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Indian Journal of Community Medicine

Prevalence of 'At Risk' Under-Five Children in a Rural Area

Author(s): S. Sharma, B.P. Gupta

Vol. 30, No. 1 (2005-03 - 2005-03)


Research question : What is the point prevalence of 'at risk' under-five children in the rural area?

Objectives : To estimate the point prevalence of 'at risk' under-five children and the association of demographic, socio-economic and environmental factors with 'at risk' children.

Study-Design : Cross-Sectional Study.

Study Period : July 2000 to June 2001.

Setting : Pachhad Block of Distt. Sirmour, H.P.

Participants : A total of 612 under-five children found in the study area of Pachhad Block.

Study Variables : Various 'risk factors' like weight below 70% of the reference standard, introduction of bottle feeding before six months, birth weight of less than 2500 gms, twins etc.

Statistical Analysis : Chi-square Test.

Results : 'At risk' children identified were 65.7%. Children in 0-5 years age group constituted 10.1% of total population. Literacy of parents and prevalence of 'at risk' children had inverse relation. 'At risk' children living in house with unsatisfactory lighting and ventilation were 68.4%.

Conclusion : Identification of 'at risk' children will help in providing them more efficient child health care through 'risk approach' strategy.

Key Words : 'At risk' children, 'Risk factors' , 'Risk approach' strategy


The overall perspective of health problems in our country is dominated by overpopulation. The brunt of this strain is felt by the vulnerable groups, i.e. mothers and children. Children under-five years of age constitute about 14% of the total population1. This age group is most affected by various common morbidities, some of which lead also to mortality in this vulnerable population. In India, 35-40% of all deaths in children occur under the age of 5 years. Deaths in the age group of 0-1 year account for 20.9% and in the age group 1-4 years account for 10.7% of the total deaths in the country2.

Although a lot of research has been done in the field of maternal and child health, from the very beginning, it was the mother who got the main attention. The 'at risk' pregnancy was the chief concern with final aim of a healthy mother. The sub-area of MCH, 'a healthy baby' was neglected. The major causes of deaths in the age group 0-5 years are preventable. It is therefore necessary to identify particularly those 'at risk' and provide them with efficient paediatric services, because it is these 'at risk' babies, which contribute so largely to perinatal, neonatal and infant mortality. The principles of 'risk approach' involve identification of 'risk factors' relevant to the local situation, screening the population for 'at risk' children and providing them extra care in proportion to their need according to predecided risk management plan. Thus 'risk approach' aims at correcting the inverse proportion of availability and accessibility of health care vis-a-vis its need by reallocation of existing resources3. The indicators for identifying 'at risk' babies may vary from place to place, but the basic criteria remains the same. This community based study was therefore undertaken to estimate the prevalence of 'at risk' children and to find out its association with demographic, socioeconomic and environmental factors.

Material and Methods

The present study was conducted for a period of one year in Pachhad Block of Distt. Sirmour, H.P. The sample size was calculated by taking into consideration permissible level of error at 10%. The required sample size was computed as 600 under five children. Two subcentres and one MCH centre were chosen by simple random sampling. In order to get the required sample, complete enumeration of under-five children was under taken in all the villages falling under these three centres. In all, 612 under-five children were found in the study area. All the households were visited during the survey. The houses found locked were visited again to ensure complete coverage of children. All under-five children in the study area were examined and general informations as well as those specific to the study subjects were elicited by interviewing parents (preferably mother). The children were screened for the prevalence of 'at risk' children. Data thus recorded was analyzed and interpreted to find out the relevant association. 'At Risk' children were those who fell under one or more of the following categories:

Weight below 70% of the expected weight for age, introduction of bottle-feeding before six months, delay in giving supplementary weaning foods, birth weight of less than 2500 grams, twin births, birth order 4 or above, spacing of children < 2 years, mid-arm circumference 12.5 cms (1-5 years), history of deaths of >2 siblings below the age of 12 months, death of either or both parents and mother working outside for > 8 hours a day.


In the present study, 612 under five children were surveyed. There were 323 (52.78%) males and 289 (47.22%) females children. Out of 612 children, 402 (65.69%) were found to be 'at risk' as shown in table I.

In the age groups, 0-12 months, 13-24 months, 25-36 months, 37-48 months and 49-60 months, 'at risk' children were found to be 60.33%, 68.13%, 80.16%, 63.73%, 63.73% and 67.14% respectively. It was observed that 'at risk' children were relatively more (80.16%) in the age group 25-36 months. Percentage of 'at risk' children was more among female children in all the age groups. At risk children were significantly more from the low socio-economic status group.


Table I : Point Prevalence of 'At Risk' Children in Relation to Age and Sex

Age Group Children Surveyed At Risk Children Identification
(in months)
  M F Total No (male) % No (female) % Total No %
0-12 69 52 121 41 59.42 32 61.54 73 60.33
13-24 49 42 91 28 57.14 34 80.95 62 68.13
25-36 66 60 126 46 69.96 55 91.67 101 80.16
37-48 68 66 134 33 48.53 39 59.10 72 63.73
49-60 71 69 140 37 52.11 57 82.60 94 67.14
Total 323 289 612 185 57.28 217 75.09% 402 65.69%

Illiterate mothers had 89.33% of these children 'at risk'. Literacy status of mothers bore inverse relation with the prevalence of 'at risk' children. The increase in prevalence of 'at risk' children in the level above high school group could be due to chance variation as the sample size was small in this category as shown in table II.

Table II : Distribution of 'At Risk' Children in relation to Educational Status of Mother

Educational Status of Mother No. of Children No. of 'at risk' Children % at risk
Illiterate 150 134 89.33%
Primary 239 159 66.53%
Middle 92 46 50.00%
High 101 46 45.54%
Above 29 16 55.17%
Expired 1 1 100.00%
All Groups 612 402 65.69%
x2 = 66.62 P < .001

Table III : Distribution of 'At Risk' Children in Relation to Housing, Overcording, Lightening and Ventilation.

Variable Children Surveyed Children At Risk x2 dt P
    No. %      
1. Housing
Pucca 153 47 30.72 122.64 2 0.00
Kacha Pucca 397 295 74.31      
Kacha 62 60 96.77      
Total 612 402 65.69      
2. Overcrowding 24.63 1 0.00
Present 204 162 79.41      
Absent 408 240 58.82      
Total 612 402 65.69      
3. Lighting & ventilation
Un satisfactory 453 310 68.4 5.83 1 0.02
Satisfactory 159 92 58.8      
Total 612 42 55.7      

Table III shows association of Physical environment with 'at risk' children. There was increased prevalence of 'at risk' children among those living in poor housing conditions, overcrowding, ill-lighted and ill-ventilated conditions.

157 (25.65%) children were found to weigh more than 80% of the reference weight for age. Among these children, 20 (12.74) were identified 'at risk'. In grade I malnutrition group, out of 197 children as many as 124 (62.94) were identified as 'at risk' children. Since malnutrition beyond grade I (weight less than 70% of the reference standard) has been taken as a risk factor, all the children (100%) falling in the groups of grade II, III and IV of malnutrition were 'at risk'.


Majority of 'at risk' children in our study were found in the age group of 25-36 months. Higher prevalence of 'at risk' children in this age group may be due to the fact that in our country, pregnancies occur too close and by the time, the child is 2 years old, mother has another sibling in her lap. So the elder sibling is neglected and left in the care of some substitute. Literacy is an index of awareness and knowledge and plays an important role in detecting the behavior of a person towards health and disease. Educated people are relatively more health conscious than uneducated. So as the literacy status of parents' increases, the prevalence of 'at risk' factors decreases. Physical environmental factors like housing overcrowding, lighting and ventilation have an important bearing on the health status of the population.

The predominant risk factor found were weight less than 70% of the reference standard (64.17%), delay in giving supplementary weaning foods (54.23%), spacing of children less than 2 years (22.64%), birth order 4 or more (19.15%).

The study has brought about some important epidemiological factors of 'at risk' children. The strategy of 'risk approach' will result in the improvement of coverage and quality of health care provided within the constraints of meagre resources.

Routine preventive and promotive care can be provided by less trained health auxillaries while providing basic care, they can simultaneously identify the under-five population for the presence of 'risk factors'. Those who don't have any recognizable 'risk factor' can continue to receive routine care by the health auxillaries. The children thus identified as 'at risk' depending upon the underlying factor/factors, can be managed at appropriate levels depending upon the availability of expertise and equipment to manage the complicated cases.

There is an urgent need and scope for operationilization of 'at risk' children through enhancement of competence of the staff and providing logistic support.


  1. Health information of India, Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, Nirman Bhawan, New Delhi, 1991.
  2. WHO (1983), Strategies for HFA by the year 2000. Regd. Office for South-East Asia, New Delhi.
  3. Cental Technical Committee on Health and Nutrition Monitoring and Continuing Education System. Intergrated Child Development Services, All India Institute of Medical Sciences, 1986:1-151.
  4. Sen P, Mishra C.P., Gupta V.M. An Epidemiological study of risk factors in preschool children of rural areas of Jaunpur Distt. Indian J Public Health, 1995; 2:58-63.
  5. Bhasin S.K., Pandit K, Kapil U, Dubey K.K. Prevalence of 'at risk' factors in under five children. Indian Paediatrics, 1994; 31:1537-1539.
  6. Kapil U, Bali, P. Prevalence of 'at risk' factors in under-five children. Indian Paediatrics, 1988; 25:1180-1183.
  7. Lal Sunder. 'At risk' factorsa in a rural area. Indian J. Paediatrics, 1991; 48:605-608.

Deptt. of Community Medicine,
IGMC Shimla

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