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Indian Journal for the Practising Doctor

Household Survey of Childhood Morbidity & Parental Practices in Budgam District

Author(s): Bukhari S, Gaash B, Ahmad M, Farheen A

Vol. 4, No. 6 (2008-01 - 2008-02)

Bukhari S, Gaash B, Ahmad M, Farheen A

ISSN: 0973-516X


Shawkat Bukhari, MSc Health, Dr Aesha Farheen, MD and Dr Bashir Gaash, MD, are from the Regional Institute of Health & Family Welfare, Kashmir.
Dr Muzaffar Ahmad, MD, is Director Health Services, Kashmir


Introduction

Underfives–a highly vulnerable groupconstitute 13% of the total population in India. Each year 13-15 million children -98% of them in developing countries-die before reaching the age of five. The regrettable side to the issue is that most of these deaths are easily preventable by simple interventions. Dehydration due to diarrheal diseases which kills an estimated 4 million children’s each year1 can be treated effectively by oral rehydration therapy.

Under-fives form the main group affected by acute respiratory infection, diarrhoea, and other vaccine preventable diseases, because the immunity is low. In developing countries, the incidence of pneumonia among under-fives is estimated to be 30%. In India, again, the most common disease affecting children is acute respiratory infection (ARI), which is responsible for about 30-50% of visits to health facilities and for about 20-40% hospital admissions.

An estimated 1.8 billion episodes of diarrhoea occur each year and 3 million underfives die of diarrhoea in developing countries. Eighty percent of them are children under 2 yrs. Overal, children are down with diarrhea for 10-20% of their first 3 yrs of life.

During the last quarter of the 20th Century, emphasis has been placed on reducing the U5 childhood mortality through immunization, ORS and control of acute respiratory infections. Therefore, it is pertinent to know the actual morbidity of underfives in a given community to plan appropriate management strategy.

Objectives: The study aimed at finding out the morbidity profile of underfives and the extent of health services utilization by their parents.

Methodology: House-to-house survey and interview of parents (mainly mothers) using pretested questionnaire.

Sampling: Systematic random sampling technique was employed.

Study area: Kashmir – an irregularly oval Himalayan Valley – has 12 administrative districts, one of them being Budgam. This district, at an altitude of 5281, has a mixed topography and is bounded by Baramulla in the northwest and Srinagar in the northeast and southeast. There are 501 villages out of which 480 are inhabited. The district has 5 blocks, out of which 3 blocks (Budgam, Khansahib and Chrar-i-Sharief) were selected for the present study, where all the households of one PHC catchment area from each block, were surveyed from September 2005 to May 2006. Budgam block is a fairly large block with most of the area located in the urban and plain terrain. Chari-sharief, 30 km away from district headquarter, is mostly hilly and covered with forests. Khansahib, again, a hilly block is situated westwards. The total number of households thus covered was 2070.

Male:Female Proportion Among Sick U5s

Table 1: Breakup of children with any morbidity during the last 2 weeks

Children affected % of the total
morbid child
population
Remarks
I Child population with any morbid
condition in the past 2 weeks
  100% Of the total U5s surveyed, 612 (44.83%)
reported illness in the last 2 wks
i Infants 142 23.20% Morbid infants formed 55.46% of
the total infant population
ii Children up to 24 months 265 43.30%  
iii U5 girls 259 42.32% Girls reporting sickness in the
past 2 wks formed 40.21% of the
total U5 females.
iv U5 boys 353 57.67% Boys reporting sickness in the
past 2 wks formed 48.95% of the
total U5 male population.
v Infant (males) 77 53.84% of male infant population,
54.22% of morbid infant population,
10.67% of the total male population
vi Infant (females) 65 57.52% of female infant population,
25.09% of morbid female population,
10.62% of total morbid population,

Results

Under-fives formed 10.75% of the population (1365 underfives in 2070 households with a total population of 12705 persons). The sex ratio among infant population was 790, which increased to 893 for the total U5 group.

Table 2: Demographic profile of the study population

S No Indicator No. %
1 Households covered 2070
2 Child Population <5 yrs covered 1365
3 Average no of children <5 yrs per household 0.659
4 Sex ratio of U5s 893/1000
Gender breakup of U5s M=721 52.82%
F=644 47.17%
5 Gender Breakup of Infants M=143 F=113 55.85% 44.14%
Sex Ratio among infant population 790/1000

Age breakup of underfives

The morbidity profile shows that 44.83% of under-five population has had an episode of illness during the past two weeks. Gender-wise, more boys (57.67%) than girls (43.32%) reported illness during the preceding fortnight. In case of the infants, this proportion was still higher (55.46% of the total infants). Among the infants, gender-wise distribution was almost equal (53.84% boys:57.52% females).

Infantile morbidity among studied group

Disease-wise categorization shows that fever (353), diarrhoea (291) and difficult breathing (340) were the 3 most commonly reported symptoms. Fever was found to be most common co-existing symptom with both ARI and Diarrhoea.

Morbidity Profile of U5s

Only 51.2% of U5s suffering from diarrhea had received ORS during the last reported episode. No specific reason could be elicited for not giving it. However, among those who practiced giving ORS to their child during diarrhea, “the doctors’ advice” was the most commonly cited reason.

Duration of Diarrhoea

Breast feeding was continued during illness in 83.77% of children under 2 years of age. However, it implied that, in at least 16% of infants and young children breastfeeding is withheld during a bout of illness.

Food restriction, mostly advised at home, was followed in illness only by 14.70%.

Food practices during diarrhoea

Regarding treatment seeking behaviours and practices, parents of 88.56% children sought treatment for the illness, out of which 47.78% went to a public health facility (CHC, PHC, Dispensary), 45.02% to a private health practitioner, and 6.45% to a health worker. Significantly, 100 parents (16.33%) were not told by the practitioner about what illness their child had.

Dietary Restriction Advised

Treatment Sought During Illness

More than 84% of parents knew the local health worker by name, which shows acquaintance which can facilitate informal communication between them.

Discussion

As per the 2001 Census, the under-six children made up 15.49% of the total population2. This is the most crucial age group as many important milestones of life are crossed during this very period. The mortality is very high in the first year, primarily concentrated in the neonatal period. When the child is born, she is exposed to a totally new environment full of physical, social, chemical and biological hazards. In the first year of life, as the child begins to grow and develop rapidly, she is exposed to various new experiences, some of which may be potentially adverse to her health, like bottle feeding, faulty weaning, crawling and eagerness to explore. Later threats to the U5s are mainly from infection and infestations, insufficient or unbalanced food, and contaminated water.

Diarrhoea and acute respiratory infection (ARI) form the most lethal challenges to underfives in the developing world. Till the advent of the ORS, diarrhea was the leading killer followed by ARI. Now, the duo have changed places in areas where most diarrhoeal episodes are managed by ORS. However, in places like Kashmir, where the rate of ORS use is still very low, dehydration mortality among the underfive population could be very high. In one populationbased survey in the same district, conducted under the Shejar Project3 of the Reproductive and Child Health Program, in 76 underfives suffering from diarrhea, the mortality was as high as 13 (17.10%).

The NFHS II (1998-99)4 data showed that only 32% of children in Jammu & Kashmir received increased fluids when sick with diarrhea and only 14% received gruel. However, one third of children with diarrhoea did not receive any ORT at all. Our study reveals that 48.8% of the diarrhoeal children were not given ORS, which means that, instead of experiencing an increase in the utilization of ORS, our peripheries are showing an actual decline.

Among those who administered ORS to their diarrhoeal children, majority had given it at the insistence of the treating doctor. The role of health educators or subcentre staff, which have ample time for such motivational awareness generation, was minimal.

ARI has become the leading killer of underfives in India. NFHS-II found a much higher incidence (28%) in the Kashmir region than in Jammu (16 percent). Higher altitude, colder season and crowded conditions are expected to result in a higher incidence. The likelihood of suffering from ARI increase with the age of the child, peaking at age 12-23 (25%) and declining thereafter.5 In our study, 31.83% of those reporting sickness had symptoms of severe ARI (reported as ‘breathlessness’ or ‘difficult breathing by parents), followed by diarrhoea (27.24%). More than half of those with ARI had cough lasting for 5-10 days.

Both the prominent symptoms of ARI - breathlessness and cough - could be in part infectious (pneumonia, croup, or bronchiolitis) and partly allergic (asthma). Pediatricians believe that the main causes of persistent cough among the underfives in our place are asthma or pulmonary phase of ascariasis. Most of the children had had multiple coexisting symptoms; fever being the most common (38%) of them.

In ARI, mortality could be much higher, since diarrhoeal severity is usually immediately apparent to the parent, while severity of an ARI episode (pneumonia; severe pneumonia) would not unravel so easily to a parent, more so to an illiterate rural mother. Though it was necessary we never taught mothers how to suspect severe illness in their young child. Mothers, particularly in rural areas, have to be sensitized if mortality from ARI is to be reduced in developing countries.

The present study shows that homeimposed food restriction was reported in only 14% of sick children. Although not ideal, the finding is encouraging since 2 decades back every childhood illness was managed by withholding food, leading to or aggravating malnutrition. Some 16% of < 2 yr olds were not given breastmilk during diarrhea.

That implies, a baby who has 3-5 episodes a year, will be starved for at least 25-30 days (ie 1 month) each year (if a typical diarrhoeal episode lasts for 5-7 days). Same applies to the 14% undefives forced food restriction for the period of sickness. Thus, no wonder, almost 21% of the U5 children in our study were found to suffer from malnutrition. Restriction may not be limited to staple foods, liquids are also restricted; 38% mothers in the NFHS II survey admitted that they restricted fluids to their child during diahhoea6.

Almost equal number of parents contacted government facility or a private practitioner for treatment of their sick child. This has dual implication for the health care planners: on the one hand, they need to motivate more people to avail of government health services which are free and freely available, and on the other, should let private sector to operate in a big way but with continuous monitoring ensuring quality at an affordable cost. Very significantly, a mere 6% of parents consulted the nearest available health worker (MPW) for their child’s sickness. That suggests a failure of sub-centre concept, and gives credence to dissidents in health planning who believe that CHC and PHC should be further strengthened without trying to pump in more funds to keep the subcentre concept resuscitated.

The data shows a higher sex ratio (893) in children after the first year than among infants (790). This implies that more boys than girls are lost after infancy. The trend is maintained subsequently, as the adult sex ratio in Budgam is 9187. This aspect of improved sex ratio, on the one hand, may point to a healthy trend of selective improvement in girl child’s nutrition and care, yet needs careful study into whether this is happening at the cost of the male child.

References

  1. Mosley WH and Cowley P. Population Reports, Child Survival and Health – The Challenge. Wld Hlth Popul Bulletin 1992; 46 (4): 1-37
  2. Registrar General of India. The Census of India, 2001.
  3. MOHFW. Shehjar project. RCH Newsletter, 4 (2), 2001. Deptt. of Family Welfare, Ministry of Health and Family Welfare, New Delhi.
  4. IIPS. National Family Health Survey-II, J&K State (1998-99). International Institute for Population Sciences, Bombay. 2002; page 145
  5. International Institute for Population Sciences (NFHS-2) J&K,(1988-89); page 140
  6. International Institute for Population Sciences (NFHS-2) J&K; page143
  7. J&K Govt. Area and Population. Digest of Statistics, 2001. Directorate of Economics Statistics – Planning and Development Deptt. (DOS.)(26), 2001; pg 47
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