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University of Khartoum
Graduate College
Medical and Health Studies Board
Goiter among Secondary School Girls: Prevalence and Associated Factors in Nyala
- South Darfur State -2010
By:
Khalid Mhajoup Osman Ali
B.sc in Public And Environmental Health
(University of Gazeira) 2001
A thesis submitted in partial fulfillment for the requirements of the degree of MPEH
(Public Health)
Supervisor:
Dr. Kamil Mirghani Ali
Associate Professor - Faculty of Public and Environmental Health
U of K
2010
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Dedication
To my wife
To my daughter with much love.
Tomy brothers, sister, and all members of my family.
To everyone who encouraged me to conduct this study.
Khalid
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Table of Contents
ITEMS
PAGE
Dedication
Table of Contents
i.
Acknowledgement
ii.
Abbreviations
iii.
English Abstract
iv.
Arabic Abstract
v.
List of Figure
vi.
List of Tables
vii.
Chapter One:
1- Introduction
1
2-Objectives
4
Literature Review
5
Chapter Two:
Materials and Methods
18
Chapter Three:
Results
20
Chapter Four:
Discussion, Conclusion and Recommendations
36
References
42
Appendices
44
i
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Acknowledgement
First and last I thank my God
I would like to thank my supervisor Associate Professor Dr. Kamil Margani, Dean
Faculty of Public and Environmental Health, University of Khartoum, which
provided valuable advice and guidance throughout the study.
Special gratitude goes to colleagues at south Darfur state, and all colleagues in
Public Health Department.
, and for everyone who participated in printing this research.
ii
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Abbreviations
IDD- Iodine Deficiency Disorder.
T3 –Trithyroxine .
T4-Thyroxine.
TSH-Thyroid Stimulating Hormone .
UIE- Urinary Iodine Excretion.
RDA-Recommended Dietary Allowance.
WHO- World Health Organization.
FMOH- Federal Ministry of Health
UNICEF- United Nation , Children Fund.
N- Sample size.
CIDDS
- Council for Iodine Deficiency Disorders
ICCIDD- International Council for Community Iodine Deficiency Disorders
WHO/NHD – World Health Organization /North Head Department
iii
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Abstract
Background:
Goiter is said to be due to iodine deficiency when the prevalence in a population
is 10%. The body gets the iodine mainly from the diet and medical combination
.Iodine deficiency is caused by not having enough iodine in the diet, and as a
result the goiter gland is enlarged .A lot of studies and surveys about iodine
deficiency were conducted in western Sudan, but most of these studies were
conducted for the general population.
Across – sectional, descriptive, school-based study was designated for secondary
schoolgirls (Nyala- South Darfur State
2009-2010) to measures the prevalence
rate of goiter and to relate it to some socio-demographic variables.
Materials and Methods:
Six secondary schools were randomly selected. Systematic random selection
was used to select 275 students from the 6 schools. The data were collected by
structured interview of the school girl’s and neck examination for goiter grades.
Results:
The prevalence rate of goiter grade 2 was (41.1%) among the secondary
schoolgirls. Prevalence rate was high among students of age more than 20 years
(75%), and there was a statistically positive association between age distribution
and goiter disease (P-value =0.001). 78.9% of these families used millet as the
main meal and (92.9%) out of them were affected by goiter. There is (56.3%) less
knowledge about iodized salt and the study showed a statistically highly
significant association between less knowledge about iodized salt and girls
affected with goiter (P-value=0.000) . The prevalence of goiter among the
families of students was (31.3%), and the relation between student’s affected by
goiter and family history of goiter is highly significant (P-value=0.000). The
iv
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study reflected a statistically significant association between students affected
with goiter and low family monthly income (P-value=0.0223). The study also
showed that illiteracy among mothers of those girls was (31.3%), and the relation
between low mother education and girls affected by goiter is highly significant
association (p-value=0.000).
Recommendation:
The study strongly recommends raising health awareness among student girls,
and the community about the importance of iodized salt.
v
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vii
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List of Figures
Figure NO
List
1
Intake of Fish, Millet and sorghum within Study
PAGE
31
Population in Nyala, South Darfur State 2010).(n=275)
2
Hear about Iodized Salt within Study Population in
31
Nyala, south Darfur state -2010. (n=275)
Do you use iodized salt?,Nyala-2009.(n=275)
32
Prevalence of Goiter grade 2 according to neck
32
3
4
examination among Study Population in Nyala,
South Darfur State -2010. (n=275)
5
Family History of Goiter among Study Population
33
in Nyala, South Darfur State -2010n=275)
6
Is the Iodized Salt available in the Villages of
33
Study Population in Nyala, South Darfur state 2010? (n=275)
7
Concept regarding Using of Iodized Salt among
34
Study Population in Nyala, South Darfur State 2010.(n=275)
8
Price of Iodized Salt in the Area of Study
Population in Nyala, South Darfur State -2010.
34
(n=275)
9
Knowledge about the Causes of Goiter among
Study Population in Nyala, South Darfur State 2010. (n=275)
viii
35
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List of Tables
TABLE No
Table1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
List
Secondary-School Girls by Class, Nyala, South Darfur
State 2010). ( n=275)
Age distribution of the study population, Nyala, South
Darfur State 2010. ( n= 275)
Father Education of Study Population, Nyala, South
Darfur State 2010. ( n= 275)
Father Occupation of Study Population, Nyala, South
Darfur State 2010. (n= 275)
Mother Education of Study Population in Nyala, South
Darfur State 2010). ( n=275)
Mother Occupation of Study Population in Nyala,
South Darfur State 2010. (n=275)
Family Monthly Income of Study Population in Nyala,
South Darfur State -2010. (n= 275)
Family Size of Study Population in Nyala, South
Darfur State -2010. ( n= 275)
Relationship between Goiter and age distribution
Among Study Population in Nyala, South Darfur State
-2010. ( n= 275)
Relationship between Goiter and Mother Level of
Education among Study Population in Nyala, South
Darfur State-2010. ( n=275)
Relationship between Students Affected by Goiter and
less Knowledge about Iodized Salt ( n=275)
Relationship between Student Affected by Goiter
disease and Students Knowledge about Goiter
( n= 275)
Relationship between Goiter and Type of Family in
Study Population in Nyala, South Darfur State -2010. (
n=275)
Relationship between Goiter and Family Monthly
Income of Study Population in Nyala, South Darfur
State -2010. ( n= 275)
ix
PAGE
24
24
25
25
26
26
27
27
28
28
29
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List of Tables
30
Table 15 Relationship between Goiteric Girls and Father
Educational Level in Study Population in Nyala, South
Darfur State -2010. ( n= 275)
Table 16 Relationship between Students Affected by Goiter and
intake millet in Study Population in Nyala, South
Darfur State -2010. ( n=275)
Table 17 Relationship between Students Affected by Goiter and
hear about Iodized Salt in Study Population in Nyala,
South Darfur State -2010.
( n=275)
Table 18 Relationship between Students Affected by Goiter and
family history with goiter in Study Population in Nyala,
South Darfur State -2010.(n=275)
x
30
31
31
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CHAPTER ONE
INTRODUCTION, OBJECTIVES AND LITERATURE REVIEW
Introduction
Iodine is an important element that we need for many functions, including
thyroid
hormone
production,
metabolism,
brain
development,
reproductive development, growth and energy. When our bodies lack
sufficient iodine, then we are unable to produce adequate thyroid
hormones. The result can be an enlarged thyroid gland, hypothyroidism
or swollen growths and nodules called goiters. (WHO/Nutrition,1997)
Approximately 40 % of the world’s population remains at risk for iodine
deficiency,” according to the American Thyroid Association; Iodine
deficiency continues to be prevalent in regions like Asia, Africa and parts
of Europe. (WHO/Nutrition, 1997)
Generally, iodine deficiency is seen across broad, large groups of people
who live in a certain geographic region rather than in individuals. This is
because certain regions have low levels of iodine in their soil; as such,
food grown there will be low in iodine, and all the people who eat that
food will be affected. (WHO-Medline, 2000)Iodine deficiency is a major
nutrition problem in the world, and until recently, iodine deficiency has
been equated with goiter. In recent years it has become increasingly clear
that iodine deficiency leads to a much wider spectrum of disorders
commencing with the intrauterine life and extending through childhood to
adult life with serious health and social implications .The social impact of
iodine deficiency arises not so much from goiter as from the effect on the
central nervous system. (WHO/Nutrition,1997)
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Goiter continues to be a serious health problem in many Third world
countries. (WHO-Medline, 2000)
Endemic Iodine Deficiency:
Areas can become deficient in iodine from the effects of heavy rain on
steep mountain slopes and from floods caused by melting snow and rain.
Crops grown on iodine-deficient soils are iodine-deficient as well. As a
result, animal and human populations totally dependent on such crops
will also become iodine deficient. Such iodine-deficient soil accounts for
the severe iodine deficiency seen throughout Asia among people living
within a system of subsistence agriculture. The content of iodine in plants
grown in iodine-deficient soil may be as low as10 µg/kg dry weight,
compared with an average of 1 mg/kg for plants grown in iodinesufficient soils. The concentration of iodine in water in areas where goiter
and IDD are endemic is, 2 µg/l, whereas the concentration in no goiter
areas is 9.0 µg/l (Hetzel and Maberly-19 86).
Iodine deficiency is a health problem of considerable magnitude in Sudan
and the neighboring countries. The number of affected people in Sudan is
high especially in western Sudan. (Kambal, 1969).
This research studies the prevalence of goiter due to iodine deficiency in
secondary schoolgirls’ .it also measures proportion of goiter among them
and the socio-economic status leading to goiter as well as to know the
behaviors and attitudes related to iodine deficiency (goiter), type of food
,and geographical structure.
Iodine is a chemical element. That is found in trace amounts in the human
body, the only known function of which is in the synthesis of thyroid
hormones. Severe iodine deficiency results in impaired thyroid hormone
synthesis and/or thyroid enlargement (goiter). Population effects of
severe iodine deficiency, termed iodine -deficiency disorders (IDDs),
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include endemic goiter, hypothyroidism, cretinism, decreased fertility
rate, increased infant mortality, and mental retardation,(Park – 2005)
Iodine is primarily obtained through the diet but is also a component of
some medications, such as radiology contrast agents, iodophor cleansers,
and amiodarone. Worldwide, the soil in large geographic areas is
deficient in iodine. Twenty-nine percent of the world's population living
in approximately 130 countries is estimated to live in areas of deficiency.
This occurs primarily in mountainous regions such as the Himalayas, the
European Alps, and the Andes, where iodine has been washed away by
glaciations and flooding. Iodine deficiency also occurs in lowland regions
far from the oceans, such as Central Africa and Eastern Europe. Those
who consume only locally produced foods in these areas are at risk for
IDD, (eMedicine-2005).
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General Objective:
To study prevalence and associated factors of goiter among secondary
schoolgirls in Nyala-South Darfur -2010.
Specific Objectives:
1- To measure the prevalence rate of goiter among secondary school
girls.
2- To relate it to the following factors:
1 – Age group.
2 - Socio-economic factors.
3- Knowledge, attitude and use iodized salt.
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Literature Review
Goiter:
Goiter is an enlargement of the thyroid gland that often produces a
noticeable swelling in front of the neck. This enlargement can be caused
by iodine deficiency, inability of the body to use iodine correctly, or a
variety of thyroid disorders including infections, tumors, and autoimmune
diseases. Some
environmental pollutants, heavy metal
poisonings, and certain drugs can also contribute to goiter formation.
Both iodine deficiency and inability to use iodine properly make the
thyroid gland unable to produce thyroid hormone, a hormone that helps to
regulate the body's metabolic rate. This state is called hypothyroidism and
the symptoms include fatigue, weight gain, heavy menstrual bleeding in
women, dry skin and hair, as well as goiter, (Scand - 1992).
Iodine-deficiency goiter can be common in regions where the soils and
foods have insufficient iodine. Pre-school children, adolescent girls,
pregnant women, and the elderly are most vulnerable to goiter and other
iodine-deficiency disorders. Areas where iodine supplies are inadequate
show high rates not only of goiter but also of birth defects and retardation
of both mental and physical development. While iodine deficiency is the
leading cause of goiter worldwide, it is a rare cause of goiter in the
developed world. For this reason, any goiter that occurs in the developed
world must be evaluated by a health care provider and its cause
determined before any treatment is given(Baillieres - 1988).
Low amounts of thyroxin (T4, one of the two thyroid hormones) in the
blood, due to lack of dietary iodine to make them, gives rise to high levels
of thyroid stimulating hormone TSH which stimulates the thyroid gland to
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increase many biochemical processes. The cellular growth and
proliferation can result in the characteristic swelling or hyperplasia of the
thyroid gland or goiter. The introduction of iodized salt since the early
1900s has eliminated this condition in several affluent countries.
However, in Australia, New Zealand, and several European countries,
iodine deficiency is a significant public health problem that is more
common in poorer nations. Public health initiatives to lower the risk of
cardiovascular disease have resulted in lower discretionary salt use at the
table, and with a trend towards consuming more processed foods. The
non-iodized salt used in these foods also means that people are less likely
to obtain iodine from adding salt during cooking (Serial Online - 2001).
Normal dietary iodine intake is 100-150 mcg/d. The US Institute of
Medicine (IOM) recommended dietary allowance (RDA) 150 mcg/d of
iodine for adults and adolescents, 220 mcg/d for pregnant women, 290
mcg/d for lactating women, and 90-120 mcg/d for children aged 1-11
years. The adequate intake for infants is 110-130 mcg/d. In areas where
iodine is not added to the water supply or food products meant for
humans or domesticated animals, the primary sources of dietary iodine
are saltwater fish, seaweed, and trace amounts in grains. The upper limit
of safe daily iodine intake is 1100 mcg/d for adults, and it is lower for
children (WHO-Medline, 2000).
Diets in most places are low in iodine unless fortified foods or food from
the sea (which is rich in iodine) are commonly eaten. The iodine level of
food is related to the level in the soil on which it is produced, so
deficiency is often most severe in mountainous area and flood plains
where the soil has been leached (Tropics texts book, 2003).
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Significance and Consequency of Iodine Deficiency:
• Iodine deficiency is a common cause of mental retardation.
• In the 1st and 2nd trimesters of pregnancy it causes varying degrees of
irreversible damage to the developing fetal brain and nervous system.
• In neonates it causes still birth, low birth weight and, occasionally
hypothyroid cretinism.
• In children and adults it causes goiters and hypothyroidism, which
affects school achievement and work output (tropics texts book,
2003).
• Hypothyroidism (occurring in adolescents and adults).
• Cretinism (severe hypothyroidism occurring during fetal or neonatal
life ).
• Reproductive failure (miscarriage, stillbirth).
• Increasing childhood mortality.
• Socioeconomic retardation.
(Mukhtar, 2001.)
Prevalence Rate of Goiter:
Goiter is said to be endemic when the prevalence in a population is 10%,
and in most cases goiter can be treated with iodine supplementation. If
goiter is untreated for around 5 years, however, iodine supplementation or
thyroxine treatment may not reduce the size of the thyroid gland
because the thyroid is permanently damaged (Dunn ,2001).
Thyroid Size:
The traditional method for determining thyroid size is inspection an
palpation.Ultrasonography provides a more precise and objective method.
Both methods are described below. Issues common to palpation and
ultrasound are not repeated in the section on ultrasound (WHO - 2007).
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Thyroid Size by Palpation:
The size of the thyroid gland changes inversely in response to alterations
in iodine intake, with a lag interval that varies from a few months
to several years, depending on many factors, such as the severity and
duration of iodine deficiency, the type and effectiveness of iodine
supplementation, age, sex, and possible additional goitrogenic factors.
The term “goiter” refers to a thyroid gland that is enlarged. The statement
that “a thyroid gland each of whose lobes have a volume greater
than the terminal phalanges of the thumb of the person examined will be
considered goitrous” is empiric, but has been used in most
epidemiological
studies
of
endemic
goiter
and
is
still
recommended(Zimmermann-2007).
Feasibility of Palpation:
Palpation of the thyroid is particularly useful in assessing goiter
prevalence before the introduction of any intervention to control IDD
but much less so in determining impacts. The Costs are associated with
mounting a survey, which is relatively easy to conduct, and training of
personnel.
These costs will vary depending upon the availability of health care
personnel, accessibility of the population, and sample size. Feasibility and
performance vary according to target groups, as follows:
Neonates: It is neither feasible nor practical to assess goitre among
neonates, whether by palpation or ultrasound. Performance is poor.
School-age children (6–12 years):
This is the preferred group, as
it is usually easily accessible. However, the highest prevalence of goitre
occurs during puberty and childbearing age. Some studies have focused
on children 8 to 10 years of age.
There is a practical reason for not measuring very young age groups.
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The smaller the child, the smaller the thyroid, and the more difficult it is
to perform palpation.
If the proportion of children attending school is low, schoolchildren
may not be representative. In these cases, spot surveys should
be conducted among those who attend school and those who do not, to
ascertain if there is any significant difference between the two.
Alternatively, children can be surveyed in households.
Adults: Pregnant and lactating women are of particular concern. Pregnant
women are a prime target group for IDD control activities because they
are especially sensitive to marginal iodine deficiency. Often they
accessible given their participation in antenatal clinics. Women
of childbearing age -15 to 44 year -may be surveyed in households .
(WHO – 2007)
Prevention of IDD:
The most logical single intervention for a community or population is the
introduction of iodine prophylaxis. The most efficient method of
delivering iodine to a population is by systematic iodine supplementation
of food or water supplies. For almost 50 years iodized salt has been the
most effective method of providing extra iodine in the diet. The first
successful large-scale intervention with iodized salt was carried out in the
United States to prevent endemic goiter (Marine and Kimbal, ’22).
Other population-based interventions with iodized salt were carried out in
Switzerland, India, Mexico, Ecuador, Guatemala, Greece, Argentina,
Australia, and Finland, resulting in reductions of both endemic goiter and
endemic cretinism. There has been a major achievement in the reduction
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of IDD in countries that have implemented universal salt iodization
,however, in some countries , the iodine intake of some people has been
unnecessarily high.
This has been associated with hyperthyroidism in some instance (Todd,
95;Bourdoux 96).
A study conducted by WHO,UNICEF and ICCIDD in seven African
countries showed that iodine –induced hyperthyroidism (IIH)may occur,
primarily in older people, when severely iodine –deficient populations
increase their iodine intake even when total amount is within the usually
range of 100-200mg/day.
On a population basis, IIH represent a transient increase in the incidence
of hyperthyroidism, and it will disappear over time with the correction of
the population’s iodine deficiency. The occurrence of IIH is more likely
in people proportional to the number of people with nodular goiters, and
the risk is directly proportional to the number of people with nodular
goiters in the population. Individuals with latent Graves’s disease may be
at risk. Although IIH has occurred when iodine intake was in the
acceptable range, the risk of IIH was greatest following ingestion of
larger amounts (WHO/Nutrition,’97).
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Technique:
The subject to be examined stands in front of the examiner, who looks
carefully at the neck for any sign of visible thyroid enlargement. The
subject i then asked to look up and thereby to fully extend the neck. This
pushes
the thyroid forward and makes any enlargement more obvious.
Finally, the
examiner palpates the thyroid by gently sliding their own
thumb along the side of the trachea (wind-pipe) between the cricoids
cartilage
and the top of the sternum. Both sides of the trachea are
checked.
The size and consistency of the thyroid gland are carefully noted.
If necessary, the subject is asked to swallow (e.g. some water) when
being examined – the thyroid moves up on swallowing. The size of each
lobe of the thyroid is compared to the size of the tip (terminal phalanx)
of the thumb of the subject being examined.1 Goiter is graded according
to the classification presented in Table (WHO - 2007)
1- Classification of Goiter by Palpation:
Grade 0:
No goiter
Grade 1:
Thyroid palpable but not visible
Grade 2:
Swelling in the neck that is clearly visible when the neck is in a normal
position (WHO - 2007)
.
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Goiter in Sudan:
Endemic goiter in the Sudan was first reported in the literature in
1952 by Woodman (1952). He described an endemic goiter area
approximately 200 miles long and 60 miles wide, extending between a
latitude of 27-29E,near the borders to Zaire and the Republic of central
Africa.( Eltom-2003 ).
Extensive survey carried out comprising 17.470 people in Darfur and
found that 57.5%were goitrous and that in 18.5% of these goiters was
large (Kambal,1969).
Prevalence of Endemic Goiter and Iodine -Deficiency Disorders(IDD)
in Sudan:
The available data regarding the iodine status in Sudan , a previous
survey carried out by Eltom 1984survey, were carried out in Darfur
region of western Sudan ,in Kosti and Khartoum in central Sudan and in
Portsudan eastern Sudan, to investigate the prevalence and etiological
factors of goiter and to implement suitable prophylactic measures. A total
of 27,830school children were examined for thyroid gland enlargement in
these areas. In addition, almost the entire populations of five small
villages in Darfur region were included in the survey.
The goiter prevalence was high in children of both sexes in adult females
of this village. The prevalence of the school children in Darfur region
87.1% were goitrous. The prevalence of goiter was also high in Kosti
(74.8%)Eltom-1985)but low in
Khartoum (17.5%)and Portsudan
(13.5%%) (Eltom, 2003).
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In mid -1970, potassium iodine tablets were distributed to elementary
school children in Darfur area(FMOH, Sudan 1999).
In June 1997 an IDD base-line survey was conducted in seven zones of
the country i.e. Northern, Central Khartoum, Darfur, Kordfan, Eastern
and upper Nile states. The survey covered 40992 school children both
boys and girls’ .The survey was funded by UNICEF and Sudan
Government.
The result of urinary iodine analysis of seven zones showed that the
problem is severe in western Sudan (Darfur ) with a median urinary
iodine level of only 1.99 mg/dl .
By looking at the goiter prevalence at the state level, 39.4%was the
prevalence rate in South Darfur (severe )whereas in North Darfur it was
16.7%(mild) (FMOH, Sudan 1999)
In a longitudinal study carried out for the 2 year plan in Darfur region
,western Sudan,2316 children received a single dose of 2 capsules of
iodized oil (400mg iodine) orally ,and 1161school children received 1ml
of same preparation im (475 mg iodine).2393 school children served as
controls .
One year after treatment, goiter prevalence was reduced from 67.0% to
36.0% among the children who had received oral iodized oil and from
71.0%to 42%in those who received it (Eltom ,1985).
The most recent goiter survey conducted in June 1997 was to assess the
groups of school children in primary class 1-6; the estimated goiter
prevalence in Darfur zone is 27.6% in a sample size of 4835 children.
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Policy and Legislation:
There is a legislation implemented in Sudan since 1994; This
legislation has been significantly revised but the government has not
published other document regarding IDD. This legislation passed by
the government made iodization salt mandatory through a ministerial
decree (FMOH-1997).
There is a local law by south Darfur State (south Darfur state
Legislative Council that shows in a regular assembly number 15 on 13
July2004 a review law was to add iodine to salt) (SMOH-2004).
South Darfur state also established iodine salt technical committee to
revise and assess situation in the state after the spread of goiter in the
state . This committee is an integrated committee between government
and other partners (SMOH-2006).
Program in Sudan:
Supplementation: Oral supplementation with iodized oil capsules is not
currently used, (FMOH-1999).
Fortification:
Production and Importation of Salt
• There is production of iodized salt in Sudan.
• The total annual national production of iodized salt is 73,000 tons/a
year (2000).
• The intended level of salt iodization at the point of production is
146,000 tons/year.
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• Large-scale of salt iodization started in 2000.
• There are three salt producers factories currently in Sudan.
• Potassium Iodate is used to iodize salt.
• The packaging method used is plastic bags and plastic containers.
• Salt is imported from Saudi Arabia.
(FMOH, 1997).
Etiology of Endemic Goiter in Sudan:
In areas with endemic goiter the urinary iodine excretion (UIE) was
low (Eltom 1984). Although the main cause of endemic goiter is iodine
deficiency ,other factors may contribute to the high endemicity ,
,although the subjects are from rural and urban Darfur had similar UIE.
The frequency of large goiter found that thiocyanate levels were in the
area of subjects from rural Darfur. This suggested the existence of
goitrogenic factors, which could accentuate the anomalies of iodine
metabolism in states of iodine deficiency (Eltom, 2003).
Osman and Fatah made dietary studies in Darfur and suggested that the
high endemicity of goiter in this region may be due not only to iodine
deficiency but also to other factors such as protein energy malnutrition
,low vitamin A intake ,high sodium ,potassium and iron contents of the
drinking water and high consumption. Staple diet in that area was further
investigated
experimentally
by
Klopfensten(1983)
who
showed
histological changes in the thyroid in millet –fed rats which were similar
to histopathological changes that occur in cases of human colloid
goiter(Eltom-2003) .
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Goitrogenic Factors:
The traditional fermentation procedure adopted in goiter endemic
area in western Sudan removes considerable amount of minerals from
pearl millet its goitrogenicity. Feeding of traditionally fermented
millet to rats was found to induce an increase in serum T3 despite a
normal or slightly increased serum T4.
Pearl millet can exert
agoitrogenic action at different levels. The presence of glucosinolates
in pearl millet cannot be excluded. Cooking of pearl was found to
have a profound quantitative and qualitative effect on its flavonoids
contents (Eltom- 2003).
Causes of Iodine Deficiency:
Since the body does not make iodine, it relies on the diet to have enough
iodine. Thus, iodine deficiency is caused by not having enough iodine in
the diet. Iodine is present naturally in soil and seawater. The availability
of iodine in foods differs in various regions of the world. Individuals in
the United States can maintain adequate iodine in their diet by using
iodized table salt (unless they have to restrict the amount of salt in their
diet), by eating foods high in iodine, particularly dairy products, seafood,
meat, some breads, and eggs, and by taking a multivitamin containing
iodine (see below). However, the amount of iodine in foods is not listed
on food packaging in the U.S., and it can be difficult to identify sources
of iodine in foods (Ata-2008).
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Common Sources of Dietary Iodine
Breads
Iodized table salt
Cheese
Saltwater fish
Seaweed (including
Cow’s milk
kelp,
dulce, nori)
Eggs
Shellfish
Frozen yogurt
Soy milk
Ice cream
Soy sauce
Iodine-containing
multivitamins
Yogurt
(Ata, 2008)
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CHAPTER TWO
MATERIALS AND METHODS
Study Area:
This study was carried out in South Darfur State, Nyala. In the
period 15/ 2/ 2010-20/11/ 2010 .
South Darfur is one of the three states that compose the region of Darfur
in western Sudan. It has an area of 127,300 km² and an estimated
population of approximately 2,890,000 (2006). Nyala is the capital of the
state. South Darfur is the biggest state in Sudan
South Darfur is composed
of 9 localities :
Nyala Locality ,Sharea
Locality ,Twolus Locality ,Poram Locality,Kass Locality ,Rehad Alberdi
Locality ,Adaein Locality ,Adela Locality, and Edalfersan Locality.
Nyala is capital of south Darfur state in the western part of the sudan ,is
located at elevation 2208 feet (673km). Nyala population was estimated
at 435000, (Census – 2009).
Study Population:
Secondary schoolgirls in the first and second class.
Type of Study:
This is across-sectional, descriptive, school-based study.
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Sampling Technique:
The sample size was determined using the following
formula:N= z2.p.q
D2
Where z is the standard normal variable corresponding to 95%
level of significance (z = 1.96).
P is the prevalence of goiter in southern Darfur (p = % 87). and p +q=1
d is marginal error (d =.04).
(1.96)2 * 0.87 *0.13 = 275
(0.04)2
Sample Size:
Six girls secondary schools were randomly selected out of
21schools. Systematic random selection was used to select students
from the 6 schools.
Data Collection:
The data were collected by neck examination for goiter, and structured
interview of the school girls.
Data Analysis:
The data was analyzed by the computer using SPSS programme
version 12.
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CHAPTER THREE
Result:
Complete data were obtained from 275 secondary schoolgirls .Table
(1)showed that the first class representing 42.5%,whilst the second class
is (57.5%).Table (2)showed the ages distribution of the study population
(15-17) represent (35.6%), and between ages (18-20) is 55.6%.
Table (3) showed father education, illiterate father represents (22.9%),
primary school is (28.4%) and secondary schools represent (21.8%). For
the father occupation table (4) showed that laborers are (64%) and
farmers are (3.6%).table (5) mother education, the illiterate mothers
represented (31.3%), primary school is (38.5%), and secondary school is
(11.3%) .And table (6) showed Mother Occupation is (21.1%) is laborer,
(19.3%) are merchants, and house- wives represent (34.5%).
Table (7) showed the monthly income for 40% of the families of study
population is the less than 150 SDG, the income between (150-300) SDG
represents (31.6%) from the total sample size, and (13.8%) for the income
between (300-600) SDG.
Table (8) showed Family size between 3-4 family members is (16%), 5-6
members is (28.4%) and more than 6 persons represents (55.6%) of all
sample size .
Table (9) showed the prevalence of goiter among students more than 20
years was high (75%) and there a significant associate between those
affected with goiter and age distributions.
Table (10) showed the relationship between goiter and a mother
educational level, so the most affected level with Goiter is illiterate
Mothers (52.9%) and this statistically significant
.It is also significant
between students with goiter and less knowledge about iodized salt in
table (11) as appeared statistically (36.6%). And it is also significant
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between students with goiter and knowledge about goiter in table (12).
The relations between goiter and type of family are significant (Pvalue=0.003) in table (13) .The table (14) showed that the relationship
between goiter and families monthly income is highly significant. Table
(15) showed that the relation between goiter and father educational level
is insignificant. Table (16) showed the relation between goiter and
students feeding on millet are significant. Table (17) showed that the
relations between goiter and knowledge’s about iodized salt was
significant
.and in table (18) the relations was significant between
students affected by goiter and family history with goiter. the figure (1)
showed that the (70.9%) do not take fish .On the other hand (78.9 %) are
take millet as main meal and showed (64.7 %) are not use sorghum as
diet. The figure (2) showed that, about (26.5) % do not have any
knowledge’s about iodized salt. Figure (3) showed that (87.3 %)
expressed their willing to use iodized salt if it is provided for them. The
figure (4) showed that prevalence of goiter grade 2 among study
population is (41.1%). Whereas the figure (5) showed (31.3%) have a
family history of goiter, whereas in figure (6) showed (16.4%) out of the
total said that iodized salt is not available for them in their market. On the
other hand in figure (7) (29.8%) have bad conceptions regards iodized
salt. Also in figure (8) about (17.8%) out of the sample size said the
iodized salt is expensive.
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Table (1): Secondary-School Girls by Class, Nyala, South Darfur State
2010.
class
Frequency
%
first
117
42.5
second
158
57.5
Total
275
100.0
Table (2): Age distribution of the study population, Nyala, South Darfur
State 2010.
Years
Frequency
%
15-17
98
35.6
18-20
153
55.6
24
8.7
275
100.0
more than 20
Total
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Table (3): Father Education of Study Population, Nyala, South Darfur
State 2010.
Education
Frequency
%
Illiterate
63
22.9
Primary school
78
28.4
Secondary school
73
26.5
university
60
21.8
1
.4
275
100.0
khlawa
Total
Table (4): Father Occupation of Study Population, Nyala, South Darfur
State 2010.
Type of jobs
Frequency
%
176
64
Employee
79
28.7
merchant
10
3.6
farmer
10
3.6
Total
275
100.0
Laborer
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Table (5): Mother Education of Study Population in Nyala, South Darfur
State 2010.
Education
Frequency
%
Illiterate
86
31.3
Primary school
106
38.5
Secondary school 52
18.9
university
31
11.3
Total
275
100.0
Table (6): Mother Occupation of Study Population in Nyala, South
Darfur State 2010.
occupation
Frequency
%
Laborer
58
21.1
Employee
55
20.0
merchant
53
19.3
House-wife
95
34.5
Others
14
5.1
Total
275
100.0
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Table (7): Family Monthly Income of Study Population in Nyala, South
Darfur State -2010.
Monthly Income
Frequency
%
110
40.0
150 -300
87
31.6
300 -600
40
14.5
more than 600
38
13.8
275
100.0
SDG
less than 150
Total
Table (8): Family Size of Study Population in Nyala, South Darfur State 2010.
Family size
Frequency
%
3-4
44
16.0
5-6
78
28.4
more than 6
153
55.6
Total
275
100.0
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Table (9) Relationship between Goiter and age distribution Among Study
Population in Nyala, South Darfur State -2010.
Years Age
With goiter
Without goiter
Total
No
%
No
%
No
%
15-17
42
37.16
56
34.5
98
35.6
18-20
53
46.92
100
61.7
153
55.6
more than
18
15.92
6
3.8
24
8.8
113
100
162
100
275
200.0
20
Total
X2=14.156
P-value=0.001
Table (10): Relationship between Goiter and Mother Level of
Education among Study Population in Nyala, South Darfur
State-2010.
Level of
Education
Students Goiter
With goiter
Without goiter
Total
No
%
No
%
No
%
Illiterate
46
40.8
41
25.31
87
31.6
Primary
42
37.17 66
40.74
108
39.3
Secondary
15
13.27 36
22.23
51
18.5
University
10
8.85
19
11.72
29
10.5
Total
113
100
162
100
275
200.0
X2 = 8.603
p-value = 0.004
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Table (11): Relationship between Students Affected by Goiter and less
Knowledge about Iodized Salt
Adequate
Goiter
Knowledge
With goiter
Without goiter
Total
about
No
%
No
%
No
%
Yes
74
65.48 128
79.02
202
73.5
No
39
34.52 34
20.98
73
26.5
Total
113
100
100
275
200.0
iodized salt
162
X2 = 6.245
p-value = 0.012
Table (12): Relationship between Student Affected by Goiter
disease and Students Knowledge about Goiter
knowing
goiter
student
With goiter
Without goiter
Total
about
No
%
No
%
No
%
Yes
29
25.66 114
70.3
143
52
No
84
74.34 48
29.7
132
48
Total
113
100
100
275
200.0
Goiter
162
X2 = 53.304
p-value = 0.001
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Table (13): Relationship between Goiter and Type of Family in
Study Population in Nyala, South Darfur State -2010.
Type of
family
goiter
With goiter
Without goiter
Total
No
%
No
%
No
%
Settled
91
80.53 150
92.60
241
87.6
Not Settled
22
19.47 12
7.40
34
12.4
Total
113
100
100
275
200.0
162
X2 = 8.938
p-value = 0.003
Table (14): Relationship between Goiter and Family Monthly Income of
Study Population in Nyala, South Darfur State -2010.
Family
Income
Goiter
Yes
No
No
%
%
No
%
50
44.24 60
37.4
110
40
150 -300
37
33.74 50
30.8
87
31.6
301 -600
16
14.10 24
14.8
40
14.5
More than
10
8.8
28
17
38
13.8
113
100
162
100
275
200.0
Less than
No
Total
150
600
Total
X2 = 4.386
p-value = 0.0223
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Table (15): Relationship between Goiteric Girls and Father Educational
Level in Study Population in Nyala, South Darfur State -2010.
Level
Goiter
Education
Yes
No
No
%
Illiterate
24
Khalwa
No
Total
%
No
%
21.23 39
24.1
63
22.9
1
.88
0
1
0.4
Primary
37
32.75 41
25.30
78
28.4
Secondary
29
25.67 44
27.15
73
26.5
University
22
19.47 38
23.45
60
21.8
Total
113
100
100
275
200.0
0
162
X2 = 3.506
p-value = 0.47
Table (16): Relationship between Students Affected by Goiter and intake
millet in Study Population in Nyala, South Darfur State -2010.
intake millet
Goiter
With goiter
Without goiter
Total
No
%
No
%
No
%
Yes
105
92.9
112
69.14
217
78.9
No
8
7.1
50
30.86
58
21.1
Total
113
100
162
100
275
200.0
X2 = 22.627
P-value = 0.0002
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Table (17): Relationship between Students Affected by Goiter and hear
about Iodized Salt in Study Population in Nyala, South Darfur State 2010.
Knowledge
about
Goiter
With goiter
Without goiter
Total
No
%
No
%
No
%
Yes
60
53.1
142
87.65
202
73.5
No
53
46.9
20
12.35
73
26.5
Total
113
100
162
100
275
200.0
iodized Salt
X2 = 40.768
p-value = 0.0003
Table (18): Relationship between Students Affected by Goiter and family
history with goiter in Study Population in Nyala, South Darfur State 2010.
family
history with
Goiter
With goiter
Without goiter
Total
No
%
No
%
No
%
Yes
46
40.70 40
24.69
86
31.3
No
67
59.30 122
75.31
189
68.7
Total
113
100
100
275
200.0
Goiter
162
X2 = 7.945
p-value = 0.0004
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Figure (1): Intake of Fish, Millet and sorghum within Study Population in
Nyala, South Darfur State -2010).
Figure (2): hear about Iodized Salt within Study Population in Nyala,
south Darfur state -2010.
ϯϬϬ
ϮϱϬ
yes
no
Total
ϮϬϬ
Ϯϳϱ
ϮϬϮ
ϭϱϬ
ϭϬϬ
ϱϬ
Ϭ
ϭϬϬ
ϳϯ͘
ϱ
ϳϯ
Ϯϲ͘
ϱ
Frequency
Percent
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Figure (3): Do you use iodized salt?
ϯϬϬ
Ϯϳϱ
ϮϰϬ
ϮϱϬ
ϮϬϬ
Yes
ϭϱϬ
No
ϭϬϬ
ϴϳ͘
ϯ
ϭϬϬ
Total
ϯϱ
ϱϬ
Ϭ
ϭϮ͘
ϳ
Frequency
Percent
Figure (4): Prevalence of Goiter grade 2 according to neck examination
among Study Population in Nyala, South Darfur State -2010.
ϯ
Ϭ
Ϭ
Ϯ
ϳ
ϱ
Ϯ
ϱ
Ϭ
Ϯ
Ϭ
Ϭ
Yes
No
Total
ϭ
ϱ
Ϭ
ϭ
Ϭ
Ϭ
ϭ
ϲ
Ϯ
ϭ
ϭ
ϯ
ϭ
Ϭ
Ϭ
ϰ
ϭ
͘
ϭ
ϱ
Ϭ
Ϭ
Frequency
ϱ
ϵ
͘
ϵ
Percent
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Figure (5): Family History of Goiter among Study Population in Nyala,
South Darfur State -2010
ϯϬϬ
Ϯϳϱ
ϮϱϬ
ϭϴϵ
ϮϬϬ
Yes
No
Total
ϭϱϬ
ϭϬϬ
ϭϬϬ
ϴϲ
ϲϴ͘
ϳ
ϱϬ
ϯϭ͘
ϯ
Ϭ
Frequency
Percent
Figure (6): Is the Iodized Salt available in the Villages of Study
Population in Nyala, South Darfur state -2010?
ϯϬϬ
Ϯϳϱ
ϮϱϬ
Yes
ϮϬϬ
No
ϭϱϬ
not applicable
Total
ϭϱϳ
ϭϬϬ
ϱϬ
Ϭ
ϰϱ
ϳϯ
ϭϬϬ
ϱϳ͘
ϭ
ϱ
ϭϲ
͘
ϰϮϲ͘
Frequency
Percent
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Figure (7): Concept regarding Using of Iodized Salt among Study
Population in Nyala, South Darfur State -2010.
Figure (8): Price of Iodized Salt in the Area of Study Population in Nyala,
South Darfur State -2010.
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Figure (9): Knowledge about the Causes of Goiter among Study
Population in Nyala, South Darfur State -2010.
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CHAPTER FOUR
DISCUSSION, CONCLUSIONS, RECOMMENDATIONS,
REFERENCES AND APPENDICES
Discussion:
The prevalence rate of goiter grade 2 and more among first and
second class was (41.1%), this appeared according to the neck
examination of goiter, which was visible when the neck in
normal position, this percentage according to WHO, UNICEF
and ICCIDD is considered an endemic of iodine deficiency
(WHO- 2007) which he said, goiter was to be due to iodine
deficiency when the prevalence in a population is 10%. the
prevalence was increased during the past years in comparison
with figures (39.4%) which are obtained by (FMOH, Sudan1999) in South Darfur State at that time this figures were
considered severe. Also a survey was conducted to estimate
goiter prevalence rate in Darfur zone for the sample size of 4835
school children groups between(1-6years)
in primary class it
was found that the goiter prevalence (27.6%) was considered
severe(FMOH-1997). I was found a highly prevalence rate of
goiter among secondary schools age especially within students
more than 20 years (75%), and there a significant association (Pvalue=0.001) between those affected with goiter and age
distributions, this finding agrees with (WHO-2007) which they
said schoolchildren in this ages is preferred group, as it is
usually easily accessible, and the highest prevalence of goiter
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occurs during this age.
The study showed that (78.9%) of
students consume millet as a main meals and (92.9%) out of
them were affected with goiter, while students not consuming
millets but affected with goiter was (7.1%), the cross tabulation
reflect highly significant association between goiter and
consumption of millet (P-value 0.00), so this finding agrees with
(Eltom, 2003) which he said, the millet interrupts and inhibits
the absorption of minerals. Family size in 55.6% is more than 6
persons .This result reflected the high pressures on the families
specially that families are supported by laborers , because the
family monthly income for 40% is less than 150 SP, and there
is statistically significant association (P-value=0.0223)between
income and those student affected by goiter, and as Izzeldin said
there is direct relation between family income and purchasing
powers of foods and the children are more at risk by mineral
malnourishment specially iodine deficiency(Izzeldin ,2008).
The
prevalence
(31.3%).Also
the
of
goiter
study
among
showed
students
statistically
families
is
significant
association (P-value=0.000) between families with history of
goiter and students affected by goiter . this shows that, iodine
deficiency is high among community as a whole, which stresses
the importance of surveys for the whole community for the
purpose of establishing the principle of prevention through
simple and practical methods (Kambal, 1969) .Also (26.5 %) of
student girls do not use iodized salt to prepare food in their
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families, which refers directly to knowledge about goiter and the
availability of iodized salt in markets or the price of iodized salt
which are seemingly factors that affect the consumption of
iodine salt. The planner and the department which is responsible
for the iodine deficiency and the impact control should consider
in the plan all these factors, (Kambal - 1969). The results
showed that (56.3%) out of the total have misconceptions of
using iodized salt by themselves and their families. These are
the most importance challenges facing the programme of iodine
deficiency control. Since the reduction of IDD in most centuries
achieved through implemented of universal iodized salt (PARK,
S-2005).The need for raising the awareness of community
appears clearly in this point. This misconception is against
public health policy aiming at providing iodized salt for every
family (WHO, 2007).The result reflected the statistically
significant
association
(P-value=0.000)
between
students
affected with goiter and levels of mother education. It also
shows the significant association between those affected with
goiter and knowledge about goiter disease. The answer by
WHO, UNICEF and ICCIDD is the training of teachers and
other workers to conduct WHO strategy focusing on grassroots
awareness building to increase the consumption of adequately
iodized salt. UN agencies also assist the Government of Sudan
and the state governments in the production and distribution of
information materials, saying for example that, when buying salt
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make sure it is labeled "iodized"(WHO-2001)
.
Also the results showed that (55.6%) said the iodized
salt is expensive. This result affected the purchasing power
especially of families that have low incomes. (6.5 %) out of the
total said that the cause of goiter is genetic, whereas. (7 %) of
students said that the causes are related to tribal race. This result
shows the low level of knowledge among students and families.
The results showed that those who attend primary schools are
(28.4%) which affected directly the knowledge of families of the
use of natural food rich in iodine and iodized salt, and the low
levels of education related directly with family income,
(Dr/virasakdi, 2002).
The study showed that (70.9 %) do not consume fish. Students
said that, they could not afford to purchase fish because the
fathers monthly income is low. Also (26.5%) out of the total
students said there is no information or knowledge about iodized
salt, which refers
directly to the subjects having low
information regarding nutrition and macro-and micro-minerals
specially
the
importance
of
iodine(Izzeldin
-2008).
The relation between stability or movement of family and goiter
disease
reflects
statistically
significant
association
(P-
value=0.003) between them. This is perhaps related directly to
the availability of iodized salt in these areas where these
families are moving.
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Conclusion:
The prevalence rate of goiter grade 2 was high among secondary
school girls, the prevalence was high among girls student (above
the age of 20 years). Millet was used by the majority of students
with goiter.
Goiter is associated with less knowledge about iodized salt, family
history of goiter, and low monthly family income.
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Recommendations:
The study strongly recommends raising health awareness among
student girls, and the community about the importance of iodized salt.
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References
1- American
Thyroid
Association
(2008)–Thyroid.org-Iodine
Deficiency.
2- Current global iodine status and progress over the last decade toward
the elimination of iodine WHO 200 ( Medline).
3- Federal Ministry of Health –Iodine Deficiency Disorder -1999 (IDD)
Base-line survey report –Khartoum.
4- Federal Ministry of Health (1997) Goiter Survey for School Children
in primary class 1-6 years.
5- Gaitan E. Goitrogens(1988). Baillieres Clin Endocrinol Metab;
2:683-702 (review).
6- Hetzel, B.S. and G.F. Maberly (1986) Iodine. In: Trace Elements in
Human and Animal Nutrition, Vol. 2. C. Mertz, ed. Academic Press,
New York, pp. 139–208.
7- IDD Newsletter (2001). International Council for Control of Iodine
Deficiency Disorders by Dunn JT- page 23-28.
8- Michael Zimmermann (2007)-Key Barriers to Global Iodine
Deficiency Disorder Control – January.
9- Mohamed Ali Eltom( May-2003)- Endemic Goiter And Iodine
Nutrition in Sudan .
10-
M .Eltom, A.M.Khamal- Journal of Clinical Endocrinology and
Metabolism (1985) The Effective of Oral Iodized Oil in the
Treatment and Prophylaxis of Endemic Goiter.
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11- Kambal A. Endemic Goiter in Darfur-1969, Sudan .M. S. thesis,
Khartoum University Sudan.
12- Short Text Book of Public Health (2003) /Medicine for tropics 4th
Edition, PP.( 321-410).
13- The Iodine Deficiency Disorders (2001), Thyroid Disease Manager
–by Hetzel BS, Delange F- (Serial Online).
14- Prescott E, Netterstrom B, Faber J, et al. (1992) Effect of
Occupational Exposure to Cobalt Blue Dyes on the Thyroid Volume
and Function of Female Plate Painters. Scand J Work Environ Health;
18:101-4.
15- PARK,S TEXT BOOK (Jan 2005 ) of Preventive and Social
Medicine 18th edition by M/S banarsdas bhanotb ,India.
16- Prof. El Daw Mukhtar A. Mukhta,MD,JRCP-Iodine Deficiency
Disorder-2001
(IDD)Clinical
Implication
and
Public
Health
Consequences- Sudan.
17- Urinary Iodine Concentration. The United States, National Health
And Nutrition Examination Survey 2001-2002 by Caldwell KL,
Jones R, Hollowell JG . (eMedicine) 2005.
18- WHO/Nutrition (1997) Recommended Iodine Levels in Salt and
Guidelines for Monitoring their Adequacy and Effectiveness.
WHO/NUT/13: 1–6.
19- WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency
Disorders and Monitoring their Elimination. A Guide for Programme
Managers. (WHO/NHD/01.1), 2nd ed. Geneva: World Health
Organization, 2001. http://www.who.int/nut.
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Iodine Deficiency Characteristics
Table 2. Median Population Urinary Iodine Values and Iodine Nutrition
MEDIAN URINARY IODINE
CONCENTRATION (µg/L)
CORRESPONDING IODINE
INTAKE (µg/day)
IODINE
NUTRITION
<30
Severe deficiency
20-49
30-74
Moderate
deficiency
50-99
175-149
Mild deficiency
100-199
150-299
Optimal
200-299
300-449
More than
adequate
>449
Possible excess
<20
>299
{From WHO, UNICEF and ICCIDD 2001 Assessment of the Iodine Deficiency
Disorders and monitoring their elimination. A guide for programme managers. WHO
publ., Geneva. WHO/NHD/01}
(EMedicine-2005)
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Time table:
Activities
10/
/ to 30/1 1/2
/time
20
Proposal
*
to 15/5
to 15/8
15/4 /2010 20/7/2010
/2010
writing
Training
*
Literature
*
preview
Data
*
collection
Data analyzed
*
Report
*
writing
Presentation
*
to
20/11
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Ϣ
ϴ
Σή
ϟ
΍
ϦϤ
Σή
ϟ
΍
Ϳ΍
Ϣ
δΑ
University of Khartoum
Faculty of Public and Environment Health
Department of Epidemiology
Questionnaire to study Goiter prevalence and associated
factors among Secondary Schoolgirls (first and second class)
at South Darfur in Nyala 15/2/2010 to 15/4/2010
Section One: Identification
1. Name of School……………………….
2. Class …………………………………
3. Locality ……………………………….
4. Student age
a- from 15 – 17 yrs ( ) b- 18-20 yrs (
) c- more than 20yrs ( )
1. Section Two : Education ,Demography and Socio – economic
status of students family :
1- Father education
a- illiterate (
) b- basic ( ) c- secondary (
) d- university (
)
E- Khalwa ( )
2- Father occupation
a- labor ( ) b- employee (
) c- free occupation (
) d- other ( )
3- Mother Education
a- illiterate (
) b- basic ( ) c- secondary (
) d- university (
E- Khalwa ( )
4- Mother occupation
a- labor ( ) b- employee (
) c- free occupation (
) d-other ( )
)
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5- Family monthly income …….
A- Less than 150 SP (
) b- 150- 300 SP (
C- 300-600 SP (
)
) d- more than 600 SP ( )
6- Family size
a- from 3-4 (
) b- 5-6 (
) c- more than 6 (
)
7- Type of food yesterday consumed by family
a- milk (
) b- egg (
sorghum ( ) f- other (
) c- fish (
) d – millet ( ) e-
)
8- Do you hear iodized salt?
a- Yes ( )
b- No ( )
9- Do you use iodized salt?
a -Yes ( ) b- No ( )
10- If No, explain the adequate Knowledge.
………………………………………………………….
11- Is iodize salt available in your village or sector?
a- Yes (
) b- No (
)
12- Is iodize salt cheap or expensive?
A – Cheap ( )
b – Expensive
( ).
13- By neck examination of students have enlarged goiter?
(A) Yes (
) (B) NO
(
).
14- The student in which age groups?
A-15-17 Years (
than 20 Years (
) (B)
18-20 Years (
)
(C) More
).
15- Do you have any other person having goiter in your family?
a- Yes (
)
b- No
(
)
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16- What are the causes of enlarged goiter gland?
A-Nutrition problem (
c - Ethnic problem (
) b- genetic problem ( )
) d – other ( ).
17- Suitability and movement of family from area to another.
a. Suitable ( )
b- movable family ( ).
Many thanks for co-operation…
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Photo appeared Case of Goiter
Worldwide distribution of iodine deficiency disorders. Based on total goiter prevalence in school age children. Data from the CIDDS
database, ICCIDD, updated January 1995.