing of RCTs with use of various biomarkers and
multitargeted therapeutic approach are required to develop
disease modifying drug which can ameliorate suffering of
alzheimer disease patients.
Key words: Alzheimer Disease, Management, New Targets,
Dementia
INTRODUCTION
Alzheimer’s disease (AD) is a progressive
neurodegenerative disorder and a commonest
cause of dementia in elderly people. It is one of
the major health problems in the United States
and the developed world. Because the presence
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of clinical AD doubles with every 5 years after
60, preventing the onset of clinical AD by 5 years
would reduce the AD population by half. About
5.5 million persons in the United States have AD,
and the odds of receiving a diagnosis of AD after
the age of 85 exceeds one in three.1 With
increasing population of elderly people,
prevalence of AD is also increased. As a disease
which makes patient dependent, is booming,
effective treatment for that is the need of the
hour. The U.S. Senate has passed National
Alzheimer's Project Act (NAPA) to combat this
major problem. NAPA calls for a coordinated
effort across the federal government and from
research, care, and institutional services and to
home and community based programs to combat
the crisis across the broad spectrum of the
disease.
Initially, loss of cholinergic neurons in the
hippocampus and frontal cortex was thought to
underlie the cognitive deficit and loss of shortterm memory in AD patients and so treatment
was based mainly on increasing central
cholinergic transmission with cholinergic drugs.
Tacrine followed by donepezil, rivastigmine and
galantamine were mainly used. For many years,
treatment was based only on a single factor.
Therapy provided limited therapeutic benefits.
Later on two microscopic characteristic features
of the disease i.e. extracellular amyloid plaques,
consisting of amorphous extra cellular deposits of
β-amyloid protein (known as Aβ), and
intraneuronal neurofibrillary tangles, comprising
filaments of a phosphorylated form of a
microtubule-associated protein (Tau) discovered.
They appear also in normal brains, although in
smaller numbers. The early appearance of
amyloid deposits presages the development of
AD, although symptoms may not develop for
many years. Altered processing of amyloid
protein from its precursor (amyloid precursor
protein, APP) by
B and Y secretase
enzymes is recognised as the key to the
pathogenesis of AD. The genetic analysis of
certain rare types of familial AD discovered
mutations of the APP gene, or of other genes that
control amyloid processing. The APP gene
resides on chromosome 21, which is duplicated in
Down's syndrome; in which early AD-like
dementia occurs in association with over
expression of APP.2 Recent studies have shown
that AD is a complex disease and the aetiology
may be multifactorial. 3
Though research succeeded in identifying many
potential targets for AD, its causes might not yet
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be understood at a level adequate for
discovering disease modifying drugs. Inability to
identify potential targets and penetrating blood
brain barrier, absence of early diagnostic and
prognostic methods are important factors
leading to failure of clinical trials for developing
disease modifying drugs. Early detection and
treatment of Alzheimer's disease is essential for
better outcome. But, conventional methods of
diagnosis such as cognitive tests are helping to
catch the disease at its advanced stages, when
the patient is already suffering from distinct
cognitive impairments.
METHODS
We document the pharmacological aspects
associated with Alzheimer’s disease. To provide
a context for the review, we first present the key
questions and analytic framework. Next we
describe the methods used to identify articles
relevant
to
our
key
questions,
our
inclusion/exclusion criteria.
Data source are MEDLINE® and the Cochrane
Database of Systematic Reviews. Additional
studies were identified from reference lists and
technical experts.
Key Questions:
1.
2.
3.
4.
Which are the newer /latest diagnostic tools
for Alzheimer’s disease?
Which are the different criteria By National
Institute on Aging and the Alzheimer’s
Association?
What are the therapeutic aspects for
Alzheimer’s disease?
Which are the different drugs useful in
Alzheimer’s disease and it’s mechanism of
action?
Inclusion and Exclusion criteria:
1.
2.
3.
4.
Pharmacological study for Alzheimer’s
disease.
Time period: 2007 to June 2012
Publication language: English
Good quality systematic reviews that
addressed a question of interest and used
eligibility criteria consistent with our
inclusion /exclusion criteria.
Original research studies that provide
sufficient detail regarding methods and
results to enable use of the data and results;
relevant outcomes must be able to be
abstracted from data presented in the papers.
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For all questions, we were interested in new
targets and latest information. We included
primary literature to update eligible reviews or
when good quality reviews were unavailable.
Using the pre-specified inclusion/exclusion
criteria, titles/abstracts were examined relevance
to the key questions. Articles included by
underwent full-text screening. In this process, we
identified 276 possible sources of information
which, upon further scrutiny, were eventually
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reduced to 30 appropriate studies for inclusion in
the review.
RESULTS
Identification of multifactorial aetiology, recent
development of early diagnostic methods could
serve as a ray of hope for disease modifying anti
alzheimer drugs. Newer methods for early
diagnosis of AD may become the main
cornerstone in patient management. (Table-1)
Table 1: Newer Diagnostic tools for Alzheimer’s disease
Tool
Positron emission
tomography
(PET) scan
USE
It is a molecular imaging technique, is used to detect the formation of beta-amyloid plaques
in the brain. Subjects had PET scans using 11C Pittsburgh Compound-B (11C-PIB), a PET
imaging agent that binds to beta-amyloid in neural tissues.
Patients with a strong family history of Alzheimer's or who show mild signs of memory loss
could be screened for the development of the disease in order to help them plan for the
future. This imaging technique could also be used to evaluate the effectiveness of new
treatments as they become available 2
Radioactive dye,
Amyvid
Biomarkers
The dye binds to clumps of a beta amyloid plaque and light up on a positron emission
tomography, or scan.4
Use of various biomarkers indicative of the AD pathophysiological process
Like CSF Ab42, CSF tau, both total tau and phosphorylated tau (p-tau); decreased
18fluorodeoxyglucose (FDG) uptake on PET in temporo–parietal cortex will allow scientists
to test treatments or preventions far earlier in the disease, when they could be more
effective. These newer methods may be more useful for research and in specialized medical
centres for diagnosing patients with symptoms of Alzheimer's dementia. It requires proper
standardization of these methods and appropriate cut-off level before routine clinical use.
Biomarker test results can fall into three categories–clearly positive, clearly negative, and
indeterminate.
The NINCDS-ADRDA criteria, describing
clinical diagnosis of AD, proposed by the
National Institute of Neurological and
Communicative Disorders and Stroke (NINCDS)
and the Alzheimer’s disease and Related
Disorders Association (ADRDA) have been quite
successful, surviving for over 27 years. However,
with advancement of understanding the
pathophysiology of AD and invention of new
targets, these criteria requires revision.
Therefore, the National Institute on Aging and
the Alzheimer’s Association workgroup has
proposed revised the criteria and to classify
individuals with dementia caused by AD in to
three category(1) Probable AD dementia, (2)
Possible AD dementia, and (3) Probable or
possible AD dementia with evidence of the AD
pathophysiological process. The first two are
intended for use in all clinical settings. The third
is currently intended for research purposes. 5
Here, we are trying to provide a review of
important new targets and drugs (table-3) for
treatment of AD.
1) Cholinergic drugs: Inspite of wide use of
cholinergic in AD, various clinical trials have not
been able to develop any potential drug. Trials
with muscarinic receptor agonists has had
limited success owing to unavoidable side
effects.6 Ispronicline (AZD-3480) is a selective
agonist of the nicotinic receptor α4β2.I n Phase-2
trial neither it nor donepezil showed significant
effect on the primary outcome (ADAS-cog) after
12 weeks of treatment, but post-hoc analysis
suggested a positive effect on ADAS-cog at the
20 mg dose.7 However, two recent developments
occurred in existing cholinergic therapy.
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Table 2: Proposed Revised Criteria By National Institute on Aging and the Alzheimer’s
Association5
AD Category
Probable AD
dementia
Criteria
1)Insidious onset(months to years),
2)worsening of cognition by report or observation,
3)initial and prominent cognitive deficits involving one of the following domains:
− Amnesia(in learning and recall of recently learned information) ,
− Nonamnestic(Language, Visuospatial)
− Executive dysfunction (impaired reasoning, judgment, and problem solving.
4) Deficits in other cognitive domains mentioned in Criteria for all-cause dementia i.e.
Impaired reasoning and handling of complex tasks, poor judgment or Changes in
personality, behavior, comportment should be present.
Criteria should not be applied when there is evidence of substantial concomitant
cerebrovascular disease or
evidence for another concurrent, active neurological disease, or a non-neurological medical
comorbidity or use of medication that could have a substantial effect on cognition.
Possible AD
dementia
1) Atypical course course meets the core clinical criteria of the cognitive deficits for AD
dementia, but either has a sudden onset of cognitive impairment or demonstrates
insufficient historical detail or objective cognitive documentation of progressive decline, Or
2) Etiologically mixed presentation meets all core clinical criteria for AD dementia but has
evidence of
(a) concomitant cerebrovascular disease or (b) Dementia with Lewy bodies or (c) evidence
for another neurological or a non-neurological medical comorbidity or medication use that
could have a substantial effect on cognition
Probable AD
dementia with
evidence of
the AD
pathophysiolo
gical process
To increase the certainity of diagnosis, In addition to core clinical criteria , also depends on
two Classes of Biomarkers
1) of brain amyloid-beta (Ab) protein deposition like low CSF Ab42 and positive PET
amyloid imaging
2) biomarkers of downstream neuronal degeneration or injury. The three in this category
are elevated CSF tau, both total tau and phosphorylated tau (p-tau); decreased
18fluorodeoxyglucose (FDG) uptake on PET in temporo– parietal cortex; and
disproportionate atrophy on structural magnetic resonance imaging in me-dial, basal, and
lateral temporal lobe, and medial parietal cortex.
Table-3 Current Status Of Some Important Targets For Alzheimer Disease
Cholinergic drugs
Y secretase modulators
α-secretase activators
β secretase inhibitors
Increasing Aβ removal
Drugs targeting Tau protein
Tyrosine kinase inhibitors
Sigma1 receptor agonists
Higher-Dose donepezil HCl 23 mg Tablet
Rivastigmine patch
Tarenflurbil
Etazolate (EHT 0202)
Bryostatin-1
ADAM10 protein
PPAR-Y agonists type-II antidiabetic drugs
Monoclonal antibody – Bapineuzumab
Human immune globulin
Vaccination
AL-108
Masitinib
ANAVEX 2-73
Higher-dose donepezil HCl
Donepezil HCl is the first and only prescription
medication approved by the FDA for the
treatment of all stages of AD—mild, moderate
and severe. It was prescribed as 5 mg -10 mg
tablet once a day. The recommended starting
dose is 5 mg once daily and can be increased to
10 mg once daily after four to six weeks. The
Approved by U.S.FDA
Approved by U.S.FDA
Phase 3
Positive results in Phase2
Phase 2
Preclinical
Failed due to cardiotoxicity
Phase 3
Phase 3
Failed in Phase 2
Phase 2
Phase 3
Phase 1
U.S.FDA approved a new once-daily, higherdose donepezil HCl (Aricept) 23 mg tablet for the
treatment of moderate-to-severe Alzheimer's
disease (AD). Moderate-to-severe AD patients
who are established on a regimen of 10 mg
donepezil tablet for at least three months are
candidates for dose escalation to 23 mg . A large
study of donepezil HCl 23 mg tablet versus 10
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mg tablet in 1,400 patients with moderate-tosevere AD demonstrated a statistically
significant improvement in cognition measure,
Severe Impairment Battery (SIB), but no
significant improvement in Clinician's InterviewBased Impression of Change Plus Caregiver
Input (CIBIC+), a measure of global function.
Nausea, vomiting, diarrhea, difficulty in
sleeping, anorexia and weight loss were the most
common adverse events noted with 23 mg
donepezil tablet. Incidence of nausea and
vomiting was more in patients taking 23 mg/day
donepazil versus 10 mg/day.8
Rivastigmine transdermal patch
Rivastigmine transdermal patch provides an
innovative way to deliver an effective medicine
for mild to moderate AD patients instead of an
oral capsule. It is applied to the back, chest or
upper arm and provides smooth and continuous
delivery of medication over 24 hours. Patch
showed similar efficacy to capsules and the
recommended dose (9.5 mg/24 hours) was
generally well tolerated by patients. Patch not
only improves compliance but also reduces
common gastrointestinal side effects of
cholinesterase
inhibitors.9
Rivastigmine
transdermal patch is approved by the U.S.FDA
for treating mild to moderate Alzheimer's
disease.
2) Drugs decreasing Aβ generation
γ-secretase modulators: γ-secretase is the
enzyme responsible for the final step in Aβ
generation. The reasons which could inversely
affect development are collateral effects of γsecretase inhibitors like haematological and
gastrointestinal
toxicity, skin reactions, and changes to hair
colour, mainly caused by inhibition of the notch
signalling pathway, which is involved in cell
differentiation.
Tarenflurbil is a modulator of the activity of γsecretase and decreases Aβ42 .It is a derivative of
flurbiprofen, a NSAIDs. In a phase 2 trial in 210
mild AD patients, receiving 800 mg tarenflurbil
twice per day had lower rates of decline in
activities of daily living and global function
compared with placebo.10 The results stimulated
a large multicentre, phase 3 trial of tarenflurbil in
1,684 subjects with mild AD at doses of either
400 or 800 mg twice daily or placebo. 18 months
score on the Alzheimer's disease Assessment
Scale showed tarenflurbil had no beneficial effect
on the primary or secondary outcomes. The
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discrepant findings between the phase 2
subgroup analyses and the phase 3study may be
due to low dose and requires strongly caution
against designing trials and analysis.11
α-secretase activators: APP is also cleaved in a
non amyloidogenic pathway by α-secretase
within the Aβ domain thereby preventing the
formation of Aβ. Etazolate (EHT 0202) is in a
new class of disease modifying therapies which
stimulate the α-secretase pathway, thus
enhancing the production of the procognitive
and neuroprotective sAPPα fragment of APP.
Preclinical and Phase I studies demonstrated
good tolerability of EHT 0202. Recently
published results of EHT 0202 phase IIa study
showed clinical safety and tolerability in mild to
moderate Alzheimer's disease patients. The effect
of two different doses of EHT 0202 (either 40 or
80 mg twice a day) as adjunctive therapy to one
acetylcholinesterase inhibitor was evaluated in
comparison to placebo.12
Bryostatin-1, another α-secretase activator is in
phase 2 to evaluate safety in patients with mildto-moderate Alzheimer’s disease (NCT00606164).
ADAM10 protein:
Processing of APP by α-secretase generates the
soluble APPsα ectodomain, which may have
neuroprotective and neurotrophic properties.
The resulting membrane-bound C-terminal
fragment is further cleaved by γ-secretase to
produce p3, an N-terminal truncated Aβ
derivative. Three members of the ADAM (a
disintegrin and metalloprotease) family of
metalloproteases are described to have αsecretase activity, namely ADAM9, ADAM10
and ADAM17. This is in accordance with PeerHendrik Kuhn et al who concluded When
ADAM10 is less active; the precursor protein is
more likely to be cleaved in a way that promotes
the formation of beta-amyloids.13
In contrast, a large-scale (n = 576: Controls, 271;
AD, 305) resequencing study of ADAM10 in
sporadic AD do not support a significant role for
ADAM10 mutations in AD.14 Further studies are
required to determine the role of ADAM
proteins in AD.
β secretase inhibitors:
Developing β secretase inhibitors is challenging
because the enzyme has wide substage
variability which can affect other functions also
including myelination. The type-II antidiabetic
drugs rosiglitazone and pioglitazone showed β
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secretase inhibition but their cardictoxicity failed
further development.15
3) Increasing Aβ removal:
Monoclonal antibody - Bapineuzumab is a
humanized anti-Aβ monoclonal antibody. It is
directed against the N-terminus of Aβ and is
hypothesized to bind to Aβ in the brain to
facilitate its removal. A phase 2 multipleascending-dose trial in mild to moderate AD
tested the safety and efficacy of bapineuzumab.16
A safety concern was the occurrence of reversible
vasogenic edema. Results of phase-II were not
conclusive and phase-III studies are ongoing.
However, a recent study showed that treatment
with bapineuzumab for 78 weeks reduced
fibrillar amyloid burden in subjects with AD,
shown by Pittsburgh compound B positron
emission tomography ((PiB-PET) 17
Vaccination in a phase 2a trial (NCT00021723)
resulted in encephalitis18, and follow-up of
immunized patients showed no cognitive or
survival benefit despite diminution of plaques.
4) Drugs targeting Tau protein: AL-108 inhibits
hyperphosphorylaiton of tau and formation of
neurofibrillary tangles. AL-108 given intranasally
by spray also resulted in a significant
improvement.19 AL-108 (10mg twice daily) gave
a statistically significant improvement in the
delayed match-to-sample test (DMTS 12s) in a
phase 2 study after 12 weeks of treatment. With
low dose (5 mg) AL-108 did not produce any
significant results.20
5) Tyrosine kinase inhibitors
Neuroinflammation is thought to be important in
Alzheimer's disease pathogenesis. Mast cells are
a key component of the inflammation and
participate in the regulation of the blood-brain
barrier's permeability. Masitinib is a new orally
administered tyrosine kinase inhibitor of mast
cells. It effectively inhibits the survival,
migration and activity of mast cells.
Masitinib administered as an add-on therapy to
standard care for 24 weeks to 35 patients in a
phaseII trial showed significant decrease in the
cognitive decline compared to placebo, with an
acceptable tolerance profile. The rate of clinically
relevant cognitive decline according to ADASCog response (increase >4 points) after 12 and 24
weeks was significantly lower with masitinib
(6% versus 50% for both time points; p=0.040 and
p=0.046, respectively. Adverse events occurred
more with masitinib treatment (65% versus 38%
of patients); however, the majority of events
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were of mild or moderate severity and
transitory. Masitinib also lead to gastrointestinal
disorders, oedema, and rash. Although the
sample size was too small to make any definitive
conclusions about treatment efficacy, the
evidence is sufficiently compelling to warrant
further phase 3 investigation.21
6) Sigma1 receptor agonists: Sigma1 receptors
are ligand regulated receptors on endoplasmic
reticulum, involved in alzheimer’s disease,
stroke, amnesia, pain, ethamphetamine or
cocaine addiction, depression, HIV infection and
cancer. Sigma1 receptors cause modulation of
ion channels, including Ca2+-, K+-, Na+, Cl−,
and also NMDA and IP3 receptors. Various
studies showed the role of Sigma 1 receptors in
AD. Donepezil, a potent acetylcholinesterase
inhibitor is also a potent sigma-1 receptor
ligand.22
Tetrahydro-N,
N-dimethyl-5,
5-diphenyl-3furanmethanamine hydrochloride (ANAVEX 273) is the first compound which act through
sigma-1
receptor
agonism,
muscarinic
cholinergic
effects
and
modulation
of
endoplasmic reticulum. It has demonstrated
potent neuroprotective, anti-amnesic, anticonvulsive and anti-depressive activity in preclinical studies and prepared to enter in phase-1
clinical trials.23 It could be the gleam of hope for
patients of alzheimer’s disease.
7) Others
NIPSNAP1:
Hemachand
Tummala
and
colleagues24 observed that in Alzheimer's
disease, mitochondria are damaged and lose
their function. This happens long before the
appearance of symptoms. Study on mice showed
APP directly interacts with the neuron-specific
mitochondrial
protein,
4nitrophenylphosphatase domain and nonneuronal SNAP25-like protein homolog 1
(NIPSNAP1) and may thereby regulate
mitochondrial function in neurons. Drugs
targeting NIPSNAP1 could prevent early onset
and progression of AD.
Presenilin 1 Gene: Presenilin 1(PS1) plays a key
role in "macroautophagy". It is a process for
digesting and recycling unwanted proteins and
essential for neuron survival. Mutations of
PS1can lead to defective lysosomal proteolysis,
pathogenic protein accumulations and neuronal
cell death in AD and suggests previously
unidentified therapeutic target. The other
mechanism could be disruption of calcium
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homeostasis by increase release of calcium from
endoplasmic reticulum in to cytoplasm.25
Statins: Role of statins is appealing but
controversial and the exact mechanism is still not
clear. A defect in cholesterol metabolism is an
appealing hypothesis because it ties together the
apolipoprotein E (APOE) genetic risk, amyloid
production and aggregation, and vasculopathy
of Alzheimer’s disease. Glial-derived APOE is
the primary cholesterol transporters in the brain3
. A single E4 allele increases the risk of AD.
However, a large observational study has found
statins appear to cut the risk of developing
Alzheimer's disease by up to 56%, even among
those with the high-risk apolipoprotein E4 allele.
Also, the association between statin use and risk
reduction was consistent for both lipophilic and
hydrophilic agents, but absent in non-statin
cholesterol-lowering drugs. Simvastatin followed
by atorvastatin and pravastatin were commonly
prescribed. The proposed mechanisms are
improved endothelial functioning, reduced
atherosclerosis and oxidative stress.26
However, no significant clinical benefit on
cognition or global functioning was shown for
atorvastatin in a 72-week, phase 3 RCT in
patients with mild-to-moderate alzheimer’s
disease already taking donepezil.27
5 LOX inhibitors A study found that the genetic
absence of 5-LOX in mice resulted in a significant
reduction in brain Aβ levels and deposition.28
Zileuton, used in asthma, (5 LOX inhibitor) had a
significant reduction in the amount of Aβ formed
and deposited in mice brains. It is in preclinical
stage and needs more clinical studies to confirm.
Antioxidants: R-lipoic acid delivered in the
plasma can cross the blood brain barrier and be
reduced to DHLA.DHLA a very powerful
intracellular antioxidant1. It also increases
glucose uptake and glucose metabolism,
improving the energetic state of cells. DHLA is
also an effective chelator of iron. It also is able to
regenerate vitamin C, vitamin E, and glutathione
from
their
oxidized
products.29
Also,
combination of R-lipoic acid (300 mg) with
vitamin-c could be beneficial to the patients.
Intramuscular administration of deferoxamine,
an iron chelator, significantly improved daily
living skills and slowed the clinical progression
of dementia in a two-year single blind study in
patients under 74 years of age with probable
AD.1
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According an in vitro-culture study by Ning
Chen and colleagues,30 on the brains of adult and
aged rats, HUCBs were not only able to protect
hippocampal neurons (an area for long term
memory) but also promoted the growth of
dendrites - the branching neurons acting as
signalling nerve communication channels - as
well as induced the proliferation hippocampal
neurons. These effects may be a function of
growth factors and cytokines produced by the
HUCB cells.
CONCLUSION
Present alzheimer therapy is only providing
limited symptomatic relief to patients.
Researchers have identified potential targets and
are at preclinical or clinical stages of drug
development. Though results of several RCTs are
disappointing, turned focus towards identifying
potential errors in conducting RCTs. Proper
selection and number of patients is must to avoid
influence of multifactorial etiology and genetic
polymorphism. Use of various biomarkers
instead of using subjective rating scale could be
more effective measure of efficacy of disease
modifying antialzheimer drugs. Understanding
the role and extent of factors causing AD, robust
designing of RCTs with use of various
biomarkers and multitargeted therapeutic
approach are required to develop disease
modifying drug which can ameliorate suffering
of alzheimer disease patients.
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Margaret L. Moline, Qin Wang et al.Effectiveness and
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Alzheimer's disease: A 24-week, randomized, doubleblind study. Clinical Therapeutics, 2010, 32(7); 1234-51.
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Original Article ▌
A STUDY OF OSTEOARTICULAR TUBERCULOSIS IN A
TERTIARY CARE HOSPITAL OF BHOPAL, MADHYA
PRADESH
Saurabh Sharma1, Sanjay Kumar Gupta2, Atul Varshney3, Archa Sharma4, Akhil Bansal5, Ashlesh
Choudhary1
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Sharma S, Gupta SK, Varshney A,
Sharma A, Bansal A, Choudhary A.
A Study of Osteoarticular
Tuberculosis in a Tertiary Care
Hospital of Bhopal, Madhya
Pradesh. Natl J Community Med
2013; 4(1): 117-20.
Author’s Affiliation:
1Senior Resident, Department of
Orthopedics, PCMS & RC, Bhopal;
2Associate Professor, Department of
Community Medicine; 3Professor,
Department of Orthopedics; 4PG
student, Department of
Microbiology, CMC, Vellore;
5Assistant professor, Department of
Orthopedics, GMC, Bhopal
Correspondence:
Dr Sanjay Kumar Gupta,
Email: sanjaygupta2020@gmail.com
Background: Osteoarticular tuberculosis (TB) represents 1–5% of
all cases of tuberculous disease and 10–18% of extra pulmonary
involvement. Signs and symptoms are frequently nonspecific
making the disease difficult to diagnose. This study was
conducted to find out the trend of various osteoarticular TB.
Methods: It was a hospital based descriptive study
Results Of the total 118 were studied , maximum were in the age
group of between 21-30 years .Males were higher 58 % (68) than
females 42.37 %( 50). Maximum cases were from Rural
background 73% (87). Hindus were maximum 87.28 %( 103)
cases followed by Muslims 12 %( 14) . According to site of the
joint various Regions/Joints were involved, most common
osteotuberculr site was Spine 75.57% (88) followed by Hip12.71%
(15), least common site observed in our study was shoulder joints
. Other associated medical conditions were also observed like
Psoas abscess in 6.8% (8), paraplegia/paresis in 11.84% (14) and
Pleural Effusion in 5.93% (7) cases. Around 16.10% (19) cases
underwent surgeries, 4.23% (5) cases confirmed by biopsy. After
conducting this study we learnt that many time we unable to
reach firm diagnosis of bony problem or not responding to usual
treatment in that time very high chance patients may have
osteoarticular tuberculosis.
Conclusion: TB spine is the comments site of osteoarticular
tuberculosis, so developing country like India any person walk in
the department with history of spinal problems always to be
consider TB one of the cause.
Date of Submission: 09-10-12
Date of Acceptance: 29-01-13
Keywords: Osteoarticular, Tuberculosis, Tertiary care hospital,
Bhopal MP.
Date of Publication: 31-03-13
INTRODUCTION
Tuberculosis remains a world-wide public health
problem despite the fact that the causative
organism was discovered 100 years ago and
highly effective drugs and vaccine are available.
South East Asia Region accounted for (35%) of all
notified new and relapse cases. 1, 2 The annual
risk of TB in high burden country is estimated
0.5 to 2 %. India is the highest TB burden country
in the world and accounts nearly one- fifth (20%)
of global burden of TB. Every year
approximately 1.8 million persons develop
tuberculosis; of which about 0.8 million are new
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smear positive highly infectious cases.3
Osteoarticular tuberculosis (TB) represents 1–5%
of all cases of tuberculous disease and 10–18% of
extra pulmonary involvement. 4,5 Signs and
symptoms are frequently nonspecific and easily
misdiagnosed as brucellosis, aspergillar ,
spondylitis, tumor metastasis
and juvenile
rheumatoid arthritis. 4, 9, 10, 11 Moreover, up to
50% of patients do not show concurrent
pulmonary disease . Because of this, the disease
is difficult to diagnose.13 The delay in diagnosis
may range from months to years and it may
damage joints or cause spinal cord compression
resulting in paralysis.9, 13, 14, 15 Therefore, it is
very important to maintain a high degree of
clinical suspicion, especially in Spain where the
TB rate per 100 000 inhabitants is one of the
highest among the developing nations .16
Objectives: To find out the trend of various
osteoarticular tuberculosis (TB) and to study the
socio demographic factors in relation to TB
MATERIALS AND METHOD
Present study was carried out in the Peoples
College of medical sciences and Research
Institute Bhopal; it is an 1100 bed tertiary care
Medical college hospital, for the period of 3
years from 2009 September to 2012 September.
Data of all osteo tubercular patients were
collected from medical record department;
information was collected regarding patient’s
general and medical information like age, sex,
religion, occupation, areas,
type of joint
involvement, duration of hospital stay and
associated medical problems and type of
investigation and their finding were recorded
and analysed.
OBSERVATIONS
Of the total 118 cases maximum were in the age
group of between 21-30 years with lowest age
being 2.5 years old and maximum being a 85
year old . Male cases higher 68 (58%) than female
cases in the study group 50(42.37%). Maximum
cases were from Rural background 87(73%) and
Hindus 103(87.28%). Duration of stay maximum
was for the group 08-15 days which had
36(30.50%).
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Table 1: Osteoarticular TB cases according to
their socio-demographic profile
Category
Age groups
0-10
11-20
21-30
31-40
50 and above
Sex
Male
Female
Religion
Hindu
Muslim
Others
Occupation
Farmer/unskilled worker
Skilled worker
House wife
Areas
Rural
Urban
Cases (%)
10 (8)
21 (18)
39 (33)
34 (29)
14 (12)
68(57.62)
50(42.37)
103(87.28)
14(11.86)
1(0.84)
58(49.15)
08(6.77)
52(44)
87(73.72)
31(26.27)
Table 2: Distribution of osteoarticular TB cases
according to their joint involvement
Joint Involved
Knee
Hip
Spine
Shoulder
TB Osteomylitis
Ankle joint
Elbow
Cases (%)
06(5%)
15(12.71%)
88(74.57%)
01(0.84%)
01(0.84%)
04(3.38%)
03(2.54%)
According to site of the joint various
Regions/Joints were involved, most common
osteotuberculr site was Spine 88(75.57%)
followed by Hip15 (12.71%), least common site
observed in our study was shoulder joints.
Tubercular Osteomylitis with shaft of femur
involvement was least common 0.84%. All the
cases admitted to the ward were asked to
undergo various laboratory investigations
including x-rays, ESR, Monteux test, Sputum
positivity for those suspected of having
Respiratory focus, MRI, however 17 (14.40%) .
Table 3: Osteoarticular TB cases according to
gender wise associated complication
Category
Psoas abscess
Paraplegia
Pleural effusion
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Male (%) Female (%) Total (%)
05(7.35%)
03(6%)
08(6.775)
10(14.70%)
04(8%)
14(11.86%)
03(4.41%)
04(8%)
07(5.93%)
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Table 4: Osteoarticular TB cases according to
investigation
performed
and
operative
procedure required
Investigation
ESR
Monteux +
Sputum for AFB +
X-ray suggestive
MRI suggestive
Biopsy for AFB +
Known cases of TB
Operative procedure
required
No investigation done
Male
Female
Total
31 (45.6 ) 24 (48) 55 (46.6)
10 (14.7 ) 02 (4) 12 (10.2)
02 (2.9)
03 (6)
05 (4.2)
08 (11.8) 06 (12) 14 (11.9)
10 (14.7) 08 (16) 18 (15.2)
04 (5.9) 02 (2.9)
06 (5)
08 (11.8) 04 (8) 12 (10.2)
18 (26.5) 20 (40) 38 (32.2)
09 (13.2)
08 (16 ) 17 (14.4)
Figure in parenthesis indicate percentage
In
laboratory
investigations
Erythrocyte
Sedimentation rate ( ESR )may be considered for
probable diagnosis, 10(14.70%) of the males
tested positive for Monteux while only 2 (4%)
females tested positive for the same , 2(2.94%) of
the male cases tested positive for sputum for
Acid Fast Bacilli as opposed to 3(6% ) cases
belonging to the female gender , suggestive x
ray findings of osteoarticular TB were found
in14 (12%), MRI Findings suggestive of
osteoarticular TB was seen in 18(15.25%) cases ,
Other associated medical conditions were also
observed Psoas abscess in 8(6.8%) of cases,
paraplegia/paresis14( 11.84% ) of the cases and
Pleural Effusion in 7(5.93%) . Around 19(16.10%)
cases underwent surgery and 5(4.23%) cases
confirmed by biopsy positivity.
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symptoms such as pain, swelling in the joints,
fever,
loss
of
weight/appetite,
cough,
breathlessness, tenderness, effusion, restriction
of movements, elevated ESR, and history of
pulmonary TB or past TB diagnosed by either Xray or Magnetic Resonance Imaging (MRI) ,
similar type of observation also made by Ruiz G
, KD Vaughan and K Kumar .19,20,21In our study
we have followed the local population especially
the rural set up in a tertiary care hospital and
have highlighted the above points and also tried
to understand the various physical and
psychosocial plaguing the general population
leading to improper treatment and hence
increasing the morbidity and mortality. It cannot
be over emphasized that inspite of Revise
National Tuberculosis Control Programme
(RNTCP) health programs we need to recognize
and
properly
treat
the
osteoarticular
Tuberculosis cases.
CONCLUSION
TB spine is the comments site of osteoarticular
tuberculosis, according to the outcome, it is very
important to have a high level of clinical
suspicion, especially in patients at risk in
countries like India with a high prevalence of
tuberculosis. , it shows that how skeletal
tuberculosis is actually managed in our
environment (Hospitals) where the disease
remains a public health issue, but significant,
percentage of osteoarticular involvement.
DISCUSSION
Present study was reported 118 cases of
osteoarticular TB in last three years,
Osteoarticular tuberculosis remains a significant
worldwide problem, being a source of functional
disability, which could lead to severe infirmities.
Therefore, it should be recognized and treated
early. As TB is endemic in India, most orthopedic
surgeons diagnose osteoarticular TB based on
clinical and imaging findings only and initiate
empirical anti-TB treatment. In the present study
Osteoarticular TB to be maximum in the spine
followed by the hips and the knees while a some
percentage of cases in other sites –ankle, long
bones, hand joints, elbow, shoulder, ribs, pelvis,
foot and hand bones ,similar type of observation
also made by Sukamal Bisoi et al . 16 The
another study conducted by Poppel MH et al
and Goldblatt M et al, they also reported spine is
the comments site for tuberculosis.17,18 The
clinical features suggesting the diagnosis were
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et al. Tuberculosis extrapulmonar diseminada con
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afección cutánea, ganglionar y ósea. An Med Interna
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Meier JL. Mycobacterial and fungal infections of bone
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Evanchik CC, Davis DE, Harrington TM. Tuberculosis
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Rheumatol 1986; 13:187–9.
10. Goldblatt M, Cremin BJ. Osteoarticulat tuberculosis; its
presentation in coloured races. Clin Radiol 1978; 29:66977.
11. Cordero M, Sanchez I. Brucellar and tuberculous
spondylitis. A comparative study of their clinical
features. J Bone Joint Surg Br1991; 73: 100–3.
12. Ur-Rahman N, Jamjoom ZA, Jamjoom A. Spinal
aspergillosis in nonimmunocompromised host
mimicking Pott's paraplegia. 1: Neurosurg Rev 2000; 23:
107–11.
13. Jacobs JC, Li SC, Ruzal-Shapiro C et al. Tuberculous
Arthritis in Children. Diagnosis by Needle Biopsy of the
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Ellis ME, El-Ramahi KM, Al-Dalaan AN. Tuberculosis of
peripheral joints: a dilemma in diagnosis. Tuber Lung
Dis 1993; 74:399–04.
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Sukamal Bisoi, Amitabha Sarkar, Sharmila Mallik,
Anima Haldar, Dibakar Haldar , A study on
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RNTCP 2007;32:245-48.
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Gottlieb J, Noer HH. Skeletal tuberculosis. Two case
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Poppel MH, Lawrence LR, Jacobson HG, Stein J.
Skeletal tuberculosis: a roentgenographic survey with
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K Kumar, MBL Saxena. Multifocal Osteoarticular
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Original Article ▌
TRENDS OF UTILIZATION OF FAMILY PLANNING
METHODS AT DISTRICT HOSPITAL OF MADHYA
PRADESH: A RETROSPECTIVE STUDY
Garima Namdev1, Swarna K Likhar2, Mahesh Kumar Mishra3, Arvind V Athavale4, Umashanker
Shukla5
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
Introduction: Population stabilization is the answer to curtail
existing population growth of 1.2% in India and it can be
achieved by effective use of contraception by couples. This study
was designed to analyze the trends of utilization of different
family planning methods in relation with socio-demographic
factors at district hospital in last five years.
How to cite this article:
Namdev G, Likhar SK, Mishra MK,
Athavale AV, Shukla U. Trends of
Utilization of Family Planning
Methods at District Hospital of
Madhya Pradesh: A Retrospective
Study. Natl J Community Med
2013; 4(1): 121-4.
Material and Method: A retrospective study was done by
analyzing last five year records from family planning clinic at
district hospital.
Author’s Affiliation:
1PG resident; 2Associate Professor;
3Professor; 4Professor & HOD;
5Lecturer, statistics, Community
medicine, PCMS&RC, Bhopal
Correspondence:
Dr. Garima Namdev,
Email: garima_namdev@yahoo.com
Date of Submission: 20-10-12
Results: At family planning clinic, 1,84,522 individuals visited out
of 12,33,753 individuals came for utilization of outdoor services at
hospital during the five year period. Among them, 96%
individuals utilized temporary methods and only 4% utilized
permanent methods. Among temporary methods, 81.4% utilized
condom, 10% OCP’s and 3.8% IUCD, whereas among permanent
methods, 3.4% utilized tubectomy and 0.6% vasectomy. The trend
of utilization of family planning methods was found decreasing
from 84.4% to 78% among male whereas increasing among female
from 15.6% to 22% in last five year duration.
Conclusion: The utilization of contraceptive methods was more
common among male especially temporary (condom) as
compared to the female but the utilization of permanent methods
was more in rural folks as compared their urban counterparts.
Date of Acceptance: 24-01-13
Date of Publication: 31-03-13
Key words: Trends, Utilization, Family Planning methods
INTRODUCTION
Growing population is the burning problem
adversely affecting the development and social
security in the world today, mainly in Asia,
South America, and Africa and especially in
India.
India with a population of 1.22 billion (according
to 2011 census) is the second most populous
country in the world.1 With current trends, the
Indian population with a growth rate of 1.2%
annually, will increase from 1.028 billion to 1.4
billion during the period from 2001-2026, an
increase of 36% in 25 years and is further
projected to reach 1.53 billion by the year 2050. 1
Current annual increase in the population is also
adversely affecting the resources, endowment
and environment.2 Thus population stabilization
is the answer to all these problems and it can be
achieved by effective use of contraception. But
unmet need of contraception poses a challenge to
family planning programme – to reach and serve
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million of women who for some or other reason
are not using contraceptive. 2
It is a well known fact that the acceptance of
contraception by a couple is governed by many
factors like availability of services and facilities
for provision of contraceptive devices. Apart
from it, various socio demographic factors like
age, sex, religion, education, income, occupation,
urban /rural differences, and family size also
affecting the use of contraceptives by couple.
Thus present study attempts to analyze the
trends of utilization of different contraceptive
services in last five years at District hospital of
Madhya Pradesh.
MATERIAL AND METHODS
A retrospective record based study was done to
analyze the trends of utilization of different
contraceptive methods in last five year. The data
was collected by analyzing the records of last
five year i.e. from April 2006 to March 2011 from
family planning clinic in District hospital,
Sehore, a small town in Madhya Pradesh.
An inclusion criterion for this study was the
individuals who adopted contraceptive methods
at family planning clinic.
The various socio-demographic factors like age,
gender, religion, family size and utilization
pattern in reference to urban and rural area were
analyzed for adoption of different family
planning methods.
Data were analyzed by using statistical tests like
semi average method of time series and Z test of
proportion.
RESULTS
During the five year period, 12,33,753
individuals utilized the services on outdoor basis
at District hospital. Out of this, 1, 84,522 (15%)
individuals visited at family planning clinic and
adopted various kinds of contraceptive methods
like condom, intrauterine contraceptive device,
oral contraceptives, medical termination of
pregnancy, tubectomy, and vasectomy.
At family planning clinic, 96% individuals
utilized temporary methods whereas only 4%
utilized permanent methods. Among temporary
methods, 81.4% utilized condom, 10% utilized
OCP’s and 3.8% IUCD, whereas among
permanent methods, 3.4% utilized tubectomy
and 0.6% vasectomy. (Table 1)
Table 1: Utilization Pattern of different contraceptive methods in last five years
Year
2006-07
2007-08
2008-09
2009-10
2010-11
Total
Condom (%)
26218 (83.8)
29065 (84.05)
29133 (83.09)
31064 (80.55)
34696 (77.47)
150176 (81.4)
Vasectomy (%)
195 (0.62)
192 (0.55)
219 (0.62)
236 (0.61)
253 (0.56)
1095 (0.6)
OCP’s (%)
2692 (8.6)
2702 (7.8)
2921 (8.3)
3908 (10.1)
6085 (13.5)
18308 (10)
IUCD (%)
1055 (3.37)
1258 (3.63)
1363 (3.8)
1575 (4.07)
1730 (3.85)
6981 (3.8)
MTP (%)
244 (0.78)
278 (0.8)
295 (0.84)
350 (0.9)
383 (0.8)
1550 (0.8)
T.T. (%) Attendees at FP clinic
877 (2.8)
31281
1084 (3.1)
34759
1128 (3.2)
35059
1455 (3.7)
38688
1668 (3.7)
44915
6212 (3.4)
184522
Table 2: Age wise utilization of contraceptive methods in last five years
Year
2006-07
2007-08
2008-09
2009-10
2010-11
Total
18-22 yr. (%)
3308 (1.8)
4200 (2.3)
5680 (3)
3182 (1.8)
3402 (1.9)
19772 (10.8)
23-27 yr. (%)
12550 (6.8)
13275 (7.2)
15525 (8.5)
13883 (7.6)
12256 (6.7)
67489 (36.6)
The maximum utilization of family planning
methods was found in age group of 23-27 year
(36.6%) (Table 2) and among Hindus (57.4%).
However, utilization of permanent methods was
more in rural folks (66.2%) as compared their
urban counterparts (33.8%).
28-32 yr. (%)
11025 (6)
12112 (7)
13734 (7.5)
9961 (11.8)
11234 (6)
58066 (31.5)
>32 yr. (%)
7800 (4.2)
8544 (4.7)
10426 (5.7)
7755 (4.2)
4670 (2.6)
39195 (21.2)
Total (%)
34683 (18.8)
38131 (20.7)
44365 (24)
34781 (18.8)
32562 (17.7)
184522
The utilization of contraceptive methods was
more common among male as compared to the
female, but the trend was found decreasing from
84.4% to 78% among male whereas increasing
among female from 15.6% to 22% in last five year
duration. (Table 3)
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Table 3: Gender wise utilization of different
contraceptive methods
Year
2006-07
2007-08
2008-09
2009-10
2010-11
Total
Male (%)
Female (%)
26413 (84.43)
29257 (84.6)
29352 (83.7)
31400 (81.6)
35059 (78.3)
151371(82.09)
4868 (15.6)
5322 (15.4)
5707 (16.3)
7288 (18.8)
9866 (22)
33051(17.91)
Attendees at
FP clinic (%)
31281 (16.95)
34579 (18.74)
35059 (19)
38688 (21)
44915 (24.34)
184522 (15)
Figure in parenthesis indicate percentage
Table 4: Trend of Tubectomy with family size
in last five year
Year
2 children(%) 3 children(%) >3 children(%)
2006-07
285 (32.5)
307 (35)
285 (32.5)
2007-08
334 (31)
402 (37)
348 (32)
2008-09
373 (33)
429 (38)
326 (29)
2009-10
435 (30)
588 (40.5)
432 (30)
2010-11
447 (27)
701 (42)
520 (31)
Total
1874 (30.2)
2427 (39)
1911 (30.8)
The trend of tubectomy was consistently
increasing with 3 children i.e. from 35% in 200607 to 42% in 2010-11(Table 4), whereas the trend
of vasectomy among couples having 2 children
was found consistently increasing in last five
year from 38% to 45%. (Table 5)
Table 5: Trend of Vasectomy with Family size
in last five year
Year
2 children(%) 3 children(%) >3 children(%)
2006-07
74 (38)
66 (34)
55 (28)
2007-08
75 (39)
53 (28)
64 (33)
2008-09
90 (41)
74 (34)
55 (25)
2009-10
104 (44)
54 (23)
78 (33)
2010-11
114 (45)
45 (18)
94 (37)
Total
457 (41)
292 (27)
346 (32)
Table 6: Trend of MTP services in last five yrs
Year MTP services Z value P value
Significant
A
0.78
5.71
<0.0001 Highly significant
B
0.84
A
0.78
11.4
<0.0001 Highly significant
C
0.9
A
0.78
6.65
<0.0001 Highly significant
D
0.85
A = 2006-07, B = 2008–09, C = 2009-10, D = 2010-11
The trend of utilization of MTP services were
found increasing from 0.78% to 0.9% in duration
between 2006-07 to 2009-10 and then decrease
from 0.9% to 0.85% from 2009-10 to 2010-11. Semi
average method of time series was applied in the
trend of utilization of permanent methods and
no significant results were found. Z test of
proportion was applied in the trend of MTP
services in last five years and were found results
highly significant. (Table6)
DISCUSSION
The present study revealed that 96% individuals
accepted temporary methods for spacing and
limiting birth whereas only 4% beneficiaries
chosen permanent methods. Out of 96%,
majority of beneficiaries (81.4%) preferred the
use of condom and followed by oral
contraceptives by 10% and intrauterine
contraceptive device preferred only by 3.8%
beneficiaries. Out of permanent methods,
utilization of tubectomy (3.4%) is higher as
compared with vasectomy (0.6%). A study in
urban population of North India 3 and another at
Karachi 4in 2008 too had found that condom was
the most common method followed by oral pills
and IUCD which is in tandem with our study.
This could be due to easy availability of condom
at vending machine at hospital and more bold
T.V. campaigns for use of condom by media for
prevention of HIV/AIDS created more
awareness.
However, results of several other studies in
neighboring country are contrary to our findings
like at Lahore 5and Sindh 6 it was reported that
tubal ligation was the most common method of
family planning followed by condom and IUCD
which may be due to social customs, fear and
cultural misbelieves about accepting IUCD of
that particular area.
Utilization of contraceptives is found highest
among Hindus (57.4%) as compare to Muslims
(33.8%) in present study which is similar with
finding reported by Renjhen 7 at Sikkiam.
The interesting finding emerged out of this study
is that adoption of permanent methods was more
among rural folks as compared to their urban
counterparts. This is contrary to another studies
conducted by Tuladhar etal in Nepal 8and Sajiid
etal at Lahore 5 . More acceptances of permanent
methods among rural folks in our study could be
due to targeted approach given to health care
providers with the result more mass camps are
being organized in rural area with lucrative
incentive to achieve allotted target. These camps
are patronized by high level government
functionary and active social workers which
motivate rural folk to seek surgical methods.
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Decline trend of utilization of services by
beneficiaries from 84.4% to 78% amongst male
(2006-07 to 2010-11) may be due to a number of
reasons to name few availability of better quality
product in the market at competitive price,
availability of alternative health services i.e.
sponsored campaigns by various NGO’s closer
to door steps, where such services could be
received and new privately owned specialist
clinics in the area. However, traditionally female
beneficiaries do not visit alone to such facilities
and continued to pattornize government service
providers.
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LIMITATIONS OF STUDY
1. As it is a Hospital based study, in which,
records were taken from only one hospital.
Hence these results cannot be extrapolated to
general population.
2. Information on some important variables of
socio demographic factors like education,
occupation, income of family planning acceptors
was not available from records.
REFERENCES
1.
K. Park, Park’s Text book of Preventive & social
medicine, 21st edition, 2011, Jabalpur, Banarsidas Bhanot
Publishers.
2.
Santhya, K.G.(2003), Changing Family Planning
scenario in India. An overview of recent evidence.
Regional Working Paper no. 17, New Delhi: Population
council, South and East Asia. Chopra S.,Dhaliwal
L.,Knowledge,attitude and practices of contraception in
urban population of north India.Arch Gynecol
Obstet2010;281:273-277.
3.
Chopra S.,Dhaliwal L.,Knowledge,attitude and
practices of contraception in urban population of north
India.Arch Gynecol Obstet2010;281:273-277.
4.
Rozina Mustafa, Uzma Afreen and Haleema A.
Hashmi,Contraceptive Knowledge Attitude and Practice
Among Rural Women. Journal of the College of
Physicians and Surgeons Pakistan 2008, Vol. 18 (9): 542545.
5.
Sajiid A.,Malik S.,Knowledge,Attitude and Practice of
Contraception among Multiparous Women at Lady
Aitchison Hospital, Lahore.Annals2010;Vol16nov4:26669.
6.
Seema Bibi, Amna Memon, Zehra Memon, Misbah Bibi,
Contraceptive, Knowledge and practices in two districts
of Sindh, Pakistan:A hospital based study.J Pak Med
Assoc.2008;vol.58: 254-57.
7.
Renjhen P.,Gupta S.,Barua A.,Jaju S.,Khati B.,A Study of
Knowledge,attitude and practice of family planning
among the women of reproductive age group in
Sikkiam.Journal of ObetetGynecol India
Vol.58,No.1;January/February2008pg.53-57.
8.
Tuladhar H.Marahatta R.Awareness and practice of
Family Planning methods in women attending Gyne
OPD at Nepal Medical College Teaching Hospital.Nepal
Med Coll J2008;10(3):184-191.
CONCLUSION
In present study, trend of utilization was found
most common for temporary (96%) as compared
with permanent (4%). Among temporary
methods, 81.4% utilized condom, 10% utilized
OCP’s and 3.8% IUCD, whereas among
permanent methods, tubectomy was more
preferred method (3.4%) as compared with
vasectomy (0.6%).
Utilization of permanent methods was more in
rural folks (66.2%) as compared their urban
counterparts (33.8%). The trend of utilization of
family planning methods was found decreasing
among male whereas increasing among female
in last five year duration.
RECOMMENDATIONS
More emphasis should be given on imparting the
training of health care providers on how to
engage the couples and promote the usage of
various contraceptive methods by using flip
charts, lecture and talk show. Proper counseling
and motivational activities for target couples
should be boosted up. More and more
beneficiaries should be encouraged for adopting
the permanent methods of family planning as it
is very cheap, safe, and easy to perform and free
of side effects.
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Original Article ▌
ADOLESCENCE: THE DILEMMA OF TRANSITION
Bhawana Pant1, Anuj Vaish2, Parul Sharma3, Anuradha Davey3, Rahul Bansal4, Harinder Singh5
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Pant B, Vaish A, Sharma P, Davey
A, Bansal R, Singh H. Adolescence:
The Dilemma of Transition. Natl J
Community Med 2013; 4(1): 125-31.
Author’s Affiliation:
1Professor; 2Post Graduate Student;
3Assistant Professor; 4Professor &
Head, Community Medicine,
Subharti Medical College, Meerut;
5Asstistant Professor, Community
Medicine, Gian Sagar Medical
College , Ram Nagar, Banur,
District Patiala, Punjab
Correspondence:
Dr Anuj Vaish,
Email: drbpant2007@rediffmail.com
Date of Submission: 27-11-12
Date of Acceptance: 04-03-13
Date of Publication: 31-03-13
Introduction: Generally Adolescence group is considered healthy
and has not been given adequate attention in health programs.
Not only are needs of the adolescents related to their physical, but
also to their emotional and psycho-social development. This
study was conducted to study the epidemiological correlates of
physical, psycho-social & spiritual attributes & their risk
behaviors among adolescents in urban Meerut city of Uttar
Pradesh, India.
Methodology: A cross-sectional study was conducted among 200
adolescents from two colleges of Meerut.
Results: The study on physical dimension depicted that very few
(26.6%) adolescents exercised daily, approximately two-thirds
consumed fruits and vegetables routinely, and 95% missed meals
whereas 98% showed dependency on fast foods. The personal
dimension highlighted that a greater proportion (88.5%) were
aware about dangers of unsafe sex but only 26.8% believed it to
be a route for HIV/AIDS transmission. The spiritual dimension
showed that 77% adolescents prayed regularly. The social
dimension depicted that 58% adolescents were given importance
in family decisions. It also showed that one-third resorted to
drinking under stress.
Conclusions: Current research indicates a need for early
intervention, rather than dismiss these as a transitory experience.
School & college authorities should take monthly sessions on the
issues related to adolescence with the parents. The dismal picture
of HIV awareness should be addressed through intensive
HIV/AIDS awareness campaigns &IEC activities.
Key words: College Adolescents, Physical, Psycho-social,
Spiritual, Meerut, India.
INTRODUCTION
Each culture recognizes a time of passage from
childhood to adulthood- the Adolescence, where
experimentation is dominant and the need to
challenge authority evident. It is defined by
WHO1 as the age group of 10-19 years. In India,
adolescents constitute 21.8 percent of the
population2 and are a significant human resource
that needs to be given ample opportunity for
holistic development towards achieving their full
potential. Adolescence is generally divided into
three stages of development: early (10-13 years),
middle (14-15 years), and late adolescence (16-19
years).3,4 Not only are needs of the adolescents
related to their physical, but also to their
emotional and psycho-social development. With
an estimated 1.2 billion adolescents alive today,
the world has the largest adolescent population
in history.5
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Many adolescents die prematurely every year, an
estimated 1.7 million lose their lives to accidents,
violence, pregnancy related complications and
other illnesses that are either preventable or
treatable.5
Generally this group is considered healthy and
has not been given adequate attention in health
programs. The reason is age specific mortality is
comparatively low in this age group as
compared to others.
Community surveys have the advantage of being
more representative; they include adolescents
who do not attend counseling centers and to the
best of my knowledge there are no large scale
community-based studies to assess awareness
about the various factors. Hence, the present
study was undertaken to evaluate the effect of
various physical, psycho-social & spiritual
attributes, their awareness and source of their
information.
The subjects who were not willing to participate
were told that they may not return the
questionnaire. Anonymity was maintained by
not including the names of the respondents.
The reasons for noncompliance by 14 adolescents
were involvement in other events of the college
& lack of interest in the questionnaire, and being
too shy to respond.
The information collected was converted into a
computer-based spreadsheet. Data was entered
and replies to different questions were analyzed
statistically by applying z-test.
RESULTS
The present cross-sectional study focused on
physical (life-style), emotional, social & spiritual
attributes of the adolescents. Among the above
mentioned 250 students, 214 were in the age
group of 17-19 years, & thus only these were
included in the study.
MATERIAL AND METHODS
Physical/Life-style Dimensions (Table 1):
A cross sectional study was conducted among
200 adolescents attending the educational
institutes of Meerut city in the state of Uttar
Pradesh, India. The study was conducted under
the auspices of the department of Community
Medicine with ethical approval from our
institution.
The life-style attributes studied were- exercise,
intake of fruits & vegetables, intake of milk &
milk products, fast-food & habit of missing
meals & statistically significant results (p-value <
0.05) were obtained for all the above mentioned
attributes.
Consecutive sampling technique was used & all
the first year students from the medical (150
students) & dental fraternity (100 students)of
two educational institutes were included in the
study from October 2010 to Dec 2010. Age was
recorded in completed years based on college
records.
Data was collected by interviewing
adolescent boys and girls. A previously
tested,
pre-designed,
validated,
administered & close ended questionnaire
used to collect the information.
the
preselfwas
Prior informed verbal consent was taken from
the respondents for the study. Questionnaire
consisted of questions targeted at information
regarding various attributes related to physical,
psycho-social & spiritual dimensions of
adolescents.
The questionnaire was first explained to the
adolescents and then they were asked to fill it
carefully. The students were also told that it was
not mandatory to fill/return the questionnaire.
The current study revealed that 15.5% of the
adolescents do not have the routine of doing
exercise whereas the majority (84.5%) preferred
to do exercise. Among these, only one-fourth
(26.6%) had a habit of doing it daily & majority
(65.7%) of them did it occasionally.
On studying the inclination towards the intake of
fruits & vegetables, it was found that 98.5% were
practicing it. The daily intake was seen in 68%, &
16.8% were consuming them occasionally. The
remaining 15.2% have it when forced by their
parents. After studying the life-style for the
intake of milk & milk products, most of them
(96.5%) followed the routine whereas the
remaining were ignorant for the same. The
pattern of intake was 70.5% once a day willingly
& 5.7% when forced by the parents.
The highly prevalent fondness of fast-foods for
fast life, which is one of the important predisposing factors for NCD’s was studied & it was
seen that 98% have a dependency on fast-food, &
among these 15.8% were consuming it regularly.
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Missing meals has become a common part of
today’s life-style due to number of reasons. A
surprisingly high figure of 95.5% stated that they
miss meals, & among these 24.6% were doing it
because of their inclination towards junk food,
whereas 6.8% do it willingly for good body
physique.
Table 1: Distribution of Adolescents According
to the Physical Dimensions (n=200)
Variable
Adolescents z-score p-value
Exercise
No
31 (15.5)
13.27
<0.05
Yes
169 (84.5)
Daily
45 (26.6)
Thrice a Week
13 (7.69)
Occasionally
111 (65.7)
Intake of Fruits & Vegetables
No
3 (1.5)
60.6
<0.05
Yes
197 (98.5)
Daily
134 (68)
When Parents forces me
30 (15.2)
Occasionally
33 (16.8)
Intake of Milk & Milk products
No
7 (3.5)
35.77
<0.05
Yes
193 (96.5)
Twice a day willingly
46 (23.8)
Once a day willingly
136 (70.5)
When Parents forces me
11 (5.7)
Fast-food (for Fast Life)
No
4 (2)
53.33
<0.05
Yes
196 (98)
Daily
31 (15.8)
Twice a Week
71 (36.22)
Once a Week
94 (47.9)
Missing Meals
No
9 (4.5)
30.33
<0.05
Yes
191 (95.5)
When I am not hungry (in 131 (68.6)
hurry)
Because of Junk Foods
47 (24.6)
Willingly (for good body
13(6.8)
shape)
Multiple responses; Figure in bracket indicates percentage.
Personal Dimensions (Table 2A, 2B, 2C):
Sex during adolescence saddles one with health
risks because the nervous system is still under
formation. Such type of attitude predisposes
them to RTI’s/STI’s. Talking about the intimate
physical relationship, 54% were decisive on the
thought of being physical only after marriage,
whereas the remaining was expedient being
physically related before marriage, but these
results were not statistically significant.
The viewpoints collected for the avoidance of
unwanted pregnancy showed us the dominoeffects as 89% were aware about it & the results
were statistically significant.
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Table 2A: Knowledge & Views Regarding
Sexuality among Adolescents (n=200)
Variable
Adolescents z-score p-value
Intimate Physical Relationship
Before Marriage
92(46)
1.14
>0.05
After Marriage
108 (54)
Avoidance of Unwanted Pregnancy
Aware
178 (89)
17.73
<0.05
Unaware
22 (11)
Knowledge about Safe Sex
Aware
131 (65.5)
4.56
<0.05
Unaware
69 (34.5)
Dangers of Unsafe Sex
Aware
177 (88.5)
16.74
<0.05
Unaware
23 (11.5)
Given Education on Sexuality
No
40 (20)
10.71
<0.05
Yes
160 (80)
Parents
14 (8.75)
Teaches
36 (35)
Friends
56 (35)
Television & Books
49 (30.6)
Others
5 (3.1)
Best & Reliable Source
Parents
73 (36.5)
3.97
<0.05
Teachers
44 (22)
9.65
Friends
64 (32)
5.45
Documentary Movies in
60 (30)
6.25
Schools
Multiple responses; Figure in brackets indicates percentage
A relaxing figure of 65.5% of the adolescents was
aware about the knowledge of safe sex, but the
remaining crestfallen figure of 34.5% was still
found unaware. More than three-fourths i.e.
88.5% were aware about the dangers of unsafe
sex. A great proportion (80%) of the adolescents
agreed that they have been educated about
sexuality, & the majority gained the knowledge
through friends, television & books (35% &
30.6% respectively). The other sources were
parents & teachers, but the best & reliable source
was parents (36.5%) as others could distort the
information, though because of cultural barriers
this is often not possible in Indian scenario.
Table 2B: Knowledge of HIV/AIDS among
Adolescents (n=200)
Variable
Adolescents z-score p-value
Transmission of HIV/AIDS
Sexual Contact/Unsafe Sex
195 (26.8)
7.48
<0.05
Contaminated Needles
183 (25.1)
8.3
Blood Donation
181 (24.9)
8.37
From Mother to Child
168 (23.1)
9.28
AIDS Cannot Spread By
Touching/Kissing/Hugging
188 (27.3)
7.09
<0.05
Using Same Razor
54 (7.8)
22.2
Sharing Same Toilets
157 (22.8)
9.38
Sharing Towels/
164 (23.8)
8.73
Clothes/Utensils
Bitten By Same Mosquito
126 (18.2)
11.77
Multiple responses; Figure in brackets indicates percentage.
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Knowledge about transmission of HIV/AIDS is
really important now-a-days & its prevalence is
increasing in this group. 26.8% believed the
underlying cause to be unsafe sex, 25.1% thought
the cause being contaminated needles & the
remaining one-quarter each thought it to be due
to blood donation & peri-natal transmission
respectively.
(17.5%) confessed that they pray only during
exams or other stressful situations. 2.5% prayed
when asked by somebody else while 3% did not
pray at all.
Even in today’s era, three-fourth of the
adolescents feel that HIV/AIDS can spread by
touching/kissing/hugging,
sharing
same
toilet/towels/clothes/utensils or bitten by same
mosquito and shockingly these results were
statistically significant.
Variable
Adolescents z-score p-value
When Do You Pray
Everyday
154 (77)
9
<0.05
Exams & Other Stressful
35 (17.5)
12.03
Conditions
When Told By Someone Else
5 (2.5)
43.18
Does Not Pray At All
6 (3)
39.17
When Do You Feel Near To God
While Praying
66 (33)
5.15
<0.05
By Obeying Parents
59 (29.5)
6.4
By Helping Poor/Needy
65 (32.5)
5.3
By Fasting
5 (2.5)
43.18
I Don’t Feel Near To God
5 (2.5)
43.18
Views Regarding Wrong Deeds Affecting Your Destiny
God Punishes On The Same
32 (16)
13.08 <0.05
Day
God Punishes In The Same Life 148 (74)
7.74
God Punishes In Another Birth 2 (1)
70.00
Doesn’t Affect Destiny
11 (5.5)
27.81
(as destiny once written can’t be
changed)
I Don’t Believe In Karmic Law 7 (3.5)
35.77
Multiple responses; Figure in brackets indicates percentage
Table 2C: Distribution of Adolescents
According to the Substance Abuse (n=200)
Variable
Adolescents z-score p-value
Cigarette/Tobacco/Alcohol Ever Experienced
Yes
50 (25)
8.33
<0.05
No
150 (75)
Role of Peer Pressure in Smoking/Alcoholism
Yes
88 (44)
1.71
>0.05
No
112 (56)
Reason for Indulging in Smoking/Alcoholism
Peer Pressure
129 (40.8)
2.6
<0.05
Status Symbol
83 (26.2)
7.93
Imitating Parents & Elders
22 (6.9)
23.94
Sign That You Are Grown-up 69 (21.8)
9.72
Others
13 (4.1)
32.78
Multiple responses; Figure in brackets indicates percentage
It is seen that smoking and drinking become
symbols of maturity and independence, among
the young people.
When questioned about their drug-abuse
behavior, 25% agreed they have ever
experienced cigarette, tobacco or alcohol. When
asked about the reason for indulging, 40.8% said
it to be due to peer pressure. About a quarter feel
it to be a status symbol & another quarter
consider it to be a sign of grown-up. A small
percentage of 6.9 indulge imitating their parents
& elders.
Table 3: Distribution of Adolescents According
to the Spiritual Quotient (n=200)
The further study on spiritual quotient went
forward asking as to when you feel near to God33% said while praying, 32.5% felt while helping
poor/needy & another 29.5% believed by
obeying parents. 2.5% by fasting & rest 2.5%
never felt close to God. Also, the above results
were statistically significant.
Even in today’s materialistic world, people still
rely on destiny i.e. Karmic Law, & this has been
revealed through our present study that only a
small proportion of 3.5% doesn’t believe in
karmic law, & again only 5.5% reckon that
destiny once written can’t be altered. Threefourths (74%) opine that God punishes in the
same life for the wrong deeds.
Spiritual Dimensions (Table 3)
Social Dimensions (Table 4):
Though an important dimension, WHO has
not included it in the definition of health
because it is difficult to quantify & there are
no scales available to measure it, still we
made an attempt to whatever little we can
extract on spirituality in the present study.
We questioned as to how much their words
mattered in the family, & more than half (58%)
said that they were taken seriously while 10%
never gave suggestions.
When asked about the frequency of praying, a
statistically significant figure of 77% conceded
that they do it regularly. Less than a quarter
When asked that whom they would resort to
when under stress, 34.8% preferred talking to
friends & another 24.2% always conversed with
the parents. The study also brought forward the
dependency on drug abuse like smoking &
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alcoholism under stress, but only a small
percentage of 2.6 resorted to the same.
There is a rising scale of working women which
brings forward a major question as to which
nurturing is better: 77.5% of the adolescents were
of the opinion that the upbringing by a homemaker is better than a working mother, & these
results were statistically significant.
It is important to have an idol for an ideal life, &
when questioned about the same, more than
three-fourths (83.5%) believed that there should
be an idol, & among these more than half (59.5%)
considered their parents as their idol.
Table 4: Distribution of Adolescents According
to the Social Quotient (n=200)
Variable
Adolescents zpscore value
Your Say in the Family
It’s Taken Seriously
116 (58)
2.29
<0.05
Only Heard But Not
48 (24)
8.67
Implemented
I Am Not Just Involved
16 (8)
22.11
I Don’t Give Suggestions
21 (10)
19.05
Under Stress You Would
Talk To Friends
108 (34.8)
4.47
Talk To Parents
75 (24.2)
8.6
<0.05
Talk To Relatives
36 (11.6)
16.7
Watch Television/Play Games
20 (6.6)
24.11
Go To Sleep
31 (10)
19.05
Avoid Talking
27 (8.7)
20.65
Smoking/Drinking
8 (2.6)
43.09
Others
5 (1.6)
48.4
Upbringing By Which Mother Is Better
Working
45 (22.5)
9.16
<0.05
Housewife
155 (77.5)
Footprints You Would Follow
No Idol Followed
33 (16.5)
12.88 <0.05
Idol Present
167 (83.5)
-Parents
119 (59.5)
-Others
48 (24)
Views Regarding Treatment To Be Given To Elderly In The
Family
Must Be Taken Care-Off In The 148 (74)
8
<0.05
Home Itself
Old-Age Homes & Day-Care
8 (4)
32.86
Centers
Joint Family System To Be
41 (20.5)
10.17
Revived
Are Capable To Care About
1 (0.5)
70
Themselves
Others
2 (1)
53.33
Multiple responses also considered; Figure in parenthesis
indicates percentage.
Now with the advancements in the medical
technology & increasing life expectancy, India
too has an increasing graph of the geriatric
population, & when the adolescents viewpoint
were taken about the treatment they would give
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to the elderly in the family, about three-fourths
(74%) feel that they must be taken care-off in the
home itself, & strikingly a quarter (20.5%) of
them felt that the joint family system should be
revived for their better care. Only 4% were
comfortable with the idea of old age homes &
day-care centers.
DISCUSSION
As India is in the transitional phase & the recent
data states that 53% of the overall mortality is
due to non-communicable diseases (NCD’s),
increasing emphasis is being laid on the life-style
factors, as this is the time when the seeds of
harmful practices are sowed. Hence, there is a
definite need to monitor the prevalence of these
risk factors in this age group and plan
interventional measures for the same.
Physical/Life-style Dimensions:
On studying the inclination towards the intake of
fruits & vegetables, it was found that 98.5% were
practicing it. However, Singh A K et al6 (2006) in
Delhi reported contrasting result and found an
extremely low consumption of fruits and
vegetables, only 39.4% adolescents had fruits
daily.
In the current study, 98% of the adolescents have
a dependency on fast-food, & among these 15.8%
were consuming it regularly. A study done by
Singh A K et al6 (2006) in Delhi found that about
one-third of the adolescents ate fast food more
than three times a week.
Personal Dimensions:
Sex during adolescence saddles one with health
risks because the nervous system is still under
formation. Such type of attitude predisposes
them to RTI’s/STI’s.
In the present study, a great proportion (80%) of
the adolescents agreed that they have been
educated about sexuality, & the majority gained
the knowledge through friends, television &
books (35% & 30.6% respectively). The other
sources were parents & teachers, but the best &
reliable source was parents (36.5%) as others
could distort the information, though because of
cultural barriers this is often not possible in
Indian scenario. A study by Sadhna Gupta et al7
(2006) revealed that regarding reproductive facts,
now a day’s television is the most important
source of information on sexuality, pregnancy,
contraception, AIDS and STD, followed by
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books, friends and elders in descending order.
Watsa8 in his study showed that they received
sex information usually from mass media and
friends but it was not reliable. Teachers were ill
equipped to clear their doubts on sex. Francis et
al in a Delhi-based study observed that most
frequent source of information on reproductive
facts was books (53.8%) followed by friends
(47.3%). Gaash Basir et al9 (2003) in a study in
Srinagar observed that the chief source of
information about HIV/ AIDS in case of 73.34
per cent adolescents was media, both electronic
(47.8%) and print (25.56%) followed by friends,
teachers, parents and siblings.
When questioned about their drug-abuse
behavior, 25% agreed they have ever
experienced cigarette, tobacco or alcohol. A
study by Rahul Sharma et al11 (2010) in Delhi in
the age-group of 14-19 years revealed ever tried
cigarette or bidi smoking was acknowledged by
16.0%, the prevalence of tobacco use overall,
including smoking and smokeless form
consumption, was found to be 20.9% in his
study. The World Health Organization estimates
that 70% of premature deaths among adults are
due to behavioral patterns that emerge in
adolescence, including smoking, violence, and
sexual behavior.12
Knowledge about transmission of HIV/AIDS is
really important now-a-days & its prevalence is
increasing in this group. 26.8% believed the
underlying cause to be unsafe sex, 25.1% thought
the cause being contaminated needles & the
remaining one-quarter each thought it to be due
to blood donation & peri-natal transmission
respectively. Gaash Basir et al9 (2003) in a study
in Srinagar observed that majority (23%) of
respondents mentioned contaminated needles
and syringes as the major risk factor in
transmission, followed by sexual contact
(20.5%),infected blood (7%) & perinatal
transmission (3.5%). On the contrary, AIDS and
STDs were well known to 70% respondents in
Watsa’s study conducted in 1994,8 whereas only
14% adolescent girls were aware in a study done
by Sadhna Gupta et al in 2006.7
When asked about the reason for indulging,
40.8% said it to be due to peer pressure. About a
quarter feel it to be a status symbol & another
quarter consider it to be a sign of grown-up. A
small percentage of 6.9 indulge imitating their
parents & elders. A study by Rahul Sharma et al
(2010)11 in Delhi in the age-group of 14-19 years
revealed 31.6% of the students had seen their
father smoke, boys being more than girls in
number. A very small number had seen their
mother ever smoking. A sibling had been seen
smoking by 5.1% and a best friend by 16.4%.
Large numbers of the respondents (43.5%)
reported having seen their favorite celebrity
smoking cigarettes.
Even in today’s era, three-fourth of the
adolescents feel that HIV/AIDS can spread by
touching/kissing/hugging, sharing same toilet/
towels/clothes/ utensils or bitten by same
mosquito and shockingly these results were
statistically significant. Gaash Basir et al (2003)9
in Srinagar observed that most of the adolescents
believed that HIV/AIDS could spread through
handshake (82%), eating with the victim or
sharing utensils (64%) or use of fumets (52%).
It is seen that smoking and drinking become
symbols of maturity and independence, among
the young people. Cigarette smoking, the leading
cause of premature mortality, has not declined
since 1984; 29% of all high school seniors smoke
regularly (Johnston et al, 1988; Johnston, 1989).
For them, the use of tobacco provides an
opportunity for taking part in a behavior that
defies established social norms.10 Boys are more
likely than girls to smoke, drink, and use drugs.
This holds true in developing countries too,
although rates for girls are increasing faster.3
Social Dimensions:
We questioned as to how much their words
mattered in the family, & more than half (58%)
said that they were taken seriously while 10%
never gave suggestions. Mizanur M et al (2007)13
in a study in Bangladesh observed that although
about one-third of the adolescents participated in
household matters, the acceptance of their
opinions was minimal; only in 7.0% of the study
subjects, their opinions were accepted, in less
than two-thirds (62.3%), their decisions were
occasionally accepted, and in 30.7% cases the
decisions were very rarely accepted.
CONCLUSION
Current research in the area of adolescent
physical, psycho-social & spiritual behavior
indicates a need of early intervention, rather than
dismiss these as a transitory experience. In the
absence of intervention, adolescents with
abnormal psycho-social behavior may develop
any of several disorders including affective,
anxiety or impulse control disorder. Based upon
our study findings we recommend that school &
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college authorities should take up at least a
weekly session on the issues related to
adolescence with the parents. They can invite
various experts at times to address important
issues. Teachers should also address some issues
in the class and also inform the students about
good and reputable sources which they should
access for correct information.
Our observations are important indicators of
changing pattern and mood of the society where
electronic media plays a significant role. These
areas need further research and analysis by
varying specialists, like sociologists and
psychologists.
Results from this study highlight the importance
of enhancing school, college and communitybased actions to promote healthy eating and
physical activity addressed to children and
young people.
The study showed a dismal picture of HIV
awareness among urban, educated adolescents,
indirectly pointing to the likelihood of a much
worse level of awareness among the rural,
illiterate counterparts. The matter is serious and
needs to be addressed appropriately through
intensive HIV/AIDS awareness campaigns.
There was hardly any scientific knowledge in
circulation among the adolescents studied. The
situation is alarming, as there exists widespread
ignorance among adolescents about the ‘risk
groups’.
IEC activities are needed to promote healthy
behavior in the community because the behavior
of various role models in their environment was
seen to influence the adolescents’ own risk status
significantly.
Qualitative research methods can be utilized in
further studies to have in-depth analysis of the
issues concerned with adolescence.
Further studies are needed with large sample to
generalize the observations of the present study.
LIMITATION
A major limitation of this study is that the above
observations may be true only for the study
population because of convenient sample and
cannot be generalized to other adolescents
belonging to different socio-economic or cultural
backgrounds. Further studies are needed that
cover the groups of adolescents who are out of
school or college, as the prevalence of health&
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related risk behaviors is likely to be higher
among such adolescents.
Due to the use of closed ended questionnaire, the
exploration of responses was limited with
respect to some of the issues.
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Singh A K, Maheshwari A, Sharma N, Anand K.
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Rahul Sharma, Vijay L Grover, and Sanjay Chaturvedi.
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Original Article ▌
AN EDUCATIONAL INTERVENTIONAL PROGRAMME FOR
PREVENTION AND MANAGEMENT OF NEEDLE STICK
INJURIES AMONG NURSING STUDENTS AT A TERTIARY
CARE HOSPITAL, JABALPUR, MADHYA PRADESH
Anshuli Trivedi1, Pradeep Kumar Kasar2, Rajesh Tiwari3, Prashant Verma4, Arvind Sharma4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Trivedi A, Kasar PK, Tiwari R,
Verma P, Sharma A. An
Educational Interventional
Programme for Prevention and
Management of Needle Stick
Injuries among Nursing Students at
a Tertiary Care Hospital, Jabalpur,
Madhya Pradesh. Natl J
Community Med 2013; 4(1): 132-6.
Author’s Affiliation:
1Assistant Professor, Department of
Community Medicine, Gandhi
Medical College, Bhopal (M.P.);
2Professor & Head; 3Associate
Professor; 4Assistant Professor,
Department of Community
Medicine, NSCB Medical College,
Jabalpur (M.P.)
Correspondence:
Dr Anshuli Trivedi,
Email: dranshulitrivedi@yahoo.com
Background: Nursing students are at increased risk of acquiring
blood borne infections, this is largely due to NSI which they
encounter in there every day work. They are frequently unaware
of prevention and management of NSI and proper BMW disposal.
Objective: To assess and enhance knowledge of nursing students
for prevention and management of NSI .
Methods: This was a Quasi experiment study conducted at
Nursing College, NSCB Medical College Jabalpur (M.P.) among
100 nursing students. A preformed questionnaire was used to
assess existing knowledge of prevention and management of NSI,
then students were given series of lectures and interactive
sessions to prevent and manage NSI then same group was
subjected to post intervention assessment.
Results: It was observed that 78% respondents suffered NSI was
during recapping of needle. Other than needle,86% respondents
mentioned of getting struck by stylet of IV catheter, 14% subjects
recalled more than 5 incidences of NSI in past 15 days. In post
intervention assessment it was observed that intervention made a
significant (Wilcoxon signed rank Test Z=6.68,p<0.001)) impact in
knowledge of students for prevention and management of NSI.
The intervention motivated 5 more students for Hepatitis B
immunization.
Conclusions: Sensitization of nursing students for prevention and
management of NSI is quintessential in preventing these
occupational hazards and should be included in nursing training
curriculum.
Date of Submission: 30-11-12
Date of Acceptance: 19-02-13
Key words- Needle stick injury, Quasi experimental study,
Wilcoxon signed Rank Test.
Date of Publication: 31-03-13
INTRODUCTION
A needle stick injury (NSI) is puncture of the
skin by a needle that may have been
contaminated by contact with an infected patient
or fluid.1 All Health Care Personnel including
emergency care providers, laboratory personnel,
autopsy personnel, hospital employees, interns
and medical students, nursing staff and students,
physicians, surgeons, dentists, labour and
delivery room personnel, laboratory technicians,
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health facility sanitary staff and clinical waste
handlers and health care professionals at all
levels are at risk of acquiring NSI during their
routine work.2
NSI poses occupational hazard for transmission
of blood borne infections like hepatitis B virus
(HBV), the hepatitis C virus (HCV), and the
Human Immunodeficiency Virus (HIV). There is
0.3 percent risk for HIV, 9–30 percent for HBV
and 1–10percent for HCV following needle stick
exposure.2
NSI most frequently occurs during drawing
blood, administering an intramuscular or
intravenous drug, or performing other
procedures involving sharps. The needle can
deviate and injure the healthcare worker.
Reasons for NSI are thought to be, poor
knowledge of health workers about handling
sharps, its hazards and management of NSI and
proper disposal of sharps wastes.
In turn, a NSI may also pose a risk for a patient if
the injured health professional carries HBV,
HCV or HIV. Despite their seriousness as a
medical event, NSI have been neglected and
under reported. Nurses are most common health
care professionals who encounter NSI in there
day to day work. Nursing students are most
suitable candidates for training of prevention
and management of NSI as they are likely to
come across such situations in future. Also there
behavior is likely to be modulated as they are
still in nascent stage of their career. This study
aims at assessing knowledge of prevention and
management of NSI of nursing students.
Following this they were made aware of
prevention and management of NSI by
educational programme and promoted for
Hepatits B vaccination.
METHODOLOGY
A quasi experimental cross-sectional study was
conducted, in which 100 nursing students of
NSCB
Medical
College
Jabalpur
were
interviewed, to assess their existing knowledge
of prevention and management of NSI using
preformed questionnaire. The questionnaire
contained multiple choice questions that covered
their knowledge of hazards of NSI, history of
NSI during the preceding 15 days, type of
instrument and procedures causing NSI ,
protocol of management of NSI, sharps waste
disposal, universal precautions and Hepatitis B
immunization status. Data obtained was
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complied & processed by Microsoft excel. All the
respondents were graded under three grades
(Grade-I –more than 20 correct responses GradeII-11-20 correct responses ,Grade-III more than
20 correct answers,) on the basis of correct
responses.
Following this participants were given weekly
lectures and demonstrations pertaining to the
hazards of NSI and their prevention, handling
sharps during use and there appropriate
disposal, management of post exposure
HIV/Hepatitis B, notification protocol for NSI
and availability of PEP drugs in premises. The
respondents were interviewed again after 15
days using the same questionnaire to assess
impact of intervention. Pre & post intervention
grades were compared to establish significance
of training by using Wilcoxon Signed-Rank Test.
RESULTS
In the pre intervention assessment 87 percent
respondents agreed that NSI is serious type of
injury. In the study it was observed that 100
percent respondents were aware that NSI can
cause HIV. Only 32 percent respondents were
aware that NSI can spread Hepatitis B and only 7
percent respondents were aware of spread
Hepatitis C by NSI. It was observed that 26
percent respondents mentioned that NSI was
hazardous even in absence of bleeding.
Table 1: Distribution of respondents on the
basis of knowledge of use of universal
precautions (n=100)
Wash hands
Use of gloves
Use of needle cutters
Use of color coded bins
for waste disposal
Pre
intervention
Yes
No
16
84
17
83
24
76
41
59
Post
intervention
Yes
No
77
23
26
74
30
70
56
44
In the study ,78 percent respondents mentioned
that most common procedure causing NSI was
during recapping of needle, about 62 percent
respondents suffered NSI during artificial
rupture of membrane (ARM) and 51 percent
respondents mentioned that they suffered NSI
following administration of injection especially
in a non cooperative patient and before
disposing waste sharps. It was also observed that
40 percent respondents suffered NSI during
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drawing of blood and 36 percent during assisting
in surgical process.
In the study 100 percent respondents mentioned
that they suffered NSI by needles, 55 percent
respondents suffered NSI from Blood filled
hollow needles and 12 percent respondents
suffered NSI by solid needles during suturing or
during handling drapes from which needles
were not removed after surgery.
In the study it was seen that 86 percent
respondents mentioned of getting struck by
stylet of IV catheter, 31 percent respondents
suffered NSI by surgical blade/scalpels and 2
percent from scissors. Of all the respondents 62
percent respondents recalled less than 5
incidences of NSI in past 15 days,14 percent
respondents recalled more than 5 incidences of
NSI, whereas 24 percent respondents could not
recall any incidence of NSI in past 15 days.
Table 2: Distribution of respondents on the
basis of number of incidence of NSI in past 15
days (n=100)
Incidence if NSI
in past 15 days
Less than 5 incidence
More than 5 incidence
Cannot recall
Pre
intervention
62
14
24
Post
intervention
69
23
8
In the study it was noticed that 69 percent
respondents reported washing hand of with soap
and water following NSI. Only 45 percent
respondents applied antiseptic following injury
and only 12 percent required dressing for wound
caused by NSI. In total 77 percent respondents
reported to have taken Tetanus toxoid
prophylaxis following NSI. Only 14 percent and
8 percent respondents reported to have come
across atleast 1 patient suffering from Hepatitis B
and HIV in past 3 month respectively. None of
the respondents reported of taking Post
Exposure Prophylaxis (PEP) against HIV
following injury.
Only 16 percent respondents washed hands after
intervention on each patient, 17 percent
respondents used gloves during work at ward.
None of the respondents used masks, goggles or
caps during work at ward. Only 24 percent
respondents reported of using needle cutter
before disposing needles. Almost 41 percent
respondents were aware of use of color coded
bins for biomedical waste disposal.
Following this post-intervention assessment was
done in which the impact of intervention was
assessed. All the respondents were graded
similarly.
Table 3: Distribution of respondents on the
basis of pre & post intervention grades
Grades
Pre
Postintervention intervention
I (20-30correct responses)
6
56
II (11-19 correct responses)
79
39
III (0-10 correct responses)
15
5
In the above table a statistically significant result was
obtained on comparing whole pre and post intervention
grades using Wilcoxon signed rank Test. However individual
grades were not compared. (Wilcoxon signed rank Test
Z=6.68,p<0.001)
In the post intervention assessment as expected
the respondents scored better , all the
respondents were now aware that NSI is
hazardous, even in absence of bleeding and
carries risk of transmission of HIV, Hepatitis B
and C. In post intervention assessment, 69
percent respondents recalled less than 5
incidences of NSI in past 15 days, 23 percent
respondents recalled more than 5 incidences of
NSI, whereas only 8 percent respondents could
not recall any incidence of NSI in past 15 days. It
was found that there was a significant
(Z=4.19,p<0.001) increase in incidence of recall of
NSI following educational programme.
After intervention 77 percent respondents
mentioned washing hands after intervention on
each patient. Of all 26 percent respondents now
used gloves during work at ward. None of the
respondents used masks, goggles or caps during
work at ward as they were not still available in
ward. After intervention 30 percent reported of
using needle cutter before disposing needles.
Following intervention now 56 percent
respondents were now aware of use of color
coded bins for biomedical waste disposal. All the
respondents now knew the protocol of reporting
NSI and PEP and its availability in premises.
Following intervention 5 more respondents were
motivated for Hepatitis B vaccination. The pre
and post intervention grades were compared to
establish usefulness of training, In this Wilcoxon
signed Rank test was used & it was observed
that there was a significant(Z=6.68,p=<0.001)
improvement in knowledge of students
regarding prevention and management of NSI
following training.
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DISCUSSION
The present study addressed certain aspects of
NSI in tertiary care government hospital located
in central India which caters 10 districts in
vicinity. The study was unique as previously no
educational programme for prevention and
management of NSI was conducted in this
nursing college. Also the impact of educational
programme for enhancing knowledge of
prevention of NSI was assessed. It was observed
that all the respondents were aware of spread of
HIV by NSI probably due to widespread
knowledge about it by media and preliminary
knowledge given in school.
Most common instrument causing NSI were
needles, this finding is similar to findings of
study conducted in Rawalpindi Pakistan that
mentioned that 85.1percent participants suffered
NSI most commonly from syringe needle,
followed by 47.52 percent by surgical stitch
needle, and 9.5 percent by surgical blade. 3
In our study 78 percent respondents mentioned
that most common procedure causing NSI was
during recapping of needle. The findings are
similar to findings of study performed by
Khurram M etal3 in which it was found that most
of NSI took place while recapping needles in 33
percent cases followed by surgical procedures in
27.7 percent instances and during drawing blood
samples in 26.2 percent cases.
The study revealed that 55percent respondents
suffered NSI from Blood filled hollow needles
which carries more hazard of HIV sero
conversion, as stated in a literature review by
Veekan H etal 4 that concluded that the risk of
mean sero conversion rate after an injury by a
hollow needle contaminated with HIV to be 0.49
percent.
In the study it was found that that there was
significant increase in recall of incidence of NSI
following intervention, this was probably due to
fact that the intervention enhanced the
knowledge of respondents about NSI which
made them more cautious & vigilant. These
results are comparable with a study conducted in
Taiwan that stated that the average number of
NSI per student was 8.0 times/year.5
In our study NSI management was found to be
similar to a study performed in New Delhi6 in
which 45.5 percent of HCWs confirmed that they
would wash the area with soap and water
following NSI. In that study 34 percent felt that a
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shot of tetanus toxoid was sufficient, though the
present study shows better responses.
In our study training nursing students about
prevention and management of NSI was found
to be very effective in enhancing knowledge of
nursing in prevention and management of NSI.
Training nursing students is very important in
preventing NSI as they are most vulnerable
group exposed to NSI, which could be prevented
and managed by training them as stated by a
study by Simon LP in Delhi.7 Also it has been
stated by Diprose P that the risk of sero
conversion following needlestick injury may be
reduced by enhancing knowledge of body fluids
that are high risk and enhancing knowledge of
post-exposure prophylaxis following possible
HIV-contaminated needle stick injury. 8
Also it is very cost effective to prevent NSI by
training as compared to managing the sequel of
NSI as found Lee JM etal in Maryland U.S. Also
not only NSI causes physical injury and exposes
subject to blood borne infection it can also cause
significant fear, anxiety, and emotional distress,
sometimes resulting in occupational and
behavior changes.9
Only 5 percent respondents were immunized
against Hepatitis B infection which is very low. It
is important to promote vaccination campaigns
and improve knowledge and awareness about
Hepatitis B among health care workers as Global
seropositivity for HBV of 1.7 percent amongst
health care workers as stated in study conducted
in Brazil.10
In conclusion it is recommended that all nursing
students should be adequately trained for
prevention and management of NSI as
seropositive nurses can act as mode of
transmission of blood borne infection. This could
not be achieved by a single training programme
but it has to be taken up as a continuous ongoing
activity by including it in nursing training
curriculum. Trained nurse is an asset to health
set up and must be protected from blood borne
infections.
Acknowledgement
We acknowledge the support of Dr Prashant
Verma, Assistant professor Department of
Community Medicine NSCB Medical College
Jabalpur MP; Sister, tutor-Nursing College NSCB
Medical College Jabalpur MP; and Ku Ankit
Garg;
Ramkumar
Raghuvanshi,Lekhandou
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Nouguchi, undergraduate
Medical College Jabalpur.
students
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vocational school nursing students in southern Taiwan
American Journal of Infection Control Volume 32, Issue
8, December 2004, Pages 431–435.
NSCB
6.
Sumathi Muralidhar, Prashant Kumar Singh, R.K. Jain,
Meenakshi Malhotra and Manju Bala Needle stick
injuries among health care workers in a tertiary care
hospital of India.Indian J Med Res 131, March 2010, pp
405-410.
REFERENCES
1.
Dictionary of Medical epidemiology.5th edition Oxford
university Press edited by Miqeal Porta
;2008;Needlestick;p 164
7.
2.
NACO, Ministry of Health and Family Welfare,
Government of India. Antiretroviral Therapy Guidelines
for HIV-infected Adults and Adolescents including
Post-exposure Prophylaxis, May.2007.p.72,73.
Simon LP Prevention and management of needlestick
injury in Delhi Br J Nurs.2009 Feb 26-Mar 11;18(4):252-6.
8.
Khurram M, Ijaz K, Bushra HT, Khan NY, Bushra H
HussainW Needlestick injuries: a survey of doctors
working at Tertiary Care Hospitals of Rawalpindi. J Pak
Med Assoc. 2011 Jan;61(1):63-5.
Diprose P, Deakin CD, Smedley JIgnorance of postexposure prophylaxis guidelines following HIV
needlestick injury may increase the risk of
seroconversion. Br J Anaesth. 2000 Jun;84(6):767-70.
9.
Veeken H,Verbeek, J Houweling H Cobelens F
Occupational HIV infection and health care workers in
the tropics.Royal Tropical Institute (KIT), Amsterdam,
The Netherlands.Trop Doct. 1991 Jan;21(1):28-31
Lee JM, Botteman MF, Xanthakos N, Nicklasson L
Needlestick injuries in the United States. Epidemiologic,
economic, and quality of life issues AAOHN J. 2005
Mar;53(3):117-33.
10.
Carvalho P, Schinoni MI, Andrade J, Vasconcelos Rêgo
MA etal Hepatitis B virus prevalence and vaccination
response in health care workers and students at the
Federal University of Bahia, Brazil Ann Hepatol. 2012
May-Jun;11(3):330-7.
3.
4.
5.
Ya-Hui Yang,Ming-Tsang Wu, Chi-Kung Ho Hung-Yi
Chuang etal Needlestick/sharps injuries among
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Original Article ▌
REFRACTIVE ERRORS IN SCHOOL GOING CHILDREN –
DATA FROM A SCHOOL SCREENING SURVEY
PROGRAMME
Harpal Singh1, V K Saini1, Akhilesh Yadav1, Bharti Soni1
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Singh H, Saini VK, Yadav A, Soni B.
Refractive Errors in School Going
Children – Data from a School
Screening Survey Programme. Natl
J Community Med 2013; 4(1): 13740.
Author’s Affiliation:
1Department of Ophthalmology,
People’s College of Medical
Sciences and Research Center,
Bhanpur, Bhopal (M.P)
Background: The prevalence of blindness in children ranges from
approximately 0.3/1000 children in affluent regions to 1.5/1000 in
the poorest communities. the importance of early detection and
treatment of ocular diseases and visual impairment in young is
obvious.
Aim and objective - The basic aim of this study was to assess the
status of refractive errors in school going children through school
screening program.
Method: the study was done on students aged 05 years to 15
years, selected randomly from rural and urban schools in and
around the periphery of Bhopal, Madhya Pradesh.
Result: A total of 18,500 children were screened, Out of them
10730 were boys (58.00%) and rest 7770 (42.00%) were girls.
Ocular morbidity (refractory errors) was found in 2422(13.09%)
children out of which 1059 (5.72%) were boys and 1363(7.36%)
were girls. Of these there were a total of 1,313 myopes ; 740
hypermetropes ; 277 with astigmatism and 92 amblyopic children.
Correspondence:
Dr. Harpal Singh
Email: singhdrharpal@yahoo.in
Conclusion: school screening program is an effective way to
detect the causes of visual impairment in school children.
Date of Submission: 02-01-13
Key words: Refractive error, amblyopia, myopia
Date of Acceptance: 20-03-13
Date of Publication: 31-03-13
INTRODUCTION
India has an estimated of 320,000 blind children,
more than any other country in the world.1 Even
though this represents a small fraction of the
total blindness, the control of blindness in
children is one of the priority areas of the World
Health Organization's (WHO) "Vision 2020: the
right to sight" program. This is a global initiative,
which was launched by WHO in 1999 to
eliminate avoidable blindness from worldwide
by the Year 20202.
Importance of early detection and treatment of
visual impairment in children is very important
aspect of our screening programme. In most of
the countries school screening programmes are
done routinely to detect the causes of ocular
morbidity .The objective of school screening
programme is to detect the cases of refractive
errors, amblyopia, strabismus and other ocular
disease. Early detection and correction of
refractive error result in a decrease in the
number of school children with poor sight. 3
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Visual impairment due to myopia typically
appear during school going years .It is the
commonest type of refractive error in school
going children and its timely and proper
correction saves permanent ocular morbidity.4.
Hypermetropia is just the opposite of myopia in
a strict optical sense. The child’s eye can easily
increase its refractive power by ten or more
diopters with accommodation, so that except in
rare, extreme degree of hypermetropia, vision
remains normal. Astigmatism is the second
commonest refractive cause of decrease vision in
childhood. It is optically correctable by
cylindrical lenses.5 Amblyopia is the decreased
vision in one or both eyes even after best optical
correction, resulting from altered visual
development despite normal retinal and optic
nerve anatomy.6
The prevalence of blindness in children ranges
from approximately 0.3/1000 children in affluent
regions to 1.5/1000 in the poorest communities.
Globally there are estimated to be 1.4 million
blind children, almost three-quarters of them live
in developing countries. 7
Major causes of childhood blindness are easy to
detect and approximately 40% are preventable.
School children are a captive audience and can
be reached more easily in comparison to general
population.
Considering the fact that 30% of India’s blind
population loses their sight before the age of 20
years, the importance of early detection and
treatment of ocular diseases and visual
impairment in young is obvious.
School screening programmes have been an
established part of the school health services
since
1907
and
remained
universally
recommended .These programmes are primarily
aimed at detecting refractive errors and
amblyopia.8
In this three year study, we are presenting the
result of the on going school screeining
programme in department of ophthalmology
peoples college of medical sciences and research
centre Bhopal (MP).
MATERIAL AND METHODS
This is a community based study. School surveys
were conducted in various government schools
of rural, urban and semi urban areas of Bhopal
between JAN-2006 to JAN-09. A total of 18,500
school children between age group 5 to 15 years
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had under gone the complete ocular
examination. The School was informed well in
time for appropriate arrangements at a given
date and time. Formal permission was taken
from the principals of these schools; informed
consent was obtained from the parents or
guardian. The list of the students was taken from
the attendance registers.
Our
survey
Team
consisted
of
an
Ophthalmologist,
Optometrist,
ophthalmic
technician and two other staff. All the Children
underwent comprehensive ocular examination
which included detailed history of present and
past ocular problems, along with relevant family
history. Visual Acuity was taken unaided, with
pinhole, with glasses on Snellen’s or ‘E ‘chart at a
distance of 6 meters. anterior segment was
examined with torch light. Color vision was
tested on Ischihara chart. Convergence test and
test for Squint were carried out. where vision
was not improving with pinhole fundus
examination done to rule out any organic cause.
Criteria’s for inclusion of children for ocular
morbidity:Visual acuity of <6/9 and improving with
pinhole was considered to be refractive error.
Vitamin A Deficiency was considered by
recording Bitot’s spot, Conjunctival and Corneal
xerosis and night blindness. The history of night
blindness was obtained from the child.
Strabismus was diagnosed by recording corneal
light reflex combined with extra ocular
movements and cover -uncover tests.
A probable diagnosis of amblyopia was made if
the vision was <6/9, not improving with pin
hole and no organic lesion was detected after
complete ocular examination.
The student who were found to have a vision
equal to or less than 6/9, improving with pinhole
was considered as refractive error, appropriate
spectacles were prescribed to the children.
OBSERVATIONS
The data are collected from school surveys
conducted in various government schools of
rural, urban and nearby areas of Bhopal (MP) . A
total of 18,500 children were screened, Out of
them 10730 were boys (58.00%) and rest 7770
(42.00%) were girls. Ocular morbidity (refractory
errors) was found in 2422 (13.09%) children out
of which 1059 (5.72%) were boys and 1363
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(7.36%) were girls. Of these there were a total of
1,313 myopes; 740 hypermetropes; 277 with
astigmatism and 92 amblyopic children. The
distribution of decreased visual acuity in males
and females is shown in table – 1.
A study done on visual impairment in school
children in southern India by Kalikivayi et al10 in
1990 reported prevalence rate of myopia to be
8.6%; hypermetropia 22.6%; astigmatism 10.3%
and amblyopia 1.1%.
Figure in parenthesis indicate percentage
However, in our study we did not consider the
predictors of refractory errors mainly myopia as
reported in various studies. These include
socioeconomic status, parent’s education,
hereditary factors and prolonged use of visual
display terminals and television viewing. The
data presented here pertains only to decreased
visual acuity due to refractive errors, improved
with the proper prescription of correct spectacles
glasses.
Table 2 – comparison of decreased visual acuity
in different age groups
DISCUSSION
Table 1 – comparison of decreased visual acuity
in males and females
Refractive
Error
Myopia
Hypermetropia
Astigmatism
Amblyopia
Myopia
Hypermetropia
Astigmatism
Total
(n=18500)
1313 (7.09)
740 (4.0)
277 (1.49)
92 (0.49)
Male
(n=10730)
551 (5.13)
332 (3.09)
131 (1.22)
45 (0.41)
Female
(n=7770)
762 (9.8)
408 (5.25)
146 (1.87)
47 (0.60)
5- 10 yr age 11-15 yr age
Total
(n=8325)
(n=10175) (n=18500)
616 (7.4)
697 (6.85) 1313 (7.1)
332 (3.98)
408 (4.0)
740 (4)
107 (1.2)
170 (1.6)
277(1.5)
Figure in parenthesis indicate percentage
From this table girls with decreased visual acuity
(refractory error) ares more as compared to
males. The distribution of decreased visual
acuity did not differ between boys and girls, in a
study conducted by Murthy et al , 2002.9
The comparison of decreased visual acuity in in
different age groups is shown in table-2. The
number of students with decreased visual acuity
increased with age However, since there were
more children with decreased vision in this age
group (11-15 years age group), therefore we may
have found more children with decreased vision
in this group. Similar findings were reported in
by Kalikivayi etal in 1999.10
Table 3- comparison of decreased vision in
children from rural versus urban schools
Refractive error
Myopia
Hypermetropia
Astigmatism
Rural (n=10545)
1O14 (9.9)
572 (5.42)
134 (1.27)
Urban (n=7955)
299 (3.75)
168 (2.1)
143 (1.79)
Figure in parenthesis indicate percentage
The children with decreased visual acuity were
more common in the children from rural schools,
when compared to urban schools. These findings
were different from findings of Dandona et al
999 of Andra Pradesh.11 may be because more
students were from rural areas.
The ocular morbidity if detected and treated
early in life can prevent the social and
intellectual under development of the child.
Despite the recognized importance of correcting
ocular morbidity in children, population based
data on this issue is limited. More over there is a
large global variation in the prevalence and
causes of ocular morbidity. In our study the
prevalence of ocular morbidity (refractory errors)
was found to be 13.09%) Results were
comparable to the study of Kalikivayi et al10
Visual impairment in school children in southern
India (1997) , The high prevalence of preventable
causes of blindness like refractive error as
highlighted by the present study needs to be
addressed first. WHO introduced the global
initiative called ‘VISION 2020’ is based on the
identification of prevalence of such avoidable
causes. Refractive error has been chosen in part
because they are very common and corrective
spectacles provide a remedy that is inexpensive,
effective and associated with huge functional
improvement.
As outlined by the study issues to reduce visual
impairment due to uncorrected refractive errors
are:
1.
Increase parental awareness of symptoms in
a child suggestive of poor vision.
2.
Attempt to link visual screening with other
population based activities.
3.
Involvement of school teachers in visual
screening of children.
4.
Children with history of refractive error in
family should be screened at an early age.
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CONCLUSION
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school-going children 8 to 16 years. Indian J Ophalmol
1982;30:517-518.
5.
Greenwald MJ .Refractive abnormalities in childhood .
Ped Clinic N Am 2003;50:197-212.
6.
Rubin SE ,Nelson LB .Amlyopia- Diagnosis and
management . Ped Clinic N Am 1993;40:727-735.
7.
Rahi JS, Gilbert CE, Foster A, Minassian D. Measuring
the burden of childhood blindness. British journal of
ophthalmology 1999;83:387-
8.
Spoward KM ,Simmers A ,Tappin DM .Vision testing in
school: an evaluation of personnel ,test and premises. J
Med Screening 1998;5:131-132.
9.
Gilbert C, Rahi J, Quinn G. Visual impairment and
blindness in children. In: Johnson, Minassian, Weale,
West, editors. Epidemiology of eye disease. 2nd edition
UK: Arnold Publishers; 2003.
Murthy, GVS, Gupta, SK, Ellwein, LB, Refractive error
in children in an urban population in New Delhi
Investigative Ophthalmology Visual Science 2002(
43),623-631
10.
2.
World Health Organization, Global initiative for the
elimination of avoidable blindness. WHO/PBL/97.61.
Geneva: WHO; 1997.
Kalikivayi V ,Opt B,Naduvilath TJ,etal. Visual
impairment in school children in southern India .Indian
J Ophthalmol 1997;45:129-134.
11.
3.
Greenwald MJ. Refractive abnormalities in childhood.
Ped Clinic N Am 2003;50:197-212.
4.
Chandra DB, Swarup D, Shrivastav RK .prevalence and
pattern along with socioeconomic factor of myopia in
Dandona R, Dandona L, Naduvilath TJ, shriniwas M
,Me Carty CA, Rao GN : Refractive errors in an urban
population in southern India: The Andhra Pradesh Eye
Disease Study .Investigative Ophthalmology Visual
Sciences, 1999; 40(12),2810-2818.
Though we have to be cautious in extrapolating
the results of this study to the entire population
of school children in India, but these data
validate the need for vision screening of school
children. School screening programmes should
be mandatory by the government health
authorities.
.
REFERENCES
1.
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Original Article ▌
ASSESSMENT OF KNOWLEDGE OF MOTHERS OF
UNDERFIVE CHILDREN ON NUTRITIONAL PROBLEMS: A
RURAL COMMUNITY BASED STUDY
Divya Shettigar1, Ansila M2, Maryes George2, Jeena Chacko2, Reena J Thomas2, Shahila Shukoor2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Shettigar D, Ansila M, George M,
Chacko J, Thomas RJ, Shukoor S.
Assessment of Knowledge of
Mothers of Underfive Children on
Nutritional Problems: A Rural
Community Based Study. Natl J
Community Med 2013; 4(1): 141-4.
Author’s Affiliation:
1Lecturer, 2B.Sc. Nursing Students,
Department of Community Health
Nursing, Yenepoya Nursing
College, Mangalore, Karnataka
Correspondence:
Ms. Divya Shettigar,
E-mail:divyashettigar24@gmail.com
Date of Submission: 02-01-13
Date of Acceptance: 06-03-13
Date of Publication: 31-03-13
Introduction: Good nutrition is the fundamental basic right for
the maintenance of positive health. Nutritional problems like
protein energy malnutrition, anemia, vitamin A deficiency iodine
deficiency and obesity continues to plague large proportion of
under-five children in India.
Objectives: To assess the knowledge regarding the common
nutritional problems of under-five children and its prevention
among mothers.
Method: This cross sectional descriptive study was conducted to
assess mothers of under-five children residing at rural community
area. Mothers were selected through Non probability convenient
sampling.The data was collected using a pretested structured
questionnaire.The data was analysed using SPSS version 16 and
the results expressed as proportions
Results: A total of 50 underfive mothers were included in the
study. Of the mothers surveyed, Knowledge about underfive
nutritional problems and its prevention was reported to be nearly
half of the mothers 27 (54%) had poor knowledge, around 19
(38%) had average knowledge, and only 4 (8%) had good
knowledge regarding the common nutritional problems and its
prevention. Mothers had poor knowledge on underfive
nutritional problems and its prevention. None of the mothers had
very good knowledge.
Conclusion: A significant number of mothers were unaware of
the prevention and management of underfive nutritional
problems. So, frequent health education campaigns should be
conducted in the field of child nutrition.
Keywords: Underfive children, Nutritional problems
INTRODUCTION
Children are the most important segments for a
nation for the optimal physical, mental,
emotional development of its future worthy
citizens.1 A nation’s health depends on the
healthy citizen. A healthy adult emerges from a
healthy child.2 Nutrition of the under-five
children is of paramount importance because the
foundation of our life time health, strength and
intelligence vitality is laid during this period3.
Good nutrition is the fundamental basic right for
the maintenance of positive health.4 A proper
diet is essential from early stage of life children
below age of five year constitute over 20% of our
population and also form a most vulnerable
group. The foundation of good health and sound
mind are laid during this period of life.5
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The word nutrition means ‘the process of
nourishing or being nourished,’ especially the
process by which a living organism assimilates
food and uses it for growth and replacement of
tissues. ‘Nutrients are substances that are
essential to life which must be supplied by food.6
Nutritional problems like malnutrition, anemia,
vitamin A deficiency iodine deficiency and
obesity continues to plague large proportion of
under-five children in India. 7
India is home to 40% of worlds malnourished
children and 35% of developing world low birth
weight infants (IFPRI 2008). Every year 2 million
children die in India (UNICEF 2009), accounting
for one in five child death in the world.
According to global Hunger Index (GHI)
developed by IFPRI, India ranks 117th of 119
countries in child malnutrition.8
Children are future of society and mothers are
guardian of that future, Knowledge of mothers
has an important role in the maintenance of
nutritional status of the children. Hence to
ensure sound foundation and secure future of
any society health and nutrition of their children
needs protection.12By this above background,
which highlighted the importance of mothers
knowledge regarding common nutritional
problem of underfive children. This study was
conducted to assess the mothers of under-five
children
knowledge
regarding
common
nutritional problems and its prevention.
METHODS
This cross sectional study was undertaken in
Kotekar rural community of Mangalore, with the
approval from the District Health Officer,
Mangalore and Institution Ethical committee.
The study consisted of 50 underfive mothers
within the age group of 20-40 years. Mothers
were selected by Non-probability purposive
sampling. The participants were briefed about
the nature of the study, consent was given and a
pre-tested
structured
questionnaire
was
administered to them. Data that recorded
include general data comprised of age, religion,
occupation, education status, type of family,
family monthly income and source of
information on nutritional problems and its
prevention. The information pertaining to the
pattern of nutrition problems, causes of nutrition
problems, clinical features of nutrition problems,
prevention and management of nutrition
problems were included in the questionnaire.
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RESULTS
A total of 50 mothers were selected by non
probability purposive sampling, of whom 19
(38%) belong to the age group of 20-25 years and
a least of 3(6%) were 36-40 years. Most of the
mothers were belonging to Hindu 26(52%).
Depending on occupation 33(66%) were
housewives and 2(4%) were private employees.
Table 1: Description of demographic
characteristics of mothers of under-five
children
Demographic variables
Mothers (N=50) (%)
Age in years
20-25
19 (38)
26-30
16 (32)
31-35
12 (24)
36-40
3 (6)
Religion
Hindu
26 (52)
Muslim
21 (42)
Christian
3 (6)
Occupation
Government Employee
5 (10)
Private Employee
2 (4)
Self Employee
10 (20)
House Wife
33 (66)
Educational Status
No formal Education
8 (16)
Primary Education
12 (24)
Secondary Education
24 (48)
Graduation
6 (12)
Type of family
Nuclear
30 (60)
Joint
19 (38)
Extended
1 (2)
Family monthly income in Rupees
< 3000/
10 (20)
3000-5000/24 (48)
5000-10,000/11 (22)
>10,000
5 (10)
Source of information
29 (58)
Mass Media
Friends and Relatives
7 (14)
Health Professionals
9 (18)
No Information
5 (10)
Nearly 24(48%) of mothers had completed their
secondary education, 12(24%) and 6(12%) have
completed their graduation. Based on family
30(60%) of them belong to nuclear family.
24(48%) have their monthly income of Rs 30005000 and 5(10%) had more than Rs 10000. The
most common source of information about
nutritional problems and its prevention was
mass media 29 (58%) while 10% had no
information.(Table 1)
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Table 2 : Distribution of knowledge level
among mothers
Level of knowledge
Poor
Average
Good
Very good
Overall
Scores
0-10
11-16
17-20
>21
Mothers (n=50) (%)
27 (54)
19 (38)
4 (8)
0 (0)
50 (100)
Table 3 depicts the level of knowledge of
mothers, nearly half of the mothers 27 (54%) had
poor knowledge, around 19 (38%) had average
knowledge, and only 4 (8%) had good
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knowledge regarding the common nutritional
problems and its prevention. None of them had
very good knowledge.
Area-wise mean score percentage on knowledge
regarding common nutritional problems and its
prevention among mothers had highest mean
percentage 41% (2.46±1.20) in the area of
knowledge regarding causes of nutritional
problems, 40.77%(5.3±2.30)basic concepts of
nutritional problems. 34% (2.04±1.12) clinical
features of nutritional problems and prevention
and management of nutritional problems had
34.67% (1.04±0.88) (Table 3).
Table 3: Description of area-wise mean, standard deviation and mean percentage of knowledge
score
Aspects of knowledge
Basic concepts
Causes of nutritional problems
Clinical features of nutritional problems
Prevention & management Causes of nutritional problems
Total
Mean score
5.3
2.46
2.04
1.04
10.84
Max score
12
5
3
2
22
SD
2.30
1.20
1.12
0.88
3.68
Mean%
40.77
41.00
34.00
34.67
38.71
Table 3: Association of knowledge with selected demographic variables of adolescents (n=50)
Sample characteristics
≤ median
> median
Age in years
20-25
9
10
26-30
6
10
31-35
5
7
36-40
3
0
Religion
Hindu
14
12
Muslim
7
14
Christian
2
1
Educational Status
No formal Education
3
5
Primary Education
9
13
Secondary Education
9
5
Graduation
2
4
Type of family
Nuclear
14
16
Joint
9
10
Extended
0
1
Family monthly income in Rupees
< 3000/
6
4
3000-5000/11
13
5000-10,000/4
7
>10,000
2
3
Source of information on nutritional problems and prevention
Mass Media
10
19
Friends & Relatives
4
3
Health Professionals
6
3
No Information
3
2
χ2 value
df
p value
4.09
3
7.82
2.52
2
5.99
2.73
3
7.82
0.87
2
5.99
1.27
3
7.82
3.84
3
7.82
NS* Not significant, S* significant, χ21=3.84, χ22=5.99, χ23=7.82; p< 0.05
The chi square values of demographic variables
like age, religion, education, occupation, type of
family, family monthly income, source of
information regarding common nutritional
problems and its prevention were not significant
at 0.05 level of significance. There was no
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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significant association between knowledge score
and the selected demographic variables.
DISCUSSION
Childhood malnutrition is a massive crisis
caused by a combination of factors including
inadequate food intake, childhood diseases,
harmful child care practices, low socio economic
status, all these contribute to poor health and
millions of deaths annually. Malnutrition is like
an iceberg, which affects the community both
directly and indirectly. The direct effects are the
occurrence of frank and subclinical nutritional
deficiency diseases. The indirect effects are high
morbidity and mortality among young children
.Malnutrition is an extremely complex
phenomenon with multiple causes, multiple
manifestations and is intergenerational.
Our study denoted that there is no significant
association between knowledge level of mother
and selected demographic variables which is in
concordance with other study conducted by
Khokar.A in rural area, Tamilnadu. The sample
size selected was 68, in which 34 mothers of
severely malnourished children under four years
of age were selected as experimental group and
34 mothers of well-nourished as control group.
Purposive sampling technique was used. The
result revealed that the knowledge level of
control group was higher (59%) when compared
to experimental group. Finally the researcher
concluded that the knowledge of mothers has an
important role in the maintenance of nutritional
status of the children. There is no significant
relationship between the level of knowledge and
demographic variables.10
Mishra RSK et al11 did a similar study and the
result reveals that about 65% of mothers had low
knowledge, 15% had average knowledge, 20%
had high knowledge. And more than half of
mothers were illiterate. The researcher
concluded that Protein energy malnutrition is a
significant public health problem. Thus
implementation of appropriate health awareness
program and improvement in socioeconomic
condition improving nutritional status.11
CONCLUSION
The present study has found that mothers had
poor knowledge on underfive nutrition
problems and its prevention. A significant
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number of mothers were unaware of the
prevention and management of underfive
nutritional problems. The knowledge level of the
mothers can be empowered with essential health
information. This again emphasizes the need to
strengthen IEC activities.
The limitations of this study included the
absence of a comparative group, the small
sample size and the absence of interventions like
providing information regarding prevention and
management of nutritional problems
Acknowledgement
We would like to express our gratitude to the
mothers of Kotekar, Mangalore. We would
equally thank Mr. Yenepoya Abdulla Kunhi
,Chancellor, Dr. P. Chandra Mohan Vice
chancellor, Dr. Janardhan Konaje, Registrar
Yenepoya University and Mrs. Sathya.P., Former
Principal in-charge of Yenepoya Nursing
College, Mangalore.
REFERENCES
1.
K Park. Textbook of preventive and social medicine, 20th
ed. Jabalpur: Banarasidas Bhanot Publishers; 2005. p 255
2.
Sudheer K. A textbook of nutrition, 11th ed. India:
Florence Publishers; 2010. p 32
3.
Sreevani R. Malnutrition and mental development.
Nightingale Nursing Times. 2000; 4(12):21.
4.
Ghosh S, Shah D. Nutritional problems. Journal of
Indian Paediatrics. 2004;15-16
5.
Surabi SM. Malnutrition among children. Times of
India. 2004;249(7):92-7.
6.
BT Basavanthappa. Community health nursing, 2nd ed.
New Delhi: Jaypee Brothers Medical Publishers; 2011. p
135
7.
Freedom for hunger for children. Available at:
http://URL:www.save_the_children.in//html.
Accessed June 20th 2012
8.
Sohi D. Textbook of nutrition. Iodine deficiency, 5th ed.
Jalandhar: Medical Publishers; 2008. p. 14-19
9.
Udavu PM. Protein energy malnutrition a global
problem in under-five children. India J Paediatr.
1992;59:165-70.
10.
Khokar A. A study to assess the knowledge of mothers
with regard to nutritional status of under-five children
in selected rural community area. India J Paediatr.
1998;63:122-23.
11.
Mishra RSK, Biswa R, Kumar R, Halden, Chattrjee T.
Assess the knowledge and magnitude of protein energy
malnutrition and its associated factors. Indian J Public
Health. 1999; 43(1):49-54.
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Original Article ▌
ETIOLOGY OF PERITONITIS AND FACTORS PREDICTING
THE MORTALITY IN PERITONITIS
Jeetendar J Paryani1, Vikas Patel1, Gunvant Rathod2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Paryani JJ, Patel V, Rathod G.
Etiology of Peritonitis and Factors
Predicting the Mortality in
Peritonitis. Natl J Community Med
2013; 4(1): 145-8.
Author’s Affiliation:
1Resident; 2Professor, Department
of Surgery, Civil Hospital,
Ahmedabad, Gujarat
Correspondence:
Dr. Jeetandar Paryani,
Email id paryani.jeetu@gmail.com
Date of Submission: 12-01-13
Date of Acceptance: 01-03-13
Introduction: Peritonitis is a life threatening surgical emergency
that requires prompt and optimum surgical attention. This study
aims to describe the different factors affecting the final outcome of
the patient.
Materials and methods: A retrospective study of hospital records
was done on 60 patients who underwent alaparotomy for
treatment of peritonitis in the month of January and February
2012at Civil Hospital and B. J. medical college.
Results: Out of 60, 16 patients died (26.7%). The most common
etiology was peptic perforation (50%); the most mortality was also
for peptic perforation (8/16, 50%). Factors causing adverse
outcomes were extremes of age (p < 0.05), delay in presentation to
hospital, tachycardia, and hypotension extremes in total count
(septicemia) and altered renal function (p < 0.01).
Conclusion: The mortality rate (26.7%) of peritonitis is quite high.
The late presentation to the hospital--a very important cause of
adverse outcome in patients, leads to deterioration of patients.
Tachycardia, hypotension, renal failure and septicemia are the
factors significantly predicting death (each significant at 1%).
Thus if patients could be detected early having above mentioned
symptoms and prompt treatment could be provided; mortality
can be reduced.
Date of Publication: 31-03-13
Key words:
Hypotension.
INTRODUCTION
Peritonitis is inflammation of peritoneum which
is most commonly due to generalized or
localized infection. Peritonitis may be primary
or secondary. Primary peritonitis rarely requires
any surgical treatment. Secondary peritonitis
can be due to perforation of bowel which results
in contamination of peritoneal cavity with
contents of bowel and bacterial colonization
depending on site of perforation. It results in
rapidly fluid loss into 3rd space and sepsis. The
body responds in form of inflammatory response
resulting in leukocytosis with shift towards left,
Peritonitis,
Peptic
perforation,
Tachycardia,
release of cytokines and other mediators. All the
factors mentioned above when unattended push
the patient towards septic shock1.
It is the most common surgical emergency in
India1. Despite modern surgical techniques,
antimicrobial therapy and intensive care
support, management of peritonitis continues to
be highly challenging task demanding proper
knowledge, experiences, continued care and
close monitoring. The etiology of perforation in
India continues to be different from that of
western countries where most commonly
peritonitis occurs due to lower GI perforations as
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diverticulitis is more common whereas in our
settings upper GI perforation especially peptic
perforation is more common2.
High morbidity and mortality resulting from
delayed presentationexpresses a gap that can be
filled by improvement in care through a better
ability to recognize and treat peritonitis3.
Therefore, the objectives of this study are to
determine the etiology,physical and laboratory
findings and assess their correlation to mortality
in case of peritonitis.
METHODS
Study setting: The study was conducted at the
Civil hospital and B.J Medical College,
Ahmedabad after obtaining approval from
institutional ethical committee. It is a tertiary
referral center catering to referrals from entire
state of Gujarat, Madhya Pradesh and Rajasthan.
Data collection: Patients admitted to Civil
Hospital, Ahmedabad who underwent an
operation for treatment of peritonitis during the
calendar month of January and February 2012
were enrolled in the study after obtaining
informed consent. Peritonitis was defined as
guarding (localized or generalized), rigidity or
rebound
tenderness.Wetracedthe
patients
retrospectively through a review of operative log
book of the emergency operation theatre and
medical records of those patients obtained
through record section.Variables such as gender,
age, duration of symptoms, date of admission
and discharge or death, surgical procedure and
operative diagnosis, vital signs on presentation
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(including heart rate (HR), systolic blood
pressure (BP), and respiratory rate (RR),
presence of guarding), date and results of initial
complete blood count and abdominal ultrasound
if performed were considered.
Analysis of data: We calculated the descriptive
statistics for our variables such as operative
diagnosis,
overall
and
diagnosis-specific
mortality rates, age, time (in days) from onset of
symptoms, outcome, presenting vital signs
including systolic BP (< 100mmhg, 100 to
120mmhg, and > 120mmhg), RR (< 30/min, ≥
30/min), HR (< 100/min, 100 to 120/min, and >
120/min), total count (TC) (< 4000/dL, 4000 to
12000/dL, > 12000/dL), Creatinine (< 1.5mg/dL,
≥ 1.5mg/dL) and presence or absence of free
fluid.
The above variables were compared in two
groups: expired (group A) and survived (group
B). Chi-square (χ2) test was used to compare
variables and tests were considered significant
when P-Value < 0.05.
RESULTS
In the present study, 60 patients studied were
divided in two groups: Group A included those
who expired (27% = 16/60) and Group B
included those who got discharged (73% =
44/60).
The mean and median ages were
45.5±4.2 and 44 yearsrespectively and the range
was 14-90 years.Table 1 indicates that Peptic
perforation (50%) was the most common etiology
with highest rate of overall mortality (8/16,
50%).
Table 1: Distribution of patients according to Etiologies
Type of Infection
Traumatic jejuna perforation
Peptic perforation
Perforated appendix
Acute intestinal obstruction due to adhesive band
Rectal perforation
Ruptured liver abscess +ascending colon perforation
GB perforation
Acute intestinal obstruction +sigmoid volvulus
Acute intestinal obstruction +obstructed right inguinal hernia
Others
Total
Table 2 shows factor that affect survival. Age
and Symptoms duration have significant effect
on mortality at 5% (p = 0.0400, p = 0.0048).
Mortality rate was highest in the age group < 20
Expired
0 (0)
8 (13)
2 (3)
0 (0)
0 (0)
2 (3)
2 (3)
2 (3)
0 (0)
0 (0)
16 (27)
Discharged
4 (7)
22 (37)
2 (3)
2 (3)
4 (7)
0 (0)
2 (3)
0 (0)
2 (3)
6 (10)
44 (73)
years; symptoms durations ≥ 2days increased the
mortality rate from 0% to 36%. Vitals—HR, BP,
and RR all have significant effect on mortality at
1% (p = 0.001, p = 0.0002, p = 0.0001). HR >
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120/min, BP < 100mmhg, and RR ≥ 30/min was
fatal for the patients (mortality rate 67%, 80%,
and 67% respectively). Similarly investigations –
TC <4000/dL and >12000/dL, Creatinine
≥1.5mg/dL, and Free fluid also have significant
effect on mortality at 5% (p = 0.0153, p = 0.0038,
p = 0.0036).
Table 2: Factors Affecting Mortality
Factor
Expired
(n = 16)
Age
< 20 years
4 (67)
20- 50 years
6 (18)
> 50 years
6 (30)
Symptoms Duration
≤ 2 days
0 (0)
≥ 2 days
16 (36)
Heart Rate
< 100/min
2 (11)
100 to 120/min
6 (20)
> 120/min
8 (67)
Blood Pressure
< 100mmhg
8 (80)
100 to 120mmhg
6 (18)
> 120mmhg
2 (13)
Respiratory Rate
< 30/min
8 (17)
≥ 30/min
8 (67)
Total Count
< 4000/dL
2 (50)
4000 to 12000/dL 6 (15)
> 12000/dL
8 (50)
Creatinine
< 1.5mg/dL
6 (15)
≥ 1.5mg/dL
10 (50)
Free Fluid
Absent
0 (0)
Present
16 (32)
***Significant
at 1%,
Discharged
(n = 44)
P-value
2 (33)
28 (82)
14 (70)
0.0400**
16 (100)
28 (64)
0.0048**
16 (89)
24 (80)
4 (33)
0.0017***
2 (20)
28 (82)
14 (88)
0.0002***
40 (83)
4 (33)
0.0001***
2 (50)
34 (85)
8 (50)
0.0153**
34 (85)
10 (50)
0.0038**
10 (100)
34 (68)
0.0367**
**Significant
at 5%
DISCUSSION
Peritonitis is a commonly encountered surgical
emergency in developing countries like India4, 5.
In most of cases the presentation to the hospital
is delayed with well-established generalized
peritonitis. Thus purulent/faecal contamination
leads to varying degree of septicaemia. The
signs and symptoms are typical making it
possible to make a clinical diagnosis of
peritonitis in nearly all patients.
The perforations of proximal gastrointestinal
tract were significantly more common compared
to other aetiologycontrasting to studies from
developed countries like United States, Greece
and Japan which revealed that distal
gastrointestinal tract perforations were more
common.1, 4, 5, 6.
Proximal bowel perforation is mainly on the
decrease in the developed nations because of
adoption of therapies against Helicobacter
pylori. Also better availability of proton pump
leads to better ulcer relief and healing leading to
decreased progression of peptic ulcer disease.
Distal bowel perforations especially colonic
perforations are leading cause of perforation
peritonitis in the western world 7.
Etiology and site of perforation also affects the
outcome. Gastro duodenalperforation occurring
mainly due to peptic perforation is most
common cause which accounts for major
mortality in developing nations 4, 5, 6. Also, the
occurrence of peptic perforation is mainly in the
older age group. Post-operative occurrence of
abdominal abscesses and pneumonia is common
which contributes to morbidity and then
mortality8. Occurrence of higher risks of
pneumonia can be explained by upper
abdominal operation.Also the higher output of
proximal GI tract as compared to lower GI tract
may be another reason for the higher mortality9.
Age is important predictor of outcome; with
extremes of age groups the body tolerance to
insult caused by peritonitis is reduced which
shows in the study as there is significantly high
mortality in those age groups. Physiological
limitations of human body increase with age in
terms of cardiovascular respiratory and renal
systems. Such comorbid conditions may be
present in about two thirds of such patients10.
Hypotension and tachycardia also indicate poor
prognosisas the perfusion to the tissues is
reduced which is confirmed by this study6. So,
preoperative aggressive management of these
patients in the emergency unit decreases the
ASA grade of the patient and is associated with
better outcomes9.
Septicaemia (TC<4000/dL or TC >12000/dL)
indicates that insult of peritonitis has made the
general state as hyper catabolic state thus
significantly reducing the survival rate. Most
important of all; the majority of our patients
came late to the hospital (after2 days of the
appearance of symptoms) and succumb to
death;Either they ignored the earlier symptoms,
or had taken medicinal care for local health
facility, or were located in places far from centres
with surgical facilities,so had to travel long
distances to reach a referral centre.
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Delayed presentation also leads to septicaemia
and thus reduces the survival rate9. Also it leads
to widespread dissemination of the insult
leading to more generalised peritonitis making
the control of pathology difficult and resulting in
poor intraoperative outcome 12. It could be
regarded as the most important factor predicting
in the prognosis of peritonitis especially peptic
perforation13.
Future research could be done to evaluate
whether preoperative correction of above
mentioned statistically significant factors
improves survival, and which canbe done by
comparing data from Government hospitals and
Private hospitals in periphery.
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adult patients with perforation peritonitis, Indian
Journal of Critical Care medicine 2011
4.
Shahida Parveen Afridi, Faiza Malik, Shafiq UrRahman,Shahid Shamim,Khursheed A Samo, Spectrum
of perforation peritonitis in Pakistan: 300 cases Eastern
experience, World Journal of Emergency Surgery 2008,
3:31
5.
Dinesh Yadav & Puneet K. Garg Spectrum of
Perforation Peritonitis in Delhi: 77 Cases Experience
Indian J Surg DOI 10.1007/s12262-012-0609-2
6.
Jonathan C Samuel et al , An Observational Study of the
Etiology, clinical presentation and outcomes associated
with peritonitis in Lilongwe, Malawi, World J Emerg
Surg. 2011; 6: 37
7.
Mark A Malangoni , Tazo Inui,Peritonitis – the Western
experience World Journal of Emergency Surgery 2006,
1:25
8.
Naoto Fukuda,Joji Wada,Michio Niki,Yasuyuki
Sugiyama,Hiroyuki Mushiake, Factors predicting
mortality in emergency abdominal surgery in the
elderly, World Journal of Emergency Surgery 2012, 7:12
9.
P. Kujath, O. Schwandner,H.-P. Bruch, Morbidity and
mortality of perforated peptic gastroduodenal ulcer
following emergency, Langenbecks Arch Surg (2002)
387:298–302
10.
Ahmer A Memon, Faisal G Siddiqui, Arshad H Abro,
Ahmed H Agha, Shahzadi Lubna Abdul S Memon, An
audit of secondary peritonitis at a tertiary care
university hospital of Sindh, Pakistan World Journal of
Emergency Surgery 2012, 7:6
11.
J. O. Larkin ,R. Waldron, M. G. Bourke, K. Barry, A.
Muhammed ,P. W. Eustace Mortality in perforated
duodenal ulcer depends upon pre-operative risk: a
retrospective 10-year study, Ir J Med Sci (2010) 179:545–
549
12.
N. Torer, K. Yorganci, D. Elker, I. Sayek, Prognostic
factors of the mortality of postoperative intraabdominal
infections, Infection (2010) 38:255–260
13.
Michael Imhof, Stefan Epstein,Christian Ohmann,HansDietrich Ro¨her: Duration of Survival after Peptic Ulcer
Perforation World J Surg (2008) 32:408–412.
CONCLUSION
Peritonitis is one of the commonest emergencies
in
surgical
department.
And
delayed
presentation significantly adds to the mortality.
An aggressive preoperative evaluation and steps
to correct deranged homeostasis, an early
surgery and vigilant postoperative care are the
keys to avoiding postoperative mortality in such
patients.
REFERENCES
1.
Sanjay Gupta ,Robin Kaushik , Peritonitis the eastern
experience , World journal of emergency Surgery 2006
;1:13
2.
Rajender S Jhobta et al , Spectrum of perforation
peritonitis in India review of 504 consecutive cases,
World Journal of Emergency Surgery 2006, 1:26
3.
Ranju Singh , Nishant kumar , Abhijit Bhattacharya ,
Homay Vajifdar, Preoperative predictors of mortality in
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Original Article ▌
A STUDY ON OBESITY IN RELATION TO SOCIO ECONOMIC STATUS IN MEN AND WOMEN
Vinod Porwal1, Anand Verma1, Sameer Inamdar1, Pranay Bajpai2
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
Introduction: Obesity now a day’s considered an epidemic earlier
was considered a disease of western world, and highly affluent
society. But now days it is seen more in low socio economic group
also.
Objective: To investigate obesity in relation to socio economic
status inmen & women in Indians.
How to cite this article:
Porwal V, Verma A, Inamdar S,
Bajpai P. A Study on Obesity in
Relation to Socio-Economic Status
in Men and Women. Natl J
Community Med 2013; 4(1): 149-52.
Methods: We reviewed data from a health check up program of
workers at Municipal Corporationworking as sweeperswhich was
done at SAIMS Medical CollegeIndore and executives coming for
routine health check up. Data was pooled, and was used to
compare ratio of obesity and socio economic status.
Author’s Affiliation:
1Associate Professor; 2Resident,
Medicine, SAIMS Medical College,
Indore
Results: Obesity was observed more in men & women of low
socio economic status as compared to high socioeconomic status,
and in the same low socioeconomic group it was observed more
in women.
Date of Submission: 22-01-13
Conclusion: Higher education and high socio economic status
were associated with low risk of obesity in men & women, where
as higher occupation status was associated with lower riskof
obesity. It has been shown in some studies that the group having
low socio economic status had increased risk of obesity
Date of Acceptance: 15-03-13
Keywords: BMI, Socio-economic status, Obesity, Sex
Correspondence:
Dr. Vinod Porwal,
Email: vinporwal@yahoo.co.in
Date of Publication: 31-03-13
INTRODUCTION
In recent years there is extensive work being
done on obesity which is now considered as
epidemic. Earlier obesity was considered a
disease of western world, and highly affluent
society, but nowdays it is seen more in low socio
economic group also.1
Socio economic status is most often measured as
one of these indicators, income, occupation
status and education.2 Income primarily affects
the ability to buy food and do physical exercises.
Low status jobs are also having less autonomy,
which make it difficult to spare and manage time
for healthy life style, but in males it involves
more physical activity in low occupation than
high occupation which protect them from
obesity.3 Education is the third commonly used
indicator and is associated with knowledge and
beliefs. Mirowksy and Ross4 have suggested that
education enable people to apply healthy
lifestyle and even pass it to their children.
As these all 3 variables namely education,
occupation and socioeconomic status operate in
different ways. The relationship between sex and
Socio economic status and obesity may vary
according to index used. An US study5
compared education, income and occupation in
predicting risk of cardio vascular diseases. In
finland, Sarlio-lahteenkorva and lahelma6 found
sex differences in relationship between various
measure of SES and obesity. WHO’S MONICA
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(monitoring trends and determinants in CVD)
project showed association between educational
level and obesity was stronger among women
than man. 7
In present study we examined the association of
obesity with socioeconomic status
METHODS
We retrospectively reviewed data from health
checkup program of workers employed at
Municipal Corporationof low socioeconomic
status and another data from an urban center
where the executives came for routine health
checkup program. We included 200 persons each
of having high socioeconomic status and low
socioeconomic status
Adults more than 18 yrs were included; their
height in meters, weight in Kg and BMI was
calculated. Pregnant females were excluded;
persons suffering from chronic illness were
excluded from the study
Measurements
To measure weight electronic weighing
machines were used. All participants advised to
remove shoes and heavy garments. Body Mass
Index (BMI) was calculated by formula wt
(kg)/ht (mt2) and obesity defined as BMI of 30 or
more
Indicators of socio-economic status were
primarily based on occupation. Occupation
status was coded as per national classification of
occupation 2004 India.
Division 1 to 10 aredefined, we included division
1 as high socioeconomic status which includes
executives and division 9 as low socioeconomic
status which includes sweepers. As an indicator
of income they were categorized as per their
occupation. Their occupation indirectly indicated
their income. Age was noted and grouped in 10
yr segments. Statistical analysis was doneusing
chi square method, where we observed.
RESULTS
In our study we observed obesity in 23 persons
(11.5%) in high socio economic group, while 30
persons (15 %) were obese in low socioeconomic
group.
In high socioeconomic group we had 13 (8.22%)
male were obese while10 (23.80%) of obese
female were seen
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In low socioeconomic group14 (13.08%) males
were obese and 16(17.20%) females were obese
When we applied statistical formulas for its
significance ,Significant interaction effects were
found between sex and occupational status , p
value of 0.199 was observed in male with obesity
in high socioeconomic group and low
socioeconomic group and p value of 0.516 was
observed in female with obesity in high
socioeconomic group and low socioeconomic
group.
Table: 1 -Obesity in relation to Socio Economic
status (SES) and sex
Total
Socio Economic Status
High SES
200
Low SES
200
High SES
Male
158
Female
42
Low SES
Male
107
Female
93
Male
High SES
158
Low SES
107
Female
High SES
42
Low SES
93
Obese (%)
P Value
23 (11.50)
30 (15.00)
0.30
13 (8.22)
10 (23.80)
0.004
14 (13.08)
16 (17.20)
0.416
13 (8.22)
14 (13.08)
0.199
10 (23.08)
16 (17.20)
0.516
DISCUSSION
Our Data showed differences in the ways in
which, occupational status, and economic status
are associated with obesity. Men and women
who had low socio economic status were more
likely to be obese than were those with high
occupation group, analyses showed that this
effect was similar in men and women, This
observation is in line with results of other studies
conducted in the United States 8,9 , Sweden 10 ,
and Finland11
showing similar linear
associations between education and obesity.
By
contrast,
the
association
between
occupational status and obesity differed between
men and women, as has also been found in the
United States.12 Among women, lower
occupational status was associated with an increased risk of obesity
Economic predictors of obesity have attracted the
least attention in the literature, with some
studies revealing an association between low
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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income and obesity (but not in multivariate
analyses) 6 and others indicating less clear-cut
patterns. 8,9,12
The present results could be considered
informative about the mechanisms through
which SES might influence obesity. And also the
group of LSE we included was sweepers; some
bioaeresol exposure has been linked to increased
prevalence of obesity.
The male–female differences in relation to
occupational status are important and might
have a number of different explanations. Lower
occupational status is associated with restrictions
in time and opportunity to make healthy eating
and activity choices as well as with higher levels
of work stress, either of which could affect
obesity risk, 13 but further research is necessary
to determine whether these processes could
account for the sex difference in risk. It has been
shown that people in higher occupational status
groups are more concerned about body shape
and engage in more efforts to lose weight, 14
perhaps reflecting shared beliefs about the
unacceptability of obesity; although there are sex
differences in level of weight concern, however,
the occupational gradient is similar in men and
women.
Manual occupations tend to be more physically
demanding, especially for men. These higher
activity jobs could contribute to prevention of
weight gain among men in manual occupations.
Alternatively, reverse causation could be in
operation, such that female obesity is more
discouraged than is male obesity in higher-SES
occupations.
Without a direct measure of income, it is difficult
to be precise about the effect of income on
obesity risk, but it does appear that economic
deprivation is associated with an increased risk
of being obese. There is a good but
comparatively little research on the effects of
poverty on food choices, and it is important to
note that any such effects appear to function
independently of the effects of education and
occupational status.
In view of the well-established differences in the
patterns of obesity and SES in developed as
compared with developing countries,1 our results
can be generalized only to industrialized nations
similar to England. The present findings are
somewhat limited by the lack of a direct measure
of income, although the economic markers used
provided a good indication of income and
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wealth.
Because
of
the
size
and
representativeness of the sample, the use of
measured rather than self-reported heights and
weights, and the inclusion of potentially
confounding variables in multivariate analyses,
the observed pattern of obesity by SES and sex
can confidently be assumed to reflect true
patterns in many Western societies.
Education is one of the SES variables which are
most amenable to change. Other studies have
demonstrated the importance of educational
level in predicting weight-related behaviors,diet
15 and physical activity 16 and have suggested
that knowledge might play an important role in
a range of health-related behaviors. Although
many other mechanisms are likely to be
involved, these results suggest that raising levels
of understanding of the diet and activity choices
that might protect against weight gain could
make a substantial contribution toward tackling
the public health problem of obesity. Targeting
education interventions to lower-SES groups
could also assist in reducing the increasingly
wide inequalities in health
CONCLUSION
Higher education and high socio economic status
were associated with low risk of obesity in men
& women, where as higher occupation status
was associated with lower risk of obesity. It has
been shown in some studies that the group
having low socio economic status had increased
risk of obesity
REFERENCES
1.
Sobal J, Stunkard AJ. Socioeconomic status and obesity:
a review of the literature. Psychol Bull. 1989;105:260–
275.
2.
Krieger N, Williams DR, Moss NE. Measuring social
class in US public health research: concepts,
methodologies, and guidelines. Annu Rev Public
Health.1997;18:341–378.
3.
Colhoun H, Prescott-Clarke P. Health Survey for
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Stationery Office; 1996.
4.
Mirowsky J, Ross CE. Education, personal control,
lifestyle and health.Res Aging. 1998;20:415–449
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Winkleby MA, Jatulis DE, Frank E, Fortmann SP.
income, and occupation contribute to risk factors for
cardiovascular disease. Am J Public Health. 1992;82:816–
820.
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6.
Sarlio-Lähteenkorva, Sirpa, and EeroLahelma. 1999.
"The Association of Body Mass Index Wtih Social and
Economic Disadvantages in Women and Men."
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Molarius A, Seidell JC, Sans S, Tuomilehto J, Kuu-level,
relative body weight and changes in their association
over 10 years: an international perspective from the
WHO Monica Project. Am J Public Health. 2000;90:1260–
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Flegal KM, Harlan WR, Landis JR. Secular trends in
body mass index and skinfold thickness with socioNutr.
1988;48:535–543.
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Flegal KM, Harlan WR, Landis JR. Secular trends in
body mass index and skinfold thickness with socioeconomic factors in young adultmen. Am J
ClinNutr.1988;48:544–551
10. Kuskowska-Wolk A, Bergstrom R. Trends in body mass
index and prevalence of obesity in Swedish women
1980–89. J Epidemiol Community Health. 1993;47:195–
199.
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11.
Rissanen AM, Heliövaara M, Knekt P, Reunanen A,
Aromaa A. Determinants of weight gain and overweight in adult Finns. Eur J ClinNutr. 1991;45:419–430.
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Jeffrey RW, Forster JL, Folsom AR, Luepker RV, Jacobs
DR Jr, Blackburn H. Therelationshipbetween social
status and body mass index in the Minnesota Heart
Health Program.Int J Obes.1989;31:59–67
13.
Wardle J, Steptoe A, Oliver G, Lipsey Z. Stress, dietary
restraint and food intake. J Psychosom
Res.2000;feb;48(2):195-202
14.
Wardle J, Griffith J. Socio-economic status and weight
control practices in British adults. J
EpidemiolCommunity Health. 2001;55:185–190
15.
Wardle J, Parmenter K, Waller J. Nutrition knowl- edge
and food intake. Appetite.2000;34:1–8.
16.
luepker RV, RosamandWD , Murphy R et al .
Socioeconomic status and coronary heart disease risk
factor trends : the Minnesota heart survey . circulation
1993 :88:269-275
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Original article ▌
EPIDEMIOLOGY OF ANIMAL BITE CASES ATTENDING
MUNICIPAL TERTIARY CARE CENTRES IN SURAT CITY: A
CROSS-SECTIONAL STUDY
Pradeep Umrigar1, Gaurang B Parmar2, Prakash B Patel3, R K Bansal4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Umrigar P, Parmar GB, Patel PB,
Bansal RK. Epidemiology of
Animal Bite Cases attending
Municipal Tertiary Care Centres in
Surat City: A Cross Sectional Study.
Natl J Community Med 2013; 4(1):
153-7.
Author’s Affiliation:
1DPH Student; 2Resident; 3Assistant
Professor; 4Professor & Head,
Department of Community
Medicine, SMIMER, Surat
Correspondence:
Dr. Gaurang Parmar
Email:dr.gaurangparmar09@gmail.
com
Date of Submission: 15-01-13
Context: Animal bite, especially dog bite is an important public
health problem in urban India. Socio-cultural practices and myths
consider as major problem for post-exposure prophylaxis of
animal bites.
Objectives: To study the epidemiological characteristics and
determinants of post-exposure prophylaxis of animal bite victims.
Methodology: It was a cross-sectional study conducted among
new cases of animal bites registered at Tertiary Care Centres of
Surat city.
Results: Out of total 382 cases of animal bites majority (58%)
belongs to 15-45 years of age-group and 83 % were male. Stray
dogs were involved in 94% animal bite cases. Majority (81%) of
bites were unprovoked. Category II bites were seen in 204(54 %)
of cases. In 81.4% cases lower extremities were affected. Only two
hundred ninety two cases had attended the ARV clinic within 24
hours of bite. Only 75 % of cases had done the wound washing.
Conclusion: Wound washing immediate after bite form the prime
step of management of any animal bite which was absent in
majority of cases.
Keywords: Animal bites, rabies, epidemiological, health seeking
behaviour, Surat
Date of Acceptance: 29-02-13
Date of Publication: 31-03-13
INTRODUCTION
Large numbers of human morbidities and
mortalities, including rabies are attributed to
animal bite, which is defined as claw wound or
bite from an animal.1 Dog is responsible for
about 96% of animal bite cases in urban areas.
Transmission of rabies virus occurs through
saliva from animal to human beings or animal to
other animal by means of bites, scratches, licks
on broken skin and mucous membrane.2 99 % of
all human rabies victims attributed to canine
rabies which is continues to terrify 87 countries
or territories of the world.3 According to WHO
report, worldwide human deaths from endemic
canine rabies were estimated 55000 deaths in a
year4 with 56% share from South East Asia
Region.5 20,000 Deaths and 17.4 million animal
bite cases were reported in India alone every
year.5 Rabies is reported in India throughout the
year from all states except Lakshadweep and the
Andaman & Nicobar Islands.6 More than 99% of
all human rabies deaths occur in the developing
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world7 and reliable data regarding rabies is not
available due to lack of organized surveillance
system.8 Even though available control measures
both economic and effective, due to presence of
multiple religious & socio-cultural practices &
beliefs associated with rabies, economic and
political factors and lack of accurate data; the
disease has not been brought under control.2,8
Community knowledge and concern about
animal bite injuries play an important role in
countering this problem.9
This study was carried out with the objectives of
to explore epidemiological factors associated
with animal bites including dog bite cases
reporting at Urban Health Centres (UHCs) of
Surat city and also elucidating the factors
influencing the post-exposure treatment.
MATERIAL & METHODS
The present cross-sectional study was conducted
at Surat Municipal Institute of Medical
Education & Research (SMIMER), Surat (Gujarat)
by the Department of Community Medicine,
over a period of four months, June-September
2012 after taking approval from institutional
ethical committee. Surat Municipal Corporation
was providing tertiary care facility through 2
centres- SMIMER and Maskati Charitable
Hospital & C. F. Parekh dispensary. All new
cases of animal bite visiting at both tertiary care
centres during the study period were included in
the study. Personnel interview of patient and
clinical examination was done for each case after
taking informed written consent. A pre tested
semi structured questionnaire was used to
record data pertaining to the epidemiology as
well as determinants of post exposure
prophylaxis. The collected data were analyzed
using Epi info software.
Categorization of exposures was done as per
guidelines given by World Health Organization
(WHO)10. Bite resulted from subject initiating
interaction with the dog such as playing with the
dog or annoying the dog during his meal was
considered as provoked.
RESULTS
Total 382 cases were reported during the study
period, 280 (70%) were at Surat Municipal
Institute of Medical Education & Research
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(SMIMER) and 112 (30%) at Maskati Charitable
Hospital & C. F. Parekh dispensary. Male
constituted 317 (83%) cases with male female
ratio was 4.87:1. Majority of the victims 223
(58.4%) were in the age group of 15-45 years.
Table 1: Age-group
distribution
Age-group
0 to 5
6 to 14
15 to 45
46 to 60
> 60
Total
Female (%)
14 (3.7)
8 (2.1)
28 (7.3)
11 (2.9)
4 (1.0)
65 (17.0)
and
Male (%)
20 (5.2)
62 (16.2)
195 (51.1)
29 (7.6)
11 (2.9)
317 (83.0)
gender
wise
Total (%)
34 (8.0)
70 (18.3)
223 (58.4)
40 (10.5)
15 (3.9)
382 (100)
Table 2: Occupational category of animal bite
cases based on travel history (n=358#)
Occupational category
Occupation with extensive or some
travel##
Occupation with least or no travel
Frequency
217 (60.6%)
141 (39.4%)
15 cases were below 5 years of age and history not given by
9 cases; ## Salesman, driver, vendor, beggar , workers in
diamond, textile, machine industry, labourer etc.
#
217(61%) cases had given history of occupation
involving extensive or minimal travel.
Dog was involved as biting animal in 371(97.1%)
cases. Stray animals were involved in 362 (94.7%)
cases while pets and wild animals in 19(5 %) and
1(0.3%) cases respectively. The municipal
licensing and ARV coverage of pet dogs were
found unsatisfactorily, 1 (5.2%) and 5 (26%) cases
respectively.
Table-3: Distribution of cases according to age
group and category of exposure.
AgeGroup
0 to 5
6 to 14
15 to 45
46 to 60
> 60
Total
Exposure Category based on WHO
guidelines10 (%)
Cat 1
Cat 2
Cat 3
Total
0 (0.0)
18 (4.7)
16 (4.2)
34 (8.9)
0 (0.0)
46 (12.0)
24 (6.3)
70 (18.3)
7 (1.8)
118 (30.9) 98 (25.7) 223 (58.4)
1 (0.3)
17 (4.5)
22 (5.8)
40 (10.5)
2 (0.5)
5 (1.3)
8 (2.1)
15 (3.9)
10(2.6)
204(53.4)
168(44)
382(100)
Bites were unprovoked in 310 (81.2 %) cases.
Bites were occurred within city in 380 (99.5%)
cases. Lower limb was the most common site of
bite (81.7 %) among all age group. In 5 cases
multiple site bites had been noted. Morning (4 to
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11 am) was found most common time of bite in
143(37.4%) cases.
Majority, 204 (53.4 %) cases had class II exposure
according to WHO guidelines. In all age group
class II exposure was highest except 46-60 years
and more than 60 years of age-groups where
class III exposure was highest.
Table 4: Duration between bite & wound
cleaning with running water or water with soap
(n=219)
Duration between bite and
wound cleaning
< 1 hour
1 to 6 hours
7 to 24 hours
> 24 hours
Frequency (%)
102 (46.5)
65 (29.7)
49 (22.4)
3 (1.4)
Biting animal was alive in 337 (83.2%) cases till
the time of seeking treatment. Fate of 39 (10.2%)
animals was unknown while 5 (1.3%) animals
were dead or killed by people.
Wound was not cleaned by any means in
94(24.6%) cases. Out of 288, 237 (82.3 %) cases
had history of wound cleaning with running
water or water with soap. Only 102 (46.5 %)
victims had wound cleaning history within 1
hour.
Table 5: Educational status and duration
between bite & first dose of ARV (n=350*)
Education Status
Illiterate
Just literate
Primary (up to 5th)
Middle (up to 8th)
Secondary (up to
10th)
Higher-secondary
(up to 12th )
Graduation & above
Total
Duration between bite & first
dose of ARV (%)
Within 24 hours
> 24 hours
32 (9.1)
10 (2.8)
9 (2.6 )
5 (1.5)
59 (16.9)
21 (5.9)
48 (13.7)
18 (5.1)
60 (17.1)
19 (5.5)
36 (10.3)
20 (5.7)
264 (75.4)
8 (2.3)
5 (1.5)
86 (24.6)
*Education status was missing in 30 cases while duration
history was missing in 2 cases while both educational status
and duration history was missing in 2 cases. Total cases
coming after 24 hours were 90 but education status of 4 cases
were missing.
241 (76 %) cases had received first dose of ARV
within 24 hours after exposure while 15 cases
had taken their first dose of ARV after 7 days
period. Formal literate & Illiterate and even
shockingly graduate people had not taken first
dose of ARV within 24 hours in 36 %, 24 % &
25% cases respectively. Table-5 show details of
educational status and duration between bite
and visit to ARC.
Ignorance regarding prognosis of rabies and
availability of health facility were major reasons
for coming late (after 24 hours of animal
bite).Various reasons for coming late was given
in table-6.
Table 6: Reason for coming late (after 24 hours)
for first dose of ARV (n=89*)
Reason for coming late (after 24 hrs)
Ignorance regarding rabies prognosis
Staying away from treatment facility
No knowledge about the availability
of health facility
Ignorance regarding rabies
Lack of time
Outside city
Not inform parents about bite
Others**
Frequency(%)
39 (43.8)
17 (19.1)
10 (11.2)
9 (10.1)
4 (4.5)
3 (3.4)
3 (3.4)
4 (4.5)
one case had not given any reason; **Others include lack of
money, no accompanied person and didn’t confirm about
dog bite.
*
Pre-treatment was taken by 259 (68%) animal
bite cases which includes 180(69.5%) of home
treatment alone, 23 (8.8%) treatment from
medical practitioner either qualified or
unqualified and 56(21.7%) had both home and
medical practitioner. Out of 236 home treatment
cases, 83 (35%) had applied indigenous products
over wound.
Table 7: Categories of home treatment (n=236)
(multiple answers)
Category of home treatment
Soap & water
Only water
Chili powder
Lime and salt
Local antiseptics
Turmeric
Snuff
Herbs
Bitter leaves
Others$
Frequency (%)
110 (46.6)
76 (32.2)
27 (11.4)
24 (10.2)
21 (8.9)
11 (4.7)
4 (1.7)
2 (0.8)
2 (0.8)
13 (5.5)
$Others include kerosene, jaggery, baba’s bhabhuti, bandage,
rai oil, sindur, ghee etc.
Wound was not washed with soap & water or
running water/saline in 93.7% cases attended by
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medical practitioner while TT injection was not
given in 20 (25.3%) cases.
At tertiary care facility, out of 168, only 55 cases
of class III exposures were given ARS while in
313 (82 %) cases wound dressing was not done.
In 1 case occlusive dressing was done. In
majority cases ARV was given through
intradermal route.
Out of 59 cases with previous history of animal
bite only 32 (55 %) had completed post exposure
immunization which was given through
different routes (ID, IM, SC). No history
regarding vaccine reaction had been noted.
DISCUSSION
Animal bites, especially dog bites still poses
public health problem in urban area of our
country.
Epidemiological profile of animal bite cases of
surat city revealed that men were affected more
than women, due to occupational travelling of
man as compared with women, as found in our
study where male to female ratio was 4.87:1
quite similar to previous studies.9,11,13-17
Predominantly of cases belongs to 15-45 years of
age group (58 %) similar to Behera et al (2006).15
Different studies evolves different age-group as
predominance Jyoti et al14 (below 15 years),
Behera et al(2004)16(below 10 years),Venu shah et
al13 (below 25 years) and Icchapujani et al(2001)11
(2-18 years). And these findings were in contrast
to our studies were we found only 27 % cases
which involved children of age group of 0-14
years.
Biting animal includes dogs, rats, cats, monkey.
In majority (97.1%) of cases the biting animal
was dog similar to other studies 9,11,13-17. Stray
animals were attributed to majority (94.7%) cases
while pets(5%) and wild animals(0.3%)
attributed to small proportion which were
similar to findings of Behera et al15 and
Icchapujani et al(2001)11. The municipal licensing
and ARV coverage of pet dogs were not
satisfactorily (5.2% and 26 % respectively) similar
to study by Sudarshan M.K (2003)17.
Bites were unprovoked (81.2%) in majority cases
which was match with the study by Behera et al
(2006)14 and Icchapujani et al(2001)11 in which
they found unprovoked bites in 56.6% & 64.3 %
cases respectively. In majority (96.1%) of cases
bites were occurred within city. Lower limb was
the most common site (81.7 %) similar to other
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studies studies9,11,13-17 and found among all agegroup exposed to animal bite. In 5 cases multiple
site bites had been noted. Bites over trunk and
head & neck were seen more in age group of 6-14
years and 0-5 years respectively while upper
limb bite and multiple bites were more
commonly seen in 15-45 years of age group.
Majority (37.4 %) bites occur between 4 and 11
am in the morning in contrast to study by Venu
shah et al (2011)12 in which she described 38.8%
of bites between 4 and 8 pm.
Majority (53.4 %) cases had class II exposure
according to WHO guidelines in contrast to other
studies where class III was most common9,11,13,15.
In all age group class II exposure was highest
except 46-60 years and more than 60 years of
age-groups where class III exposure was highest.
Upper limb, head & neck and multiple bite bites
found more commonly in category III exposure
while trunk bites found more in category II
exposure. In majority (88.2 %) cases biting
animal was alive till the time of seeking
treatment.
Only 62.0 % cases had history of wound cleaning
with running water or water with soap which
was major issue of concern which include only
46.5 % victims with history of wound cleaning
within 1 hour. On the contrary 3 cases had no
history of wound cleaning by any means.
According to availability of health facility and
residence of animal bite cases, mean duration to
reach health facility is 23.5 minutes, even though
only 76 % cases had received first dose of ARV
within 24 hours after exposure, which is in
accordance with other studies.13 Ignorance
regarding prognosis of rabies and availability of
health facility were major reasons for late coming
(after 24 hours) to the health facility.
Majority (68%) of animal bite victims had taken
pre-treatment
either
home
or
medical
practitioner. Indigenous products were applied
over the wound by 35% of home treatment cases
which was also found in other studies.9,11,13,15-17
At concern health facilities, wound dressing was
not done at in most (82%) cases, ARS not given
in majority (67%) category III exposure victims
while occlusive dressing was done in one case.
All these were matters of great concern.
Seventy six percent of victims with previous
history of bite had taken home treatment for
current exposure which was also the matter of
great concern.
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CONCLUSIONS
Majority bites are attributed to stray dogs and
unprovoked, occurred during morning and
involve lower limb as most common site and
victimized adults and children most. Vaccination
and municipal licensing of pet dogs are not
satisfactorily. The majority bite victims had
occupation involving more or less travel. Most
commonly bite victim were having WHO
Category II animal bite exposure and mostly
without proper wound care. Home treatmentindigenous treatment was quite prevalent even
amongst educated people, even though
availability of nearby health facility and major
reason was ignorance regarding prognosis of
rabies. Treatment seeking behaviour was quite
poor amongst victim of previous bite history. At
medical practitising clinics and even at tertiary
care center quality of primary wound
management (washing) and post exposure
prophylaxis was compromised.
RECOMMENDATIONS
Popular misconceptions about treatment and
blind beliefs about the disease need to be
addressed immediately. This can be countered
by effective I.E.C. activities, which should be
carried out regularly at every health facilities.
Incorporation of messages related to animal bite
and its management in to routine health advice
would also be helpful. Since young children are
more prone to provoke dog resulting a bite, they
should be target of anticipatory guidance by
parents and teachers.
Vaccination and municipal licensing of pet dogs
must be enforced.
Precious lives can be saved if cases are reported
and treated within 24 hours. The need of the
hour is effective knowledge, which has to be
communicated to the public using mass media
and other measures of health education. This
will help to early self reporting of cases to
qualified medical practitioners.
Qualified private practitioner and even the
government doctors need to be updated on latest
guideline of post exposure vaccination and
would management.
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Eslamifar A, Ramezani A, Razzaghi- Abyaneh M,
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APCRI guidelines for rabies prophylaxis. Available at
http://rabies.org.in/rabies/wp-content/uploads/
2009/11/ APCRI-Guidelines-for-RabiesProphylaxis.pdf. Accessed on November 22nd, 2012.
7.
WHO Expert Consultation on Rabies: first report (2004).
Available at http://whqlibdoc. who.int/trs/ WHO
_TRS_931_eng.pdf .Accessed on November 22nd, 2012.
8.
Ichhpujani. R.L et al: Rabies in humans in India. 4th
International Symposium on rabies control in Asia.
Symposium proceedings Merieux Foundation & WHO.
Ed. Betty Dodet & F. X. Meslin, 2001, Hanoi, Vietnam.
John Libbey, Eurotext, London.
9.
Anita Khokhar, G.S. Meena, Malti Mehra. Profile of dog
bite cases attending m.c.d. dispensary at Alipur, Delhi
2003. Indian Journal of Community Medicine Vol.
XXVIII, No.4: 157-60.
10.
WHO guide for post exposure prophylaxis. Available at
http://www.who.int/rabies/ human/postexp/en/
accessed on 21st February 2013.
11.
Ichhpujani RL et al. Epidemiology of Animal Bites and
Rabies cases in India. A Multicentric study. J Commun.
Dis. 40 (1) 2008: 27-36
12.
Menezes R. Public health: Rabies in India. CMAJ 2008
Feb 26; 178(5): 564–6
13.
Venu Shah, D V Bala, Jatin Thakker, Arohi Dalal, Urvin
Shah, Sandip Chauhan, Kapil Govani. Epidemiological
determinants of animal bite cases attending the antirabies clinic at V S General Hospital, Ahmedabad.
Healthline. 2012; 3(1).
14.
Jyoti, Goel Manish Kumar, Vashisht BM, Khanna
Pardeep. Pattern and Burden of Animal Bite Cases in A
Tertiary Care Hospital In Haryana. J.Commun. Dis.
42(3) 2010: 215-218
15.
TR Behera, D M Satapathy, RM Tripathy, A Sahu.
Profile of animal bite cases attending the ARC of
M.K.C.G. Medical College, Berhampur (Orissa).APCRI
journal. 2008; 9(2).
16.
TR Behera, D M Satapathy, A Sahu. A study of attitude
of cases towards animal bite treatment.APCRI journal,
Volume IX, Issue:1, July-2007 available at
rabies.org.in/rabies-journal/rabies-091/OrgArticle2.htm accessed on 19/10/2012.
17.
MK Sudarshan, BJ Mahendra, SN Madhusudana, DH
Aswath Narayana, Abdul Raheman, NSN Rao, FX
Meslin, Derek Lobo, K.Ravikumar, Gangaboraiah.
Epidemiology of Animal Bites cases in India: Results of
WHO sponsored National Multi-Centric Rabies study. J.
Commun. Dis. 38 (1) 2006: 32-39.
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Original Article ▌
AN EFFORT TO DETERMINE BLOOD GROUP AND
GENDER FROM PATTERN OF FINGER PRINTS
Sandip K Raloti1, Kalpesh A Shah2, Viras C Patel3, Anand K Menat3, Rakesh N Mori1, Nishith K
Chaudhari1
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Raloti SK, Shah KA, Patel VC,
Menat AK, Mori RN, Chaudhari
NK. An Effort to Determine Blood
Group and Gender From Pattern of
Finger Prints. Natl J Community
Med 2013; 4(1): 158-60.
Author’s Affiliation:
1Tutor; 2Professor; 3Resident,
Department of Forensic Medicine,
B. J. Medical College, Ahmedabad,
Gujarat
Correspondence:
Dr. Raloti Sandip
Email: sandip_raloti@yahoo.com
Date of Submission: 12-01-13
Date of Acceptance: 27-02-13
Date of Publication: 31-03-13
Introduction: Two person having identical fingerprints is about
one in 64 thousand millions. A reliable personal identification is
critical in the subject of forensics as is faced with many situations
like civil, criminal, commercial and latest in financial transaction
frauds, where the question of identification becomes a matter of
paramount importance. In this study we have made an effort to
“study a relationship between pattern of fingerprint, gender and
blood group”.
Materials and methods: This study was carried out in 2012 on 89
medical students (62 male & 27 female), randomly chosen
belonging to the age group 17- 21 at B. J. Medical College,
Ahmedabad Gujarat, India. The finger-prints were taken of all ten
fingers over unglazed white paper using printer’s ink. Pattern of
fingerprints were observed by powerful hand lens and recorded.
Note was made of the sex, age, ABO blood groups.
Results: Results show that whorls occur more frequently in
males, whereas, loops occur more frequently in females. Loops
are predominant in blood group B+ and whorls are predominant
in blood group O+ (p < 0.05). We see an association between
fingerprint patterns, blood group and gender.
Conclusion: From our study we may conclude that there is an
association between distribution of fingerprint patterns, blood
group and gender and thus in our opinion, prediction of gender
and blood group of a person is possible based on his/her
fingerprint patterns.
Key words: Fingerprints, Gender, Blood Groups, Association
INTRODUCTION
Two person having identical fingerprints is
about one in 64 thousand millions 1. Fingerprints
are impression of pattern formed by papillary or
epidermal ridges of the fingertips and the
patterns in fingers do not change during the
lifetime of an individual. The combined effect of
heredity and environment arbitrates the pattern
of ridges. Environmental influence produces
stress and tension on the pattern’s growth
during foetal life2. There are four types of
patterns observed in the fingers—loops, whorls,
arches and composite 3.
Arches are the simplest patterns and also the
rarest. There are two types: plain arches and
tented arches. In both types the ridge lines flow
into the print from one side, rise in the middle of
the pattern, and flow out to the other side of the
print. The loop is the most common of all the
patterns. Loops are formed by ridge lines that
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flow in from one side of the print, sweep up in
the center like a tented arch, and then curve back
around and flow out or tend to flow out on the
side from where they entered. Loops are
designated as being either radial or ulnar,
depending on which side of the finger the lines
enter.
There are four different whorl patterns: the plain
whorl, the central pocket loop, the double loop,
and the accidental whorl 4. Their common
features are that they have at least two deltas and
one or more of the ridge lines curves around the
core to form a circle or spiral or other rounded,
constantly curving form 5. The term composite is
used for combination of patterns that does not fit
into any of the above classifications 6.
A reliable personal identification is critical in the
subject of forensics as is faced with many
situations like civil, criminal, commercial and
latest in financial transaction frauds, where the
question of identification becomes a matter of
paramount importance. Although human beings
have been using fingerprints as a means of
identification for a long time but in this study we
have made an effort to take step further to
“study a relationship between pattern of
fingerprint, gender and ABO blood group”, so
that one can get an idea about the expected blood
group and gender from the study of fingerprint
pattern and vice versa.
MATERIALS AND METHODS
This study was carried out in 2012 at B. J.
Medical College, Ahmedabad Gujarat, India. 89
medical students (62 male & 27 female),
belonging to the age group 17- 21 were randomly
selected for the study. A Performa was prepared
on a durable white paper divided into two,
marked as right and left, and each further into
five columns (marked as thumb, index, middle,
ring and little), rubber stamp ink pads were used
for smearing the balls of each finger (blue was
found to better as compared to green), imprints
were taken of each, pattern of fingerprint were
observed by powerful hand lens and recorded.
Note was made of the sex, age, ABO blood group
from their identity-cards for studying the
relationship between types of fingerprints and
relation to ABO blood type and sex. Variables
were evaluated and analyzed statistically. Chisquare (χ2) test was used to compare variables
and tests were considered significant when PValue < 0.05.
RESULTS
Out of 89 students 62 (70%) were male and 27
(30%) were female; the male-female ratio being
2.3: 1. Most common blood groups were ‘O’
positive and ‘B’ positive (33%) followed by ‘A’
positive (21%). AB positive, O negative, AB
negative and B negative are rarer being present
in 9%, 2% and 1% respectively (Table 1).
Table 1: Distribution of subjects according to
blood group and gender
Blood Group
A +ve
B +ve
B -ve
O +ve
O -ve
AB +ve
AB -ve
Male (%)
15 (24)
20 (32)
0 (0)
21 (34)
1 (2)
5 (8)
0 (0)
Female (%)
4 (15)
9 (33)
1 (4)
8 (30)
1 (4)
3 (11)
1 (4)
Total (%)
19 (21)
29 (33)
1 (1)
29 (33)
2 (2)
8 (9)
1 (1)
Males and Females have equal incidence of B
positive (32% and 33%) and O positive (34% and
30%) respectively. On the contrary, ‘A’ positive
blood group is found more in males while O
negative, AB negative and B negative are more
commonly found in females (Table 1).
Table 2: Distribution of pattern in different blood groups
Loops
Whorls
Arches
Composites
A +ve
112 (59)
45 (24)
16 (8)
17 (9)
B +ve
183 (63)
75 (26)
13 (4)
19 (7)
B -ve
7 (70)
2 (20)
1 (10)
0 (0)
O +ve
134 (46)
87 (30)
31 (11)
38 (13)
O -ve
17 (85)
1 (5)
0 (0)
2 (10)
AB +ve
48 (60)
24 (30)
6 (8)
2 (3)
AB -ve
7 (70)
1 (10)
1 (10)
1 (10)
Total
508 (57)
235 (26)
68 (8)
79 (9)
Figures in parenthesis indicate percentage
Loops are most commonly obtained fingerprints
(57%) followed by whorls (26%). Arches and
Composite fingerprints are found in 8% and 9%
respectively (Table 2). In all the blood groups,
proportion of loops was highest. Relatively
higher number of whorls is seen in blood group
O positive. Among 508 subjects having loop
fingerprint, most common blood group seen is B
positive (p < 0.0001), while O positive is most
commonly obtained in subjects with whorls (p <
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0.0001). O positive is also most common in
arches and composite (Table 2, 3).
Table 3: Comparison of loops and whorls in
different blood groups
Loops are more common in females (63% vs.
54%), whereas whorls (28% vs. 23%) and
composite (12% vs. 3%) in males; the difference
between all three patterns being statistically
significant (p < 0.05) (Table 4). However, we did
not find statistically significant difference in
arches in male and females.
Loop
A +ve B +ve O +ve
Yes
112
183
134
No
396
325
374
Total
508
508
508
P Value
P < 0.0001 (S)
Whorls
A +ve B +ve O +ve
45
75
87
190
160
148
235
235
235
P < 0.0001 (S)
S = Significant
Table 4: Comparison of loops and whorls in sex
Yes
No
Total
P Value
M
337
283
620
Loop
F
Total
171
508
99
382
270
890
0.013 (S)
M
174
446
620
Whorls
F
61
209
270
0.049 (S)
Total
235
655
890
M
46
574
620
Arches
F
Total
21
67
249
823
270
890
0.852 (NS)
M
63
557
620
Composite
F
Total
16
235
254
655
270
890
< 0.001 (S)
S = Significant, NS = Not significant
DISCUSSION
CONCLUSION
The general distribution pattern of fingerprints
in our study showed high frequency of loops
(57%), moderate whorls (26%), and low
frequency of arches (8%), which are in
accordance with the study done by Bhardwaja 7.
We may conclude that there is an association
between distribution of fingerprint patterns,
blood group and gender and thus prediction of
gender and blood group of a person is possible
based on his/her fingerprint patterns.
The present study shows an association between
distribution of fingerprint patterns, blood group
and gender. Similar to study done by Bhardwaja,
Prateek and Gowda & Rao, there is high
frequency of loops, moderate of whorls and low
of arches in blood groups A, B and O.
(correlation more for blood group A7,8,9. Contrary
to other studies and similar to Sharma frequency
of loops in our study is highest in B positive
(36%) compared to O positive (26%). Similar to
Bhardwaj, AB positive had a higher incidence of
whorls compared to other blood groups.
While blood groups A, B and O were found to be
the most common (equally predominant) among
males, blood groups B and O were the most
commonly seen in females. Similar to Prateek et
al, the present study also reveals that frequency
of loops is greater in females as compared to a
higher frequency of whorls in males 8.
According to our study, fingerprints with loops
on any suspicious site is suggestive of female
with O positive blood group, while whorls
suggest B positive blood group.
REFERENCES
1.
2.
3.
Http://www.fingerprintamerica.com/fingerprinthistor
y.asp
Cummins H. Palmar and Plantar Epidermal Ridge
Configuration (Dermatoglyphics) in Europeans and
Americans. Am. J. Phy. Anthrop. 1926; 179: 741-802.
Galton F, Textbook of Finger Prints. London: Macmillan
and Co. 1892.
4.
Kanchan, T. Chattopadhyay, S. Distribution of
Fingerprint Patterns among Medical Students. Journal
of Indian Academy of Forensic Medicine, 2006; 28(2): 6568.
5.
Vij, K. Textbook of Forensic Medicine and Toxicology.
3rd Ed. New Delhi: Elsevier, 2005: 89-91.
6.
Subrahmanyam, B.V. In: Modis Medical Jurisprudence
and Toxicology. 22nd Ed. New Delhi: Butterworths
India, 1999: 71-77.
7.
Bharadwaja A, Saraswat PK, Agrawal SK, Banerji P,
Bharadwaj S. Pattern of fingerprints in different ABO
blood groups. J Forensic Med Tox. 2004;21(2):49–52
8.
Prateek Rastogi A study of fingerprints in relation to
gender and blood group J Indian Acad Forensic Med,
32(1)
9.
Gowda MST and Rao CP. A Study To Evaluate
Relationship Between Dermatoglyphic Features And
Blood Groups. J Anat. Society of Ind. 1996; 45: 39.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
THE STATUS OF NATIONAL PROGRAMME FOR
CONTROL OF BLINDNESS IN MADHYA PRADESH
Kaushal Rituja1, Sanjay Kumar Gupta2, Neeraj Gaur3, A V Athawale4, Manmohan Gupta2, Najnin
Khanam3
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Rituja K, Gupta SK, Gaur N,
Athawale AV, Gupta M, Khanam
N. The Status of National
Programme for Control of
Blindness in Madhya Pradesh.
Natl J Community Med 2013;
4(1): 161-4.
Author’s Affiliation:
1Resedent; 2Associate Professor;
3Assistant Professor; 4Professor and
Head, Department of Community
Medicine, Peoples College of
Medical Sciences and Research,
Bhanpur, Bhopal
Correspondence:
Dr. Sanjay Kumar Gupta,
Email: sanjaygupta2020@gmail.com
Date of Submission: 06-10-12
Date of Acceptance: 16-01-13
Date of Publication: 31-03-13
Background: National Programme for Control of Blindness was
launched by Government of India in 1976, but in Madhya Pradesh
(MP) it was launched in 1978. It is a 100% centrally sponsored
programme to overcome the major public health problem
(blindness) in India. Keeping this viewpoint in mind, the study
was conducted with the objectives of to assess the status of
national programme for control of blindness in MP , to find out
the district wise status and comparisons and to know the status of
school children in Programme.
Materials and Methods- Study Design: Record based
retrospective observational. Period of study: From 2007-08 to Aug
2012-13.
Results: Data showing that during the year 2011-12, hundred
percent target were achieved for cataract operation followed by
95% in 2010-11. From 2007-08 to 2012-13. In the all cataract
operation in M.P. around 98% intra ocular lens were also inserted.
Among school children detected refractive errors were higher
during the period of 2012-13 (3.91%) followed by 2011-12 (2.26%),
lowest detection rate were reported in 2009-10 (1.37%). Maximum
number of students given spectacles after detection of refractive
error in 2011-12 (62.57%) followed by in 2010-11 (49.88%)
.According to performance grading of districts of MP, 20% are
best performer district (A grade) and 18% in B grade, 22% 0f MP
districts are worst performer and graded E.
Conclusion: National programme for control of blindness in 20 %
of districts of MP are best performer districts but still 22% of total
districts of Madhya Pradesh are poor performer, there we have to
put more effort to make blindness control programme successful.
Keywords: Blindness, Madhya Pradesh, school children, surgery,
IOL
INTRODUCTION
National Programme for control of Blindness
was launched by Government of India in 1976
but in Madhya Pradesh (MP) it was launched in
1978. It is a 100% centrally sponsored
programme to overcome the major public health
problem of blindness in India.1 It is decentralized
in 1994-95 with the formation of District
blindness control society in each district. The
goal is – To reduce the prevalence of blindness
from 1.4 % to 0.3 % up to year 2020. At present
prevalence of Blindness is 1%. Strategy is
1.Developing eye care infrastructure & human
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resources. 2. Promoting outreach activities &
public awareness. 3. Improving quality of eye
care services & visual outcome following
medical & surgical management.Many surveys/
studies were undertaken to assess the root causes
of blindness & to cure it in a cost-effective way.
Various studies based on gender & blindness
aspect revealed – women account for between 53
% & 72% of all cataract cases2. Women don’t
receive surgery at the same rate as men.
Blindness due to cataract would reduce by about
12.5% if women received surgery at the same
rate as men. 3 Cataract is curable with
inexpensive surgery costing about US $ 20 per
person.3 A survey was undertaken by ICMR in
1971-1974 to identify main causes of blindness,
which revealed that prevalence of blindness was
1.38% & cataract was the leading cause of
blindness. Based on this survey Government of
India appointed a committee to formulate
strategies to control blindness.4 National survey
was undertaken by GOI/WHO in 1986-89, the
survey revealed increase in prevalence from 1.38
% to 1.49%.Cataract accounted for 80% of
Blindness5. Of the total estimated 45 million
blind persons in the world, approx. 7 million are
in India. An estimated 2 million new cases of
cataract are added per year.Also refractive errors
are the second commonest cause of blindness
after cataract, it accounts for over 7% of the
blindness.
Madhya Pradesh is having 7 Division, 50
Districts, 313Blocks and 52117 Villages.5
The health infrastructure in MP is CHC : 333
(every 1,20,000 popu./or Tribal population
80,000),PHC : 1156 (every 30,000 popu./or Tribal
population 20,000), Sub Centre : 8860 (every
5,000 popu./or Tribal population 3,000) , District
hospital : 48, and Urban civil hospital : 56,two
new districts are also formed in M.P. that are
Alirajpur & Singroli.
World Bank assisted cataract blindness control
project 1994-2002. To overcome the backlog of
target -17.2 lacs cataract operations. Achievement
up to 2002 -18.31 lacs cataract operations were
done. Under the Project following facilities were
provided. 1) Cataract operations were done with
IOL implant. 2) Operating microscope provided
in each district 3. Other ophthalmic equipments
were also provided, a scan, Slit lamp,
Keratometer, Tonometer,Direct ophthalmoscope,
and streak Retinoscope. 4) IOL training given to
120 eye surgeons. 5) 20 bedded 15 eye wards &
OTs were constructed.6) 10 bedded 38 eye wards
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& OTs were constructed. 7) 383 dark rooms were
constructed.
OBJECTIVES
To assess the status of national programme for
control of blindness in MP; to find out the district
wise status and comparisons between districts
on performance bases; and to study the status of
school children in National Programme for
Control of Blindness.
METHODOLOGY
Data of all districts of Madhya Pradesh was
collected in standard format from 2008 to 2012-13
retrospectively, from Madhya Pradesh (MP)
blindness control programme office regarding
yearly target set for cataract operation and
Intraocular lens implantation, number of school
surveyed, number of student examined, number
of spectacle distributed for refractive error
students, under the National Programme for
control of Blindness (NPCB), all collected data
was analyse and recorded.
OBJECTIVES
1) To Assess the status of national programme
for control of blindness in MP 2) To find out the
district wise status and comparisons between
districts on performance basis. 3) To study the
status of school children in National Programme
for Control of Blindness.
METHODOLOGY
Data from all districts of Madhya Pradesh was
collected in standard format from 2008 to 2012-13
retrospectively, all collected data was analysed
in reference to target achieved for cataract
operation and IOL implantation, school survey
and detection programme.
OBSERVATION
Table 1 is showing that during the year 2011-12,
hundred percent target was achieved for cataract
operation followed by 95% in 2010-11. From
2007-08 to 2012-13 in all cataract operations in
MP around 98% intra ocular lens were also
inserted.
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Table 1: A yearly distribution of cataract
operations and Intra ocular lens insertion cases
in Madhya Pradesh
Year
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13*
Cataract Operation
Target
Achievement (%)
350000
322822 (92.0)
450000
376143 (84.0)
450000
409601 (91.0)
450000
429695 (95.5)
450000
454150 (100.9)
109440
96144 (87.8)
IOL
Rate (%)
97
98
98.47
98.72
98.76
98
Table 2 shows that refractive errors detected
among school children were higher during the
period of 2012-13 (3.91%) followed by 2011-12
(2.26%) & lowest detection rate were reported in
2009-10 (1.37%). Maximum number of students
given spectacles after detection of refractive error
in 2011-12 (62.57%) followed by in 2010-11
(49.88%), lowest spectacles’ distribution occurred
up to month of august in 2012-13 (3.94%).
*up to August13
Table 2: Distribution of School children according to target for blindness control screening in MP
Year
Target
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13*
Total
1000000
952000
4100000
4100000
4100000
4100000
Schools
examined
30597
37698
24670
37791
36285
2925
Students
examined
3848206
4210030
3796960
3490087
3211264
264226
18820773
Students with
refractive errors (%)
73668 (1.91)
75593 (1.79)
52197 (1.37)
72142 (2.00)
72768 (2.26)
10344 (3.91)
356694 (1.89)
Distribution of free
spectacles (%)
19226 (26.00)
16615 (21.97)
11179 (21.41)
35990 (49.88)
45531 (62.57)
408 (3.94)
*up to August13
Table no. 3. Various Districts of Madhya
Pradesh & their performance grading
DISCUSSION
the target of 17.2 lacs cataract Operation (to
overcome the backlog) & achievement was -18.31
lacs cataract operations.6,7 Even in 2012
,programme is going in full swing in many well
facilitated districts of M.P.But in few districts
due to poor eye care services quantitatively &
qualitatively, poor follow up services, improper
filling up of standard cataract surgery records &
discharge cards, accumulation of unspent
balances over the plan period due to poor
utilization of funds, Suboptimal coverage of eye
care services, poor maintenance of village wise
blind registers, absence of micro plan for
mopping up of the backlog of cataract blindness
,cataract surgery rates are low or even absent.
Poor infrastructure & lack of trained manpower
with non availability of ophthalmic equipments
are further hindrances in the achievement of
goals to bring down CSRs.8,9
District Blindness control society in each district
of the country was launched in the year 1994-95
with the objective of decentralizing the
implementation of the programme. Each district
covers population of approx.15-20 lacs & acts as
basic unit for delivery of eye care services.5 It
requires
co-ordination
of
activities
of
governmental, non-governmental & private
sector. Madhya Pradesh has got momentum
from World bank assisted Cataract Blindness
Control Project 1994-2002 which over shooted
Refractive errors in children – In India, refractive
errors are the second commonest cause of
blindness after cataract. It accounts for over 7%
of the blindness. In children refractive error
occurs due to the defects in the size of the
eyeball. Children usually don’t complain of
defective vision. Any problem in the vision
during the formative years can hamper the
intellectual
development,
maturity
&
performance of a person in his future life. So
timely detection of these problems & their
Achievement
target
>100%
75-100%
50-75%
<50%
<40%
Total
Grading
Districts (%)
A
B
C
D
E
10(20%)
9(18%)
9(18%)
10(20%)
12(24%)
50(100%)
Table 3 is showing that according to performance
grading of districts of MP, 20% are best
performer district (A grade) and 18% in B grade,
24% 0f MP districts are worst performer and
graded E.
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correction by spectacles can tremendously
improve the child’s potential during his
formative years. So for prevention & control
strategy it is better to catch maximum number of
children in school hours.10,11
(2.77%) and Orissa significantly
percentage (12.52%) than MP.12
School eye screening programme includes. 1.
Training of school teachers in primary screening,
2.Annual primary screening of school children,
3.Confirmation of refractive error, and
4.Provision of free glasses for the poor. School
children represent a needy & big target group
requiring identification & treatment of refractive
error due to following reasons.-They are a
captive group & can be reached through the
education system , reading & writing are their
felt needs for which good eye sight is required,
Many children, their teachers & parents realize
this. There has been significant increase in school
eye screening programme10, 11.
As per National programme for control of
blindness - 20 % of districts of MP are best
performer districts but still 24% of total districts
of Madhya Pradesh are poor performers, there
we have to put more effort to make blindness
control programme successful.
1. No. of teachers trained in school eye screening
programme has risen.
2. No. of students screened for refractive error
has risen.
3. No. of children detected with refractive errors
& no. of children provided free glasses has also
increased manifolds. If we compare these figures
with other states like Orissa, NPCB programme
figures from 2007-08 to 2012 were poorer in
performance in comparison to Madhya Pradesh,
Again Madhya Pradesh is a better performer in
achieving target of cataract operation and
intraocular lens insertions (98%) in comparison
to UP (65%).12 Maharashtra was better performer
than MP from 2007-08 to 2010-11 , but in 2011-12
MP was better performer than Maharashtra.12 In
the present study percentage of refractive error
among
school
children
was
(1.89%).
Comparatively Bihar had little higher percentage
higher
CONCLUSION
REFERENCES
1.
WHO. Epi and Vital Statis Rep1966; 19: 437.
2.
WHO .Techn. Rep. Ser 1973;518.
3.
Govt.of India. Health Information of India, DGHS, Nirman
Bhawan, New Delhi 1986.
4.
WHO. Strategies for the prevention of blindness in national
programmes, WHO, Geneva 1984; 59:313-317.
5.
WHO. WHO Chronicle1979; 33: 275.
6.
WHO. International Classification of Diseases 1977;
1:242.
7.
WHO , The World Health Report, conquering suffering,
Enriching humanity, Report of the Director-General
WHO 1997.
8.
WHO, Health Situation in the South-East Asia Region ,
New Delhi 2000.
9.
Govt. of India, Annual Report , Ministry of Health and
Family Welfare, New Delhi 2004.
10.
WHO , Strategic Plan for Vision 2020 : The Right to
sight, Elimination of Avoidable Blindness in the SouthEast Asia Region, New Delhi 2000.
11.
Govt. of India , Annual Report 2002-2003, Ministry of
Health and Family Welfare, New Delhi 2003..
12.
National programme for control of blindness available
at: http://npcb.nic.in/writereaddata/mainlinkfile/
File283, accessed on June 12th, 2012.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Original Article ▌
SCREENING OF EXTRAPULMONARY TUBERCULOSIS
SAMPLES BY ZEIHL NEELSEN STAINING IN PATIENTS
PRESENTING AT TERTIARY CARE HOSPITAL
AHMEDABAD
Lata R. Patel1, Jignesh A. Panchal2, Jayshree D. Pethani3, Sanjay D. Rathod3, Parimal H. Patel1,
Parul D. Shah4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patel LR, Panchal JA, Pethani JD,
Rathod SD, Patel PH, Shah PD.
Screening of Extrapulmonary
Tuberculosis Samples by Zeihl
Neelsen Staining in Patients
Presenting at Tertiary Care Hospital
Ahmedabad. Natl J Community
Med 2013; 4(1): 165-7.
Author’s Affiliation:
1Tutor; 2Resident; 3Asso.Prof.; 4Prof.
& Head, Microbiology, Smt.NHL
MMC Ahmedabad, Ahmedabad
Correspondence:
Dr. Lata R. Patel
Email: drlatapatel76@gmail.com
Context:
Along
with
pulmonary
tuberculosis
now
extrapulmoanary variety continues to be a major health problem
in our country & is emerging from the shadows of its senior
cousin. Diagnosis of EPTB has always been a challenge. The aims
of the present study was to detect the acid fast bacilli by zeihl
neelsen and positive samples were confirmed by fluorescent
staining from various unsuspected extrapulmonary specimens at
our hospital, and to investigate their demographic characteristics.
Objectives: To detect the acid fast bacilli by zeihl neelsen staining
in extrapulmonary samples and to investigate their demographic
characteristics.
Methods and Material: A retrospective analysis was carried out
during January 2011 to June 2011. All extrapulmonary samples
were screened for acid fact bacilli by 20% Z-N stain and positives
were confirmed by fluorescence microscopy.
Results: Total 793 extrapulmonary samples received during 1st
January 2011 to 30th June 2011, from which 18 (2.26%) samples
were found to be positive including 14(1.76 %) pus, 3(0.37%)
pleural fluid & 1(0.13%) ascitic fluid. Common age group was 10
to 30 yrs. and Female : male ratio was 1.5:1. From total positive,
11% were HIV positive patients.
Date of Acceptance: 18-02-13
Conclusions: However, based on our results TB Control
Programme might usefully target young populations for early
diagnosis of EPTB to decrease TB morbidity and mortality.
Date of Publication: 31-03-13
Key-words: Extrapulmonary tuberculosis,Acid Fast Bacilli , HIV
Date of Submission: 23-11-12
INTRODUCTION
Tuberculosis is a common, and in many cases
(i.e. extrapulmonary) lethal, infectious disease
caused by various strains of mycobacteria,
usually Mycobacterium tuberculosis. Extrapulmonary tuberculosis (EPTB) refers to disease
outside the lungs. It is sometimes confused with
non-respiratory disease. Disease of the larynx for
example, which is part of the respiratory system,
is respiratory but extra- pulmonary. Extrapulmonary TB may be characterized by swelling
of the particular site infected (lymph node),
mobility impairment (spine),or severe headache
and neurological dysfunction (TB meningitis)
etc. Extra-pulmonary TB is not accompanied by a
cough. It is equally important that both the
infectious and non-infectious forms of TB are
diagnosed and treated as both can be fatal1.
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Extra Pulmonary Tuberculosis (EPTB) has
existed for centuries. It is a milder form of
disease in terms of infectivity as compared to
pulmonary tuberculosis. Diagnosis of EPTB has
always been a challenge. It is a protean disease
affecting virtually all the organs and has a wide
spectrum of clinical presentation depending on
the anatomical site involved and presents a
diagnostic dilemma even for physicians with a
great deal of experience. For an unsuspecting
physician, the tuberculosis etiology may not
even figure in the list of probable diagnosis2.
Extrapulmonary TB often goes undetected as
acid fast bacilli load in extrapulmonary
specimens are scanty. To overcome this
diagnostic problem we need to establish a
substantial diagnostic method by introducing
newer, faster & more sensitive methods. The
bacilli in the received extrapulmonary specimens
can be detected by ZN stain and positives were
confirmed by fluorescent stain. ZN stain is
commonly used throughout the world and still
remains the standard method against which new
tests must be measured. Fluorescent stain is
regarded as a more reliable method due to more
intensive binding of mycolic acids of the bacilli
to phenol auramine, and so that the bacilli stand
out sharply against black background to allow
rapid and accurate screening under low power
objective3. The aim of the present study was to
detect the acid fast bacilli by zeihl neelsen
staining in extrapulmonary samples and to
investigate their demographic characteristics.
METHODS
A total no. of 793 extrapulmonary samples were
received during 1st January 2011 to 30th June 2011
from Sheth Vadilal Sarabhai General Hospital,
Ahmedabad, Gujarat. Out of these, 304 samples
were pus (including pus from lymph node and
other sites), 183 ascitic fluid, 230 pleural fluid &
76 CSF. All the samples were received in sterile
containers. From each samples smear were made
on new, clean, unscratched glass slide. Smear
was allowed to air dried and fixed by heat then
slide was stain by Z-N stain and examined under
oil –immersion(x100) while positive smear was
confirmed by Auramine Phenol stain and
examined using 10 x and then 40x objective
under fluorescent microscope.
The detailed patients history, physical findings,
chest radiographs and laboratory investigations
were reviewed to obtain the necessary
information about diagnosis of extrapulmonary
TB. Testing of HIV infection is carried out to all
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TB patients. Patients those suffering from MDR –
TB (following the guideline of RNTCP), those
specimens were sent for culture to IRL
(Intermediate Reference Laboratory) at Civil
Hospital, Ahmedabad. A limited number of
medical centres are able to perform accurate and
rapid culture and susceptibility testing.
RESULTS
Between1st January to 30th June – 2011, a total of
793 samples were screened for acid fast bacilli, 18
(2.26 %) samples were found to be positive for
acid fast bacilli in which 5 patients belongs to age
group 10 to 20 yrs. and 5 patients belongs 20 to
30 yrs shown on Table no.1. From total 18
positives of EPTB cases, 2 (11%) were HIV
positive while 16(89%) were HIV negative.
Table1: Case(s) of extrapulmonary tuberculosis
according to age group.
Age group in year
0 – 10
11 – 20
21 – 30
31 – 40
41 – 50
51 – 60
>60
Cases
03
05
05
02
02
01
00
In our study AFB positivity was highest in pus
14(7%) followed by pleural fluid 3(1.3%) and
ascitic fluid 1(0.5%) and no acid fast bacilli were
found from CSF. The females were more affected
11 (61.1%) than male 7 (38.9 %).
DISCUSSION
Extrapulmonary TB should be diagnosed at the
earliest to prevent life threatening complications.
Use of more sensitive methods for diagnosis are
very helpful (e.g. fluorescence microscopy) as
workload is more in tertiary care hospitals so
that every culture sample can be screened for
AFB even if it is unsuspected for TB. As AFB
load is scanty in extrapulmonary specimens
newer techniques like PCR & fluorescence
microscopy should be used for rapid diagnosis.
In present study showed AFB positivity was
highest in pus (1.76 %) followed by pleural fluid
(0.37 %) which was correlated with other studies
4,5 but rate of positivity for pleural fluid was
different. In India and other developing
countries LNTB continues to be the most
common form of EPTB and lymphadenitis due to
non-tuberculous mycobacteria (NTM) is seldom
seen6,7,8. On the other hand, NTM are the most
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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common cause of lymphadenopathy in the
developed world9
Results of our study suggest that younger may
be independent risk factors for EPTB. So the
incidence of extrapulmonary TB is more
common in younger age group (72%) in below 30
year of age5. Demographic characteristics of
EPTB cases have shown higher detection in
females and in patients of young age. Similar
observations have been made in past10.
In our study,females were preponderance, with
an overall female : male was 1.5: 1, that is
correlated with study done by Chandir Subhash
et al11 and Fawzia Al –Otaibi ,Malak M. El Hazm
et al 12. Female patients showed high incidence of
EPTB in the younger age group (20-30 years). An
explanation of this finding remains unclear, but
it suggests that women of child bearing age seem
to be most vulnerable for EPTB. This group
should be targeted for further study to find the
causes and intervention for disease prevention.
And also endocrine factors might play a role.
This is considered with studies from USA and
Europe13 which have found that younger age
was independent risk factors for EPTB14.
In our study, lymphnodes EPTB (1.76%) cases
were highest followed by pleural fluid (0.36%).
Cartain other studies10-12 have also reported high
number of cases with lymph node involvement.
In our study EPTB in HIV positive patients were
less as compare to other study5,15 indicating that
EPTB can occur in non immunocompromised
patients.
In conclusion, there is an overall increase in the
incidence of EPTB contributing to the overall
burden of Tuberculosis in developing countries
and the proportion of EPTB is relatively low and
EPTB is less infectious than PTB. Therefore,
EPTB is usually not prioritized for case finding
strategies in TB control programs. However,
based on our results TB control programs might
usefully target young populations for early
diagnosis of EPTB to decrease TB morbidity and
mortality. High index of clinical suspicion,
timely judicious use of invasive diagnostic
methods and confirmation of the diagnsosis by
establishing more sensitive method like
Fluorescent stain in comparision to Z- N stain
and early institution of specific anti tuberculosis
treatment and close clinical monitoring for
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adverse drug reactions are the key to the
successful management of EPTB.
REFERENCES
1.
Doctor’s section – Extrapulmonary Tuberculosis.
Holzkirchen, Germany, Sandoz- 2006, Industriestrasse
25, 83607.
2.
Arora V.K.and Chopra K.K. Extra pulmonary
tuberculosis. Indian Journal of Tuberculosis 2007;
54:165-167.
3.
Satya Sri S. Textbook of Pulmonary and
Extrapulmonary Tuberculosis. Interprint Publishers;
2000. 4th edn p. 63-69.
4.
Sharma S.K. & Mohan A. Extrapulmonary tuberculosis.
Indian Journal of Medical Research 2004;120: pp 316353.
5.
Arora V. K. and Gupta Rajnish. Trends of extrapulmonary tuberculosis under Revised National
tuberculosis control programme: A study from south
delhi. Indian Journal Tuberculosis.2006;53:77-83.
6.
Dandaput MC, Mishra BM, Dash SP, Kar PK. Peripheral
LNTB. A review of 80 cases. Brtish Journal of Surgery
1990 ; 77: 911-2.
7.
Subrahmanyam M. Role of surgery and chemotherapy
for peripheral LNTB. British Journal of Surgery.1993;8:
1547-8.
8.
Jawahar MS Sivasubrahmanyam S, Vijayan VK,
Ramakrishnan CV, Paramasivan CN, SelvakumarV.et al.
Short course chemotherapy for tuberculous
lymphadenitis in children. Brithish Medical
Journal.1990; 301: 354-62.
9.
White MP, Bangash H, Goel K, Jenkins PA,
Nontuberculous mycobacterial Lymphadenitis,
Archives of Diseasein Childhood. 1986;61: 368-7.
10.
Chandrashekhar T Sreeramareddy et al.Comparison of
pulmonary and extrapulmonary tuberculosis in Nepala hospital-based retrospective study. BMC Infectious
Diseases.2008;8:8.
11.
Chandir Subhash, Hussain Hamidah, Salahuddin
Naseem.Extrapulmonary Tuberculosis : A retrospective
review of 194 cases at a tertiary care hospital in Karachi,
Pakistan. Interactive Research And Developmen,
Karachi, Indus Hospital, Karachi, The Aga Khan
University Hospital, Karachi, Pakistan. Feb.2010; 60(2).
12.
Fawzia AI-Otoibi, Malak M, EI Hazmi, Extrapulmonary
Tuberculosis in Saudi Arabia, Indian Journal of
pathology & Microbiology, 2010, Vol.53, Issue 2, Page227-231.
13.
Gonazalez Oy, Adams G, Teeter LD, Bui TT, Musser JM,
Graviss EA. Extrapulmonary Manifestations in a large
metropolitan area with a low incidence of TB. Int. J
tuberc Lung Dis. 2003;7: 1178-85.
14.
Kumar A., Lymphnode Tuberculosis, Sharma S K,
Mohan A editors Tuberculosis, New Delhi – Jaypee
Brothers Medical publishers – 2001, p. 273-84
15.
Mrs.Sujata N, Dr.Renu S Bharadwaj et al “ExtraPulmonary Tuberculosis in HIV & non HIV patients in a
tertiary care Hospital, Mumbai” Indian Journal of Basic
& Applied Medical Research; June 2012: Issue-3, Vol.-1,
P. 205-208.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Page 167
Open Access Article│www.njcmindia.org
pISSN 0976 3325│eISSN 2229 6816
Original Article ▌
DEATH AUDIT OF LEPTOSPIROSIS CASES IN SURAT AND
NAVSARI DISTRICT OF SOUTH GUJARAT
Fenil Patel1, Kanan Desai1, Kallol Mallick2, Rachana Prasad3, Rajkumar Bansal4
Financial Support: None declared
ABSTRACT
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
Patel F, Desai K, Mallick K, Prasad
R, Bansal RK. Death Audit of
Leptospirosis Cases in Surat and
Navsari District of South Gujarat.
Natl J Community Med 2013; 4(1):
168-71.
Author’s Affiliation:
1PG Resident; 2Assistant Professor;
3Associate Professor; 4Professor &
Head, Dept. of Community
Medicine, SMIMER, Surat
Correspondence:
Dr. Fenil Patel,
Email: fenilpatel25885@gmail.com
Date of Submission: 23-01-13
Date of Acceptance: 18-03-13
Date of Publication: 31-03-13
Introduction: Leptospirosis, zoonotic disease with very wide
geographical distribution, is likely to be missed due to its wide
spectrum of symptoms which may mimic the clinical signs of
many other diseases. The present study was carried out to study
the epidemiology, clinical and laboratory profile of died patients
with confirm leptospirosis in Surat and Navsari Districts.
Methods and Material: A household visits were done for all
leptospirosis confirmed death cases of Surat and Navsari district
during 15th June to 31st Oct 2012.
Result: Out of 13 patients all were male, 10(76.9%) were in age
group (20-45 years), 11 (84.6%) patients had history of exposure
while working in farm in last 15 days and 12 (92.3%) patients had
received Doxycycline chemoprophylaxis in current year. Most
common presenting symptoms were fever (100%) followed by calf
muscle myalgia (92.3%), jaundice (92.3%) and Oliguria (92.3%).
Mean serum billirubin level, SGPT, SGOT, Serum blood Urea and
creatinin were 13.7mg/dl, 111.5 IU/l, 139.7 U/l, 184.85mg/dl and
4.5mg/dl respectively. Severe anemia, thrombocytopenia and coagulopathy were found in all cases. The average duration
between onset of the symptoms and first medical consultation
was 3.1 days and duration between onset of symptoms and first
dose of antibiotics was 3.7 days.
Conclusion: Hepatic dysfunction, acute renal failure, coagulopathy, ARDS were the commonest presentation requiring
artificial ventilation among deceased Leptospirosis cases. Delay in
medical consultation and first dose of antibiotics may be a reason
for Multi-organ dysfunction in these cases.
Key words: Leptospirosis, Weils’ disease, oliguric renal failure,
ARDS
INTRODUCTION
Leptospirosis, a disease caused by pathogenic
spirochetes of the genus Leptospira, is considered
the most common zoonosis in the world and has
recently been recognized as a re-emerging
infectious disease among animals and humans
and has the potential to become even more
prevalent with anticipated global warming1. It is
more than 100 years since Weil; Professor of
Medicine at Heidelberg (1886) whose name has
been given to the disease in humans first
described this disease, which is caused by
Leptospira
interrogans,
serovars
icterohaemorrhagiae or copenhageni2.
Leptospirosis cases were seen for the first time in
Gujarat in 1994 in the Chikhali block of the old
Valsad district.3. As such there exists a close
association between rains, rice fields, rodents &
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Leptospirosis. This zoonotic disease is more
prevalent in South Gujarat due to heavy rain fall,
clay soil structure which results in enhanced
water logging & high water-tables3. In addition,
the irrigated fields where they work are already
contaminated with urine of rodents & cattle. A
particular problem is that Leptospirosis is likely
be misdiagnosed, due to its wide spectrum of
symptoms which may mimic the clinical signs of
many other diseases, such as malaria, dengue
fever, hepatitis and hantavirus infection5. The
present study was carried out to study the
epidemiology, clinical and laboratory profile of
patients died due to leptospirosis in Surat and
Navsari Districts of South Gujarat.
METHODOLOGY
In 2012, up to October, 61 confirmed cases of
Leptospirosis were reported from Surat and
Navsari Districts, out of which 13 deaths
occurred according to data from RDD (Regional
Deputy Director) office, Surat. All were
diagnosed as having leptospirosis as per the
definition given by Microbiology department of
Government Medical College, Surat (GMCS) in
accordance with National guidelines NCDC
(National Center for Disease Control) &
Department of Medicine, GMC, Surat.
Laboratory Confirmation criteria used for a case
of Leptospirosis are:
• PCR Positive/ culture Positive in first blood
sample
• In single Serum Sample ELISA≥ 100 Unit OR
MAT ≥ 80 Titer
• In Paired Serum Sample in ELISA/MAT
showing Fourfold rising Titer in second
Serum.
We had visited all patients’ houses that died due
to leptospirosis and collect the relevant data
regarding the deceased from the nearest person
of the patients in pre-designed questioner (Death
audit form) by personal interview. Data
regarding clinical diagnosis and laboratory
findings are collected from the patients’ case
paper from the respected hospitals. Data
regarding environmental factors was observed
by the interviewer directly.
RESULT
All 13 were male (100%) with 10(76.9%) were in
younger age group between 20-45 years. Out of
total, 11 patients were working in the farms
either rice field or sugarcane field (61.5%).
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History of exposure in last 15 days was present
in 11(84.6%) patients. History of open air
defecation in the farm was also present in 7
(53.8%) patients which might be contributory
factor. Only 6 (46.2%) informant had some
knowledge regarding leptospirosis and source of
information for all of them were heath workers.
Table: 1 Socio-demographic Profile of
Leptospirosis Patients (n=13)
Variables
Age
20-45
45-60
Gender - Male
Occupation
Farm worker
Farmer
Type of farm (Multiple answer)
Rice field/ Sugarcane field
Vegetable or other
H/o open air defecation in farm
present
H/o occupational exposure in last 15
days
Relatives knows about Leptospirosis
Source of information (n=6) Health
worker
Doxycycline chemoprophylaxis taken
Completed 8 weeks of
chemoprophylaxis (n=8)
History of alcoholism
Patients(%)
10 (76.9)
3 (23.1)
13 (100)
9 (69.2)
2 (15.4)
8 (61.5)
3 (23.07)
7 (53.8)
11 (84.6)
6 (46.2)
6 (100)
8 (61.5)
4 (50.0)
11 (84.6)
History of Alcoholism present in 11(84.6%)
patients.
Most common symptoms were fever (100%), calf
muscle myalgia (92.3%), jaundice (92.3%),
Oliguria (92.3%), frontal headache (69.2%),
breathlessness (69.2%) and Conjuctival suffusion
(46.2%).
As per table 2, in the study population all the
patients had altered liver function with raised
mean (SD) serum billirubin level of 13.7mg/dl
(8.7 mg/dl), SGPT and SGOT were 111.5 IU/l
(109.2 IU/L), 139.7 U/l (108.0 U/ L )
respectively. All the patients had severe anemia,
leucocytosis and thrombocytopenia with altered
coagulation profile. Serum blood Urea and
creatinin level had found significantly high with
mean value 184.85mg/dl and 4.5mg/dl
respectively.
Rapid leptocheck, MAT-1, ELISA-1, and PCR
had been done in all the patients and were found
positive in 8(61.5%), 7(53.8%), 7(53.8%) and
6(46.1%) patients respectively.
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Table 2: Laboratory Profile of Leptospirosis Patients (N=13)
Variable
Serum billirubin
Direct
Indirect
SGPT
SGOT
Hemoglobin
Leucocytes count
Platelet count
Blood urea
Serum creatinin
INR (International Normalized Ratio)
Normal range
0.3-1.3mg/dl
0.1-0.4mg/dl
0.2-0.9mg/dl
7-41 IU/L
12-38 U/L
M-13.3-16.2 g/dl
3045-9060/mm3
1.65-4.15 lakh/mm3
7-20 mg/dl
0.5-0.9 mg/dl
1.0
The most frequent finding on X-ray chest was
diffuse alveolar infiltration suggesting of ARDS
in 9(69.2%) patients and 4(30.8%) patients had
clear findings of pulmonary hemorrhage. On
USG 6(46.1%) patients had mild organomegaly
with sign of medical kidney disease.
Table 3: Treatment Seeking and Care Provision
of Leptospirosis Patients (N=13)
Variables
Prior consultation in
private
Transport during referral
108 ambulance
PHC/CHC vehicle
Private ambulance
Accompanied by Doctor
during transport/referral
Patients
(%)
9 (69.2)
9(69.2)
3(50.0)
1(7.7)
0 (0.0)
95% CI
41.3-89.4
41.3-89.4
14.7-85.3
0.4-32.5
0-20.6
As per table 3, most of patients 9(69.2%) had
prior consultation in private before consultation
in government set up and most common mode
of transport was 108 ambulance (69.2%) service
of the Government, but none of the patients
accompanied by any Doctor.
Table 4: Time Taken at Various Level of Care
(N=13)
Variables
Interval between onset of symptoms and
first consultation (Private/Govt.) (days)
Interval between onset of symptoms and
rapid leptocheck test (days)
Interval between onset of symptoms and
first dose of antibiotic (days)
Interval between onset of symptoms and
death (days)
Mean(SD)
3.1(2.1)
4.3(1.8)
4.5(1.8)
8.4(4.2)
Mean(SD)
13.7(8.7)
10.7(6.7)
2.9(2.5)
111.5(109.2)
139.7(108.0)
8.0(2.9)
14261.5(8414.1)
36583.3(20156.0)
184.45(79.4)
4.7(2.0)
1.4(0.5)
Range(Min-Max)
1.9-27.3
1.2-21.5
0.4-7.3
25-389
42-320
3.5-13.0
2200-36400
10000-70000
84-311
2.0-8.0
1.0-4.16
DISCUSSION
Leptospirosis classically presents in two forms,
icteric and anicteric form of Leptospirosis. The
first phase of the disease is commonly referred to
as the septisemic phase. This phase is followed
by the brief afebrile period of variable duration
which in turn, is followed by the immune phase
of illness 6, 7.
Majority of patients died due to leptospirosis in
this study were in their 3rd and 4th decade
of life which is comparable to the report done
by other studies 8,9,10 .
In our study we had found that most of the
patients died due to leptospirosis were young
male as also observed previous studies 7,11,12.
Male preponderance is believed to be due to
occupational differences rather than sex- linked
susceptibility.
In our study we had also found that the patients
died due to leptospirosis were either on the
chemoprophylaxis or completed it and still they
developed disease later on this might be due to
factors the fact that this year there was delay in
rainy
season
and
associated
exposure
(September-October), where as 8 weeks
chemoprophylaxis round had been completed
much earlier at the expected time of rain (JulyAugust).
Most common presenting symptoms in our
study were same as other study 13. All patients
were presented with oliguric renal failure in
current study as comparable to previous study,
which reported higher frequency of nonoliguric
renal failure with lower morbidity and mortality
rates14.
In a study by Dupont et al15, total 18% of the
patients died due to leptospirosis, most of them
presented with dyspnoea, oliguria, leucocytosis,
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Leptospirosis in the Asia Pacific region.” BMC
Infectious Diseases 2009, 9:147
and alveolar infiltration on chest radiograms.
These finding are similar to current study.
Hepato-renal form and the pulmonary form of
leptospirosis is associated with high case fatality
rate ranging 10% to 15%16.This findings are
similar to this study.
5.
Tappero, J. W., D. A. Ashford, and B. A. Perkins.
2000.Leptospira species (leptospirosis), p. 2495-2501. In
G. L.Mandell, J. E. Bennett, and R. Dolin (ed.),
Principles and practice of infectious diseases, 5th
ed. Churchill Livingstone, Philadelphia, Page 34
Microscopic agglutination tests (MAT) is the
Gold standard test, but it is less sensitive and
complicated compared to ELISA and SAT17. In
our study we had found that only 8(61.5 %)
patients were rapid leptocheck positive other
were either MAT-1 positive or ELISA -1 positive,
so we cannot rely on only rapid leptocheck17.
6.
Sethi S, Sharma N, Kakkar N, Taneja J, Chatterjee SS,
Banga SS, et al. Increasing trend of leptospirosis I
Northern India: A clinic-epidemiological study. Plos
Negl Trop Dis 2010;12;4:e579
7.
Shekatker SB, Harish BN, Menezes GA, Parija SC.
Clinical and serological evaluation of leptospirosis in
Punducherry, India. J Infect Dev Ctries 2010;4:139-43
8.
Isselbacher KJ, Fauci AS, Braunwald E, et al.
Harrison's Principles of Internal Medicine. New York:
MeGraw- Hill, 1998: p. 1036
9.
Atora BD, Nambayan A, Perez J, et al. Leptospirosis in
Santo Tomas University Hospital: Analysis of 17
cases,1967-71. Phil J Microbiol Infect Dis 1973; 11(1):1122
10.
Manaloto CB, Alora AT, Alora BD. Leptospirosis: An
analysis of 29 cases. Phil J Microbiol Infect Dis
1980;9:75-81
11.
Villanueva S, Dans A, Tanchuco J. Leptospirosis in
the Philippine General Hospital: A review of initial
presentation on admission 1980-1985. Acta Medica
Philippina 1986; 22:143-157
12.
Marcial MR, Dy ER, Alora AT. Leptospirosis revisited
at the Santo Tomas University Hospital. Phil J
Microbiol Infect Dis 1973; 23 (1):20-33
13.
V Chauhan, DM Mahesh, P Panda, J Mokta, S Thakur.”
Profile of Patients of Leptospirosis in Sub-Himalayan
Region of North India.” JAPI june 2010 VOL. 58; 354356
14.
Seguro AC, Lomar AV, Roch AS, Acute renal failure of
leptospirosis: Nonoliguric and Hypokalemic forms.
Nephron 1990; 55:146-51
15.
Dupont H, Dupont-Perdrizet D, Perie JL, ZehnerHansen S, Jarrige B, Daijardin JB. Leptospirosis:
Prognostic factor associated with mortality. Clin Infect
Dis 1997;25:720-4
16.
Vijyachari P, Sugunan AP, Sharma S, Roy S,
Ntarajaseenivasan K, Sehgal SC. Leptospirosis in the
Andaman Islands, India. Trans R Soc Trop Med Hyg
2008; 102: 117-22
17.
Shivakumar S, Shareek PS, Diagnosis of leptospirosis
utilizing modified Faine’s criteria. J Assoc Physicians
India 2004;52:678-9
18.
Patil Vaibhav C,Patil Harsha V, Agrawal Vaibhav.
Clinical profile and outcome of leptospirosis. Journal of
Academy of Medical sciences. 2012; 2(1);30-37
Though, results of present study cannot be
exactly compared with other studies because of
region to region difference in the economic
profile, social factors, environmental factors
including rainfall patterns, epidemiological
factors, health care facilities, community
awareness as well as different serovars of
leptospira involved in different endemics/
epidemics etc.
CONCLUSION
Hepatic dysfunction, acute renal failure, coagulopathy, ARDS were the commonest
presentation requiring artificial ventilation
among deceased Leptospirosis cases. Delay in
medical consultation and first dose of antibiotics
may be a reason for Multi-organ dysfunction in
these cases.
REFERENCE
1.
Yang CW. Leptospirosis in Taiwan- an underestimated
infectious disease. Chang Gung Med J 2007; 30:109-15.
2.
Edward A., Hodder, Staughton. Leptospirosis. Quoted
in Topley and Wilson’s Principles of Bacteriology,
Virology and Immunity. 8th edn. Vol. 3, 619, 1990.
3.
Gandhi S, “Scenario of Leptospirosis in Gujarat, India”.
lib.bioinfo.pl/blid:2205 p-1.
4.
Ann Florence B Victoriano, Lee D Smythe, Nina
Gloriani-Barzaga,Lolita L Cavinta, Takeshi Kasai,
Khanchit Limpakarnjanarat, Bee Lee Ong,Gyanendra
Gongal, Julie Hall, Caroline Anne Coulombe,Yasutake
Yanagihara, Shin-ichi Yoshida,and Ben Adler .”
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Short Communication ▌
A STUDY TO ASSESS GENUINENESS OF OBSTETRICS /
GYNECOLOGICAL PATIENTS COMING OR BEING
REFERRED TO MEDICAL COLLEGE HOSPITAL IN
SOUTHERN DISTRICT OF RAJASTHAN
C P Sharma1, Shalabh Sharma1, Arun Kumar1, Chetan K Jain1
1Department
of Community Medicine, Rabindra Nath Tagore Medical College, Udaipur, Rajasthan
Correspondence: Dr. C.P. Sharma Email: cppsm09@rediffmail.com
ABSTRACT
Background: In recent years it has been observed that medical college hospitals have been over
burdened, bed occupancy has doubled and hospitals are finding it difficult to handle this increased
patient load, putting enormous pressure on already scarce manpower and infrastructure resources.
Objective: To assess the reasons of increased indoor patient registrations specially focusing on the
department of obstetrics and gynecology of RNT Medical College, Udaipur.
Material and methods: 300 patients in different Wards of the department of obstetrics and
gynecology and only those coming from outside municipal limits of Udaipur were interrogated
through a predesigned structured questionnaire and responses of treating doctors were also taken
over a period of 1 month.
Results: Total 300 admitted patients were included in the study. Participants belong to 17-44 years
age group (mean age 29.06±12.06 years). Majority of 172(57.3%) patients sought services of this
hospital for some genuine gynecological problems, 77(25.66%) for pregnancy with complication
.About 147(49%) patients had come to the tertiary level hospital for non availability of assured, round
the clock specialist services in their own areas. Fear of complications 172(57.33%) and lack of faith and
confidence in locally available medical officer 122(40.66%) have been the major reason for not availing
services at periphery.
Conclusion: In view of the above findings there is urgent need to strengthen services and
infrastructure in tertiary level hospitals to cope up with the increased workload.
Key words: genuineness, Obstetrics / Gynecological, referred.
INTRODUCTION
With an aim to bring about architectural
correction in the quality of health care in rural
areas and to improve maternal and child health,
Govt. of India had launched a National Rural
Health Mission in 20051, with an ultimate goal to
bring down Maternal Mortality Rate and Infant
Mortality Rate. In recent years it has been
observed that medical college hospitals have
been over burdened, bed occupancy has doubled
and hospitals are finding it difficult to handle
this increased patient load, putting enormous
pressure on already scarce manpower and
infrastructure resources. In view of the above a
study was conducted to know the genuineness of
these cases coming to the hospital instead of
availing the services in their residential areas and
to assess the reasons of increased indoor
registration specially focusing on the department
of obstetrics and gynecology of RNT Medical
College, Udaipur.
METHODS
A hospital based cross sectional design was
adopted for the study. Study was conducted at
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department of obstetrics and gynecology at
Maharana Bhupal Hospital, Udaipur during July
2011.
Three hundred patients admitted in different
wards of the department of obstetrics and
gynecology, who came from outside municipal
limits of Udaipur were included the study.
Data were collected on a predesigned prestructured questionnaire through the interviews
of the patients, available indoor records and
interview of treating doctors during the month of
July 2011.
Data thus collected was
Microsoft Excel version 2007.
analyzed
using
RESULTS AND DISCUSSION
Total three hundred admitted patients were
included in the study. Participants belong to 1744 years age group (mean age 29.06±12.06
years).Table 1 depict the socio-demographic
profile of patients)
Table 1: Socio-demographic Characteristics of
patients
Characteristic
Age(In years)
≤ 20
21-30
31-40
>40
Residence
Rural
Urbal
Religion
Hindu
Muslim
Marital status
Married
Un-married
Literacy status of patients
Illiterate
Primary
Secondary
Graduate and above
Husband literacy
Illiterate
Primary
Secondary
Graduate and above
Patients (%)
27(9)
207(69)
54(18)
12(4)
219(73)
81(27)
198(66)
102(34)
214(71.3)
86(28.7)
124(41.5)
113(37.6)
41(13.6)
22(7.3)
69(23)
143(47.6)
55(18.4)
33(11)
About 108(36%) patients seeking services at this
institute are from adjoining districts of nearby
state (MP) and districts bordering Udaipur and
rest from various blocks of Udaipur district. Easy
access and availability of substantially good
quality round the clock, assured services seems
to be one of the potential reasons for coming to
this hospital. Highest number of patients coming
to this hospital from block rural Kanod 69 (23%)
in spite of availability of a proactive specialist in
the field are from village which are
geographically located at a distance from
Community Health center Head Quarter and
have much easier access to this hospital, whereas
services in other blocks need to be strengthened
to restore faith and confidence of patients with
special reference to qualified staff and not only
the infrastructure. Rajasthan Government
initiative to make available services of specialists
in the periphery by providing six months
training has not delivered desired results. Doctor
trained for such duration either lack confidence
or do not want to take responsibility or deal with
emergency/complication.
Majority 172(57.3%) of the patients had come to
seek the services of this hospital at their own,
reflects the level of their confidence and faith in
the quality of care being rendered at this
institution. Majority of 172(57.3%) patients
sought services of this hospital for some genuine
gynecological problems, i.e. 77(25.66%) came for
pregnancy with complication .Similarly Sweta
Rajani,Harsha S. Gaikwad et al2 found
gynecological morbidity was most common at
both peripheral and tertiary level centers
followed by obstetric morbidity. About 147(49%)
patients had come to the tertiary level hospital
for non availability of assured, round the clock
specialist services in their own areas. Majority of
patients
172(57.33%)
reported
fear
of
complications as the major reason for not
availing services at periphery and alternatively
lack of faith and confidence in locally available
medical officer have been reported by
122(40.66%) patients as reason for not availing
services at periphery, on the contrary Palas S.
Das, Mausumi Basu et al3 reported in rural
Bengal, non-availability of doctor as a issue by
only 17% of the patients, and poor confidence in
doctor only by 9.63% of patients . Only 34(11.33
%) patients had come with a hope to get all
medical care free of cost here, which is not
available to them in rural areas, whereas
miscellaneous reasons like improper response of
medical staff, staff demanding money in lieu of
providing the services, rude and complacent
behavior of health staff at periphery and
pressure of family or relatives support in town
has been the reason in 15(5%) patients.
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In the present study non availability of blood
transfusion facilities was reported by 180(60%)
patients, similarly Kranti S. Vora, Dileep V.
Mavalankar et al4 reported that over 70% of the
FRUs and CHCs do not have linkages with a
district blood-bank. Many medical officers at
periphery are hesitant to deal with anemic/poor
nutritional status patients to avoid any
controversies in media or abuse / litigation by
relatives, this is the reason that 132(44%) of the
patients could not be treated in a peripheral
institution as per the gut feeling of health care
providers in apex institution.
About 51(17%) of normal deliveries coming from
periphery with obvious reasons of lack of faith
and confidence in medical officer and fear of
complications need to be investigated. Rural
health statistics5 of India reported that about 67%
posts of obstetrics/gynecology specialists are
vacant in community health centers in Rajasthan.
Similarly in present study 147(49%) patients
came from area where specialists in
obstetrics/gynecology were not available. As per
gut feeling of treating doctor at tertiary level
hospitals majority of patients 167(55.6%) could
be treated or managed at the peripheral health
care facility.
CONCLUSION AND RECOMMENDATIONS
Looking to the findings of study, patient
opinions and responses of doctors attending the
increased workload at tertiary level hospitals,
there is urgent need to strengthen and improve
quality of services, infrastructure and availability
of trained manpower at peripheral health
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institutions to restore confidence of rural
patients. In view of the above findings and the
option of a cafeteria choice to patients seeking
medical care, it is the responsibility of the
department to strengthen medical college
hospitals in terms of increasing number of Post
Graduate seats to have more qualified doctors in
the field in near future and increase in no. of
faculty members and infrastructure in medical
colleges alongside ensuring availability of
trained and qualified doctors at periphery with
compensatory remuneration at par with
corporate sector and improving facilities like
mini blood banks, investigations and ensuring
availability of services of anesthetists at all first
referral units may it on contractual/ part time
basis.
REFERENCES
1.
Available from: http://www.mohfw.nic.in/nrhm.htm
2.
Sweta Rajani, Harsha S Gaikwad, Vrijesh Tripathi,
Sudha Salhan. A study of reproductive morbidities
among women reporting to primary and tertiary care
centers in and around Delhi. International Journal of
Health Research, March 2011; 4(1):29-35
3.
Palas Das, Mausumi Basu, T Tikadar et al Client
Satisfaction on Maternal and Child Health Services in
Rural Bengal. Indian J Community Med. 2010 Oct-Dec;
35(4): 478–481.
4.
Kranti S. Vora, Dileep V. Mavalankar et al Maternal
Health Situation in India: A Case Study. J Health Popul
Nutr. 2009 April; 27(2): 184–201.
5.
Bulletin on Rural Health Statistics in India, March
2011.Available from: http://nrhmmis.nic.in/UI/RHS/RHS%202011/RHS%20March%202011-%20Tables-%20Final%209.4.2012.pdf.
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Current Topic ▌
IS 30 THE MAGIC NUMBER? ISSUES IN SAMPLE SIZE
ESTIMATION
Sitanshu Sekhar Kar1, Archana Ramalingam2
1Assistant Professor; 2Post- graduate, Department of Preventive and Social Medicine, JIPMER, Puducherry
Correspondence Dr Sitanshu Sekhar Kar, Email: drsitanshukar@gmail.com
ABSTRACT
Research has become mandatory for career advancement of medical graduates. Researchers are often
confounded by issues related to calculation of the required sample size. Various factors like level of
significance, power of the study, effect size, precision and variability affect sample size. Also design
issues like sampling technique and loss to follow up need to be considered before calculating sample
size. Once these are understood, the researcher can estimate the required sample size using softwares
like Open Epi. Correct estimation of sample size is important for the internal validity of the study and
also prevents unnecessary wastage of resources.
Keywords: sample size, estimation, epidemiological studies, Open Epi
INTRODUCTION
MCI has recently amended, both the ‘PG medical
education regulations’ and the ‘minimum
qualifications
for
teachers
in
medical
institutions’.1,2 These have made active
participation in research mandatory, be it for
getting a PG degree or for promotions in medical
institutions. The statement ‘publish or perish’
sums up the situation well.
The path towards quality research is not one
without hurdles. Many researchers face difficulty
in the various steps of conducting a study,
starting
with
framing
the
research
question/hypothesis up to the analysis of data
and interpretation of results. In this section we
would like to focus on sample size estimation,
one of the steps which invariably confound most
researchers.
Even though statistical textbooks give formulae
for sample size estimation, the wide range of
formulae that can be used for specific situations
and study designs makes it difficult for most
investigators to decide which method to use.3
Many a time, questions like “Is there a magic
number?”, “Is it not okay if I include only 30
subjects in each group?”, “How to know whether
the number studied is adequate or not?” perplex
many researchers.
NEED FOR SAMPLE SIZE ESTIMATION
Why at all are we so concerned about sample size?
Research is always resource intensive. Hence, it
is not always possible to study the entire
population. So, we conduct the study on a
sample and then generalize the results to the
study population. In order to do so, our sample
should be ‘representative’ or in other words not
different from population.
If our sample size is too small then we may fail
to detect what we intended to. On the other hand
if we study a large sample then we would
unnecessarily invest more resources in the form
of manpower, materials, money and minutes
(time). Also, we would be subjecting more
number of people than required to the adverse
effects of drugs.
There are a few principles which govern the
estimation of sample size. These are: Level of
significance, Power of the study, Effect size,
Variability and Precision.
Level of significance:
Level of significance (alpha level) is the
probability of rejecting the null hypothesis when
it is actually true. This type of error in hypothesis
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testing is called Type I error. Simply put, it is the
probability of saying that the drug/intervention
has an effect when it actually does not, or getting
a positive result in a diagnostic test when in
reality the disease is absent i.e. false positive
result. We usually set the level of significance at
5% by convention, though 1% and 0.1% are also
used by researchers.
When we decrease the level of significance from
5% to 1% we are reducing the chances of
committing type I error and to do so we require a
larger sample size. So, smaller the level of
significance, larger the required sample size
(provided other factors are kept constant).
Power of the study:
The power of a statistical test is the probability
that the test will correctly reject a false null
hypothesis. In lay man’s terms, it is the
probability of detecting the true effect of
treatment
after
administration
of
a
drug/intervention. So, if we choose the power to
be 80% then the study will be able to detect a
true effect of the drug 80% of times i.e. false
negative results will occur only 20% of times.
Failure to reject the null hypothesis when it is
false is called type II error. Higher the power of
the study, greater will be the required sample
size.
Effect Size:
Effect size provides the magnitude of association
between a predictor and an outcome variable. In
simple terms, it gives the magnitude of treatment
effect of a drug (for example: reduction of mean
BP by 2%). Usually the effect size can be found
from review of literature, through a pilot study
or by asking an expert in the field. To correctly
identify small treatment effects, we need a larger
sample size.
Variability:
Variability indicates the spread of a continuous
variable. Usually the variability is measured
using standards deviation (SD) or standard error
of mean (SEM), the latter being a better measure
of variability than the former. When the
variability is high, the required sample size is
more.
Precision:
Precision is a measure of how close our sample
estimate is to the true value of a population
parameter. It is of two types: absolute or relative.
Let us take the prevalence of hypertension in the
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population as 20%. An absolute precision of 5%
means that the prevalence of hypertension in our
sample population will be between 15% and
20%. If we take relative precision of 5%, then the
prevalence in the sample population will be
between 19% and 21 %.( 5% of 20 is 1; hence the
prevalence in the sample will be between 19 and
21). By convention the relative precision is taken
between 5% and 20%. The closer we need our
sample estimate to be to the population mean,
the greater should be the size of the sample we
use.
Calculations on how, an increase or decrease in
each of these principles affect the sample size is
beyond the scope of this review. To read further,
please refer to: Statistics for the behavioral
sciences 8th edition. 4
HOW DO WE ESTIMATE THE REQUIRED
SAMPLE SIZE?
Do we always require an expert for calculation of
sample size? The answer is no, however it is
always better to cross check the result from an
expert.
The sample size can be estimated from:
1. Statistical packages
2. Formulae and tables from standard books and
3. Nomograms (not used these days).
The formulae for calculation of sample size for
common study designs are given in the table 15.
The most easy and preferred way of calculating
sample size is by using an appropriate statistical
package. The popular ones are “OPEN EPI”,
“Stat Cal” and “STATA”.
Open Epi is a free, web-based, open source,
operating
system-independent
series
of
programs for use in epidemiology, biostatistics,
public health, and medicine, providing a number
of epidemiologic and statistical tools for
summary data. The Open Epi developers have
had extensive experience in the development
and testing of Epi Info, a program developed by
the Centers for Disease Control and Prevention
(CDC) and widely used around the world for
data entry and analysis.
It is freely
downloadable
from
the
web
address:
http://www.openepi.com/6
The information required for sample size
calculation using Open Epi for various study
designs is given in Table 2.
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Table 1: Formulae for sample size calculation
Type of study
Descriptive study:
Mean
Formula for minimum sample size Required information
Z 1-α/2: Value of normal deviate at considered level of
N=[{Z 1-α/2}2 s2]/d2
Descriptive study:
Proportion
N=Z2 1-α/2p(1-p)/d2
Z 1-α/2: Value of normal deviate at considered level of
confidence
p : Expected prevalence of the event in the study group
d : Expected absolute allowable error in the mean
RCT:
Equivalence of two
means
N= (Z 1-α+ Z 1-β)2[ v1+v2]
[d-(m1-m2)]2
Z 1-α: Value of normal deviate at considered level of
confidence (one sided)
Z 1-β: Value of normal deviate at considered power of
study
m1: Anticipated mean of the variable in the standard
treatment group
m2: Anticipated mean of the variable in the new
treatment group
v1: Anticipated variance of the variable in the standard
treatment group
v2: Anticipated variance of the variable in new treatment
group
Cohort Study
N= { Z 1-α/2√[2p’(1-p’]+ Z 1-β√[p1(1p1)+p2 (1-p2)]2 /(p1-p2)2
Z 1-α/2: Value of normal deviate at considered level of
confidence (two sided
Z 1-β: Value of normal deviate at considered power of
study
p1 : Anticipated probability of disease/event in the
people exposed to factor of interest
p2 : Anticipated probability of disease/event in the
people not exposed to factor of interest
Anticipated relative risk: RR: p1/ p2
p’ : (p1- p2)/2
Case control
N= { Z 1-α/2√[2 p2 (1- p2)]+ Z 1β√[p1(1-p1)+p2 (1-p2)]}2 /(p1-p2)2
p1: Anticipated probability of exposure for cases
p2: Anticipated probability of exposure for controls
Anticipated odds ratio: OR= [p1/(1-p1)]/[ p2/(1- p2)]
Z 1-α/2: Value of normal deviate at considered level of
confidence (two sided
Z 1-β: Value of normal deviate at considered power of
study
confidence
d : Expected absolute allowable error in the mean
s: Expected standard deviation of the variable in the
group
Following are a few examples for calculating
sample size using OPEN EPI7
Example 1: Case control study
Calculation of the sample size for studying the
association of obesity with breast cancer using a
hospital based case control design. The list of
information required to calculate the sample size
is given in table 2.
After literature search let us say that we found
the proportion of controls with obesity to be 15%
and the odds ratio to be 3. Let us take the level of
significance to be 5% and power to be 80%. After
inputting these data into Open Epi we can
calculate the required sample size (Figures 1 and
2). The sample size for this example comes to 170
(85 in each group) using Open Epi software
Table: 2. Information required for calculating sample size for various study designs
Descriptive
(Prevalence)
Case control
Anticipated frequency
Confidence limits
Precision
Percentage of controls
exposed
Percentages of cases
exposed/OR
Ratio of cases and controls
RCT
(Proportion)
Percent of outcome in
control group
Percent of outcome in
intervention group
Ratio of subjects in control &
intervention
RCT
(Continuous )
Mean & SD of Control
Group
Mean & SD of Intervention
Group
Ratio of subjects in control &
intervention
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Figure 1: Sample size calculation for Case
control studies using Open Epi : “Enter Data
Page”
Figure 3: Sample size calculation for RCT using
Open Epi: “Enter Data Page”
Figure 2: Sample size calculation for Case
control studies using Open Epi: Results Page
Figure 4: Sample size calculation for RCT using
Open Epi: “Results page”
*Circled in red is the required sample size
* Circled in red is the required sample size
Example 2: Randomised control trial
Calculation of sample size for studying the
efficacy of Drug ‘P’ in lowering BP levels using a
randomized placebo control trial. Since drug ‘P’
is a new drug, no data about the required
information (as mentioned in table 1) is
available. So after doing a pilot study, let us say
that we found the mean BP after giving drug ‘P’
to be 126 mmHg ± 18mm Hg and after giving
placebo to be 130mmHg± 15 mmHg. Using this
data and keeping the level of significance at 5%
and power of the study as 80% the sample size is
calculated to be 540 (270 in each group) by using
Open Epi software. (Figures 3 and 4)
DO SAMPLE SIZE CALCULATIONS DIFFER
BASED ON SAMPLING TECHNIQUES AND
ISSUES LIKE LOSS TO FOLLOW UP?
a) Design Effect:
All along we have discussed about the sample
size required if simple random sampling is
followed. However if we use other sampling
techniques like cluster sampling or multistage
sampling then the required sample size will
change as we have to take into account the fact
that each member of the sampling frame may not
have an equal chance of getting selected. So we
multiply the calculated sample size by design
effect. Formulae for calculation of design effect
can be found in statistics textbooks and beyond
the scope of this article, but by convention we
take design effect to be between 1.5 and 3.
b) Adjustments for loss to follow up or non-response:
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Sometimes it may so happen that some of the
recruited participants may not continue in the
study and are termed as ‘loss to follow up’. In
other cases some participants may not respond
to our questionnaire and they will come under
the non-response group. These issues also must
be considered while calculating sample size. Let
us say that we expect x% of the participants to
fall under non-response or loss to follow up
category then the required sample size will be:
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dealing with clustered data are not dealt in this
manuscript. It is better to take the help of an
expert when one is in doubt or while dealing
with complex study designs.
REFERENCES:
1.
Medical council of India Postgraduate medical
education regulations, 2000 (amended up to December,
2010) [Internet]. [Cited on 16/2/2012]. Available from:
http://www.mciindia.org/rules-andregulation/Postgraduate-Medical-EducationRegulations-2000.pdf
2.
Minimum Qualifications for Teachers in Medical
Institutions Regulations, 1998 (amended up to
November, 2010). MCI. [Internet]. [Cited on 16/2/2012].
Available from: http://www.mciindia.org/rules-andregulation/Teachers-Eligibility-QualificationsRgulations-1998.pdf
3.
Marlies Noordzij, Giovanni Tripepi, Friedo W. Dekker,
Carmine Zoccali, Michael W. Tanck,Kitty J. Jager.
Sample size calculations: basic principles and common
pitfalls. Nephrol Dial Transplant (2010) 25: 1388–1393
4.
Frederick J Gravetter, Larry B Wallnau. Statistics for the
behavioral sciences 8th edition. Wadsworth, Cengage
learning. 2009.
5.
Betty R Kirkwood, Jonathan A C Sterne 2nd edition.
Massachusetts. Blackwell Science Ltd. 2003. P 420
6.
OpenEpi [Internet]. Wikipedia, the free encyclopedia.
2012 [cited 2012 Oct 7]. Available from:
http://en.wikipedia.org/w/index.php?title=OpenEpi&
oldid=486949640
7.
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source
Epidemiologic Statistics for Public Health, Version 2.3.
[Home page from Intenet] [updated 2011/23/06 ; cited
on 2012/02/16]. Available from:
http://www.openepi.com/OE2.3/Menu/OpenEpiMen
u.htm
8.
Betty R Kirkwood, Jonathan A C Sterne 2nd edition.
Massachusetts. Blackwell Science Ltd. 2003. p423.
Adjusted sample size = Unadjusted sample size *
(100/ [100-x]) 8
x= expected percent of loss to follow up /nonresponse
CONCLUSION
This paper gives insight into basic principles of
sample size estimation. Sample size calculations
can be done with the help of statistical soft
wares, once the principles behind these are
clearly understood. Various factors like level of
significance, power, effect size, variability and
precision play an important role in determining
sample size of a particular study. We must
remember that information on these should be
gathered by the researcher through literature
search, pilot study and consulting experts in the
field. Hence, there is no such thing as a magic
number when it comes to sample size
calculations and arbitrary numbers such as 30
must not be considered as adequate. Also
calculation of sample size using Open Epi
software is discussed. Several situations like
calculation of sample size in matched case
control study, diagnostic tests and designs
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Case Report ▌
INVESTIGATION AND CONTROL OF SCABIES IN SHELTER
HOMES OF MANDYA CITY
Poornima Sadashivaiah1, Raghini Ranganathan2, Vinay M3, Shreedhara Chikkade4, Mahendra B J5
1Assistant professor; 2Post graduate student; 3Associate professor, Department of Community Medicine, Mandya
Institute of Medical Sciences; 4Medical Officer, Primary Health Center, Kyathamgere, Mandya; 5Professor and
head, Department of Community Medicine, MIMS, Mandya, Karnataka
Correspondence: Dr Raghini Ranganathan, Email: raghinister@gmail.com
ABSTRACT
Two children with scabies and impetiginisation were admitted to Mandya institute of Medical Sciences
(MIMS). Epidemiological investigation revealed that these children were traced to a common childcare
facility in Mandya City. Cluster testing of the children from different childcare facilities led to
identification of 38 cases of scabies. Blanket treatment was initiated with Lindane lotion and the
children were monitored. This outbreak investigation explains how cluster testing led to diagnosing,
treatment, control and prevention of scabies in the child care facilities.
Keywords: Scabies, epidemiological investigation, lindane
INTRODUCTION
Scabies has been labelled one of the neglected
diseases of the neglected population1. Scabies is
found worldwide and affects people of all races
and social classes. Scabies is an infestation of the
skin by the human itch mite (Sarcoptes scabiei). The
most common symptoms of scabies are intense
itching (more at the night time) and a pimple-like
skin rash. The disease spreads by direct,
prolonged, skin-to-skin contact with a person who
has scabies. Scabies can spread rapidly under
conditions of overcrowding and or where close
body and skin contact is frequent. Scabies can
cause complications like pyoderma, acute renal
failure
(ARF),
post
streptococcal,
glomerulonephritis (PSGN), abscess, cellulitis and
septicaemia in infants2. Scabies does not cause
epidemiological emergencies, but the disease
impacts the quality of life and impose financial
burden on the families and the community.
Institutions such as orphanages, military
battalions, child-care facilities, prisons etc are
often sites of scabies outbreaks.
Two children aged 7 and 9 years, presented to the
Pediatrics outpatient department with fever and
blisters over both the hands. They had papular
lesions over the web spaces and extensor aspects
of both knees associated with intense itching,
aggravated in the night. They were diagnosed to
be
having
Scabies
with
secondary
impetiginisation. History revealed that they were
sisters and that they lived in a childcare facility in
the city. Both the children were admitted and
treated with lindane lotion and parenteral
antibiotics. The department of Community
medicine was notified about the cases of scabies.
A health team consisting of an Epidemiologist, the
Medical officer of the concerned Primary health
Centre, the ANM of the PHC, post graduate
students and house surgeons of MIMS, Mandya
was formed. The health team visited the child care
facility for girls. It had 29 inmates aged 3 to 16
years. Only 3 children were found at the child
care facility. The other 26 children attended a
school nearby. The health team appraised the
school authorities about the investigation
following which children hailing from the girls’
childcare facility were gathered and screened for
scabies.
RESULTS
7 children out of the 26 girl screened at the school
had scabies. The school teachers’ reported similar
looking lesions among the boys studying in the
school. It was found that these boys resided at a
boys’ childcare facility and a government boys’
hostel. Out of the 32 children residing at the
government boys’ childcare facility 21 children
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tested positive for scabies. It was observed that, of provided with individual towels or blankets
the 90 children residing at the government boys’ unlike the older children. Hence, it was decided to
hostel only children aged 10-12 years had scabies. treat the children aged 10-12 year.
These children lived in a dormitory and were not
Table 1: Proportion of inmates screened and proportion of children positive for scabies
Name of the shelter home
Government Girls’ child care facility
Government Boys’ child care facility
Government hostel for Boys
Residing
29
32
90
Number of children
Screened (%)*
Positive for Scabies (%)*
27#(93.10)
7(24.13)
32(100.00)
21(65.62)
90(100.00)
10(11.11)
*Figures in parentheses indicate percentage of the total inmates; #2 children were admitted in the hospital and were under
treatment for scabies
Blanket treatment was planned for all the children
residing in the child care facilities. Drugs required
for blanket treatment were procured with the
coordinated
support
of
the
Medical
superintendent of MIMS and the District health
office. The children were treated with 1% topical
lindane lotion and Tab. Chlorpheniramine 4mg
twice daily for three days. The blanket treatment
of the children was synchronized with washing,
sun drying and ironing of the children’s clothes,
towels, linen, blankets, pillow covers and school
bags. The children were closely monitored for
response to the scabicide. The children, their
caretakers and supervisors were educated on the
measures to be taken to prevent recurrence. The
wardens of the child care facilities were made
responsible for the personal hygiene of the
children. Since previous history of deworming
was available they were dewormed with Tab.
Albendazole 400 mg stat dose and the
opportunity was used to treat them with Tab.
Ferrous Sulphate one tablet OD for three months.
Monthly visits by the health team have been
planned to supervise and reinforce the
maintenance of personal hygiene of the children.
dermatology clinic who have Scabies has been
estimated to vary between 7.7% and 14.2%3, 4.
There are few studies that question the role of
poor hygiene in the transmission of Scabies,
contrary to the conventional belief 5,6. In our
investigation scenario, improvement in personal
hygiene coupled with treatment and health
education has prevented recurrence of Scabies up
to 3 months after the intervention.
CONCLUSION
Cluster testing of children from a common shelter
facility, led to identification of previously
undiagnosed cases of scabies, appropriate
treatment and prevention of further spread of the
disease.
Acknowledgements: The Director (MIMS), The
Medical Superintendent (MIMS), The District
Health Officer, Staff of the department of
Community Medicine and PHC, Kyathamgere.
REFERENCES
1.
Ehrenberg JP, Ault SK (2005) Neglected diseases of
neglected populations: thinking to reshape the
determinants of health in Latin America and the
Caribbean. BMC Public Health 5: 119.
2.
Feldmeier H, Heukelbach J. Epidermal parasitic skin
diseases: A neglected category of poverty associated
plagues. Bull World Health Organ 2009; 87:152-9.
3.
Negi KS, Kandpal SD, Prasad D. Pattern of skin diseases
in children in Garhwal region of Uttar Pradesh. Indian
Pediatr 2001; 38: 77-80.
4.
Karthikeyan K, Thappa D, Jeevankumar B Pattern of
Pediatric Dermatoses in a Referral Center in South India
Indian Pediatrics 2004; 41:373-377.
5.
World Health Organisation. Epidemiology and
management of common skin diseases in children in
developing countries. Geneva: World Health
Organization; 2005
6.
Carapetis JR. A review of the technical basis for the
current WHO approach to the control of conditions
associated with group A streptococcal
infections. Geneva: World Health Organization; 2004.
DISCUSSION
Scabies is one of the common skin condition.
There are not many community based studies
which estimate the prevalence of Scabies.
However, the percentage of people attending
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Case Report ▌
HERPES ZOSTER IN CHILDREN AND ADOLESCENTS:
CASE SERIES OF 8 PATIENTS
Pragya A Nair1, Pankil H Patel2
1Professor; 2Tutor,
Skin & VD, Pramukhswami Medical College, Karamsad, Anand
Correspondence: Dr Pragya A Nair, Email: drpragash2000@yahoo.com
ABSTRACT
Herpes zoster can occur at any age but is rare in childhood and adolescents. Zoster can occur at any
time after primary varicella infection or varicella vaccination. Recent studies have shown its
increasing incidence in children. Maternal varicella infection during pregnancy and varicella
occurring in the newborn represent risk factors for childhood herpes zoster. As varicella vaccine is a
live attenuated virus, herpes zoster can develop in a vaccine recipient, but its incidence is less than
natural infection. It is usually diagnosed clinically as unilateral vesicular eruption following a
dermatome or dermatomes. Zoster in children is frequently mild, post herpatic neuralgia occurs
rarely if ever. We present eight cases of zoster in children and adolescents.
Keywords: Herpes zoster, Varicella Zoster Virus, HIV, Children, Adolescents
INTRODUCTION
Herpes zoster (HZ) or shingles is an acute
vesiculobullous
cutaneous
infection
in
dermatomal distribution, predominantly in
adults and older persons. It is caused by
reactivation of latent varicella-zoster virus (VZV)
that resides in a dorsal root ganglion.1 Children
are infrequently affected with HZ. In cases
where past history of varicella was not obtained,
it is suggested that the initial contact with the
virus may result in zoster.2 HZ occurs at an
overall rate of 3.40 cases per 1000 persons. HopeSimpson's field study showed an incidence of
0.74 cases per 1,000 population per annum
among the 0 to 9 and 1.38/1000 in 10 to 19 yearold age group. The attack rate during the first
two decades is approximately seven times less
than the seventh decade.3 The earliest age
reported is in a 3-month old infant.4 However,
the true incidence of HZ in children may be even
higher since some patients do not seek medical
attention because of the benign course. We
present eight cases of zoster in children and
adolescents.
CASE REPORT
Case 1: A 4-year-old girl had a three day h/o
asymptomatic papulovesicular eruption on the
left side of the thorax and upper limb involving
C7-8 dermatome.
Case 2: A 10-year-old boy, serologically positive
for Human Immunodeficiency Virus (HIV), had
six day h/o multiple pus filled lesion over right
abdomen, back and lower limb with mild
burning pain. Multiple pustules were present
involving right T9-10, L1-5 dermatomes with few
discrete lesions on the left side of the body(Fig.
1a &1b).
Case 3: A 5-year-old boy had a two day h/o
asymptomatic vesicular eruption over genitals
on the left side involving S2 dermatome (Fig.2a
& 2b).
Case 4: A 10-year-old girl presented with two
days history of fluid filled lesions with burning
pain on back & abdomen below umbilicus on
right side involving right T11-T12 dermatome.
She had varicella at the age of 4 years.
Case 5: A 4-year-old girl had a three day history
of fluid filled eruption on the right side of chest
and back involving T8 dermatome with fever
and burning pain. She had varicella at the age of
2½ years.
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Case 6: A 16-year-old male had pain on the right
buttock and thigh for two days followed by the
onset of vesicular eruption involving S1
dermatome. He had varicella at the age of 5
years.
Case 7: A 16-year-old female had grouped
vesicular eruption on the right side of thorax for
2 days associated with burning sensation.
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Vesiculobullous lesions on erythematous base
were present in the distribution of T4
dermatome. She had varicella at the age of 6
years.
Case 8: A 7 year old girl had 3 day history of
fluid filled lesions over lower abdomen
involving right T9-10 dermatome. P/h/o
varicella at the age of 3 years was present.
Table 1: Summary of 8 Herpes zoster cases
Known Age(yrs) at Sequalae
Exposure to Previous
Varicella
Varicella
C7-8
No
No
-None
T9-10 & Mild burning pain
No
-Secondary infection
L1-5
& scarring
S2
No
No
-None
T11-12 Burning pain
Yes
4
NoneT8
Fever& burning pain
Yes
2½
None
T12-L1 Pain
Yes
5
None
T4
Burning sensation
Yes
6
None
T9-10
No
Yes
3
None
Case Age Sex Side Derma- Associated
(Yrs)
tome
symptoms
1
2
4
10
F
M
L
R
3
4
5
6
7
8
5
10
4
16
16
7
M
F
F
M
F
F
L
R
R
R
R
R
Fig 1: 10 year old HIV positive boy with multiple pus
filled lesion; (a) abdomen, lower limb involving Right
T9,T10,L1,L2,L3,L4 dermatomes; and (b) back
involving Right T9,T10,L5 dermatomes
Fig 2: Five year old boy with vesicular eruption; (a)
genitals involving left S2 dermatome; and (b) buttock
involving left S2 dermatome
None of the children were immunized against
varicella. No P/h/o varicella in first 3 cases,
other five gave definite past history. Cases were
Immune
suppression
No
Yes
Seropositive
No
No
No
No
No
No
diagnosed clinically as HZ and supplemented by
Tzanck smear preparation. Scrapings from the
floor of the vesicles, performed in 6 cases
revealed multinucleated giant cells in 2 cases.
HIV ELISA (Enzyme Linked Immunosorbent
Serologic Assay) was negative in 7 cases except
one patient. Hemogram and peripheral smear
was normal in all cases. Herpes simplex virus
(HSV) antigen detection and viral culture was
not done due to lack of facility. All the children
were treated with oral acyclovir 20mg/kg, 4
times a day for five days along with
symptomatic treatment for pain and burning
with topical silver sulfadiazine.
DISCUSSION
Our cases ranged from 4 to 16 years of age
(Table. 1). Majority of the cases were females (5
cases), female preponderance was also seen in
Prabhu et al5 study also. The thoracic
dermatomes were affected in five children
comparable with study by Prabhu et al5, Bharija
et al2 and Hope-Simpson's3 studies, while Leung
et al6 noted predilection of cervical and sacral
dermatomes. Right sided dermatomes were
affected in 6 cases. This point is not highlighted
in any of the study till date. Only five cases had
definite history of previous varicella infection.
None were immunized against varicella. No
history of chicken pox to mother during
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pregnancy and no recent history of family
member having chicken pox noted in any case.
There are only few case reports of childhood HIV
patients
acquiring
zoster
is
reported5.
Disseminated VZV is more commonly seen in
HIV infected individuals.7 Our study reports one
HIV positive boy, who had multi-dermatomal
herpes zoster with secondary infection and
dissemination, no complications were noted in
other 7 cases
Following initial exposure to VZV, the virus may
become latent and lie dormant in the dorsal
nerve root or in the extramedullary cranial nerve
root ganglion cells. HZ is caused by the
reactivation of latent VZV. HZ arises, years or
decades following primary infection with VZV.1
HZ cases present with a characteristic unilateral,
dermatomal, vesicular eruption preceded or
accompanied by pain. Lesions heal within 2 to 3
weeks, but postherpetic neuralgia (PHN) can
persist for months or years thereafter 8 and may
be intractable. In infants and children it is more
common in girls, usually not accompanied by
pain or PHN but fever, headache and regional
lymphadenopathy can occur. Zoster in children
is frequently mild. The probability of PHN in
children and adolescents is extremely low, rarely
if it ever occurs.9 Differential diagnosis for
herpes zoster particularly in infants and children
includes irritant contact dermatitis, insect bite
and bullous impetigo which needs to be kept in
mind.
The occurrence of zoster in childhood is related
to exposure to VZV postnatal, perinatal or
intrauterine. Herpes zoster in children probably
represents the result of an immature immune
response to the transplacentally acquired VZV3.
Low levels of lymphocytes, natural killer cells,
cytokines characterize this poor response, and
virus-specific immunoglobulins may result in
inability to maintain the latency of VZV leading
to early appearance of zoster in children.10
Chickenpox in the first year of life was found to
be a risk factor for childhood zoster, with a
relative risk between 2.8 and 20.9. Neither
chickenpox in the second year of life nor recent
vaccinations were found to be risk factors for
childhood zoster.11 Such observation was not
seen in our study as none of our cases had
history of chickenpox in first year of life.
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Childhood HZ was thought to be an indicator for
an underlying malignancy, whereas recent
studies have shown no increase in the incidence
of malignancy in children with HZ.
Approximately 3% of the pediatric zoster cases
occur in children with malignancies.
CONCLUSION
HZ is an infrequent, but not a rare, disease of
children. Its infrequent recognition could be
explained by its benign clinical course. For this
reason, patients so affected may never reach the
physician. Because of a low index of suspicion,
the eruption is often treated casually as a local
cutaneous problem, and its actual nature remains
unrecognized. The probability of postherpetic
neuralgia in children and adolescents is
extremely low. Zoster is seldom associated with
undiagnosed malignancy in the primary care
setting.
REFERENCE
1.
Gnann JW Jr., Whitley RJ. Clinical practice. Herpes
zoster. N Engl J Med. 2002;347:340–6.
2.
Bharija SC, Kanwar AJ, Belhaj MS. Herpes zoster. Ind J
Pedia. 1988;55(2):301-3.
3.
Hope-Simpson RE: The nature of herpes zoster: A long
term study and a new hypothesis. Proc Roy Soc Med.
1965; 58:9-20.
4.
Handa S. Herpes zoster in a 3-month-old infant. Paed
Dermatol. 1997; 14:133.
5.
Prabhu S, Sripathi H, Gupta S, Prabhu M. Childhood
herpes zoster: A clustering of ten cases. Indian J
Dermatol. 2009;54:62-4.
6.
Leung AKC, Robson WLM, Leong AG. Herpes Zoster in
Childhood. J of Pediatr Health Care. 2006 Sept;20(5):3003.
7.
Archana Singal, Shilpa Mehta, Deepika Pandhi. Herpes
zoster with dissemination. Indian
Pediatrics:April.2006;43:353-56.
8.
Helgason S, Petursson G, Gudmundsson S, Sigurdsson
JA. Prevalence of postherpetic neuralgia after a first
episode of herpes zoster: prospective study with long
term follow up. BMJ. 2000;321:794–6.
9.
Feder HM Jr,Hoss DM.Herpes zoster in otherwise
healthy children. Pediatr Infect Dis J . 2004
May;23(5);451- 7.
10.
Huang JL, sun PC, Hung IJ. Herpes zoster in infancy
after intrauterine exposure to varicella zoster virus:
report of two cases. J Formos Med Assoc 1994
Jan;93(1):75-7.
11.
Guess HA, Broughton DD, Melton LJ 3rd, Kurland LT.
Epidemiology of herpes zoster in children and
adolescents: a population-based study. Pediatrics. 1985
Oct;76(4):512-7.
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Short Communication ▌
GENERATION OF HOSPITAL WASTE: AN AWARENESS
IMPACT ON HEALTH AND ENVIRONMENTAL
PROTECTION
Deepak Sharma1
1Lecturer/Assistant
Prof., Department of Applied Science, SCRIET, CCS University Meerut-250004, India
Correspondence: Dr. Deepak Sharma, Email: deepak22phys@gmail.com
ABSTRACT
World is generating more and more waste as the population of people in the world & Hospitals are
increasing day by day. Health care activities are a means of protecting health, curing patients and
saving lives. Waste generating from hospitals, health centers and medicals are no exceptions. Medical
waste contains toxic chemicals, can be infectious and pose contamination risks both to public health
and environment. But they also generate waste, out of which 25 percent entail risks, either of
infection, of trauma or radiation exposure. In addition the inappropriate treatment or disposal of the
waste can lead to environmental contamination or pollution. Seventy five percent of the hospital
waste is similar to household waste and do not entail any particular hazard. In general, PVC plastic
waste represents the large amount in hospital waste. In this paper we are addressing the issue of
incineration of medical waste and to control the surface water mercurial pollution, their impacts on
health, environment and their remediation.
Keywords: Environmental pollution, Health centers, Medical waste, Municipal waste
INTRODUCTION
The term “Medical waste” is generally covers all
wastes produced in health-care or diagnostic
activities. Hospitals with 200 beds will produce
an average of 1.5 to 3.0 Kg of waste per patient
per day [LLRM, Subharti Meerut]. The quantity
of waste produced in any country depends upon
the national income and type of facility
concerned within hospital. A university hospital
in a high income place can produce 10 Kg of
waste per bed per day. Seventy five percent of
hospital wastes are similar to household waste or
Municipal waste, only twenty five percent
wastes which entails hazard. This type of
particular hazard waste entails health risk and
processing
of
this
waste
causes
the
environmental pollution. Health care activities /
hospital activities purposes for protecting
health’s, curing patients and saving lives. But
they also generate waste of which entail risks
either of infection, of trauma or of chemical or of
radiation exposure. It deals with the wastes that
are created in the course of surgical, medical,
laboratory and radiological activities or nuclear
medicine. As regards viral infections such as
AIDS and Hepatitis are at most risks of infection.
Sharps and pathogenic cultures are regarded as
the most hazardous medical waste1. Poor waste
management can jeopardize care staff,
employees who handle medical waste, patients
and their families, and the neighboring
population. In addition the inappropriate
treatment or disposal of that waste can lead to
environmental contamination. Mercury is found
mainly in thermometers, manometers, dental
alloys, certain types of battery. Mercury is a
heavy metal in a liquid form at room
temperature and pressure. It is very dense and it
evaporates and can remain for up to a year in the
atmosphere. It accumulates in sediments, where
it is converted into Methyl-mercury, a more toxic
organic derivative. Health care facilities are one
of the main sources of mercury in the
atmosphere due to incineration of medical waste.
These facilities are also responsible for mercurial
pollution of surface water.
HOSPITAL WASTE & THEIR RISKS
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IMPACT ON HEALTH & ENVIRONMENT
biological fluids. As regards viral infections the
nursing staffs are most at risk of infection
through contaminated needles. According to
world health organizations in 2000 that world
level accidents happened due to sharps are very
large 66,000 cases of infections with the Hepatitis
B virus. While 16,000 cases of infections for
Hepatitis C virus. Survival of the Pathogenic
micro organism depends on the environmental
conditions (temperature, humidity, organic
solvents, presence of disinfectants etc). Bacteria
are less resistant than viruses. Hepatitis B virus
survival depends on the conditions such as
several weeks on a surface in dry air and
minimum of one week at normal temperature,
while several weeks on dried blood. HIV
remains 3-7 days in ambient air and 21 days in
2µl of blood at ambient temperature and this
virus becomes inactivated at 56oC. In general
however the survival time of microorganism
present in medical waste is short probably
because the waste contains the disinfectants. The
role played by carriers such as rats and insects
must also be taken into account in the evaluation
of survival of microorganism time. They are
passive carriers of pathogens and measures must
be taken to control their proliferation.
Health care resources are potentially dangerous
micro-organisms that can infect hospital patients,
personnel and general public. Risks of trauma
and infections are many different exposure ways
through injury, cut, and prick, through contact
with the skin or mucous membrane, through
inhalation or through ingestion. We are
discussing some of the infections that can be
caused
by
hazardous
medical
waste.
Gastrointestinal infection that can be due to
infective agent enterobacteria and transmission
agent is faeces, vomit etc. Respiratory infections
occur due to infective agent like mycobacterium
tuberculosis, SARS (Severe Acute Respiratory
Syndrome) Virus and the transmission agent of
this infection is inhaled secretions, salvia etc. Eye
infections are due to herpes virus and in this case
transmission agent is eye secretions. Eye
infections are due to infection agent
streptococcus and the transmission agent is pus.
AIDS are due to Humanimmuno Deficiency
Virus and the transmission agents are Blood,
sexual secretions, and other body fluids.
Hemorrhagic fever is due to presence of
Marburg and Junin virus is blood and secretions.
Viral hepatitis A, B and C occurs due to Hepatitis
A, B and C viruses and the transmission agents
in this case can be faeces, blood and other
Since exposure conditions are same for
employees dealing the house hold refuse and
those dealing with medical waste. High income
countries have shown the following impacts
compared to the general population, in the case
of persons employed in the processing of house
hold waste. The risk of infection is 6 times higher
and the risk of contracting an allergic pulmonary
disease is 2.5% higher as well as the risk of
contracting hepatitis is 1.2 times higher4.
Pulmonary diseases and bronchitis diseases are
caused by the exposure to the bio-aerosols
contained in the air at the sites where refuse is
dumped, stored or processed. Other impact on
health care activities may be arises due to many
chemicals and pharmaceutical products are used
in health care facilities. Most chemicals have the
nature of toxic, carcinogenic, mutagenic, irritant,
explosive, flammable, corrosive etc. Various
exposure routes for contact with these
substances: inhalation of gas, vapour or droplets
contact with skin. Some substances (chlorine and
acids) are incompatible and can generate toxic
gases when mixed. In general cleaning products
and, in particular, disinfectants are examples of
dangerous chemicals which are used in large
quantities in hospitals and some disinfectants
(such as formaldehyde) can be sensitizing or
Hazardous hospital wastes such as Sharpswaste entailing risk of injury, while waste
contains blood, secretions or excreta entailing a
risk of contamination. Anatomic waste contains
body parts, tissues entailing a risk of
contamination. Waste contains large quantity of
materials, substances or cultures entailing the
risk of propagating infectious agents. Spilled
unused medicines as well as expired drugs and
used medication receptacles, expired or left over
cytotoxic drugs equipment contaminated with
cytotoxic substances. Waste containing heavy
metals like mercury, batteries, compact
fluorescent light tubes entailing the risk to
environment.
Waste
containing chemical
substances-leftover
laboratory
solvents,
disinfectants, photographic developers and
fixers, waste containing radio substances- like
radio nuclides used in laboratories, urine or
excreta of patients treated entailing to risk.
Persons who are in contact with hazardous waste
are potentially exposed to various risks it entails
– inside the hospital as well as outside the
hospital offsite transport personal 1,2.
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
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Open Access Article│www.n
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toxic. Th
his malpractiice places th
he public in
n
danger off being exposeed to epidemiic disease3.
p
pISSN 0976 33255│eISSN 2229 68116
the merccurial pollutio
on of surfacee water as weell
as healtth and env
vironmental contaminatio
on
problem.
INCINER
RATION OF
F MEDICAL
L WASTE &
REMEDIA
ATION
A proper waste mana
agement systeem should be
required to dispose hazardous
h
m
medical
waste
neration shou
uld be the best
b
available
and incin
technolog
gy to reducce the volu
ume of thiis
hazardous waste. The
T
incineraation processs
destroys pathogens and reducees the waste
nd weight, bu
ut leaves the solid materiaal
volume an
called bio
omedical wastte incineratio
on such as ash
h
as residues which inccreases the leevel of heavy
y
norganic and organic comp
pounds in the
metals, in
environm
ment5. Disposaal of biomediical waste ash
h
in landfilll without pro
oper treatment may cause
contamina
ation of grroundwater. Incineration
n
usually in
nvolves the co
ombustion of mingled solid
d
wastes with
w
the preseence of air or
o sufficiently
y
oxygen. Typically the
t
temperaature in the
incinerato
or is more tha
an 850 0C and
d the waste is
i
converted
d into Carbon
n dioxide and some otheer
gases as well as unw
wanted polluttants such as
a
Polychlorinated Diben
nzo-p-Dioxinss (PCDD) and
d
Di-benzo furans (PC
CDF) deriveed from the
chlorinateed phenols6. Metals are not
n destroyed
d
during in
ncineration. There
T
is need to give more
attention to the separattion of mediccal waste from
m
municipall waste. Increeasing numb
ber of patientts
(cancer) can be corrrelated to the
t
impropeer
medical waste
w
burnin
ng process practiced fo
or
quite lon
ng time. So
o, it is neecessary thaat
biomedicaal wastes sh
hould be diisposed in a
manner which
w
is leastt harmful to human
h
being
g.
The use of bottom ash and fly
f
ash from
m
incineratio
on process can
c
be utilizeed in cemen
nt
and con
ncrete system
m. Slag ob
btained from
m
biomedicaal waste in in
ncinerator prrocess utilized
d
in road and anotherr utilization of ashes in
n
Portland cement
c
mortaar. One of thee vital issues is
i
for consid
deration of heeavy metals in
i the medicaal
waste, especially for mercury meetal it is very
y
dense and
d it evaporatees and can rem
main for up to
o
a year in the
t atmospheere to sort outt this problem
m
basically from thermo
ometers that are used by
y
medicine surgeon an
nd dentist, to
t avoid the
incident of
o broken therrmometers in
n the mouth o
of
a child an
nd in wastess, we should replace glasss
thermomeeters by a forehead temperature
indicator as shown in figure
f
as below.
It is possiible to avoid the incident of
o breakdown
n
of glass thermometerrs and it will reduce the
accumula
ation in sedim
ments. It willl also reduce
DICAL
BIOMED
SYSTEM
M
W
WASTE
MA
ANAGEMEN
NT
Waste generated
g
frrom biomed
dical activitiees
represen
nts a real prob
blem for natu
ure and humaan
being wo
orld. At preseent 170 comm
mon biomediccal
waste treeatment facillities are ava
ailable and 1440
incinerattors througho
out the Indiaa. The presen
nt
generatio
on of hazard
dous waste is 4.16 lakh
hs
metric ton per aannum (MT
TA), but th
he
he capacity of 3.28 lakh
hs
incinerattors have th
metric to
on per annum
m (MTA). Acccording to aan
estimate only 6.67% o
of waste is inccinerated whiile
the rest of the wastte is going to
t landfill an
nd
ntally sound
d managemen
nt
recycled.. Environmen
involves taking all practical stepss to protect all
a
human health
h
from hazardous hospital
h
wastte,
ideally th
his would meean reducing the hazardou
us
waste eq
qual to zero. P
Properly wastte managemen
nt
means separates
s
thee mingled waste
w
such as
a
proper packing
p
of diffferent compo
onents, storag
ge,
transporttation and diisposal of the waste. Rulees
and regu
ulations apply
ying at the tim
me of collectio
on
of the wa
aste from thee hospitals, illegal dumpin
ng
of the waste
w
is ano
other serious problem th
hat
should be
b avoided. Labeling of the particular
componeent of wasste is neceessary before
incinerattion [1, 6]]. Properly incineratio
on
managem
ment at partticular tempeerature is alsso
possible to reduce tthe emission of the gasees.
g of healthcare waste in
n uncontrolleed
Dumping
areas can
n have a direect environm
mental effect on
o
soil and
d undergrou
und water contaminatio
c
on.
Proper filtration maanagement of
o flue gasees
n process is required,
during incineration
otherwisse air will be polluted. In practical term
for manaagement of sound environ
nment, climaate
National Jou
urnal of Commun
nity Medicine│V
Volume 4│Issue 1│Jan – Mar 2013
Page 187
1
Open Access Article│www.njcmindia.org
conditions are also responsible, the frequency
with which the waste collection points must be
serviced timely in order to limit negative
environmental consequences. If the facilities face
any problem in conducting waste management,
any external funds should to support waste
management practices in health facilities, any
delay also impact negative in sustainable
environment.
CONCLUSION
All hospital / medical facilities should be
provided with standard operating procedures
for example color code for particular waste
collection and special containers for hazardous
waste. Some of the suggestions are - all disposal
sites should be established far from the human
settlements and should be fenced. Healthcare
waste handlers need to be adequately trained
and provided with enough personal protective
equipment like masks, apron, gloves, long boot,
and eye shield, should be provided to take care
from infectious waste. They should not handle
the waste by hands without gloves. Burying
sharp waste, needles or infectious waste should
be monitor or evaluation process is further
required to stop the environmental pollution and
chance of epidemic due to burning infectious
waste in open. It will be a good revolution in
medical society in the world if they replace glass
thermometers
to
forehead
temperature
indicators, it will control the surface water
pISSN 0976 3325│eISSN 2229 6816
problem and mercurial pollution from the waste.
ACKNOWLEDGMENT
I am thankful to Dr. S.C. Baranwal, Ex DHMO,
U.P.Govt. Senior Homoeopathie Consultant
Meerut, for discussion and kind cooperation to
borrow the thermometer strips from him.
REFERENCES
1.
Srivastav Shalini, Mahajan Harsh, Mathur B.P,
Evaluation of bio-medical waste management practices
in a government medical college and hospital. National
Journal of Community Medicine, 2012; Vol. 3: 80–84.
2.
Manual on hospital waste management, Central
pollution Control Board, New Delhi 2000.
3.
Anita Rajor, K. Kunal, Bio-Medical waste incinerator
ash: A review with special focus on its characterization,
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of Geology, Earth and Environmental science 2011; Vol.
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4.
Henry.K.S. Campbell, P.Collier and C.O.Williams:
Compliance with universal precautions and needle
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Shalini, Awareness about Biomedical Waste
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Amer M. El. - Hamouz, Medical waste incineration in
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National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013
Page 188
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