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. J. K. Kosambiya, Surat
Dr. A. M. Kadri, Rajkot
Dr. N. B. Dholakia, Gandhinagar
Dr. Girish Thakar, Surat
Dr. K. N. Sonaliya, Surat
Dr. Rachna Prasad, Surat
Dr. Deepak Saxena, Surat
Dr. Sunil Nayak, Surat
Dr. L. B. Chavan, Surat
Ms. Swati Patel, Surat
Dr. Mitesh Patel, Ahmedabad
Editorial Advisors
Dr. P. Kumar, Ahmedabad
Dr. Pankaj Jain, Etawah
Dr. S. Bhansali, Jodhpur
Dr. Manoj Bansal, Karamsad
Dr. Udai Shankar, Karamsad
Dr. M. P. Singh, Bhavnagar
Dr. K. N. Trivedi, Bhuj
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 IndMEDICA, CAB Abstract, Index Copernicus International, DOAJ, Open J-Gate, NewJour
and Global Health.
CORRESPONDENCE
Dr. Prakash Patel
The Executive Editor, National Journal of Community Medicine
Mobile: 094260 39663
Website: www.njcmindia.org
Email: [email protected]
PUBLISHER
National Journal of Community Medicine (24-022-21-39992)
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Email: [email protected]
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 2 • Issue 3 • Oct-Dec 2011 •Pages 320-507
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 NATIONAL JOURNAL OF COMMUNITY MEDICINE
Volume 2, Issue 3, Pages 320 – 507, Oct - Dec 2011
TABLE OF CONTENT
Page
Editorial
Rural Stay Exposure for Undergraduate Medical Student
Uday Shankar Singh............................................................................................................................ 320-321
Original Article
Critical Analysis of Performance of MBBS Students Using OSPE & TDPE - A Comparative
Study
Richa Nigam, Priyanka Mahawar ..................................................................................................... 322-324
Effect of Smoking on Body Mass Index: A Community-Based Study
Pragti Chhabra, Sunil K Chhabra ...................................................................................................... 325-330
Primary Pterygium – Comparsion of Limbal Conjuncitval Autografting Surgery versus Intra
Operative Mitomycin - C (0.02%) after Exicision of Primary Pterygium
Harpal Singh, A S Thakur, B L Sharma ............................................................................................ 331-334
Socio-Demographic Profile of Infant Mortality by Verbal Autopsy in Urban Area of Bhavnagar,
Gujarat
Sanat Rathod, MP Singh, Rahul Damor, Dharmendra Jankar, Vibha Gosalia, Harshad Patel,
Devang Raval ....................................................................................................................................... 335-339
Surveillance of Hospital Acquired Infection in Surgical Wards in Tertiary Care Centre
Ahmedabad, Gujarat
Patel Disha A, Patel Kiran B, Bhatt Seema K, Shah Hetal S ........................................................... 340-345
Assessment of Immunization Status of Children Between 12-23 Months in Allahabad District
Arshiya Masood, S Dwivedi, G. Singh, M A Hassan, Arun Singh ............................................... 346-348
Assessment of Medical Certificate of Cause of Death at a New Teaching Hospital in Vadodara
Amul B. Patel, Hitesh Rathod, Himanshu Rana, Viren Patel ........................................................ 349-353
Evaluation of Conventional and Serological Methods for Rapid Diagnosis of Cryptococcal
Meningitis in HIV Seropositive Patients at Tertiary Care Hospital
Shah Hetal S, Patel Disha A, Vegad Mahendra M .......................................................................... 354-357
Adverse Reactions Following Influenza Vaccination among Health Care Personnel at Govt.
Medical College, Miraj – a Longitudinal Study
Jayashree Dayanand Naik, S.S. Rajderkar, Kriti A Patel, Sanjay K Jathar ................................... 358-361
Social Class Differentiation and Its Impact on Quality of Life Among Diabetic Patients
Rohin Rameswarapu, Trupti N Bodhare, Samir D Bele, Sameer Valsangkar ............................. 362-365
Persuade Mothers in Post Natal Ward for Timely Initiation of Breastfeeding
Mamtarani, Ratan K Srivastava , B.Divakar .................................................................................... 366-370
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 2 • Issue 3 • Oct-Dec 2011 •Pages 320-507
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 Investigation of A Cholera Outbreak in Kanpur Village of Panchmahal, Gujarat
Shroff Bhavesh D, Mazumdar Vihang S........................................................................................... 371-373
An Investigation on Measles Out Break in Navagam Village of Surendranagar District of
Gujarat, India in 2008
Jaydip R Oza, Mallika Chavada, Jagruti Prajapati .......................................................................... 374-377
Study of Health Profile of Residents of Geriatric Home in Ahmedabad District
Kavita Banker, Bipin Prajapati, Geeta Kedia ................................................................................... 378-382
A Study on Availability of Basic Civic Facilities in Urban Slum Area of Bhuj, Gujarat, India
Bipin Prajapati, Kavita Benker, K N Sonalia, Nitiben Talsania, Siddharth Mukherjee, K N
Trivedi ................................................................................................................................................... 383-387
Health Status of Rural Girls
Madhuri inamdar, sameer inamdar, n. L. Sachdeva ...................................................................... 388-393
Maternal Risk Factors for Low Birth Weight Neonates: A Hospital Based Case-Control Study in
Rural Area of Western Maharashtra, India
Deshpande Jayant D, Phalke D B, Bangal V B, D Peeyuusha, Bhatt Sushen ............................... 394-398
A Socio- Demographic Profile of Infant Deaths in A Tribal Block of South Gujarat
Amul Patel, Pradeep Kumar, Naresh Godara, Vikas K Desai ....................................................... 399-403
Assessing Patient Satisfaction for Investigative Services at Public Hospitals to Improve Quality
of Services
P R Sodani, Kalpa Sharma .................................................................................................................. 404-408
Impact of School Health Program –A Retrospective Analysis of Pediatric Echo’s Done in a
Tertiary Set-Up
Poonam Singh, Dorothy Sengupta .................................................................................................... 409-412
Effect of Daily versus Weekly Iron Folic Acid Supplementation on the Haemoglobin Levels of
Children 6 To 36 Months of Urban Slums of Vadodara
K Sharma, P Parikh, F Desai............................................................................................................... 413-418
Socio-Demographic Characteristics of Postmenopausal Women of Rural Area of Vadodara
District, Gujarat
Donald Christian, Manish Kathad, Bharat Bhavsar ........................................................................ 419-422
A Study on Status of Empowerment of Women in Jamnagar District
Yadav Sudha B, Vadera Bhavin, Mangal Abha D, Patel Neha A, Shah Harsh D ....................... 423-428
Pattern of Ocular Morbidity in School Children in Central India
Harpal Singh ........................................................................................................................................ 429-431
A Study on the Knowledge of Tetanus Immunization Among Internees in A Government
Medical College of Kolkata
Ranadip Chowdhury, Abhijit Mukherjee, Saibendu Kr Lahiri ..................................................... 432-439
Specificity and Sensitivity for Malaria Detection by Rapid (Parahit) Detection Test and
Microscopic Method
Pankaj P Taviad, T B Javdekar, Bhavna A Selot, Vipul P Chaudhari ....................................... 440-442
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 2 • Issue 3 • Oct-Dec 2011 •Pages 320-507
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 Magnitude and Leading Sites of Cancer in A Tertiary Cancer Care Hospital of Western
Maharashtra
Kapil H Agrawal, S S Rajderkar ........................................................................................................ 443-447
Assessment of Personal Hygiene of Canteen Workers of Government Medical College and
Hospital, Solapur
Anant Arunrao Takalkar, Anjali P. Kumavat .................................................................................. 448-451
Biomedical Waste Management: Awareness and Practices in a District of Madhya Pradesh
Manoj Bansal, Ashok Mishra, Praveen Gautam, Richa Changulani, Dhiraj Srivastava, Neeraj
Singh Gour............................................................................................................................................ 452-456
Knowledge & Perceptions of ICDS Anganwadi Workers with Reference To Promotion of
Community Based Complementary Feeding Practices in Semi Tribal Gujarat
Purvi Parikh, Kavita Sharma ............................................................................................................. 457-464
Attitude Towards Joint Family System Among Undergraduate Students of A Medical College
in Rural Area
CL Prasher, AK Bhardwaj, Sunil Kumar Raina, Vishav Chander, BP Badola, Abhilash Sood . 465-469
A Study on Knowledge, Attitude And Practice of Laboratory Safety Measures Among
Paramedical Staff of Laboratory Services
Hansa M Goswami, Sumeeta T Soni, Sachin M Patel, Mitesh K Patel ......................................... 470-473
Missing Girls: Low Child Sex Ratio - Study from Urban Slum and Elite Area of Nagpur, IndiaA Cross Sectional Study
Sumit Dutt Bhardwaj, Babusaheb Nagargoje, Ashok Jadhao, Jyoti Khadse ............................... 474-477
A Prevalence Study of Iodine Deficiency Disorder in Children of Primary Schools in
Gandhinagar District
Shridhar V Rawal, Geeta Kedia ......................................................................................................... 478-482
HIV Sentinel Surveillance Among High Risk Groups: Scenario In Gujarat
L B Chavan, Prakash Patel, Vaibhav Gharat.................................................................................... 483-486
Seroprevalence of Primary Infertility and Acute Pelvic Inflammatory Disease Caused by
Chlamydia in Ajmer Region
Ashish Surana, Prem Singh Nirwan, Suchitra Gaur ....................................................................... 487-491
Study oOf Important Psychosocial Factors in Institutionalized Blinds
Uddhav T Kumbhar, Armaity Dehmubed....................................................................................... 503-507
Short Communication
Cross-Sectional Study of Locomotor Disabilities in Urban Slum Area of Mumbai
Shekhar B Padhyegurjar, Manasi S Padhyegurjar .......................................................................... 492-493
Occupational Exposure & Treatment Seeking Behavoiur of HCWs for Post Exposure
Prophylaxis at Tertiary Level Hospital of Western Rajasthan, India
Prabhu Prakash, Arvind Mathur, Suman Bhansali, Sneha Ambuwani, Ekta Gupta ................. 494-495
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 2 • Issue 3 • Oct-Dec 2011 •Pages 320-507
Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 Letter to Editor
Evidence Informed Community Healthcare in Developing Countries: is there a Role for Tertiary Care
Specialists?
N Asokan, K Praveenlal, K S Shaji ........................................................................................................ 496-497
Catch Them Young
Kapil H Agrawal .................................................................................................................................... 498-499
Youth and HIV
Kanan Desai ........................................................................................................................................... 500-501
Special Article
History of HIV & AIDS
L B Chavan............................................................................................................................................. 502-503
INSTRUCTION FOR AUTHORS
National Journal of Community Medicine is Online……..
All full text articles can be downloaded ……
www.njcmindia.org
NATIONAL JOURNAL OF COMMUNITY MEDICINE • Volume 2 • Issue 3 • Oct-Dec 2011 •Pages 320-507
pISSN: 0976 3325 eISSN: 2229 6816
EDITORIAL .
RURAL STAY EXPOSURE FOR UNDERGRADUATE
MEDICAL STUDENT
Uday Shankar Singh
Key words: PHC: Primary Health Centre, MCI: Medical Council of India
By and large the medical graduate carries the
values of the urban middle class. Even those
from a rural background are unwittingly coopted into the urban milieu, discarding their
social roots. As a result, fresh graduate doctors
have no concept of broad community healthcare
needs. Their professional world-view, regardless
of whether they pursue a career in the public or
private sector, is of providing curative services
with
considerable
high-tech
backup.
Professionally they aspire to specialise in one or
the other clinical disciplines, and their skills are
organically linked to the back-up infrastructure
of a tertiary care hospital. On a conceptual level,
it is quite clear that no national health system
can work through only a network of tertiary
care hospitals.1
Empathy and sympathy for the less fortunate
may be qualities lacking in doctors who are not
exposed to rural life. Their impression of the
community's health status may be lopsided. In
their future practice, students may not consider
the patient's economic status while prescribing
treatment.2
It has been observed that medical graduates are
failing not only in understanding the
community but also in evaluation of contextual
needs of the society. When they start
functioning as doctor, manager and scientist
during postings as Medical officer at PHCs;
getting difficulty by virtue of inexperience in
planning and management of health care
services.
As per Medical Council of India guidelines,
health care delivery system is a part of the
teaching curriculum covered in theory and also
the undergraduate students are supposed to be
taken for field visit to get the actual picture of
the situation 3. As a part of the MCI institutional
goals the undergraduate students coming out of
a medical institute should acquire basic
management
skills
in the area of human
resources, materials and resource management
related to health care delivery3. However studies
have shown the PHC related knowledge of the
undergraduates to be poor (4, 5).
Even during internship posting the exposure
they get regarding management aspects is
usually not adequate (6, 7).Furthermore the
duration of internship in community medicine
has been decreased to 2 months. Also there are
talks of making PHC posting mandatory. This
calls for incorporating the PHC management
related aspects in undergraduate training itself.
In short, it is felt that medical training should
largely be in a decentralized setting outside a
tertiary care hospital, in close proximity with the
public health and social environment. The
training package should include an exposure to
the rural community, covering aspects like:
agriculture, other occupations, local-selfgovernment institutions, health & education
facilities, markets, transport & communication,
family structure and dynamics, caste and
communal dynamics, cultural and religious
traditions, festivals, local maternity and child
health practices, etc. The students should also
undergo training on the roles of the various
public healthcare functionaries. 1
This editorial discuss the achievement of
students exposed to the rural community with
an objectives to understand the importance of
communication, to study the Indian Primary
Health Care system and administrative pattern
in practice to help and support the poor
community in need, to understand socioenvironmental issues that influence on rural
health, to know the family health needs and to
understand about awareness generation and its
importance in the community.
There are very few medical colleges in India
having structured village exposure cum stay
program designed to meet the demand of the
society. It has been attempted well in a single
rural based medical college of Gujarat named
Pramukhswami Medical College, Karamsad
from year 2007-08.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Nov 2011
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This medical college has designed two types of
village stay for one week duration each in 2nd
MBBBS & 3rd MBBS with different objectives
where students are staying with villagers in day
and night along with facuties from the dept. of
Community Medicine. The activities designed in
2nd MBBS are related with basic issues of daily
living a common person is exposed of. Activities
help the students in knowing the administrative
set up in villages as per Indian democracy and
how a person living below poverty line gets
support. Students are persuaded for not only to
study family but to build relationship and get
the feeling of empathy inside. They also study
Indian primary health care in practice at village
level and evaluate the structure based on certain
parameters identified. They also motivated to
arrange a health education session and practice
a mode in active participation of villagers. This
process gives those hands on experience of
community and their contextual needs.
While activities of 3rd MBBS are designed to
strengthen the knowledge and practice of health
care management and service delivery
component at Primary Health Centre. Objectives
of visit are mainly based on Supervision,
monitoring,
evaluation,
leadership
&
observation of administrative and health care
activities in Primary Health Centre. The time for
visit identified as three months before final
examination, could be considered optimum as
the students would have finished their class
room based teaching by then. In our study
observation we have tried to evaluate the effect
of this postings on the PHC related knowledge
of the undergraduates.
As we know, India is a signatory to ‘Health for
All’ and also one of the foremost endorsers of
primary health care model. PHCs are the final
point through which the integrated health
services are supposed to be channeled. Given
the sheer number of national programmes and
the staffing pattern, it calls on part of the
medical officer in charge to have considerable
managerial skills.
We are hopeful to have such exposure to be
taken place in all the medical colleges of our
country and also become the part of medical
curriculum to fulfill the dream of ‘Health for
All”
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Report (Chapter II & III): Task Force on Medical
education for the National Rural Health Mission,
Ministry of Health and Family Welfare, Government of
India, Nirman Bhawan, New Delhi-110001, Year 2005.
Bishnu Giri and P. Ravi Shankar” Community-Based
Learning in a Time of Conflict” Published online 2006
February 28. doi: 10.1371/journal.pmed.0030115.
PMCID: PMC1388064.
Graduate Medical Education regulations, 1997. Medical
Council of India [cited on 2010 Feb 03]. Available from
http://mciindia.org/know/rules_mbbs.htm
Bhatnagar S, Nath DH, Banerjee A, Trakroo PL, Murali
I, Singhal DS. A status study of training in MCH&FW
medical college of India. Health and Population Perspectives & Issues 1994; 17(3&4):190-218.
Rangan S, Uplekar M. Community health awareness
among recent medical graduates of Bombay. Natl Med
J India. 1993 Mar-Apr;6(2):60-4.
Kar K, Panda M, Mahapatra B .Knowledge of the
interns on health care delivery system. Journal of
Community Medicine [Internet]. 2008 [cited 2010 Feb
26];4(1).
Available
from
http://www.jcmorrisaa.org/index_files/page4572.htm
Lal S. Status of health management training in medical
colleges. Indian J Community Med. 1998; 23(3):95-8.
The author is Professor & Head of department of Community Medicine in P. S. Medical College at
Karamsad, Gujarat.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Nov 2011
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ORIGINAL ARTICLE .
CRITICAL ANALYSIS OF PERFORMANCE OF MBBS
STUDENTS USING OSPE & TDPE - A COMPARATIVE
STUDY
Richa Nigam1, Priyanka Mahawar1
1Asst.
Professor, Department of Community Medicine, Sri Aurobindo Institute of Medical Sciences,
Indore
Correspondence:
Dr.Richa Nigam (M.D.)
Asst. Professor, Department of Community Medicine,
Sri Aurobindo Institute of Medical Sciences, Indore
E-mail: [email protected] Mob: 9826249264
ABSTRACT
Numerous attempts are made to improve the reliability and validity of exams especially those used to
assess medical skills and clinical competence. Present study was undertaken to compare the two
methods of evaluation in examinations: OSPE and the TDPE (Traditional Practical
Examination).Mean marks obtained by students in examinations conducted on basis of OSPE and
TDPE were compared using students-t test. The p values obtained were < 0.0001 (highly significant in
all the 3 PCTs conducted. Thus structured nature of the spotting was actually responsible for the
better performance of the students in tests.
Key words: OSPE, TDPE
INTRODUCTION
The objective structured examination (OSE),
with its clinical (OSCE) and practical, nonclinical (OSPE) components, is nowadays used
all over the world due to its reliability, validity
and practicability.1-3 The OSE consists of a series
of tasks, called stations, around which the
examinees are asked to rotate. At each station
the student is required to perform a clinical task
or make some decision. Stations might involve
examining patients, technical procedures or data
interpretation. The examiners are provided with
a checklist to score the performance of the
candidate for the different operation that should
be performed for each specific task..This
approach was introduced to avoid the
disadvantages of the traditional clinical
examination and the inadequacies of the longcase formats that are restricted to one patient or
to one examiner introducing bias.3-4.
For years the traditional methods of evaluation
is being practiced in the Medical Colleges.
Department of Community Medicine conducts
spotting, viva voice and a short statistical
exercise as a part of their practical examination.
The method of examination is subjective. Some
of the problems involved in conventional
practical examination include patient and
examiner variability significantly affecting the
score. Specifically viva voice depends upon the
examiners thinking, perception and mood.. At
times they are judgmental and biased towards
some students and give them marks considering
their overall previous performances.
Yet another important question Juvenal always
remains, who will guard the guards? All the
reforms or criteria for good evaluation cannot
pay dividends until the basic modus operandi of
imparting education is thoroughly questioned.
Present study was undertaken to compare the
two methods of evaluation in examinations:
OSPE and the TDPE (Traditional Practical
Examination).
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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METHODOLOGY
Community Medicine is subject of M.B.B.S.
curriculum up to seventh semester. In the
present study students of Pre Final MBBS (main
batch) of Sri Aurobindo Institute of Medical
Sciences were included. The study was single
blinded. Topics to be asked in the tests were
covered thoroughly and it was taken into
consideration that none of the previously asked
topics were repeated in TDPE and OSPE.Based
on those topics three Part Completion tests
(PCT) were conducted.There were 75 students
but only 68 had given all the three PCTs hence
the scores of these 68 students were included in
the study. Each of the test consisted of TDPE as
well as OSPE, each carrying 20 marks. The
marks obtained in each of the test were entered
on the Microsoft excel sheet. The difference
between two means was compared by applying
unpaired t test to find out whether the difference
in the marks obtained was due to the objectivity
of the examination.
RESULTS
Unpaired t-test was applied to compare the
results of all three tests which were categorized
into TDPE and OSPE, the. The p values obtained
were < 0.0001(highly significant in all the 3 PCTs
conducted. Null hypothesis was hence rejected
and alternate hypothesis accepted. The results
were computed with 95% confidence interval.
Table 1: Distribution of Marks Obtained in Three PCT’s
Statistical Variables
Mean Marks
S.D.
S.E
C.I.
P value
TDPE
OSPE
TDPE
OSPE
PCT Marks
(Out of 20)
9.13
13.75
1.50
2.48
0.35
3.92 - 5.31
< 0.0001
DISCUSSION
Rahman N et al did a similar study to evaluate
the competency of Objective Structured Practical
Examination (OSPE) as an assessment technique
compared to Traditional Practical Examination
(TDPE) in assessment of laboratory component
of physiology, the results of Physiology practical
examination of 400 students from 4 Medical
Colleges, two Government and two non
Government
(Dhaka
Medical
College,
Mymensingh Medical College, Bangladesh
Medical College, Uttara Women's Medical
College) under Dhaka University were studied.
Students' performance in OSPE and TDPE was
compared in the department of physiology,
Dhaka Medical College. The mean score
obtained in OSPE was 77.72+/-0.66 and found
significantly higher than that for TDPE (64.44+/0.61).
Again mean scores achieved in OSPE were
compared among different Medical Colleges
and significant difference was noted. In OSPE,
male students achieved significantly higher
score than that of female students, especially in
responding question station. The outcome of the
PCT Marks
(Out of 20)
9.08
13.53
1.37
2.49
0.34
3.70 - 5.13
< 0.0001
PCT Marks
(Out of 20)
9.14
13.57
1.48
1.69
0.27
3.89 - 4.96
< 0.0001
present study thus indicates that OSPE is a
better choice as an assessment technique over
the Traditional method measuring wide range of
practical skill. It may be concluded that it is
important for competency based performance
discrimination and it also helps improving
students performance quality in laboratory
exercise.
A single examination does not fulfill all the
functions of assessment. A similar study was
undertaken by Abraham et al in Melaka
Manipal Medical College Manipal to determine
the reliability and student satisfaction regarding
the objective structured practical examination
(OSPE) as a method of assessment of laboratory
exercises in physiology before implementing it
in the forthcoming university examination. The
present study was undertaken in the
Department of Physiology of Melaka Manipal
Medical College, Manipal Campus, India. The
Bland-Altman plot showed that approximately
63% of the students showed a performance in
the scores obtained using the OSPE and TPE
within the acceptable limit of 8; 32% of the
students scored much above the anticipated
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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difference in the scores. Feedback indicated that
students were in favor of the OSPE compared
with the TPE. Feedback from the students
provided scope for improvement before the
OSPE was administered for the first time in the
forthcoming university examination.
Roy V, Tekur U, Prabhu S. did a comparative
study of Conventional practical examination
versus
objective
structured
practical
examination in pharmacology practicals:. The
scoring in the OSPE was significantly better than
in the conventional system. The average scores
of students were significantly higher with OSPE
(33.1 vs. 28.8) with 28% students scoring more
than 75% marks whereas only 4% scored more
than 75% with the conventional evaluation.
Students rarely get more than 70-75% in the
conventional evaluation system, as marks are
given in a subjective manner based on the
teachers' discretion and teachers may set their
own limits for evaluation.
actually responsible for the better performance
of the students in tests.
REFERENCES
1.
2.
3.
4.
5.
6.
CONCLUSION
Practical
examination
is
an
important
component of evaluation in the medical
curriculum. However, evaluation of students is
not easy if the criteria of objectivity, uniformity,
validity, reliability and practicability have to be
met. It is to be concluded after completing the
observation and statistical analysis of the marks
attained in the three consecutive tests that the
alternate hypothesis has to be accepted since p
value came out to be less than 0.05. This shows
that the structured nature of the spotting was
7.
8.
9.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Tervo RC, Dimitrievich E, Trujillo AL, Whittle K,
Redinius P, Welliaman L. The Objective Structured
Clinical Examination (OSCE) clinical clerkship: an
overview. S D J Med 1997; 50(5): 153-6.
Prislin MD, Fitzpatrick CF, Lie D, Giglio M, Radecki S
Lewis E. Use of an objective structured clinical
examination in evaluating student performance. Fam
Med 1998; 30(5): 338-44.
Coovadia HM, Moosa A. A comparison of traditional
assessment
with
objective
structured
clinical
examination (OSCE). S Afr Med J 1985; 67(20): 810-2.
Jolly BC, Jones A, Dacre JE, Elzubeir M, Kopelman P,
Hitman G. Relationships between students’ clinical
experiences in introductory clinical courses and their
performances on an objective structured clinical
examination (OSCE). Acad Med 1996; 71(8): 909-16.
Frye AW, Richards BF, Philp EB, Philp JR. Is it worth
it?A look at the costs and benefits of an OSCE for
second-year medical students. Med Teach 1989; 11(3-4):
291-3.
Johnson G, Reynard K. Assessment of an objective
structured
clinical
examination
(OSCE)
for
undergraduate students in accident and emergency
medicine. J Accid Emerg Med 1994; 11(4): 223-226.
Hasan S, Malik S, Hamad A, Khan H, Bilal M.
Conventional/traditional
practical
examination(cpe/tdpe) versus objective structured
practical evaluation (ospe)/semi objective structured
practical evaluation (sospe). Pak j physiol 2009;5(1):5864
Reem Rachel Abraham,Rao Raghavendra,Kamath
Surekha, and Kamath Asha:A trial of the objective
structured practical examination in physiology at
Melaka Manipal Medical College, India. Adv Physiol
Educ 2009; 33(1): 21-3.
Roy V, Tekur U, Prabhu S. A comparative study of two
evaluation techniques in pharmacology practicals:
Conventional practical examination versus objective
structured practical examination. Indian J Pharmacol
2004; 36 (6):386-8.
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ORIGINAL ARTICLE .
EFFECT OF SMOKING ON BODY MASS INDEX: A
COMMUNITY-BASED STUDY
Pragti Chhabra1, Sunil K Chhabra2
1Professor,
2Professor
Department of Community Medicine, University College of Medical Sciences, Delhi
Department of Cardiorespiratory Physiology, Vallabhbhai Patel Chest Institute, Delhi
Correspondence:
Dr Pragti Chhabra, MD
Department of Community Medicine,
University College of Medical Sciences,
Delhi-110095
Email: [email protected]
ABSTRACT
Smoking has a negative effect on Body Mass Index (BMI). This association may be confounded by
demographic factors. Secondary analysis of data of 3446 non-smokers and 948 current smokers from a
previously published community study on respiratory morbidity in Delhi was carried out to examine
the association between smoking and BMI, and the confounding effects of gender and economic
status. The BMI values were higher among non- smokers while smokers had a higher proportion of
underweights. After adjusting for gender and economic status, the odds ratio for being underweight
was 1.34 (95% CI 1.13-1.6) among smokers whereas non-smokers had an adjusted odds ratio for
overweight/obesity of 2.16 (95% CI 1.24-3.78). The study shows that smoking is independently
associated with reduced BMI after adjusting for gender and economic status in an Indian population.
Key words: Body mass index, Smoking, Community-based study, Gender, Economic status
INTRODUCTION
Epidemiological studies have generally shown
an inverse relationship between smoking and
body weight or nutritional status measured as
Body Mass Index (BMI). This association is
evident in both sexes and at all ages, and has
been shown to be present after adjustment for
caloric intake, physical activity, illness or
socioeconomic status.1-4 Negative effects of
smoking on food intake, such as anorexia and
reduced olfactory and gustatory receptor
sensitivity, may contribute to this inverse
association.
In population studies, the effect of smoking on
nutritional status has been found to be
confounded by several demographic variables.
In the WHO Monica project, carried out in 42
populations in the mid-1980s, smoking was
observed to be variably associated with lower
relative body weight in individuals as well as in
populations as a whole. The magnitude of this
association was found to be affected by the
proportion of smokers and ex-smokers.5
However, the association has weakened or even
reversed over time in western countries.5, 6 At a
population level the metabolic effects of
smoking seem to be increasingly overridden by
several other unfavorable health behaviors of
smokers such as unhealthy diet, low physical
activity and alcohol intake.2,7
Among other well known demographic
variables that affect the nutritional status are
gender and economic status.8 Given the high
prevalence of smoking habit in India with gross
gender differences (male predominance),9 and
the fact a nutritional transition is occurring with
both undernutrition and overweight or obesity
becoming
increasingly
common,10,
the
magnitude and direction of the association
between smoking and nutritional status needs to
be studied in India as both are major public
health issues. So far, only one study has been
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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carried out in India that looked into this
association, but only in underweight subjects in
Mumbai.11
Recently, we have carried out a
community-based study on the association
between respiratory morbidity and air pollution
in Delhi.12 A secondary analysis of data on
smoking and BMI from that study was carried
out to examine the association between the two,
and the confounding effects of gender and
economic status in Delhi
METHODS
Data on height and weight, gender, smoking
and economic status obtained during a
community-based study 12 was analyzed. The
study had been approved by the Ministry of
Environment and Forests, Government of India
and financially supported by the World Health
Organization.
Sample selection and Methodology. The details of
sampling have been described earlier.18 Briefly,
nine urban and four rural areas of Delhi were
surveyed. A stratified random sample was taken
from each area allowing inclusion of population
across a wide economic spectrum. In each
selected house, all the available members above
18 years of age were included and administered
a standardized symptoms questionnaire, and
examined by physicians. Standing height to the
nearest cm without shoes, and weight rounded
off to the nearest kilogram were recorded using
standard techniques. For the present analysis,
data of healthy adults (current smokers and
non-smokers) were included. Ex-smokers and
those found to have symptoms of respiratory or
any other disease were excluded. This was done
to avoid the confounding effect of diseases on
nutritional status.
Smoking status was classified as follows:
Current smokers: smoked regularly within 1
month prior to the examination; Non-smokers:
never smoked; subjects occasionally having a
smoke; Ex-smokers: stopped more than 1 month
prior to the examination. Depending upon the
monthly family income, the population was
classified into three convenient categories of
economic status (equivalent to US$): Low:
income below US$ 100; Middle: income between
$100 to 350; High: income above $350.
underweight - BMI < 18.5 kg/m2; (2) normal –
BMI 18.5 to 24.9 kg/m2; (3) overweight – BMI 25
to 29.9 kg/m2; (4) obese – BMI >= 30 kg/m2. As
the 5th, 85th and 95th percentiles have also been
used to define underweight, obesity and
overweight subjects, these were also calculated.
STATISTICS
Data was analyzed using SPSS 11.0 and
GraphPad Prism 4.01. Descriptive exploration of
data on BMI was carried out to determine the
5th, 15th, 50th, 85th and 95th percentiles among
smokers and nonsmokers. The homogeneity of
distribution was checked to decide the tests to
be applied. Comparison of mean BMI ± sd
among categories of smoking, gender and
economic status was done using student’s
unpaired t test or analysis of variance (ANOVA)
as applicable. Chi square test was applied to
study the difference in proportions of
underweight, normal, overweight and obese
subjects among smokers and nonsmokers, and
obtain unadjusted odds ratios. A General Linear
Model (GLM) analysis of variance was carried
out to study the main effects of the three
independent variables (smoking status, sex, and
economic status) as well to explore any
interactions between these. Multiple logistic
regression analysis was carried out to calculate
the adjusted odds ratio. Factors associated with
occurrence of underweight status, and for
overweight and obesity were obtained with
normal BMI category serving as the reference.
RESULTS
There were 948 smokers and 3446 nonsmokers.
The
demographic
and
anthropometric
characteristics of the study population are
shown in Table 1. Data are presented as mean ±
sd.
BMI was calculated by dividing the weight of an
individual in kg by the square of his/her height
measured in meters. The subjects were classified
into one of the four categories as follows: (1)
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Fig 1: BMI in smokers and nonsmokers
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Table 1: Demographic and anthropometric
characteristics of the study population
Smokers
Nonsmokers
(n=948)
(n=3446)
Age, years
36.87 ±12.58
35.03 ± 14.08
Height, m
1.65 ± 0.08
1.58 ± 0.09***
Weight, Kg
56.06 ± 11.33 55.57 ± 12.78ns
BMI, Kg/m2
20.42 ± 3.64
22.14 ± 4.61***
Gender ratio (M:F)
Male
830 (87.6%)
1368 (39.7%)
Female
118 (12.4%)
2078 (60.3%)
Economic statusns
Low
310 (32.7%)
846 (24.6%)
Middle
467 (49.3%)
1543 (44.8%)
High
171 (18%)
1057 (30.7%)
Ns: not significant, p>0.05, ***: p<0.001
The histogram showing frequency distribution
of BMI in smokers and nonsmokers is given in
Fig.1. The BMI ranged from 13.34 to 36.17 in
smokers and from 9.13 to 40.04 in nonsmokers.
There was a leftward shift in the frequency
distribution of BMI in smokers with the 5th, 15th,
50th, 85th and 95th percentiles being 15.69, 16.96,
19.72, 24.16 and 27.41 for smokers and 16.02,
17.47, 21.53, 26.99, and 30.47 for the nonsmokers,
respectively.
Table 2: Distribution
categories of BMI
BMI Category
of
subjects
economic status had a significantly higher BMI
as compared to smokers, males, and those with
a low economic status (Table 3).
Table 3: Comparison of BMI among categories
of smoking status, sex and economic status
Categories
BMI mean
±sd
Smoking status
Smokers
20.42 ± 3.64
Nonsmokers** 22.14 ± 4.61
Gender
Males
21.15 ± 3.95
Females**
22.38 ± 4.87
Economic status+ Low
19.75 ± 3.44
Middle***
21.49 ± 4.32
High***
24.12 ± 4.53
**: p<0.01; + : p<0.001 ANOVA (for economic
status) followed by Bonferroni test, *** p<0.001
for each paired comparison: middle vs low, high
vs low, high vs middle
GLM analysis of variance revealed that the main
effects were significant: Gender (F = 9.15,
p<0.01); Economic status: (F = 50.08, p<0.001);
Smoking status: (F = 11.13, p<0.01). The
interactions (gender × economic status, gender ×
smoking status, economic status × smoking
status and gender × economic status × smoking
status) were not significant (p>0.05).
across
Smoking status
Smokers
Nonsmokers
342 (36.1%)
847 (24.8%)
Underweight
(less than 18.5)
Normal
496 (52.3%)
(18.5 to 24.99)
Overweight
95 (10.0%)
(25 to 29.99)
Obese
15 (1.6%)
(30 or more)
Chi square 103.33, p<0.001
1701 (49.7%)
663 (19.4%)
210 (6.1%)
The proportions of subjects in the four
categories of BMI (underweight, normal,
overweight and obesity) among smokers and
nonsmokers are shown in Table 2. There were
more underweight subjects among smokers, and
more overweight and obese subjects among
nonsmokers (p<0.001). On comparison among
categories by smoking status, gender and
economic status, it was observed that
nonsmokers, females, and those with a high
Fig 2. General Linear Model Analysis of
variance results showing estimated marginal
means for BMI among smokers and nonsmokers
across categories of gender, and lack of
interactions between smoking and gender;(
_______ Females, _ _ _ _ _ Males)
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The lack of interactions is illustrated by the nearparallel and non-intersecting lines in Figs. 2 and
3 showing the estimated marginal means for
BMI among smokers and nonsmokers across
categories of gender and economic status.
The descriptive data of BMI in smokers and
nonsmokers across the three levels of economic
status for males and female subjects are shown
in Table 4.
Fig 3. General Linear Model Analysis of
variance results showing estimated marginal
means for BMI among smokers and nonsmokers
across categories of economic status, and lack of
interactions between smoking and economic
status; ( _______ High, _ _ _ _ _ Middle, ……..Low)
Table 4: BMI in smokers and nonsmokers across
the three levels of economic status among males
and female subjects
Gender Economic Smoking
level
status
Males Low
Smokers
Nonsmokers
Middle
Smokers
Nonsmokers
High
Smokers
Nonsmokers
Females Low
Smokers
Nonsmokers
Middle
Smokers
Nonsmokers
High
Smokers
Nonsmokers
BMI
19.09 ± 2.83
19.12 ± 2.63
20.34 ± 3.28
20.99 ± 3.81
22.59 ± 4.22
23.85 ± 3.98
19.42 ± 2.59
20.46 ± 3.97
21.07 ± 4.23
22.27 ± 4.79
23.19 ± 5.51
24.83 ± 4.93
Models of multiple logistic regression were
developed to identify the determinants of
underweight and overweight/obese nutritional
status. The odds and the 95% confidence
intervals are presented in Table 5. Males,
subjects with low economic status and smokers
had significantly greater odds for being
underweight as compared to females, subjects
with high economic status and nonsmokers.
Similarly, females, subjects with high economic
status and nonsmokers had greater odds for
having obesity or overweight as compared to
males, subjects with low economic status and
smokers.
Table 5: Multiple logistic regression models for underweight and overweight/obesity
Factor
Smokers
Male
Low economic status
Middle economic status
Odds for being
underweight (95% CI)
1.34 (1.13 – 1.6)
1.25 (1.08 – 1.47)
5.5 (4.44 – 6.81)
3.03 (2.47 – 3.71)
For the risk of being underweight, the reference
categories were nonsmokers, females and high
economic status; for the risk of being
overweight/obese, the reference categories were
smokers, males and low economic status.
DISCUSSION
The present community-based study shows that
in the population in Delhi, smoking is
negatively associated with BMI. The median
BMI was higher in non–smokers as compared to
Factor
Nonsmokers
Females
High economic status
Middle economic status
Odds for overweight/
obesity (95% CI)
2.16 (1.24 – 3.78)
2.44 (1.78 – 3.35)
8.10 (4.77 – 13.78)
3.09 (1.80 – 5.31)
smokers. The proportion of overweight and
obese subjects was greater among non-smokers
as compared to smokers while underweight
subjects were in higher proportions among
smokers as compared to nonsmokers. Although
gender and economic status had significant
associations with BMI, the effect of smoking was
independent of these.
The results of our study are consistent with
those of other studies1-4 that have shown a
negative association between smoking and
nutritional status.
The strength of the
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association has however been found to vary
among populations. In the WHO MONICA
project it was observed that regular smokers had
a significantly lower BMI in 20 populations for
men and 30 populations among women out of
the 42 populations studied.5 Among men, the
association between leanness and smoking was
less apparent in populations with relatively low
proportions of regular smokers and high
proportions of ex-smokers. Similarly, in the US
NHANES II data, 4 a lower BMI was observed in
the current smokers as compared to
nonsmokers. The only other study in an Indian
population that examined the association
between smoking and nutritional status was
carried out in Mumbai. 11 All forms of tobacco
use were associated with low BMI, being highest
for bidi smokers. However, the study did not
include overweight and obese subjects. The
present study thus adds new information to the
existing knowledge about this major public
health issue in India.
In our study, after adjusting for gender and
economic status, the odds for smokers being
underweight were about 30% greater than
among nonsmokers. In the study reported from
Mumbai, the adjusted OR for low BMI was 1.8
for men and 1.6 for women.11 The prevalence of
overweight subjects was significantly lower
among current smokers after adjusting for other
socio-economic and dietary factors in a Chinese
population.13 In the Inter 99 study, daily
smoking men had 3% lower BMI than neversmoking men and daily smoking women had
5% lower BMI than never-smoking women after
adjusting for age and socio-economic status.14 In
contrast, in the FINRISK studies, male smokers
were more likely to be obese as compared to
never-smokers.7 Similarly, in the Swiss health
survey, the odds for obesity adjusted for age,
nationality and physical activity were higher
among ex-smokers and heavy smokers and
lower among nonsmokers and light smokers.6
Thus, the direction and the magnitude of
association between smoking and nutritional
status is not consistent, possibly confounded by
other demographic and behavioral factors in the
population 3,7,15 as well as the proportion of
smokers and nonsmokers in the population as
shown in the WHO Monica project.5
In a Finnish study where educational status was
used as an indicator of socioeconomic status,
current smokers weighed less at the lowest level
and more at the highest level than neversmokers.16 However we observed an inverse
relation after adjusting for socioeconomic status.
This is consistent with and explained by the
observations in several studies that high
socioeconomic status is negatively associated
with obesity in developed countries but
positively correlated with it in developing
countries.16 Similar to our results, in the WHO
Monica
project
too,
adjustment
for
socioeconomic status did not affect the
relationship between smoking and leanness.5
Our study has a few limitations. It is a
retrospective secondary analysis of data of an
earlier study. Although only subjects who were
apparently healthy were included, other factors
that could contribute to abnormalities of
nutritional status such as diet, genetics, exercise
habits and other life style factors were not taken
into account. These could yet confound the
association between smoking and nutritional
status. However, identification of determinants
of the nutritional status was not the objective of
the present study. Hence, only two well-known
and major determinants, gender and economic
status, were included as confounding factors.
To conclude, smoking is associated with
reduced BMI in a population sample in Delhi. Its
effect is independent of gender and economic
status of the subject, both of which also
influence the nutritional status.
Acknowledgements
This work is based on data collected in a study
titled “An epidemiological investigation into
respiratory morbidity due to air pollution in
Delhi” that was sponsored by the Ministry of
Environment and Forests, Government of India
and funded by World Health Organization. We
acknowledge their support.
REFERENCES
1.
2.
3.
4.
5.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Khosla T, Lowe CR. Obesity and smoking habits. Br
Med J. 1971; 4: 10-13.
Marti B, Tulomehito J, Korhonen HJ etal. Smoking and
leanness: evidence for change in Finland. Br Med J.
1989; 298:1287-1290.
French SA, Jeffrey RW. Weight concerns and smoking:
a literature review. Ann Behav Med. 1995; 17: 234-244.
Klesges RC, Klesges LM, Meyers AW. Relationship of
smoking status, energy balance, and body weight
analysis of the second Health and Nutrition
Examination Survey. J Consult Clin Psychol. 1991; 59:
899-905.
Molarius A, Seldell JC, Kuulasmaa K et al. Smoking
and relative body weight: an international perspective
Page 329
pISSN: 0976 3325 eISSN: 2229 6816
from the WHO Monica project. J Epidemiol
Community Health. 1997; 51: 252-260.
6.
Chiolero A, Jacot-Sadowski I, Faeh D et al. Association
of cigarettes smoked daily with obesity in a general
adult population. Obesity 2007; 15:1311-1318.
7.
Lahti-Koski M, Pietinen P, Heliovaara M, et al.
Associations of body mass index and obesity with
physical activity, food choices, alcohol intake, and
smoking in the 1982-1997 FINRISK Studies. Am J Clin
Nutr. 2002; 75:809-817.
8.
Chhabra P, Chhabra SK. Distribution and determinants
of body mass index of non-smoking adults in Delhi,
India. J Health Popul Nutr. 2007; 25: 294-301.
9.
Jindal SK, Aggarwal AN, Chaudhry K et al. Tobacco
smoking in India: prevalence, quit-rates and respiratory
morbidity. Indian J Chest Dis Allied Sci. 2006; 48: 37-42.
10. Griffiths PL, Bentley ME. The nutrition transition is
underway in India. J Nutr 2001; 131: 2692-2700.
11. Pedneker MS, Gupta PC, Shukla HC et al. Association
between tobacco use and body mass index in urban
12.
13.
14.
15.
16.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Indian population: implications for public health in
India. BMC Public Health. 2006; 6:70.
Chhabra SK, Rajpal S, Chhabra P et al. Ambient airpollution and chronic respiratory morbidity in Delhi.
Arch Environ Health. 2001; 56:58-64.
Xu F, Yin XM, Wang Y. The association between
amount of cigarettes smoked and overweight, central
obesity among Chinese adults in Nanjing, China. Asia
Pac J Cin Nutr. 2007; 16:240-247.
Pisinger C, Jorgensen T. Waist circumference and
weight following smoking cessation in a general
population: the Inter99 study. Prev Med. 2007; 44: 290295.
Sobal J, Stunkard AJ. Socioeconomic status and obesity;
a review of the literature. Psychological Bulletin 1989;
105: 260-275.
Laaksonen M, Rahkonen O, Prattala R. Smoking status
and relative weight by educational level in Finland,
1978-1995. Prev Med. 1998; 27: 431-437.
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ORIGINAL ARTICLE .
PRIMARY PTERYGIUM – COMPARSION OF LIMBAL
CONJUNCITVAL AUTOGRAFTING SURGERY VERSUS
INTRA OPERATIVE MITOMYCIN - C (0.02%) AFTER
EXICISION OF PRIMARY PTERYGIUM
Harpal Singh1, A S Thakur2, B L Sharma3
1Assistant
Professor, 2Professor, 3Junior Resident, Department of Ophthalmology, People’s College of
Medical Sciences and Research Center, Bhanpur, Bhopal (M.P).
Correspondence:
Dr. Harpal Singh
25 –A-Sector, Sarvadharma colony,
Kolar Road, Bhopal (M.P)
Email: [email protected] Mobile: 9826859233
ABSTRACT
Pterygium is a fibro vascular encroachment of the conjunctival tissue on the cornea causing variable
degree of ocular morbidity. Varies surgical modalities have been developing to reduce the recurrence
rate, which is the major limitation of Pterygium surgery. The idea of study is to compare the relative
efficacy of two well known procedure i.e. conjunctival autografting and intra operative Mitomycin-C
(0.02%) with recurrence to recurrence and complication.
Key words: Pterygium, Recurrent Pterygium, Limbus, Autografting, Mitomycin-C (MMC), Limbal
conjunctival autografting (LCAG), Slit lamp biomicrosocpy, Platelets derived growth factors (PDGF).
INTRODUCTION
Pterygium is one of the most common
conjunctival diseases among ophthalmic
pathologies. Pterygium is a worldwide
condition with a “Pterygium belt” between the
latitudes 300 north and south of the equator,
most prevalent in Hong Kong, situated 22
degrees north of the equator1. Ultraviolet
radiation exposure is a major risk factor for its
development2 . Susrata the great Indian surgeon
recognized the problem of recurrent pterygium.
Risk factors:• UV radiation
• Limbal stem cell deficiency
• Hot climate
• Dust & smoke
• Chronic dry eye
Indication for surgery:-
Pterygium is considered to represent a localized
Limbal cell deficiency. Limbal epithelium acts
as junctional barrier to conjunctival over
growth. Recurrence of Pterygium is due to
accelerated fibroblastic proliferation (as in
keloid formation), due to release of growth
factor (PDGF). Despite a variety of surgical
technique recurrence remains the single and
most enigmatic, complication of Pterygium
surgery with various treatment advocated in the
scientific literature.
Cosmetic disfigurement and functional problem
in the form of reduced visual acuity, diplopia
and problems in contact lens fitting are the
major indications of surgery.
Simple excision (bare sclera) is now no longer
accepted as a standard surgical procedure
because of higher and unpredictable recurrence
and complications
Pterygium is defined as triangular fibro
vascular sub epithelial in growth of
degenerative bulbar conjunctival tissue over
limbus on to the cornea.
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To prevent high recurrence of bare sclera
technique many modification of bare sclera
technique have been under consideration.
• Application of beta rays
• Thiotepa application
• MMC application
• Conjunctival autografting.
• Limbal conjunctival autografting.
• Fibrin glue.
Indication for surgery:Cosmetic disfigurement and functional problem
in the form of reduced visual acuity, diplopia
and problems in contact lens fitting are the
major indications of surgery.
REVIEW OF LITERATURE
Susrata the great Indian surgeon had
recognized the problem of recurrent Pterygium.
Desmarres – (1855) introduced the shifting of
head of Pterygium to a new position away from
cornea. Knapp- (1868) initiated splitting the
head of Pterygium. Mac Reynolds- (1902)
modified the technique by burying the tissue
under the conjunctiva. Blaskowics – (1931)
folded the head under the body. Arlt (1872)
Terson – (1941) Arruga (1937) designed various
rotating flaps to prevent recurrence. Belting
(1926) Majoras (1930) Gomez- Malqvez (1931)
introduced the use of conjunctival graft from
the same and opposite eye. Kunitoma & Mauri –
(1963) first introduced the use of MMC in
Pterygium surgery.
Inclusion & exclusion criteria
In the study cases of primary Pterygium were
included. Patient with followings were
excluded from the study.
• Recurrent Pterygium
• Previous Limbal surgery
• Ocular surface pathology
• Collagen vascular disorder
• Autoimmune diseases
• Infections
Detail ocular examination including visual
acuity, refraction, IOP, extra- ocular movement,
slit lamp biomicroscopy and fundoscopy was
done before operative procedure. All 80 patients
were randomly assigned to two groups.
Group A: Primary Pterygium excision with
LCAG – 40 eyes
Group-B: Primary Pterygium excision with
MMC 0.02% - 40 eyes
Operative Procedure
Group-A (LCAG)
•
•
•
•
•
Detachment of Pterygium head & dissection
of body from overlying conjunctiva
Excision of sub conjunctival Pterygium
tissue
Bare sclera gently cauterized
Graft taken from supero-temporal aspect of
limbus, 1mm larger than the recipient bed
Secured with 10.0 vicryl (episcleraly)
Group-B (MMC-0.02%)
AIM AND OBJECTIVES
The aim of study is to compare the relative
efficacy of two well known procedure i.e.
conjunctival autografting and intra operative
Mitomycin –C (0.02%) with recurrence to
recurrence and complications.
•
•
Intraoperative (MMC 0.02%) applied over
bare sclera for 5 minutes
Site of application was thoroughly irrigated
with BSS solution.
All patients had preoperative counseling and
both the procedures were explained in detail
with their advantages and disadvantages.
All patients were followed up for period of 18
months (3, 6, 9, 12 and 18). Any recurrences or
complications were recorded (Recurrence
defined as fibro vascular tissue invading the
Cornea >1.5 mm).
MATERIAL AND METHODS
OBSERVATION AND RESULTS
Randomized prospective study of 80 eyes of 80
pts of primary Pterygium (Jan 2009 to Jan 2010)
was done to assess the relative effectiveness of
two well known adjuvants LCAG and MMC
0.02%.
Table 1 shows demographic data of patients in
group A and group B.
Recurrence was 4% and 6% in group A and
Group B respectively.
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Table 1: Demographic data of study
participants
Mean age (in yrs)
Age (in yrs)
Sex
Male
Female
Rural
Urban
Group –A
(LCAG)
60
35 - 70
Group-B
(MMC)
60
35 – 70
26
14
33
07
24
16
32
08
Table 2: Observed recurrences in both groups
Month post
operative
3months
6months
12months
18 months
Total
Group –A
(LCAG)
01
01
02(4 %)
Group-B
(MMC)
02
01
03(6%)
In group 1 Graft edema and hyperemia are
noted which was recovered by frequent Steroid
and antibiotic eye drop instillation. Graft
retraction (because of loose suture) was
corrected by re-suturing. Granuloma formation
occurs between graft and junction was excised
and resuturing. In group 2 Edema and
hyperemia of surrounding conjunctiva was
noted, subsequently disappeared in two weeks.
Scleral thinning was noted in one patient. These
eyes have been followed up further to study
possible long term outcome.
Table 3: Observed complications in both groups
Group –A (LCAG)
Graft edema,
hyperemia-(15)
Group-B (MMC)
Edema & hyperemia of
surrounded conjunctiva –
(12)
Graft retraction (01) Scleral thinning (01)
Conjunctival cyst (02) Conjunctival cyst (0)
Granuloma (0)
Granuloma (0)
Dellen (01)
LCAG appeared to be technically difficult, time
consuming and required skillful dissection and
placement of graft, which is main limiting factor
for successful grafting.
Single intra operative MMC (0.02%) for five
minutes appear to be simple and equally
effective and useful adjunctive therapy without
serious complication.
The choice of adjuvant should be carefully made
by assessing the individual recurrence risk
factors, and most importantly surgeon’s
expertise.
DISCUSSION
Pterygium is considered to represent localized
Limbal cell deficiency. Limbal epithelial is an
important cell for the continue renewal of
corneal epithelial which are most important for
normal corneal surface. Due to deficiency of
Limbal epithelial cells, its barrier function has
lost which leads to conjunctival over growth on
to the cornea. Conjunctival autografting with
inclusion of Limbal cells is an excellent method
of decreasing Pterygium recurrence.
Recurrent Pterygium is difficult clinical
condition to manage due to accelerated
fibroblastic proliferation (due to release of
growth factors). Inclusion of Mitomycin –C in
different concentration in the management of
recurrent Pterygium is found to be the excellent
mode to prevent its recurrence.
In our series of cases of group -1 (Pterygium
excision with LCAG, The recurrence rate was
04% with minimal ocular complication (few
suture related complication) but in group -2 (
Pterygium excision with MMC 0.02%) the
recurrence rate was 06%, with irritation,
lacrimation, photophobia and hyperemia and
Edema of surrounding conjunctival were more
in MMC group.
We compare our results with other studies
which shows the following.-
CONCLUSION
1.
Simple excision of Pterygium followed by
Limbal conjunctival autografting (LCAG) and
Mitomycin -C (MMC) 0.02% for 5 minutes. Both
yielded acceptable and comparable results &
both are safe and effective adjuvant of
Pterygium surgery.
2.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Comparison of Limbal conjunctival auto
graft and intraoperative 0.02% MMC for
treatment
of
Primary
Pterygium.
Recurrence in group1 -3.3%, group-2 5.76%
- Akinei A, Zilelioglu O. Viteroretinal
sugery unit, Turkey, Br.J Ophthalmology
2007 Oct25.
Treatment of Pterygium with conjunctival
limbal auto graft and MMC- a comparative
Page 333
pISSN: 0976 3325 eISSN: 2229 6816
study –recurrence in group-I 3%and
group-II recurrence 10% - Biswas MC,
Shaw C, Mandal R, Islam MN, Chakraborty
M. Department of ophthalmology, NRS
Medial
College
Kolkata.
Indian
J
Ophthalmol 2007 March – April)
3. Conjunctival autografting combined with
low-dose MMC for prevention of primary
Pterygium
recurrence-.Fruch
–Pery,
Raiskup E, IIsar M, Landau D, Orucov F,
Solomon A. Department of Ophthalmology
Hadassah
University,
Hadassah.
Recurrence 6.6%in group –I &13.3% in
group4. Randomized
trial
comparing
0.02%
Mitomycin C and Limbal conjunctival auto
graft after excision of primary Pterygium
Recurrence- in group-1 (1.9%) in group-2
(15.9%).Young AL, Leung GY, Wong AK,
Cheng LL, Lam DS. Department of
Ophthalmology & Visual Sciences, The
Chinese University of Hong Kong, Prince of
Wales Hospital, Shatin, NT, Hong Kong..
5. Conjunctival-Limbal auto graft, amniotic
membrane
transplantation,
and
intraoperative Mitomycin C for primary
Pterygium .Keklikci U, Celik Y, Cakmak
SS, Unlu MK, Bilek B. Department of
Ophthalmology, Faculty of Medicine, Dicle
University, Diyarbakir, TR-21280, Turkey.
6. Comparison of three methods for the
treatment
of
pterygium:
amniotic
membrane graft, conjunctival auto graft and
conjunctival auto graft plus Mitomycin C
recurence in - Group -I (4%) to (16%)
Group –II (25%), Group-III (0%) Katircioğlu
YA, Altiparmak UE, Duman S. Department
of Ophthalmology, S.B. Ankara Research &
Training Hospital, Ophthalmology Clinics,
Ankara. Turkey.
7. A randomized trail comparing 0.02%
Mitomycin C and Limbal conjunctival auto
graft after excision of primary pterygium.
Recurrence in group-I (15.9%) & group-II
(1.9%) Young AL, Leung GY, Wong AK,
Cheng LL, Lam DS. Department of
Ophthalmology & Visual Sciences, The
Chinese University of Hong Kong, Prince of
Wales Hospital, Shatin, NT, Hong Kong.
Our results were comparable to study of Akinei
A, Zilelioglu O. Viteroretinal sugery unit,
Turkey, Br.J Ophthalmology 2007 Oct25.,
Comparison of limbal conjunctival auto graft
and intraoperative 0.02% MMC for treatment of
Primary Pterygium. Recurrence in group-1-3.3%, group-2-- 5.76% & study of Biswas
MC,shaw C,Mandal R, Islam MN ,chakraborty
M Department of ophthalmology, NRS Medical
College Kolkata. Indian J Ophthalmol 2007
March-April. Treatment of Pterygium with
conjunctival limbal auto graft and MMC- a
comparative study –recurrence in group-I 3%
and group-II recurrence 10%.
REFERENCES
1.
Karukonda SR, Thompson HW, Beureman RW, et al.
Cell cycle kinetics in Pterygium of three latitutes. Br J
Ophthalmol 1995;79;313-17.
2.
Moran DJ, Hollows FC. Pterygium and ultraviolet
radiation: a Positive correlation. Br J Ophthalmol
1984;68:343-6.
3.
Conjunctival – Limbal auto graft, amniotic membrane
transplantation, and intraoperative Mitomycin C for
primary Pterygium. Keklikei U, Celik Y, Cakmark SS,
Unlu MK, Bilek B. Department of Ophthalmology,
Faculty of Medicine, Dicle University, Diyarbakir, TR21280, Turkey..
4.
A randomized trail comparing Mitomycin C and
conjunctival auto graft after excision of primary
Pterygium [Am J Ophthalmol. 1995]. Combined
“symmetrical conjunctival flap transposition” and
intraoperative low-dose Mitomycin C in the treatment
of
primary
Pterygium.
[Clin
Experiment
Ophthalmol.2006]
5.
A randomized trail comparing mitomycin C and
conjunctival auto graft after excision of primary
Pterygium. [Am J Ophthalmol.1995]
6.
Current concepts and techniques in Pterygium
treatment. Ang LP, Chua JL, Tan DT. Singapore
National Eye centre, Singapore,.
7.
Efficacy of mitomycin C associated with direct
conjunctival closure and sliding conjunctival graft for
pterygium surgery.
8.
Comparison of Limbal-conjunctival auto graft and
intraoperative 0.02% Mitomycin -C for treatment of
Primary Pterygium. Akinei A, Zilelioglu O.
Vitreoretinal Surgery Unit Ulucanlar Eye Hospital,
Ulucanlar Cad, Dikmen, Ankara, Turkey..
9.
Combined
“symmetrical
conjunctival
flap
transposition” and intraoperative low-dose mitomycin
C in the treatment of primary Pterygium. Ucakhan OO,
Kanpolat A.
10. Conjunctival autografting combined with low-dose
mitomycin C for prevention of primary Pterygium
recurrence. Frucht- Pery J, Raiskup F. IIsar M, Landau
D, Orucov F, Solomon A. Department of
Ophthalmology, Hadassah University Hospital, The
Hebrew University, Hadassah.
11. Conjunctival –Limbal auto graft, amniotic membrane
transplantation, and intraoperative mitomycin C for
primary Pterygium. Ann Ophthalmol (Skokie). 2007
Dec;39(4):296-301. PMID: 18025649 [PubMed – indexed
for MEDLINE] Kelklikci U, Celik Y, Cakmak SS, Unlu
MK, Bilek B.
12. Efficacy of mitomycin C associated with direct
conjunctival closure and sliding conjunctival graft for
Pterygium surgery. Br J Ophthalmol.2007 Oct25; [Epub
ahead of print] PMID: 17962392 [PubMed – as supplied
by publisher].
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
SOCIO-DEMOGRAPHIC PROFILE OF INFANT
MORTALITY BY VERBAL AUTOPSY IN URBAN AREA OF
BHAVNAGAR, GUJARAT
Sanat Rathod1, MP Singh2, Rahul Damor3, Dharmendra Jankar4, Vibha Gosalia3, Harshad Patel5,
Devang Raval5
1Tutor, 2Professor
& Head, 3Asst. Professor, 4RCSO Ahmedabad, 5Asso. Professor, Department of
Community Medicine, Govt. Medical College, Bhavnagar
Correspondence:
Dr. Sanat Rathod,
Department of Community Medicine,
Govt. Medical College, Bhavnagar.
E-mail: [email protected]
ABSRTACT
Objectives: To study socio-demographic profile of all registered infant deaths in Bhavnagar city.
Materials and Method: This was a community based retrospective analytical study carried out in
municipal corporation area of Bhavnagar city for which list of all registered infant deaths from 1st
January 2009 to 31st December 2009 from municipal corporation, Bhavnagar was obtained. Data
collection was carried out between January to May 2010 at respondent’s house with help of
restructured verbal autopsy questionnaire developed by WHO.
Result: Out of 96 total verbal autopsies 73(76%) infant deaths were in neonatal period chiefly focus in
early neonatal period (62.5%). Male infant were 57.3% & 42.7% were female. Average family size was
4.9%. 61.5% from socio-economic class IV and 38.5% from classV. Poor housing was reported in 90%
cases. Mother age less than 20 years at time of birth of the baby was in 15%. >1/3rd infant deaths in
gravida & parity one. In 53.9% cases birth spacing was <2years.
Conclusion: By studying verbal autopsy, this study shows how important it is to correctly identify
socio-demographic factors responsible for infant deaths. The present study concluded highest chances
of infant deaths in ENP( Early Neonatal Period) mainly within one hour with significant male infant
deaths in ENP. Most deaths were in lower socio-economic strata & first gravida/parity with birth
spacing less than two years.
Key words: Infant mortality, early neonatal deaths, verbal autopsy.
INTRODUCTION
Infant Mortality Rate (IMR) is regarded as an
important and sensitive indicator of the health
status of a community. It also reflects the
general standard of living of the people and
effectiveness of interventions for improving
maternal and child health in a country.
Compared to other indicators like crude birth
rate, maternal mortality rate and under-five
mortality rate etc, this indicator has always been
accorded greater importance by the public
health specialists because infant mortality is the
single, largest category of mortality. Moreover,
deaths during infancy are due to a particular
mix of diseases and conditions to which the
adult population is less exposed and less
vulnerable. Changes in specific health
interventions affect IMR more rapidly and
directly and consequently it may change more
dramatically than crude death rate in a
population. This is clearly demonstrated in a
developing country like India1. There are wide
variation seen in different parts of the world
(2/1000 LB in developed countries like
Singapore & Switzerland to 89/1000 LB in subSaharan Africa)2. Same way wide variation is
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seen within India ranging 12/1000 LB in Kerala
state to 70/1000 LB in Madhya Pradesh in year
2008 as per SRS Bulletin Oct.20093.
respondent
during
household
visit
&
maintained confidentiality concerning the cause
of death arrived at throughout verbal autopsy.
The method used for analysis of sociodemographic factors responsible for infant
deaths in the study was verbal autopsy which is
defined as an investigation of train of events,
circumstances, symptoms and signs of illness
leading to death through an interview of
relatives or associates of the deceased4. Similar
type of method also used in other studies5,6. It is
hoped that valid and reliable data of infant
death shall be available to policy makers and
planners which is an absolute vital for strategy
making, health sector planning, monitoring and
assessment of health programs, field research
evaluation and epidemic consciousness.
Table 1: Distribution of infant deaths according
to various family based characteristics
MATERIALS AND METHOD
This was a community based retrospective
analytical study carried out in municipal
corporation area of Bhavnagar city for which list
of all registered infant deaths from Municipal
Corporation Bhavnagar was obtained. Total 147
infant deaths were registered from 1st January
2009 to 31st December 2009 included in the study
out of these verbal autopsy of 96 cases of infant
deaths became possible due to various reasons
like house could not be traced due to incomplete
address or respondent refuses to give
information or knowledge of person giving
information is not enough or migration of the
family. Field based data were collected between
January to May, 2010 at respondent’s house in
the language they could understand for
interview. The child’s mother was selected as
respondent wherever possible. In her absence or
non-availability, father or foster parents who
used to take care of the child were selected as
respondent. Before starting interview, I
introduced myself and explained all the reasons
for the study & took informed verbal consent of
every participant before interview.
Study tool: The tool used in this study was
designed verbal autopsy questionnaire prepared
with the help of the standard Verbal Autopsy
questionnaire developed by WHO restructured
to address the local need and requirements
based on other studies.
Ethical concern: The Institutional Review Board,
Government Medical College, Bhavnagar
approved the study. Informed verbal consent in
the local language was obtained from the
Family based Characteristics (N=96)
Family Type
Nuclear
Joint
Three generation
Family Size
1-5
6-10
More than 10
Education of
Illiterate
Mother (N=74) Up to Primary
Up to higher
secondary
Graduate & above
Mother’s Age of 15 – 18
Marriage
19 – 21
22 – 24
≥ 25
Mother’s Age at 16 – 18
Birth of
19 – 21
Deceased Child 22 – 24
≥ 25
Education of
Illiterate
Head of Family Up to Primary
Up to higher
secondary & above
Occupation of Unemployed
Head of Family Unskilled Worker
Semiskilled worker
Other
Socioeconomic Upper & Upper
Class
middle I & II
Lower Middle III
Upper Lower IV
Lower V
Birth Spacing
< 2 yrs
≥2 yrs
No.(%)
33 (34.4)
49 (51.0)
14 (14.6)
64 (66.7)
30 (31.2)
2 (2.1)
27 (36.5)
41 (55.4)
5 (6.8)
1(1.4)
50 (52.1)
38 (39.6)
6 (6.3)
2 (2.1)
6 (6.3)
28 (29.2)
35 (36.5)
27 (28.1)
43 (44.8)
39 (40.6)
14 (14.6)
34 (35.4)
59 (61.5)
2 (2.1)
1 (1.0)
- - 59 (61.5)
37 (38.5)
29 (53.7)
25 46.3)
Data analysis: Data analysis was done in epi
info 3.2 software & applied suitable statistical
test [Z, χ2] to the various determinant of the
study wherever required.
Limitation: (i) As this study test assumptions in
urban area, so we purposely selected such areas
(convenient sampling). Therefore, the study
does have selection bias. (ii) Consciously we
have not commented on IMR in the area, as
sample size was small. (iii) There was no control
group for comparing results. So, study cannot
quantify the role of various attributes on infant
mortality. (iv)Information gathered relied totally
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(within one day) which indicates higher chances
of deaths in male in one day and if we compared
deaths within one hour it was more in
female[Figure I]. A study done in urban slum of
Tamil Nadu10 also shows 54.7% male and 45.3%
female infant deaths. Another study11 in which
53% infant deaths in female and 47% death in
male infant reversed as compared to our study.
Considering NFHS-3 data9 as a whole, it is seen
that IMR is marginally higher in females (58%)
than males (56%). However, in the neonatal
period, like elsewhere, mortality in India is
lower in female (37%) than male (41%) same as
our study. In Gujarat mortality is more in male
(63.1%) as compared to female (62.5%). As
children get older, female are exposed to higher
mortality than males in the post neonatal period
which was also revealed in our study with
26.8% female died in postnatal period whereas
21.9% in case of male infant deaths.
on recall of events by the informants, therefore,
recall bias might have influenced the results.
RESULT & DISCUSSION
Total 96 respondent were interviewed for verbal
autopsy among them 73(76%) of total infant
deaths in neonatal period with highest (62.5%)
focused during early neonatal period & 13%
occurred during late neonatal period [Figure I]
which is similar to various studies6-8. NHFS-3
data of India and Gujarat9 shows neonatal
mortality of around 68.4% and 67.4% of total
infant mortality rate respectively which is little
less as compared to our study.
There was consistent preponderance of male
deaths 55(57.3%) in overall infancy as compared
to female 41(42.7%). This difference was
statistically significant in early neonatal deaths
particularly deaths occurred immediately
30
28
Male
Female
No. of Infant Deaths
25
20
15
10
12
12
8
5
5
5
5
2
0
<1 hr
1 day
11
8
1 week
28 days
1 year
Age
Fig 1: Age and Sex distribution of infant deaths
Various family based characteristics were
presented in Table 1. Based on family type, it
was found that in majority (51.0%) families were
of Joint type, 34.4%t families were Nuclear and
14.6% were of Three-generation type of families.
It was observed that 66.7% had small family size
with members between 1 and 5 while others
(33.3%) were with family size more than five.
Average family size was 4.9. Out of total
respondent mothers, 36.5% were illiterate. Only
one mother was educated up to graduate level
while 62.8% mothers were educated up to
higher secondary level. Considering legal age at
marriage (18 years for female) 26.04% mothers
got married before attaining the legal age of
marriage with mean age at marriage of 18.8
years. According to DLHS-3 (2007-2008)11 mean
age of marriage for girls in Gujarat is 19.8 years
and for urban area it is 21.1 years of age which is
little higher than our result with mean age of
18.8 years. Girls married before attaining the
legal age of marriage (18 years for female) is
18.9% which is less as compared to our study.
The proportion of women married before
reaching the legal minimum age of 18 is lowest
in Goa (11%)8 with lowest IMR in India
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(10/1000LB). In another study done in
Manipal12, average age of marriage was found to
be 21.7 years, which is higher as compared to
our study. The teenage pregnancy and
motherhood brings strain on the girls, who is
still maturing and therefore is not capable of
withstanding the nutritional and metabolic
stresses of these events, thereby affecting infant
survival largely. In 15% cases, Mother’s age at
birth of deceased child was <20 years and in
6.25% cases, it was ≥30 years. Mean age at birth
of deceased child was 23.16. A study done by
Saksena et al13, shows distribution of deliveries
by age of mother exhibited a sharp increase in
perinatal mortality rate (77.3%) from the age
group below 20 years. Characteristics of head of
family displayed in table 1 shows 44.8% were
illiterate, while education up to primary and
higher secondary & above in 40.6% and 14.6%
respectively. Majority of them (61.5%) were
unskilled worker while 35.4% were unemployed
and rest (3.1%) included in semiskilled worker
and other. So according to Kuppuswamy’s
socioeconomic classification 61.5% from upper
lower social class (class IV), while rest (38.5%)
were from the lower (class V) which was
comparable with various studies14,15. Poor
housing, poor environment sanitation, low
maternal education, early marriage and
pregnancy which are factors affecting infant
deaths go hand in hand with poverty that is
indicated by social classification which were
also seen in our study.
Table 2: Distribution of infant deaths
according to gravida and parity of mother
Gravida /
Parity
1
2
3
4
5
Gravida
No. (%)
33 (34.4)
31 (32.3)
23 (24.0)
6 (6.3)
3 (3.1)
Parity
No. (%)
37 (38.5)
31 (32.3)
19 (19.8)
8 (8.3)
1 (1.1)
Birth Order
No. (%)
42 (43.8)
30 (31.3)
18 (18.8)
6 (6.3)
-
Table 2 revealed Gravida and Parity status
shows little difference as maximum deaths
(38.5%) occurred in first parity. Similar finding
reported in a study by Aggarwal et al16 & study
done in Nepal6 which shows highest mortality
in primiparous. In our study, most of infant
death (85.1%) birth order of child was first or
second [Table 2]. It might be consequences of
early marriage and teenage pregnancy as mean
of age of marriage and first pregnancy of mother
was 18.8 years and 19.4 years respectively.
Similar finding also reported according to
NFHS-3 data showing lowest IMR for birth
order 2 or 3 (47%), and higher for first birth
order (64%)8. Another studies also shows
highest mortality in 1st birth order7,17,18. Main
reason for high infant death for first birth orders
were teenage pregnancies, which is also
common in lower socioeconomic groups, where
mortality tends to be higher. Regarding birth
spacing & infant deaths it was found that 53.7%
of the deaths were among babies born with a
spacing less than 2 years which is comparable
with NFHS 3 date showing 65.7% mortality in
birth spacing less than 2 years. Other studies17,18
also revealed similar finding.
REFERENCES
1.
Bir Singh. Infant Mortality Rate in India: Still a Long
Way to Go, Indian Journal of Pediatr 2007(5);74.
2.
UNICEF. The State of The World’s Children 2009, 2006
& 2004. Maternal and Newborn Health, Basic Heath
Indicator.
Page
119.
Available
at
http://www.unicef.org/protection/SOWC09FullReport-EN.pdf. Assessed at June 11, 2010.
3.
Sample Registration System Bulletin, Regional General,
India 2009(10),44 No.1.
4.
Kumar BS, Manish P. Reporting system for cause of
death in India (Major findings) & recent incorporation
of verbal autopsy method in sample registration
system: A powerful tool for reliable mortality
information, Journal of Forensic Medicine and
Toxicology 2003(2);20.
5.
Shrivastava SP, Kumar A, Oza A. Verbal Autopsy
Determined Causes of Neonatal Deaths. Indian Pediatr
2001;38:1022-25.
6.
Katz J, West KP, Khatry SK, et al. Risk Factors for Early
Infant Mortality in Sarlahi District, Nepal. Bulletin of
world health organization. 2003(10);81.
7.
M. Shaikh, RK Baxi, U. Naik, et al. Neonatal MortalityAn Experience by Verbal Autopsy. Public Health and
Human Rights, APHA 134th Annual meeting and
Exposition 2006 (11), Boston, MA. Available at:
http://apha.confex.com/apha/134am/techprogrm/pa
per_125247.htm Accessed April 11th, 2010.
8.
National Family Health Survey (NFHS-3): International
Institute for Population Sciences, Mumbai: IIPS. 200506: India:Volume I.
9.
A.Vaid, A. Mammen, B. Primrose, et al. Infant
Mortality in an Urban Slum, Indian Journal of Pediatr
2007;74(5): 449-54.
10. R. Khanna, A. Kumar, J.F. Vaghela, et al. Community
Based Retrospective Study of Sex in Infant Mortality in
India. BMJ 2003(7);327:1-4.
11. DLHS-3 Data: Gujarat-Key Indicators. Available at:
http://www.rchiips.org/pdf/rch3/state/Gujarat.pdf.
Accessed May 18th, 2010
12. B.K. Chakladar, N. Udya kiran, Lalitha krishnan, R. S.
Phaneendra Rao. A study of infant mortality in field
practice area of Kasturba Medical College, Manipal-A
Preliminary analysis. http:/www.ijcm.org.in.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 338
pISSN: 0976 3325 eISSN: 2229 6816
13. Saksena DN, Srivastava JN. Biosocial Correlates of
Perinatal Mortality: Experiences of an Indian Hospital.
Journal Biosoc.Sci. 1980;12:69-81.
14. Kapoor RK, Srivastava AK, Misra PK. Perinatal
Mortality in Urban Slum in Lucknow. Indian Journal of
Pediatr 1996(6);33(1): 19-23.
15. Hosseinpor
AR,
Mohammad
K,
Majdzades.
Socioeconomic Inequality in Infant Mortality in Iran
and Across Its Provinces. A Hospital Based Study.
Indian Pediatr 2005(11);83:837-44.
16. Agrawal A, Kumar R, Kumar P. Early Neonatal
Mortality in a Hilly North Indian State: SocioDemographic Factor and Treatment Seeking Behaviour;
Indian J. Prev. Soc. Med 2003(34); 46-51.
17. Quamrul HC, Rafiqul I, Kamal H. Effect of
Demographic Characteristic on Neonatal, Post
Neonatal, Infant and Child Mortality. Current Research
Journal of Biological Sci 2010;2(2):132-38.
18. Claeson M, Edurad R, Tazim M, et al. Reducing Child
Mortality in India in New Millennium. Bulletin of
World Health Organization Genebra 2000(78);10.
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Page 339
pISSN: 0976 3325 eISSN: 2229 6816
ORIGINAL ARTICLE .
SURVEILLANCE OF HOSPITAL ACQUIRED INFECTION
IN SURGICAL WARDS IN TERTIARY CARE CENTRE
AHMEDABAD, GUJARAT
Patel Disha A1, Patel Kiran B2, Bhatt Seema K3, Shah Hetal S4
1Assistant
Professor, Department of Microbiology, 2Assistant Professor, Department of
Anaesthesiology, B. J. Medical College, Ahmedabad 3Associate Professor, M & J Institute 4Associate
Professor, Department of Microbiology, GMERS Medical College, Sola
Correspondence:
DR. Patel Disha A.
50, Raichandnagar Society,
Near Visat Petrol Pump, Sabarmati,
Ahmedabad 382424, Gujarat.
Email: [email protected]
Mobile: 9428804260
ABSTRACT
Present study was undertaken to know the rate of Hospital acquired infection in general surgical
wards with special reference to surgical site infections with their antibiotic resistance pattern and to
find out the source of the infection to develop preventive measures to reduce the risk of hospital
acquired infection.
Prospective surveillance for hospital acquired infections was performed during period from January
2006 to June 2006 in the wards of general surgery. One day prevalence study was carried out to find
out rate of various hospital acquired infections. Incidence rate for Surgical Site Infection (SSI) found
out by monitoring all operated cases throughout their stay, and after discharge. All surgical operation
theatres were studied in detail to find out various physical parameters, policies and procedures,
various cleaning procedures and fumigation.
Over all prevalence rate of hospital acquired infections in surgical wards was about 21.9% comprising
of 10.9% for SSI, 8% for local blood stream infection (i.e. thrombophlebitis) 2% for urinary tract
infection (UTI) and 1% for the other infection (like bed sore). Incidence rate of surgical site infections
was 12.72 %. Klebsiella spp. was the most common isolate responsible for SSI. The prevalence of HAI
and incidence of SSI in our hospital has encouraged the development of recommendations for
prevention of such infections in our hospital.
Key words: Hospital acquired infection, surgical site infection, nosocomial infection
INTRODUCTION
Nosocomial infection or hospital acquired
infection refers to the infection occurring in
patients after admission at the hospital that was
neither present nor incubating at the time of
admission. It is one of the public health
problems throughout the world. The infection
causes the patient’s physical and mental
sickness that makes the patient stay longer in
the hospital without necessity.1 Infections
acquired in the hospital account for major
causes of death, morbidity, functional disability,
emotional suffering and economic burden
among the hospitalized patients. These
nosocomial infections (NI) occur among 7-12%
of the hospitalized patients globally with more
than 1.4 million people suffering from the
infectious complications acquired in the
hospital.2
The most frequent nosocomial infections are
infections of surgical wound, urinary tract
infections and lower respiratory tract infections.3
Surgical site infections (SSI) are the third most
commonly reported nosocomial infection and
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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they account for approximately a quarter of all
nosocomial infections.4 Surgical site infections
are the most common nosocomial infections in
surgical patients- accounting for about 24% of
the total number of nosocomial infections.5, 6, 7
It’s rate has varied from a low of 2.5% to high of
41.9%.4
In the view of all above fact this study is
undertaken to know the rate of surgical site
infections and other nosoconial infections in
general surgical wards with their antibiotic
resistance pattern and to find out the source of
the infection.
MATERIAL AND METHODS
This prospective study was carried out on
patients admitted in the general surgical wards
at one of the largest tertiary care centre hospital
in Ahmedabad, Gujarat, West India, from
January 2006 to June 2006. The teaching hospital
is the major tertiary health institution offering
diagnostic and therapeutic services to entire
Gujarat state as well as the neighbouring states
of Madhapradesh and Rajasthan. A total of
consecutive 100 patients admitted in the surgical
words were taken as a study group and assessed
for any kind of nosocomial infection.
A preliminary visit of the hospital was done to
identify various general surgical wards and
among them two wards were selected for the
study. For SSI patients were excluded from the
study by following criteria: deficient medical
records; having undergone surgical intervention
at another hospital and then referred to our
hospital; or death after surgery or within the
following 30 days.
Data that recorded include; General data
comprised of age, gender, operative procedure,
date of admission, date of operation, date of
discharge, discharge status; stratification and
preoperative data comprised of any invasive
procedure done on the patient, wound
contamination class (cdc, 1999 – clean, clean
contaminated, contaminated, dirty), multiple
operating procedures done, duration of
operation, type of surgery (urgent vs. elective),
the American Society of Anaesthesiologists
(ASA) physical status classification (healthy,
mild systemic disease, sever systemic disease,
incapacitating systemic disease or moribund
patient), use of antibiotic prophylaxis, date of
infection and causative microbial agent in
culture positive results. CDC definitions were
used to detect SSI. 8
Prevalence rate was calculated by visiting every
patient (100) on a single day, taking appropriate
history, reviewing their medical and nursing
charts, interviewing the clinical staff to identify
infected patients as per definition given by
‘WHO manual of prevention of Hospital
acquired Infections.’
Among all 100 patients, operated once were
further followed up to find out incidence rate of
SSI by monitoring them. They were followed
throughout their stay, and after discharge.
Swabs were collected from appropriate site and
were processed aerobically for culture. Isolate
were identified by standard methods and the
antibiotic susceptibility was determined by
Kirby-Bauer disk diffusion method as per CLSI
recommendations.9, 10 The information from
interviews and medical records were analyzed
to search risk factors of nosocomial SSI.
To identify the source of SSI, pre and post
fumigation swabs of operation theatres, where
the patients operated were taken. All surgical
operation theatres were studied in detail to find
out various physical parameters, policies and
procedures, various cleaning procedures and
fumigation.
Informal
interview
with
surgeon,
anaesthesiologist and nursing staff was done to
find out about the awareness of HAI and
prevention of it.
RESULTS
Total 100 patients were studied; among which
over all one day prevalence rate of hospital
acquired infections in surgical wards was about
21.90%. 55 patients were operated among which
6 patients developed SSI during prevalence
study, thus prevalence of SSI was 10.9%. Local
blood stream infection (i.e. thrombophlebitis)
was 8%, UTI was 2% and only 1% was of the
other infection (like bed sore).
All operated patients were followed up further
to find out incidence rate. It was found after
follow up that 7 patients got SSI infection.
Among which 4 patients were operated in Major
surgical operation theatre (MOT) and 3 patients
were operated in emergency operation theatre
(EOT). Thus incidence rate of SSI was 12.72%.
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Table 1 shows distribution of SSI based on risk
factors. Table 2 shows results of direct
observation of OTs and recommended solutions.
Investigating about microbiological reports of
wound, organism, Klebsiella spp. was found in
the most of the patients who were operated at
MOT and organism, Staphylococcus was found
in the patients who were operated at emergency
OT.
Table 1: Distribution of surgical site infections based on risk factors
Age (years)
Gender
Preoperative stay
Wound class
Type of intervention
ASA score
Duration of operation
Surgical procedures
Chronic diseases
< 25
25-60
> 60
Male
Female
<7
>7
Clean
Clean Contaminated
Contaminated
Dirty/Infected
Emergent
Elective
1
2
>/=3
< 2 hours
> 2 hours
Cholecystectomy
Colon surgery
Appendecectomy
Hernia
Amputation
Renal stone operation
Prostatectomy
I&D
Skin grating
other
Yes
No
Reviewing pre and post fumigation report of
MOT and emergency OT; organism Klebsiella
was found from A.C. machine and OT self in
prefumigation swab report of the MOT. These
swabs were taken at the same week end day in
which all the surgical site infected patients were
operated.
One of the Limitations of our study was that we
could not able to find reports of the emergency
operation theatre because pre and post
fumigation swabs were not taken on the regular
bases.
Data of SSI with their risk factors were
evaluated by chi square (X2 statistical test, p ≤
0.05 was considered to be significant).
SSI (n=7) (%)
0 (0)
2 (5.26)
5 (41.66)
5 (14.29)
2 (10.00)
1 (2.17)
6 (66.67)
0 (0)
2 (15.38)
0 (0)
5 (23.81)
3(18.75)
4 (10.26)
0 (0)
3(13.04)
4 (14.29)
2 (5.88)
5 (23.81)
0 (0)
5 (29.41)
0 (0)
0 (0)
02(50)
0 (0)
0 (0)
0 (0)
0(0)
0 (0)
1 (6.67)
0 (0)
No SSI (n=48) (%)
5 (10.48)
36 (94.74)
07 (58.33)
30 (85.71)
18 (90.00)
45 (97.83)
03 (33.33)
19 (100)
11 (84.62)
02 (100)
16 (76.19)
13 (81.25)
35 (89.74)
04 (100)
20 (86.96)
24 (85.71)
32 (94.12)
16 (76.19)
02 (100)
12 (70.59)
03 (100)
02 (100)
02 (50)
03 (100)
04 (100)
13 (100)
04 (100)
03 (100)
14 (93.33)
40 (100)
Total (n=55)
05 (100)
38 (100)
12 (100)
35 (100)
20 (100)
46 (100)
09 (100)
19 (100)
13 (100)
02 (100)
21 (100)
16 (100)
39 (100)
04 (100)
23 (100)
28 (100)
34 (100)
21(100)
02 (100)
17 (100)
03 (100)
02 (100)
04 (100)
03 (100)
04 (100)
13 (100)
04 (100)
03 (100)
15 (100)
40 (100)
D IS C U S SIO N
Nosocomial infection is a major public health
problem throughout the world. A one-day
prevalence survey was conducted to estimate
the prevalence of HAI in 100 patients present in
a surgical wards for at least 24 hours and not
due for discharge or transfer on the day of the
survey. The overall prevalence of HAI was
21.90% including 10.9% of surgical wound
infection, 8% of local blood stream infection (i.e.
thrombophlebitis), 2% of urinary tract infection
and only 1% of other infection like bed sore. No
patient suffering from nosocomial respiratory
tract infection or central blood stream infection.
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Fifty five patients out of 100 were operated,
followed up to find out incidence rate and it was
also calculated by monitoring all operated
patients included in this study, among them 7
patients were got postoperative surgical wound
infection. So overall incidence rate of surgical
site infection was (7/55) 12.72 %. Number of the
studies carried out in India reported rate of SSI
was ranging from 2.5 to 41.9%. 4 Our SSI rate
was favorably compared with SSI rate of
Shrivastava et al (10.19%), shaw et al (16.9%)
and desa LA et al (18.92%).11, 12, 13
Table 2: Direct observation of operation theatres and recommended solutions
Attributed
assessed
MOT and
EOT
Identified problem
1.
2.
3.
4.
1.
2.
1.
2.
3.
1.
1.
2.
3.
1.
Solution
Only four suites were available for • According to Rao committee (1968)16 one
400 surgical beds.
operation suite/50 beds required. So more
Ill structured and ill equipped OT.
numbers of OTs required according to
Zoning are not present
number of surgical beds strength.
Basic infrastructure for staff like • Renovation should be done
changing rooms, toilets, refreshment
is suboptimal.
Overcrowding
• Glass chamber should be constructed
Not much restriction on movement
above the OT for viewing of the students
of personnel in and around OT
without actually entering the OT for
reducing overcrowding.
• Strict traffic protocols should be
employed.
• Restricted entry should be there
Improper ventilation
• Air conditioning must be present in each
Air conditioning is not adequate and
operation suit and in working condition.
present in only one suit and in EOT • Air filters should be there solution
it is not at all.
Air changes – not present and Air
filters (HEPA filters) – not present
Elbow operated taps are not there
• There should be elbow operated taps in
scrub station
OT cleaning, disinfection not up to • It must be done at the beginning and at
the mark.
the end of the day and also in-between the
Improper fumigation
surgeries.
Swabs are not taken regularly
• Fumingation should be done in proper
way.
• Before and after fumigation, swab must be
taken weekly on regular bases
Proper use of barrier is not then
• Sterilized cap, mask and gown must be
worn by each and every person entering
inside the OT.
So far as wound type was concerned, we found
clean wounds in 19 cases (34.55%); cleancontaminated wounds in 13 cases (23.64%);
contaminated wounds in 2 cases (3.64%) and
dirty infected wounds in 21 cases (38.18%). In
our study SSI rate for clean surgery was 0%, for
clean contaminated surgery was 15.38%, for
contaminated surgery was 0% and for dirty
surgery was 23.81%. We could not find any SSI
in clean and contaminated surgery. Reason
behind it is only few numbers of patients (19)
were operated for clean surgery and very few
numbers (2) were operated for contaminated
surgery. According to other studies carried out
in India, overall infection rate for clean surgeries
was 4.04 to 30% and for clean contaminated
surgeries was 10 to 45%.4 A study carried out by
Lilani SP et al showed rate of SSI was 3.03% and
22.41% for clean surgeries and clean
contaminated surgeries respectively.4 Our study
is well correlated with this study.
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Describing risk factors of SSI, majority of SSI
(41.66 %) occurred in the age group of more than
60 years followed by 5.26 % in the age group of
25 to 60 yrs and 0% in the age group of less than
25 yrs. This indicates the role of immunity
system in control or development if infection.14
Male (71.43%) were more infected than female
(28.57%) as more number of male candidates
(35) was operated than female (20) candidates.
Infection rate was minimum (2.17%) when
preoperative hospital stay was less than 7 days
and maximum (66.67%) when preoperative
hospital stay was more than 7 days. Longer
preoperative stay increases colonization in
patients with nosocomial strains of bacteria
which are most resistant to antibiotics, and also
it indirectly increases infection rate by lowering
resistance of patients.15 Surgical procedures
were classified as emergent in 16(29.09%) and
elective in 39 (70.91%), among which, 3 patients
got infection during emergent procedure and 4
got infection during elective procedure. It was
observed that wound infection rate is influenced
by duration of operation. The finding in present
study is in agreement with the reported
literature. Infection rate was maximum (23.81%)
when the duration of operation exceed 2 hrs
whereas only 5.88% of patients acquired SSI
when duration of operation less than 2 hrs. This
study confirmed the association between SSI
and age of the patients, preoperative day,
duration of procedure and CDC wound class. (p
< 0.5) Though SSI increased with high ASA
score, emergent intervention and in male sex,
there was no association found with SSI and
these factors in our study because very low
difference was found among patients having SSI
with and without risk factors in our study. As an
antimicrobial prophylaxis (AMP), for clean
wound, injection cefotaxime alone or with
combination with gentamicin single dose was
given at the time of the incision or total three
doses were given; for clean-contaminated
surgery same antimicrobials with addition of
metrogyl if anaerobic organisms suspected with
duration of 3-5 days given, for contaminated
and dirty wound surgery cefoparazonesulbactum/piparacillin-tazobactum
with
amikacin and metrogyl were given. The AMP
used here was not according to the standard
guideline.3
Culture report from the wound site showed that
Klebsiella spp. was isolated from 57.14% (4/7) of
the SSI cases, where as Staphylococcus aureus
was isolated from 42.86% of the SSI cases.
Klebsiella spp. was isolated from those who
were operated in major operation theatre and
Staphylococcus was isolated from those who
were operated in emergency operation theatre.
All isolated of Klebsiella spp. were ESBL
producing strains and they were resistance to
third generation cephalosporin, ciprofloxacin,
gentamycin, chloramphenicol, co-trimoxazole
and tetracycline. Staphylococcus aureus were
resistance to penicillin, ampicillin, amoxicillin,
tetracycline, and co-trimoxazole. One strain of
Staphylococci
was
methicillin
resistance
(MRSA). Pre and post fumigation report of MOT
showed that organism Klebsiella was found
from A.C. machine and OT self, confirmed the
Klebsiella spp. as a source of infection among
the patients operated in MOT. These swabs were
taken at the same week end day in which all the
surgical site infected patients were operated. We
could not able to find reports of the emergency
operation theatre because pre and post
fumigation swabs were not taken on the regular
bases in emergency OT.
As shown in table 2 we had also visited both of
the operation theatres to observe planning &
design, work load, utilities, equipments used
and policies & procedures. Necessary
suggestions were noted to improve physical
structure of operation theatres as well as certain
policies regarding sterilization and disinfection
of it to minimize the nosocomial infection. These
includes need of adequate numbers of OT suits
depending on bed strength, properly structured
OTs, proper zoning of OTs, basic infrastructures
nearby OT, proper ventilation facilities
including air conditioning and air filters inside
OTs, requirements of elbow operated taps,
requirements of policies for OT cleaning and
disinfection and pre and post fumigation swabs,
restricted entry to solve problem of
overcrowding and proper use of barrier to
minimize infections.
In conclusion, nosocomial infections especially
surgical site infection is a considerable problem
in our hospital. Identification of risk factors for
surgical site infections and study of operation
theatres in detail has encouraged the
development
of
recommendations
for
prevention of such infections. Also appropriate
active surveillance and infection control
measures should be introduced during
preoperative, intra-operative, and postoperative
care to reduce infection rates.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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pISSN: 0976 3325 eISSN: 2229 6816
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Luksamijarulkul P, Parikumsil N, Poomsuwan V, et al.
Nosocomial Surgical Site Infection among Photharam. J
Med Assoc Thai 2006; 89 (1): 81-9.
Kamat US, Ferreira V, Savio R, et al. Antimicrobial
resistance among nosocomial isolates in a teaching
hospital in Goa. Indian J Community Med 2008; 33(2): 8992.
€€Ducel G, Fabry J, Nicolle L. Prevention of hospital
acquired infections - a practical guide, 2 nd ed. Geneva:
WHO; 2002.
Lilani SP, Jangale N, Chaudhary A, et al. Surgical site
infection in clean and clean-contaminated cases. Ind J
Med Microbiol 2005; 23(4): 249-52.
Green J, Wenzel RP. Post operative wound infection.
Ann surg. 1977; 185: 264-8.
Haley RW. The scientific basis for using surveillance
and risk factor data to reduce nosocomial infection
rates. J Hosp infect 1995; 30(suppl): 3-14.
Everett JE, Wahoff DC, Statz CL, et al. Characterization
and impact of wound infection after pancreas
transplantation. Arch Surg. 1994; 129: 1310-17.
Horan TC, Gaynes RP, Martone WJ, et al. TG. CDC
definitions of nosocomial surgical site infection, 1992: a
modification of CDC definitions of surgical wound
infections. Infect Control Hosp Epidemiol 1992; 13: 6068.
9.
10.
11.
12.
13.
14.
15.
16.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Collee JG, Fraser AG, Marmion BP, Simmons A.
Culture of Bacteria. In:Mackie McCartney Practical
Medical Microbiology, 14th ed,(Churchill Livingstone,
London), 1996: 113-129.
National Committee for Clinical Laboratory Standards:
Performance standards for antimicrobiol susceptibility
testing. 8th Information Supplement M2A7. Vol 20, No
1-2, National Committee for Clinical Laboratory
Standards, Villanova, Pa.
Shrivastava SP, Atal PR and singh RP. Studies on
hospital infection. Ind J Surg 1969; 31: 612-21.
Shaw D, Doig CM and Douglas D. Is airbone infection
in the operating theatre an important cause of wound
infection in general surgery? The Lancet 1973; 1: 17-21.
deSa LA, Sathe MJ and Bapat RD. Factors influencing
wound infection (a prospective study of 280 cases). J
Postgrad Med 1984; 30 (4): 232-6.
Shojaei H, Borjian S, Shooshtari PJ, et al. Surveillance of
clean surgical procedures: an indicator to establish a
baseline of a hospital infection problem in a developing
country, Iran. Ndian J Surg 2006; 68(2): 89-92.
Ganguly PS, Khan MYand Malik A. Nosocomial
infections and hospital procedures. Indian J Commu
Med 2000; 25(1): 39-43.
Rao's Committee (1968): Report of the Review
committee on Delhi hospitals. New Delhi. Government
of India Press.
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ORIGINAL ARTICLE .
ASSESSMENT OF IMMUNIZATION STATUS OF
CHILDREN BETWEEN 12-23 MONTHS IN ALLAHABAD
DISTRICT
Arshiya Masood1, S Dwivedi2, G. Singh3, M A Hassan4, Arun Singh5
1Assistant
Professor, Department of Community Medicine, JNMC Aligarh (UP) India 2Professor and
Head, 3Professor and Former Head, 4Associate Professor, Department of Community Medicine,
M.L.N.Medical College, Allahabad(UP) India, 5Associate Professor, Department of Community
Medicine, Rohilkhand Medical College, Bareilly (UP) India
Correspondence:
Dr Arshiya Masood
Assistant Professor, Deptt of Community Medicine
JN Medical College, AMU
Aligarh (UP)-202002 India
E mail: [email protected] Mobile: 9412277491, 9760036213
ABSTRACT
Objectives: This study was carried out to assess the immunization status of children in the age group
12-23 months and to know the reasons for non-immunization of children
Methods: This was a cross-sectional study. We included 228 children (156 in rural and 72 in urban
areas) in 12-23 months of age group by stratified cluster sampling design from Rural and Urban areas
of Allahabad. Mothers of the children were interviewed using a predesigned schedule.
Result and Conclusion: Only around 31 percent of children were found to be fully immunized while
around 24 percent were partially and 45 percent were not immunized at all. Vitamin A prophylaxis
showed a decline from 27.2 percent to 2.2 percent from first to third dose Amongst the various
reasons for not immunizing the child, the most common in both rural (70.2%) and urban areas (72.7%)
was unawareness for the need of vaccination, however in rural areas lack of availability of services
(80.2%) was the major cause for not immunizing the child. Thus the present study shows a low
coverage of immunization and Vitamin A prophylaxis in both the areas.
Key Words: Immunization Status, Children between 12-23months,Vitamin A Prophylaxis, Allahabad
INTRODUCTION
Immunization is highly cost-effective and
relatively inexpensive health intervention. Of
the 10 million children who died during 2004,
over 2.5 million children (25%) died from
vaccine preventable diseases1 that mean most of
these deaths could be prevented by
immunization. Immunization is a highly costeffective and relatively inexpensive health
intervention. UNICEF report ranks India 49th in
child mortality2. 2.4 million Indian children
perished due to pneumonia, diarrhea, measles
and tetanus and whooping cough2 Rajasthan,
Uttar Pradesh, Madhya Pradesh accounts for
more than 50 percent of infant deaths in India2.
Vitamin A deficiency (VAD) remains major
public health problem for children under six
years of age. More over there are indications
that even subclinical VAD is associated with
measles, respiratory tract infection and
diarrhoea.3
Under the National Immunization Programme,
infants are immunized against six vaccine
preventable
diseases
viz.
tuberculosis,
diphtheria, pertussis, poliomyelitis, measles and
tetanus and five doses of vitamin A prophylaxis
is given. Though immunization is one of the
most powerful tools for saving children’s lives,
statistics
shows
an
alarming
trend.
Immunization has been declining for last two
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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decades. The reported coverage has been above
80 percent since 19904. However UNICEF Report
(2004) revealed that only 57 percent of children
aged 12-23 months were fully immunized in
India4. The present study was carried out in
Allahabad district, situated in the eastern part of
the Uttar Pradesh with the following aims and
objectives
(1) To assess the immunization status of
children in the age group of 12-23 months
(2) To know the reasons for non-immunization
of children
MATERIALS AND METHOD:
This was a cross-sectional study using thirty
cluster sampling technique. Twenty one clusters
were from rural and nine were urban areas of
Allahabad to give proportionate allocation to
rural and urban population of Allahabad
district. Rural areas were divided into blocks
and blocks were divided into villages. Urban
areas were divided into wards. Villages and
wards were taken as clusters.
Within selected clusters, households were
surveyed till the target i.e. seven children in the
age bracket of 12-23 months was achieved.
Immunization status of children between 1-2
years gives a better picture of immunization as
per UIP norms. There were 156 children in rural
and 72 children in urban areas. A total of 228
mothers having children in the age group of 12-
23 months were surveyed to provide
information regarding immunization status of
their children. The desired information was
collected on a predesigned, precoded and
pretested schedule, which was based on a pilot
survey for its validity.
RESULTS
Table 1: Immunization Status of Children
between 12 to 23 months of Age
Vaccination
Rural
(N=156)
(%)
68 (43.6)
12 (07.7)
68 (43.6)
63 (40.4)
52 (33.3)
66 (42.3)
63 (40.4)
52 (33.3)
39 (25.0)
33 (21.2)
13 (8.3)
01 (0.6)
38 (24.4)
Urban
(N=72)
(%)
46 (63.9)
35 (48.6)
43 (59.7)
40 (55.6)
38 (52.8)
43 (59.7)
40 (55.6)
38 (52.8)
34 (47.2)
29 (40.3)
13 (18.1)
04 (5.6)
34 (4(7.2)
Total
(n=228)
(%)
114 (50)
47 20.6)
111 (48.7)
103 (45.2)
90 (39.5)
109 (47.8)
103(45.2)
90 (39.5)
73 (32.0)
62 (27.2)
26 (11.4)
05 (2.2)
72 (31.6)
BCG
Polio-0
DPT-1
DPT-2
DPT-3
Polio-1
Polio-2
Polio-3
Measles
VitA-1
VitA-2
VitA-3
Fully
immunized
Partially
38 (24.4) 16 (22.2) 54 (23.7)
immunized
Not immunized 80 (51.3) 22 (30.6) 102 (44.7)
PPI
155 (99.4) 68 (94.4) 223 (97.8)
Table 2: Details Pertaining to Immunization of Children 12-23 months of age
Reason for not immunizing the Child
Child too young for immunization
Unaware for need of immunization
Place and time of immunization not
known
Fear of side effects
No faith in immunization
Services not within reach
Family problems including mother’s
illness
Child was ill
Do not remember
*Multiple choices
Rural
(N=81) (%)
6 (7.4)
57 (70.4)
19 (23.5)
Urban
(N=22) (%)
0 (0.0)
16 (72.7)
1 (4.5)
Total
(N=103) (%)
6 (5.8)
73 (70.9)
20 (19.4)
15 (18.5)
0 (0.0)
65 (80.2)
2 (2.5)
1 (4.5)
1 (4.5)
2 (9.0)
1 (4.5)
16 (15.5)
01 (0.97)
67 (65)
3 (2.9)
2 (2.5)
7 (8.6)
1 (4.5)
1 (4.5)
3 (2.9)
8 (7.8)
Table 1 reveals that only 50 percent children
were immunized with BCG. The immunization
status of children in urban areas had a clear
edge(20% higher) over rural areas. Polio-0 was
given to 7.7 percent in rural and 48.6 percent in
urban areas. Regarding three doses of DPT and
OPV, a decline was seen from first to third dose
in both the areas, ranging from around 44
percent to 33 percent in rural and 60 percent to
53 percent in urban areas. Only a quarter of
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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children in rural areas received measles vaccines
as compared to around 47 percent in urban
areas. The three doses of Vitamin A prophylaxis
showed a decline from 21.0 percent to 0.6
percent in rural and 40.3 to 5.6 percent in urban
areas.
Only around 31 percent children (23.7%in rural
and 47.2%in urban areas) were fully immunized
against six vaccine preventable diseases.
Around 45 percent children (51.9% in rural and
30.6% in urban areas) were not immunized at
all. PPI coverage was around 98 percent
(99.4%in rural and 94.4%in urban areas).
As per Table 2 amongst the various reasons for
not immunizing the child, the most common in
both rural (70.2%) and urban areas (72.7%) was
unawareness for the need of vaccination,
however in rural areas lack of availability of
services was reported to be the major cause for
not immunizing the child.
DISCUSSION
As per NFHS III6, in the age group of 12-23
months, only 44 percent children were fully
immunized in India and 23 percent in UP. This
study shows a higher percentage of fully
immunized (31.1%) than in UP. As per a Report
of Govt. of India UP (2007)7, around 39.44
percent children aged 12-23 months are found to
be fully immunized and 33.41percent partially
immunized.
NFHSIII6
shows 76 percent BCG coverage. This
study shows a lower percentage in both the
areas (43.6 percent in rural and 63.9 percent in
urban areas). The difference between the
percentage of children (11-23 months) receiving
first and third dose of DPT is 21 percentage
points and 15 percentage points for OPV in
NFHSIII. The same in our study is 9.2
percentage points and 8.3 percentage points for
DPT and OPV respectively.
NFHSIII6 report reveals 59 percent measles
vaccination against 32 percent in our study
areas. Only 13.8 percent (12.9% and 15.4% in
rural and urban areas respectively) children
have received first dose of vitamin-A along with
measles in some study8. This study shows a
higher percentage (21% in rural and 40.3% in
urban areas) of the same in both the areas.
Important reasons for non-immunization are
lack of awareness in both the areas
(around 70%) and lack of availability of services
in rural areas (80.2%).
Non-availability of
services was reported to be the single
commonest reason for non-immunization in
some studies8, 9.
CONCLUSION AND RECOMMENDATIONS
The present study shows a low coverage of
immunization and Vitamin A prophylaxis in
both rural and urban areas. Important reasons
for non-immunization were lack of awareness in
both the areas and lack of availability of services
in rural areas. Millions of lives can be saved if all
the families are empowered with essential
health information. This again emphasizes the
need to strengthen IEC activities along with
regular supply of vaccines.
Although the health care infrastructure was
there, but it appears that health care personnel
were not working properly, so accountability of
staff at various levels for services they provide
should be ensured by effective supervision and
monitoring system. PPI coverage was above 90
percent .It indicates that inter-sectoral coordination can bring forth good results.
REFERENCES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Barcelona Declaration, March 30, 2005
Statesman 7th April 2005
Kothari G.The effect of Vitamin A Prophylaxis on
Morbidity and Mortality among children in Urban
Slums in Bombay: Jour of Tropical Paed 1991 ;Jun
37(3):141
MoHFW/UNICEF2000-2001, GOI document, Measles
Mortality Reduction: India’s Strategic Plan; 20052010:12.
Mapping India’s Children: UNICEF in Action, 2004:11
National Family and Health Survey III (2005-2006)
Immunization Coverage of Children age 12-23 months.
Concurrent Assessment of Health And Family Welfare
Programme and Technical Assistance to District of
Uttar Pradesh (2007) conducted by the Department of
Medical Health and Family Welfare: 109.
Chaturvedi M, Nandan D, Gupta S C. Rapid
Assessment of Immunization Practices in Agra District;
Indian. J of Pub Health 2007; 51 (2):132-134.
Nandan D, Dabral SB. Report-Multi Indicator Rapid
Assessment
Survey
(Uttar
Pradesh)-District
Etah,Mathura and Almorah, Department of SPM,SN
Medical College,Agra,1995-1996.
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ORIGINAL ARTICLE .
ASSESSMENT OF MEDICAL CERTIFICATE OF CAUSE
OF DEATH AT A NEW TEACHING HOSPITAL IN
VADODARA
Amul B. Patel1, Hitesh Rathod2, Himanshu Rana3, Viren Patel4
1Assistant
Professor, Community Medicine Department, 2Assistant Professor, Forensic Medicine
Department, 3Associate Professor, Medicine Department, 4Assistant Professor, Pathology
Department, GMERS Medical College, Gotri, Vadodara
Correspondence:
Dr. Amul B. Patel
“Gurukrupa”, 229, Nandanvan society,
Near Abhilasha cross roads,
New Sama Road, Vadodara-390008
Email: [email protected]
Mobile: 9429823997
ABSTRACT
The study was conducted to find out errors in the medical certification of cause of death during July
2011 at a new teaching hospital in Vadodara. All certificates of in-hospital deaths in medical record
department, from May 2010 to June 2011, were assessed for major and minor errors. Data were
analyzed with SPSS 17 version software. The results revealed that out of 40 death certificates, not a
single was free from any error. Major errors occurred in 23(57.5%) cases with improper sequencing
(55%) as most frequent. Most common minor error was the absence of time interval between the onset
of disease and death (92.5%). No significant association was found between major errors and factors
like age, sex, ward and underlying cause of death. This study concluded that educational intervention
is necessary to increase physicians' awareness regarding importance of medical certificate of cause of
death and accuracy of death certificates.
Key-words: Death certificate, MCCD, Major error, Minor error, mortality statistics, ICD
INTRODUCTION
Mortality statistics is quite essential for welfare
of the community. The cause specific mortality
rates are key indicators of the health trends in
the population and are provided on scientific
basis by the system of medical certification of
cause of death (MCCD). The data on cause of
death contained in the death certificate serves
many purposes, such as assessing the
effectiveness of public health programs,
providing a feed-back for future policy and
implementation, better health planning and
management, and deciding priorities of health
and medical research programmes.1
The standard cause of death report in India
follows the recommendations of the WHO. The
causes of death are classified according to the
International Classification of Diseases (ICD)
and the MCCD is as per the format presented in
Volume 2 of ICD-10. 2After introduction of
Gujarat Registration of Births and Death Act
1973, during 1973 to 1978, the teaching hospitals
of four cities including Vadodara were brought
under the MCCD scheme on a regular basis.
According to this scheme, a medical person
attending the deceased in his/her last illness,
after death of a person shall fill in form no. 4 for
institutional deaths/4A for non-institutional
deaths. The cause of death is determined by the
certifying physician and entered in two parts in
the form. Part 1 records a sequence of conditions
beginning with the immediate cause of death
(the final disease or condition resulting in death)
on line (a) which is due to the antecedent
condition recorded on line (b), which is due to
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the underlying cause of death (the disease or
injury that initiated events resulting in death) on
line (c). However, if the sequences of event
comprise more than three stages, extra line may
be made as (d). In part 2, other significant
conditions contributing to death, but not
resulting in the underlying cause, must be
entered. Normally the condition in the lowest
line of Part I is taken as the underlying cause of
death and used for statistical analysis of
mortality by ICD-10. 1, 3
A new medical college and hospital has started
in the summer of last year in Vadodara city.
Medical record department of this new general
hospital was assigned to us for monitoring and
supervision and to make it functioning better. So
we took this opportunity to carry out this study
in order to find out errors in the medical
certification of cause of death.
MATERIALS AND METHODS
This study was carried out during July 2011 at a
new 300-bedded teaching hospital in Vadodara,
Gujarat. The general hospital has been started
since May 2010, which was previously a small
tuberculosis
hospital.
Medical
record
department of this hospital receives death
certificates in two copies from all the
departments. Then out of two copies, one copy
is sent to the registrar of births and deaths in the
city and other is kept for record in the
department. All certificates of in-hospital deaths
from May 2010 to June 2011, which were kept in
medical record department, were included.
They were assessed for the frequency and type
of errors made in the completion of MCCD.
Our main focus was on the cause of death
section of the form which we assessed for
errors, using categories previously reported
with minor modifications.4 Major errors were
considered to be those that could affect the
accurate coding of the underlying cause of
death, including any of the following: (i)
unacceptable cause of death in part 1; (ii)
competing causes of death in part 1; (iii)
immediate, intermediate and underlying causes
of death presented in an incorrect order
(sequencing error); or (iv) mechanism of death
not followed by a proper cause of death. Minor
errors, less likely to lead to misclassification of
the underlying cause of death, were any of the
following: absence of a time interval between
onset of the condition and death, use of
abbreviations, mechanism of death followed by
a legitimate underlying cause of death and
illegible writing. We also evaluated information
for completion like age, sex, date of death, the
ward where the patient died, manner of death,
status of pregnancy and delivery in case of
females. Further, from the information in the
cause of death section, underlying cause of
death was ascertained and coded using ICD-10
volumes2. Data were entered and analyzed with
computer software SPSS 17 version. A chisquare test was used to find out association
between major errors and various factors like
age, sex, ward and underlying cause of death.
RESULTS
Total deaths occurred in hospital during May
2010 to June 2011 were 45. Out of which five
were still births and their death certificates were
not received and kept in medical record
department. So they were excluded leaving 40
death certificates for study.
Table 1: Underlying causes of death according
to ICD-10 classification (N=40)
ICD-10 Chapter
Certain infectious and parasitic
diseases
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the blood and bloodforming organs, and the immune
mechanism disorder
Endocrine, nutritional and metabolic
diseases
Injury, poisoning and certain other
consequences of external causes
Certain conditions originating in the
perinatal period
Neoplasms
No
%
16
40.0
7
5
4
17.5
12.5
10.0
3
7.5
2
5.0
1
2.5
1
2.5
1
2.5
Out of 40 deceased, 52.5% were male. The
median age at death was 52 years; 30% were
aged ≥65, and 2.5% were neonates. In 3(7.5%)
cases, only a single cause of death was found. A
cause was listed on all lines of part I in 34(85%)
certificates and part II was used in 16(40%)
cases. In 3(7.5%) cases, attendant physician’s
help was needed to ascertain underlying cause
of death according to ICD-10 classification.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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Table 1 shows underlying cause of death
according to ICD-10 classification. Major
underlying cause of death was infectious and
parasitic diseases (40%) followed by circulatory
(17.5%) and respiratory (12.5%) causes.
Table 2: Type and frequency of errors in death
certificates (N=40)
Type of Error
Major Error
Improper sequencing
Competing causes of death
At least one major error
Minor error
Absence of time intervals
Mechanism of death with
underlying cause
Use of abbreviations
Illegible handwriting
At least one minor error
No
%
22
2
23
55.0
5.0
57.5
37
32
92.5
80.0
13
6
40
32.5
15.0
100.0
Table 2 presents frequency of error types. Not a
single death certificate was free from any error.
Major errors occurred in 23(57.5%) cases, among
which most common was improper sequencing
(55%). Competing causes of death was found
only in 2(5%) cases. One or other minor error
was found in all death certificates. By far the
most common was the absence of time interval
between the onset of disease and death, which
occurred in 37(92.5%) cases. Out of them in
8(21.6%) cases, column of time interval was
completely blank. Mechanism of death like
cardio-respiratory arrest, respiratory failure and
heart failure was written as immediate cause of
death and followed by legitimate causes of
death in majority (80%) of cases. Abbreviations
were used in 13(32.5%) cases. While some
abbreviations were relatively clear (COPD =
chronic obstructive pulmonary disease), others
were difficult to interpret. Illegible handwriting
was found in 6(15%) cases.
Major errors were found in two third (66.7%)
cases among ≥65 years of age followed by 15 - 64
years age group (56%). They were predominant
in female (63.1%) cases. Ward wise, they were
most common in medicine ward (66.7%)
followed by intensive care unit (60%) and
casualty (54.5%). According to underlying cause
of death, they were more frequent in infectious
and parasitic diseases (62.5%) and circulatory
causes (57.1%). No significant association was
found between these factors and major errors
[Table 3].
Completeness of information: Age, sex, date of
death and ward of deceased were entered in all
cases. Information was written at other place
than specified and corrections were made after
striking the words in 5(12.5%) cases. Manner of
death was mentioned in all cases except one.
Regarding information of pregnancy and
delivery, mistakes were made in 7(17.5%) and
13(32.5%) cases respectively.
Table 3: Distribution of major errors according
to age, sex, hospital ward and cause of death
Characteristic
N Major error (%) P value
Age (yrs)
≥65 years
12
8(66.7)
0.56
15 - 64 years
25
14(56.0)
<15 years
3
1(33.3)
Sex
Male
21
11(52.4)
0.54
Female
19
12(63.1)
Ward
Casualty
22
12(54.5)
0.92
Intensive care
5
3(60.0)
unit
Medical
9
6(66.7)
Other
4
2(50.0)
Causes by ICD-10
Infectious and
16
10(62.5)
0.33
parasitic diseases
Circulatory
7
4(57.1)
Respiratory
5
1(20.0)
Other
12
8(66.7)
Total
40
23(57.5)
DISCUSSION
In the present study, underlying cause of death
could be ascertained and coded according to
ICD-10 from the information provided in cause
of death section in most (92.5%) cases. While
only in 3(7.5%) cases, it was coded with
difficulty and attending physician’s assistance
was required. It shows that information
provided in death certificates at this hospital
was well suited for coding to ICD definitions. A
study5 reported that 12.5% causes could be
coded with difficulty and 4% could not be
coded.
We found that all certificates had some
avoidable error, while in other studies5, 6 using
identical criteria error rates were 92% to 99.2%.
Studies 7, 8 using different criteria for assessment
reported error rates varying from 32% to 45%.
Major errors (57.5%) were somewhat more than
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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in studies5, 6, 9from other places, where it was
ranging from 38% to 45%. Improper sequencing
of causes of death (55%) which contributed to
95.6% of major errors was comparatively double
of other studies (24-28%) 4-6. Competing causes
of death was reported only in 2(5%) cases, which
was very less compared to 15% to 38% found in
other studies4-6. Though studies4-6 showed major
errors like unacceptable cause of death in 15% to
40% cases and only mechanism of death without
underlying cause of death in 13% cases, in our
study no such case was found.
At least one minor error was found in all death
certificates in this study, whereas studies5, 6, 9
reported minor error rates from 78% to 98%. By
far the most common was the absence of time
interval between the onset of disease and death,
which occurred in 37 (92.5%) cases. Other
studies5, 6, 9 also found the same result with
absence of time interval as most prevalent minor
error (65%-98%). A time estimate for each cause
of death is crucial in providing complete picture
of the cause of death and determining
underlying cause of death. Since these entries
give the chronology of events and ensure the
correctness of the sequence which can prevent
major error of improper sequencing, attending
doctor should pay attention to this element
carefully. In majority (80%) of cases, mechanism
of death like cardio-respiratory arrest,
respiratory failure and heart failure were
entered as the immediate cause of death, which
was comparable with a study10 from Gujarat
(86%). However, other studies4, 5, 9 reported it in
13%-22% cases. It was quite surprising to see
this error in such abundance. Because in the
death certificate itself, instruction is written
under the heading of immediate cause in Part I
that state the disease, injury or complication
which caused death, not the mode of dying such
as heart failure, asthenia, etc. Further, the
difference between cause of death and mode of
dying is covered in MBBS curriculum and
explicitly mentioned in textbooks and literature,
still doctors get confused. Abbreviations were
used in 13 (32.5%) cases, higher than in other
studies4-6 as they reported it in 11%-24%.
Illegible handwriting (15%) was six times more
than in a study6 from abroad (2.5%).
Studies5,6 have reported increased error rates
with advancing age, while in our study
seemingly there was increased percentage with
increase in age but there was no statistically
significant association. Gender wise, major error
rate did not differ which was comparable with
other study5. A study5 from South
showed significant association of major
with ward and cause of death in contrast
study. With increase in sample size, we
get significant association.
Africa
errors
to our
might
Many doctors qualify with little or no formal
training in death certification, whereas others
may be inexperienced or have had insufficient
practice. This might be the reason for occurrence
of errors in death certificates. Other reasons may
be that doctors had lack of understanding
regarding importance of medical certificate of
cause of death in mortality statistics for
epidemiology, public health policy and research;
or carelessness and reluctance on their part to
fill in such forms. Studies4, 11, 12 showed that a
simple educational intervention can improve the
accuracy of death certificate completion and
reduce major and minor error rates in the cause
of death section. The present study is a single
hospital based study and therefore results
cannot be applied to the whole city.
Nonetheless, findings could be applicable to
hospitals with similar settings and can initiate
such studies on a large scale.
CONCLUSION
This study showed avoidable errors in all death
certificates. It reflects inadequate practice,
training and lack of awareness about importance
of medical certificate of cause of death,
carelessness and negligence on the part of
attending doctors. More attention has to be
devoted to raising physicians' awareness of the
types of errors made in completing death
certificates and they should be made aware that
certification is a fundamental requirement for
building up epidemiological data. Recurring
educational sessions, practical training on the
case to case basis at regular intervals, periodic
auditing of death certificates and feedback are
necessary to increase the accuracy of these
important documents.
REFERENCES
1.
2.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Office of the Registrar General of India, Vital Statistics
Division. Physicians’ Manual on Medical Certification
of Cause of Death. 4th edi. New Delhi: Ministry of
Home Affairs, Government of India; 2000.
World Health Organization. International statistical
classification of diseases and related health problems,
tenth revision (ICD-10), Vol. 1, 2 and 3; second edition.
Geneva: World Health Organization; 2004.
Page 352
pISSN: 0976 3325 eISSN: 2229 6816
3.
4.
5.
6.
7.
8.
State Bureau of Health intelligence, Gujarat state.
Manual on Medical Certification of Cause of Death
(MCCD Scheme). Gandhinagar: Commissionerate of
Health, Medical Services and Medical Education,
Government of Gujarat; 2002.
Pandya H, Bose N, Shah R, et al. Educational
intervention to improve death certification at a teaching
hospital. Natl Med J India 2009; 22(6):317-9.
Nojilana B, Groenewald P, D Bradshaw, et al. Quality
of cause of death certification at an academic hospital in
Cape Town, South Africa. S Afr med j 2009; 99: 648-52.
Burger EH, Van der Merwe L,Volmink J. Errors in the
completion of the death notification form. S Afr Med J
2007; 97: 1077-81.
Jordan JM, Bass MJ. Errors in death certificate
completion in a teaching hospital. Clin Invest Med
1993; 16: 249-55.
Swift B, West K. Death certification: an audit of practice
entering the 21st century. J Clin Pathol 2002; 55: 275279.
9.
Shantibala K, Akoijam BS, Usharani L, et al. Death
certification in a teaching hospital- a one year review.
Indian J Public Health 2009; 53(1):31-3.
10. Agarwal S, Kumar V, Kumar L, et al. A study on
appraisal of effectiveness of the MCCD scheme. J
Indian Acad Forensic Med 2010, 32(4):318-20.
11. Selinger C, Ellis R, Harrington M. A good death
certificate:
improved
performance
by
simple
educational measures. Postgrad Med J 2007; 83(978):
285-86.
12. Degani A, Patel R, Smith B, et al. The Effect of Student
Training on Accuracy of Completion of Death
Certificates. Med Educ Online 2009; 14:17. Available
from:
http://med-ed-online.net/index.php/meo.
Accessed July 20th 2011.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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pISSN: 0976 3325 eISSN: 2229 6816
ORIGINAL ARTICLE .
EVALUATION OF CONVENTIONAL AND SEROLOGICAL
METHODS FOR RAPID DIAGNOSIS OF CRYPTOCOCCAL
MENINGITIS IN HIV SEROPOSITIVE PATIENTS AT
TERTIARY CARE HOSPITAL
Shah Hetal S1, Patel Disha A2, Vegad Mahendra M3
1Associate
3Professor
Professor, Microbiology Department, GMERS Medical College, Sola 2Assistant Professor,
& Head, Microbiology Department, B. J. Medical College, Ahmedabad, Gujarat
Correspondence:
Dr. Hetal S. Shah
B-203, Parishram Tower,
Mirambica Road, Naranpura,
Ahmedabad-380013, Gujarat.
Email:[email protected], Mobile: 9426436121
ABSTRACT
Introduction: With the increase in the incidence of HIV infection, there is an increase in incidence of
cryptococcal meningitis. Due to lack of sensitive methods for diagnosis, high morbidity and mortality
are associated with the disease. Early and rapid diagnosis is essential to prevent serious
complications.
Objective: To know the prevalence of Cryptococcosis in HIV positive patients and to evaluate
conventional methods with rapid serological diagnostic method.
Methods : A total of 63 CSF samples of HIV seropositive hospitalized patients with history of
meningitis were evaluated for Cryptococcus by India ink staining, culture and Cryptococcal antigen
latex agglutination test(LAT) by CALAS.
Results: Out of 63 CSF samples, prevalence of cryotococcosis were 9 (14.28%) by LAT, 7 (11.11%) by
India ink preparation and 6 (9.5%) by culture. Sensitivity and specificity of India Ink is 83.3 % and
96.49 % and of latex agglutination test is 100 % and 94.7 % respectively considering culture as a gold
standard.
Discussion: Latex agglutination test is more sensitive than India ink test followed by culture.
Conclusion: LAT is a simple, rapid and sensitive test for the early detection of cryptococcal antigen in
clinical samples like CSF and may be considered as an aid in establishing diagnosis when culture is
negative.
Key words: Cryptococcal meningitis, HIV, crypyptococcosis.
INTRODUCTION
Cryptococcal meningitis is a common
opportunistic infection and AIDS-defining
illness in patients with late stage HIV infection,
particularly in South-east Asia and Southern
and East Africa. With the increase in the
incidence of HIV infection, there is an increase
in incidence of cryptococcal meningitis.
Cryptococcal meningitis is the leading cause of
meningitis in patients with AIDS.1
Cryptococcus neoformans is the second most
common fungal opportunist after Candida
albicans, causing symptomatic cryptococcosis in
up to 8.5% of HIV-infected individuals.
Cryptococcus is the commonest central nervous
system
(CNS)
fungal
pathogen
in
immunocompromized patients, particularly
among those with AIDS. 2
The morbidity and mortality in cryptococcal
meningitis is 10-30 % in developed countries
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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and 50-100% in developing countries, where
medical facilities are less accessible.3
The rising incidence of cryptococcosis in India is
posing a serious threat. Due to lack sensitive
methods for diagnosis, high morbidity and
mortality are associated with the disease. Early
diagnosis is essential to prevent serious
complications.4
Though once known to be rare, cryptococcosis
has occurred at a high frequency in India in the
past two decades.5
Diagnosis of cryptoccal infections is often
missed or delayed, with damaging and
sometimes fatal consequences, on account of
either unawareness or defects in available
diagnostic procedures.6 Unless diagnosed early
and specific treatment instituted it can be fatal.
There is an urgent need for a rapid and specific
diagnostic tool for better management of the
patients.5
So, this study is undertaken to know prevalence
of Cryptococcus and to compare and evaluate
conventional methods (India ink and culture)
with serological method (LAT ) for detection of
cryptococcal meningitis in the CSF in our setup.
MATERIALS AND METHODS
This retrospective study was conducted in the
Department of Microbioloy from July 2009 to
December 2010. A total of 63 HIV seropositive,
suspected of Cryptococcal meningitis (headache,
altered sensorium, meningitis etc.) were
included in the study. Medical records of these
patients were reviewed and data was collected
clinically.
The cerebrospinal fluid (CSF) samples were
centrifuged and deposit was processed for
fungal culture, negative staining with 10%
Nigrosin, Gram's staining and culture. The
deposit of CSF was inoculated on two sets of
Sabouraud's Dextrose agar (SDA), one incubated
at 25°C and other at 37°C. Sample is also
inoculated on Bird seed agar at 37⁰ C, and on
Blood Agar. Fungal cultures were observed for
growth, for appearance of suggestive of
Cryptococcus neoformans were followed for four
weeks. The colony morphology was noted.
Cryptococcus neoformans was identified base on
yeast like mucoid cream to buff coloured colony
on SDA, urease test, brownish colonies on Niger
seed agar.7,8
Supernatant of the CSF sample was used for the
LAT. LAT assays were performed with CALAS
(Meridian Bioscience, Inc., Cincinnati, Ohio). It
is a qualitative and semi quantitative test system
for detection of capsular polysaccharide
antigens This test utilizes latex particles coated
with anti-cryptococcal polyclonal globulin that
reacts with the cryptococcal polysaccharide
antigen causing a visible agglutination. The test
was performed according to manufacturer's
instructions. CSF specimens were inactivated by
placing in boiling water bath for 5 min prior to
each test to limit non specific interference. A
titre of >8 was considered to be positive for
cryptococcal infection; however, a final antigen
was not determined in all cases. CD4 count was
done by using FACS caliber (Becton and
Dickinson) system.
RESULT
Prevalence of Cryptococcosis was 14.28% (9/63)
by Latex agglutination test, 11.11% (7/63) by
culture and 9.5% (6/63) by India Ink
preparation.
Out of total 63 samples 44(69.84%) were male
and 19(30.15%) were female. Out of 44 male
sample for CSF 5 were positive and out of 19
CSF samples, 2 were positive. Out of 7 positive
cryptococcosis by culture, prevalence rate in
men is 5(71.42%) and in women is 2(28.57%).
The age ranging from 3 yrs to 82 years with a
mean of 33.52 years. In all suspected patient
CD4 count was < 200 µg/ml. In cryptococcal
positive case, CD4 count ranges from 24 to 143
µg/ml.
Comparative evaluation of the various
diagnostic tests was done in 63 CSF samples by
taking culture as gold standard.
Table 1: Comparison of LAT with culture
Culture Culture Total
positive negative
7
2
9
Latex Agglutination
test Positive
Latex Agglutination
0
54
54
test Negative
Total
7
56
63
Sensitivity: 100%, Specificity: 96.42%, Chisquare
= 39.7, P<0.0001
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Table 1 shows ccomparison of latex
agglutination test with the culture. It shows that
sensitivity and specificity of Latex agglutination
test is 100 % and 96.42 % respectively.
Table 2 shows Comparison of India ink with
culture. Sensitivity and specificity of India Ink is
85.7 % and 100 % respectively.
Table 2: Comparison of India ink with culture
Culture Culture Total
positive Negative
India Ink Positive
6
0
6
India Ink Negative
1
56
57
Total
7
56
63
Sensitivity: 85.7%, Specificity: 100%, Chiaquar =
43.6, P < 0.0001
Table 3: Comparison of our study with other
study
CSF India Ink
positivity
CSF cryptococcal
antigen positivity
CSF cryptococcal
culture positivity
Imwidthaya Khanna Present
et al
et al
study
91 %
87.36% 85.7%
100%
98.81%
100%
100%
100%
100%
Table 3 shows comparison of our study with the
other studies.
DISCUSSION
Cryptococcosis is the most common systemic
fungal infection in AIDS.9 and its incidence is
increasing with the rapid spread of AIDS. The
CSF may appear normal in these patients with
cryptococcal meningitis and many of them have
normal levels of protein and glucose in CSF.
Classical meningeal symptoms occur in only
about a quarter or one-third of the patients that
cause delay in the diagnosis. Asymptomatic
patients may have a positive culture of CSF with
no other abnormality of the fluid.10
As infection with HIV is widespread in India
and cryptococcal meningitis is a common
problem in those with AIDS. Recent data
indicate that incidence of C. neoformans infection
is high in developing countries like in India. 2
Cryptococcosis, one of the AIDS defining
infections,
considered
as
"sleeping
disease”...became an "awakening giant" within a
couple of years and has been now been
predicted as the "Mycosis of the future," with a
predilection that for every million patients with
AIDS,
50,000−100,000
will
contract
cryptococcosis. Its prevalence varies from place
to place.10 In our study prevalence of
cryptococcosis was 11.11% considering culture
as a Gold standard and is well correlated with
study done by Meena G et al in Western India
(The overall prevalence remained between 9 and
27%).11 Culture is considered to be the "gold
standard" method of diagnosis for Cryptococcus,
but it takes at least 3 days to a maximum time of
a month for growth cumbersome, labour
intensive, time consuming.
Our study shows that prevalence of cryptococcal
meningitis by direct microscopy was 9.52% & by
LAT was 14.29%. Positivity of India Ink , LAT
and culture in our study was 85.7%, 100% , 100%
respectively which is comparable to study
carried out by Imwidthaya et al (91%, 100%,
100%)12 and Khanna et al (87.36, 98.81%, 100%).13
Comparing LAT with culture showed that
sensitivity of LAT is 100% and specificity of LAT
is 96.42%. In this study, two samples gave false
positive results with the LAT. The reasons
behind it were: one patient was on antifungal
treatment (Amphotericin B) hence gave positive
in LAT but negative in culture and the other
patient had gram negative infection giving
positive result with LAT due to cross reactivity
with it though the patient was not suffering with
Cryptococcus. Antigen detection represents the
most immediate and rapid way to enhance
methods for diagnosis of cryptococcosis. It is a
highly sensitive as well as specific and rapid
test, and the antigen can remain detectable for
several months after infection.14
Comparing India Ink with culture, the
sensitivity of India Ink was 85.7% and specificity
was 100%. The reason behind low sensitivity
could be due to the low number of yeast cells,
which may have been below the detectable level
by microscopy in CSF.
In our study, it was observed that males were
involved slightly more 44 (69.84%) than females
19 (30.15 %), which may reflect a difference of
exposure rather than a difference in host
susceptibility, as it was noted earlier and low
number of females were also due to social
stigma, because of that they were not came up to
the hospital for the diagnosis as well as
treatment though they were suffering from the
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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disease. The age group involved in this study
were from 3 to 82 with mean age group of 33.52
years that is well correlated with study of V
Lakshmi showed mean age of 31 years and
study of P. Imwidthaya showed mean age of
32.1 years.2,12 CD4 count were 24 to 143_ with
mean of 89.77 that is higher than the study of P.
Imwidthaya showed mean CD4 count 45 mm3
and the study of Shaikh M S A mean CD4 count
was 60.27.12,1
1.
To Conclude, Infection with HIV continues to be
more important risk factor for development of
CNS cryptococcosis and is an important
contributor to morbidity and mortality in HIVinfected patients. As clinical picture may be
confusing with viral or tubercular meningitis, a
high index of suspicion and routine mycological
surveillance is required to help in an early
diagnosis and appropriate therapy, as majority
of patients responded to therapy. LAT is a
simple, rapid and sensitive test for the early
detection of Cryptococcal antigen in clinical
samples like CSF and antigen can remain
detectable for several months after infection, so
that treatment can be instituted immediately. It
is therefore a suitable choice of laboratory test
for screening and quantitative analysis of
antigen has prognostic value and it also helps in
guiding chemo therapy and period of
hospitalization. Thus LAT should be used as a
primary test to catch out all suspected
cryptococcal meningitis and all positive samples
should be further confirmed by culture.
5.
2.
3.
4.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Shaikh M S A, P Chandrashekhar. Study of
Cryptococcal meningitis in HIV Seropositive patients in
tertiary care Centre. JIACM. 2009;10(3):110-5.
V Lakshmi, T Sudha, VD Teja, et al. Prevalence of
central nervous system cryptococcosis in human
immunodeficiency virus reactive hospitalized Patients.
IJMM. 2007;25 (2):146-9.
MR Capoor, D Nair, M Deb, et al. Clinical and
Mycological profile of Cryptococcosis in a tertiary care
hospital. IJMM. 2007; 25(4): 401-4.
Saha D C, Xess I, Biswas A, et al. Detection of
Cryptococcus by conventional, serological and molecular
methods. J Med Microbiol. 58 (2009);1098-1105.
Saha D C, Xess I, Jain N. Evaluation of conventional &
serological methods for rapid diagnosis of
Cryptococcosis. Indian J Med Res. 2008;127:483-8.
Gordon MA, Vedder DK. Serologic tests in diagnosis
and
prognosis
of
cryptococcosis.
JAMA.
1966;197(12):96:1-7.
Baradkar V, Mathur M, De A, et al. Prevalence and
clinical presentation of Cryptococcal meningitis among
HIV seropositive patients. Indian J Sex Transm Dis
2009;30:19-22.
J. Chander. A textbook of Medical Mycology, 1st ed.
New Delhi: Interprint; 1996. P. 83-9.
Powderly WG. Cryptococcal meningitis in HIV-infected
patients.
Current
Infectious
Disease
Reports.
2000;2:352-7.
Kwon-chung KJ, Bennette JE, editors. Medical
mycology,1st ed. London: Lea and Febiger; 1992. p 396439.
Satpute MG, VT Nilima , Litake GM, et al. Prevalence
of Cryptococcal meningitis at a tertiary care Centre in
Western India (1996–2005) ; J Med Microbiol.
2006;55:1301-2.
Imwidthaya P, Pougvarin N. Cryptococcosis in AIDS.
Postgrad Med J. 2000;76:85-8.
Khanna N, Chandramukhi A, Desai A, et al.
Cryptococcosis in the immunocompromised Host with
special reference to AIDS. Indian J Chest Dis Allied Sci.
2000; 42 (4):311-5.
Dominic RMS, Prashanth HV, Shenoy S et al.
Diagnostic value of latex agglutination in cryptococcal
meningitis. J Lab Physicians. 2009;1:67-8.
REFERENCES
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
ADVERSE REACTIONS FOLLOWING INFLUENZA
VACCINATION AMONG HEALTH CARE PERSONNEL AT
GOVT. MEDICAL COLLEGE, MIRAJ – A LONGITUDINAL
STUDY
Jayashree Dayanand Naik1, S.S. Rajderkar2, Kriti A Patel3, Sanjay K Jathar3
1Associate
Professor, 2Professor & Head, 3Junior Resident, Department of Community Medicine GMC
Miraj, Maharashtra
Correspondence:
Dr. Mrs. Jayashree Dayanand Naik
Associate Professor, Department of Community Medicine (PSM),
Government Medical College, Miraj
Dist. Sangli, Maharashtra-416410
Email: [email protected]
Mob: + 91 9823017772
ABSTRACT
Influenza continues to be a significant cause of morbidity and mortality globally. Health Care
Personnel (HCP), the backbone of health care delivery system, have been identified as an important
source of influenza for patients. Vaccination is a useful but underused means of preventing the illness
and death associated with Influenza and the coverage is lower than expected among HCP. So, a
longitudinal study to assess the frequency and pattern of adverse reactions following influenza
vaccination among 130 HCP , participating voluntarily, was carried out at Govt. Medical College,
Miraj and they were followed for the period of one year.71.5% of the study subjects had taken nasal
type of vaccine . The overall incidence of adverse reactions after vaccination was 40%, commonly
during first 3 days, with declining frequency over 1 week and the reactions were mild. None of the
vaccinees reported severe adverse reactions.
Key Words: Influenza Vaccination, Health Care personnel, adverse reactions
INTRODUCTION
A novel influenza A H1NI virus, quite different
from the circulating seasonal influenza viruses
which got noticed in Mexico in April ,2009,
spreaded fast across the globe during 200910.On 11th June,2009, WHO declared this a
pandemic. It affected over 200 countries globally
including India. Number of affected countries &
human cases with influenza A virus claiming
their lives are increasing rapidly. 1 The majority
of the human population has no immunity to
this virus. Health Care Personnel (HCP) 2 can
acquire influenza from patients or transmit
influenza to patients and other staff.2 One
important prevention strategy is vaccinating “at
risk population” with Influenza Vaccine.
Despite the documented benefits of vaccination,
the coverage is lower than expected among
HCP.2,3
Influenza vaccination programs for hospital
workers have not met wide acceptance.4.The
plan to introduce such a program is likely to be
questioned about the adverse reactions to the
vaccine.3
MATERIAL AND METHODS
Study type – Longitudinal study. Study period:
Aug 2010 to July 2011. Sample size: A total of
130 HCP2 which included Doctors, Nurses,
Professions allied to medicine (PAMs)
5(Radiographers, dieticians, lab technicians),
students etc working in Govt. Medical College
and Hospital ( Miraj & Sangli) who had taken
influenza vaccine
either live attenuated
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Nasovac, manufactured by Serum Institute of
India, Pune or killed Injectable vaccine, Panenza
, a split virus inactivated, non adjuvanted,
monovalent vaccine, voluntarily at either Miraj
or Sangli hospital were followed for the period
of 1 year from the day of vaccination without
any drop outs. The relevant information was
recorded in the predesigned, pretested proforma
after informed consent. They were followed
daily for the first week and then weekly up to 30
days and then monthly for further 11 months.
Individuals were advised to report any reactions
telephonically or verbally in between the visit.
Those vaccinees who had reported side
reactions during the follow up were visited,
referred to physician, treated symptomatically
and monitored. The data was analyzed by chi
square test & standard error of difference
between two proportions using SPSS software.
RESULTS
Out of total 130 HCP vaccinated 56(43%) were
doctors (Table: 1). Mean age group was 33.8 ±
10.2 years. Males and females were in the ratio
of 0.83:1 (Table: 1).
Table1: Gender wise Distribution of the study
subjects taking vaccine (n=130)
Group
Doctors
Nurses
PAMs
Students
Others
Total
Male
33
05
08
11
02
59(45.3)
Female
23
40
05
01
02
71(54.7)
Total (%)
56 (43.0)
45(34.6)
13(10.0)
12(9.2)
4(3.2)
130(100.0)
71.5% study subjects had taken nasal type of
vaccine and rest 28.5% took injectable vaccine
(Table: 2).The overall incidence of side reactions
following vaccination was 40% (52/130) (Table:
2). The incidence of adverse reactions reported
were 43.01% with nasal and 32.4% with
injectable vaccine. No significant difference was
observed between adverse reactions following
nasal and injectable vaccine (Table 2).
It was observed that single reaction was
common over multiple reactions in those
vaccinees in which adverse reactions were
present. This was found to be statistically
significant. (Table: 3).
Table 2: Comparison of adverse reactions
following nasal and injectable vaccination
among the study subjects
Type of
Adverse Reactions
Total (%)
vaccine
Present (%) Absent (%)
Nasovac
40 (43.01)
53 (56.9)
93 (71.5)
Injectable
12 (32.4)
25 (67.6)
37 (28.5)
Total
52 (40.0)
78 (60.0)
130 (100)
SE (p1-p2) = 13.85, Z=5.83, P<0.5, Significant.
Table 3: Comparison of single and multiple
adverse reactions in those study subjects
Vaccine
Nasal
Injectable
Total
Adverse reactions (%)
Single
Multiple
reaction
reactions
36(90.0)
4(10.0)
11(91.6)
1(8.4)
47(90.4)
5(9.6)
Total
(%)
40(76.9)
12(23.1)
52(100.0)
Figure 1: Various Adverse Reactions seen in vaccinees
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Most of the systemic reactions were mild and
were observed during first 3 days following
vaccination with declining frequency over 1
week in both the types of vaccination. There
were no reactions observed after 7 days in both
the vaccine (Table: 4). It was found to be
statistically significant (Table: 5). X ²=1.22, df =1,
Not Significant. (* - Figures in parenthesis are
%).
Headache was the most common adverse
reaction observed in study subjects who had
taken nasal vaccine while nasal congestion was
most commonly found in injectable vaccinees.
The other mild systemic reactions observed
were fever, generalized body ache, Respiratory
symptoms(cough,
running
nose,
nasal
congestion), Gastrointestinal symptoms( nausea,
mild diarrhoea, cramps), sore throat , throat
congestion etc.
In the present study, none of the study subjects
had presented with local reactions at the
injection site in the form of soreness or pain or
swelling and none of them had severe adverse
reactions after vaccination.
Yates Correction applied, X²=3.93, df =1, P< 0.05,
Significant. (* - Figures in parenthesis are %).
DISCUSSION
In the present study, uptake of the influenza
vaccine is found to be quite low which is
consistent with the previous other study
findings .6Among HCP who denied vaccination,
majority reported fear of adverse reactions and
also expressed doubts regarding efficacy of the
vaccine. The findings of this study also show
that both the types of vaccine are associated
with adverse reactions, being more with nasal
type. Similar observations were made in various
other studies.7,8 The rate of adverse reactions
was somewhat more as compared to other
studies which can be attributed to the other
coincidental intercurrent illnesses which cannot
be differentiated from the adverse reactions and
also perhaps HCP are overanxious than other
recipients and are more apt to report them when
invited to do so.
CONCLUSIONS
Table 4: Day wise occurrence of adverse
reactions in all the study subjects
Day of
Reaction
Day 0
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9 - Upto
1 year
Individuals having
Adverse reactions
Nasovac
Injectable
vaccinees vaccinees
14
7
18
6
10
3
8
2
5
2
2
0
0
1
2
0
0
0
0
0
Total
(n=130)
21
24
13
10
7
2
1
2
0
0
Table 5: Time distribution of adverse reactions
following vaccination in study subjects
Day Of reaction Type of Vaccine (%)
Total
(%)
Nasal Injectable
Upto 3rd day
34(82.9)
7(17.1)
41(78.8)
4th day – 7th day 6(81.8)
5(18.2)
11(21.2)
8th day-upto 1 yr 0 (0.00)
0(0.00)
0(0.00)
Total
40(76.9) 12(23.1)
52(100)
Vaccination by both the types of vaccine is
associated with mild adverse reactions during
first 3 days and no serious/severe adverse
reaction is found with any of the vaccine types
even at the end of 1 year follow up. The uptake
of influenza vaccine is found to be poor among
HCP.
LIMITATIONS
1.
2.
3.
As the uptake of both the types of vaccine
was poor, our sample size was small.
There was lack of current Indian references
relating to our study.
We do not have satisfactory comparative
results with Indian population available
with us.
RECOMMENDATIONS
1.
2.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Influenza vaccination should be made
mandatory for HCP as a professional
obligation as scientific, ethical and legal
justifications support it.
Efforts are needed to promote vaccination
among HCP and to understand their
attitude/ beliefs regarding vaccination.
Page 360
pISSN: 0976 3325 eISSN: 2229 6816
3.
4.
5.
6.
7.
Rumors and fear must not be a barrier in the
process of promoting individual safety.
Proper planning by the health care institutes
to improve the acceptability of vaccine is
needed.
Tertiary care centre should make influenza
vaccination as an additional Hospital policy.
Institutional Educational campaigns should
be organized to promote the need for
vaccination.
Vaccine must be made readily available to
HCP and they must be educated about the
safety and effectiveness of the vaccine.
Similar types of studies must be promoted
taking large sample size.
2.
3.
4.
5.
6.
7.
REFERENCES
1.
8.
R.K. Shrivastava.
Special Issue: Human Swine
Influenza: A Pandemic threat. CD Alert Monthly
newsletter of NICD, DGHS, GOI; Mar- Apr 2009;12(8):
1-8
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Ates Kara, Ilker Devrim, Tolga Celik , et al. Influenza
Vaccine Adverse Event and Effect on Acceptibility in
Pediatric Residents. Japanese J of Infectious Diseases,
2007; 60:387-388.
David W., Gordean, Joyce, et al. E valuation of adverse
events after influenza vaccination in hospital personnel.
Can Med Assoc J, 1990; 142(2):127-130.
Abdulrahaman, David, Therese, et al. Comparison of
adverse reactions to whole – virion and split – virion
influenza vaccines in hospital personnel. Can Med
Assoc J, 1991; 145(3): 213-218.
Julia Smedley, Jason Poole, Eugene, et al: Influenza
immunization: attitude and beliefs of UK healthcare
workers. Occup Environ Med, 2007; 64: 223-227.
Turk , Assistt, Kocayol, et al. Vaccination against
pandemic influenza A/H1N1 among healthcare
workers and reasons for refusing vaccination in
Istanbul in last pandemic alert phase .Vaccine, Aug
9,2010; 28(35): 5703-10.
Weingarten, Riedinger, Bolton, et al: Barriers to
influenza vaccine acceptance. A survey of physicians
and nurses. Am J Infect Control, 1989;17(4):202-207.
Takayanagi IJ, Cardoso, Costo, et al: Attitudes of health
care workers to Influenza vaccination: Why are they
not vaccinated? Am J Infect Control, Feb 2007; 35(1): 5661.
Page 361
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ORIGINAL ARTICLE .
SOCIAL CLASS DIFFERENTIATION AND ITS IMPACT ON
QUALITY OF LIFE AMONG DIABETIC PATIENTS
Rohin Rameswarapu1, Trupti N Bodhare2, Samir D Bele2, Sameer Valsangkar3
1Post
graduate student, 2Assistant Professor, 3Lecturer, Department of Community Medicine,
Prathima Institute of Medical Sciences, Karimnagar, Andhra Pradesh
Correspondence:
Dr. Rohin Rameswarapu
Department of Community Medicine,
Prathima Institute of Medical Sciences,
Karimnagar, Andhra Pradesh - 505417
Email: [email protected]
Mobile: 9989709604
ABSTRACT
Social class is a significant modifier of quality of life in diabetic patients which we sought to measure
in this study. A hospital based, cross sectional descriptive was conducted in diabetic patients using a
semi structured questionnaire. A total of 103 diabetic patients consented and participated in the
study. The sample consisted of 58 males and 45 females and most respondents had a duration of
onset of diabetes between 1-5 yrs (47%). 68 (66%) of the respondents belonged to lower class, 27 (26%)
to the middle class and 8 (8%) to the upper class. 92 (89.32%) of the respondents were using oral
hypoglycemic agents and 11 (10.68%) used injectable insulin. Socioeconomic status was significant for
the number of missed doses (P < 0.04). The mean scores for upper, middle and lower class on the
items of financial burden were 3.99 ± 0.906, 3.37 ± 1.079, 3.00 ± 0.756, for general health were 3.49 ±
0.837, 2.96 ± 0.706, 2.63 ± 0.744 and for psychological distress were 3.56 ± 0.835, 2.70 ± 0.609 and 2.75 ±
0.707 respectively. Social class has a significant impact on quality of life and therapy compliance and
measures to address this must be undertaken while providing comprehensive healthcare in diabetes
for an optimal outcome.
Keywords: Diabetes, quality of life, social classification
INTRODUCTION
According to the World Health Organization
there is “an apparent epidemic of diabetes,
which strongly related to lifestyle and economic
change”. The International Diabetes Federation
estimates the total number of diabetic subjects
to be around 40.9 million in India and this is
further estimated to rise to 69.9 million by the
year 2025. [1]
With the advancement in management and
prolonging of life in chronic diseases, the
quality of life and the healthcare costs in the
daily management of such disease takes
precedence. While compliance and good quality
of life are an ideal for therapeutic end point,
several factors belie its achievement.
The rising prevalence of chronic diseases in low
and middle income nations has been attributed
largely to components of social class, namely
literacy, family income and occupation.
Available evidence from developed countries
indicates that the burden of chronic diseases
and their risk factors are predominantly
concentrated among the economically poor. [2, 3]
The poor appear to be disproportionately
burdened with the risk factors associated with
these diseases. People of lower social class are
also at a greatest risk for non compliance, lack of
adequate access to healthcare and preventive
care. [4]
Quality of life is defined by World Health
Organization as “Individuals' perceptions of
their position in life in the context of the culture
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and value systems in which they live and in
relation to their goals, expectations, standards
and concerns”. [5] The concept of health related
quality of life and its determinants have evolved
since the 1980s to encompass those aspects of
overall quality of life that can be clearly shown
to affect health either physical or mental. [6 -8] In
addition, health related quality of life
assessment has gained recognition as an
important research tool for evaluating the
impact of new medical treatments and health
care services for people with diabetes. [9, 10]
This study explores the impact factors like
literacy, family income and education on the
quality of life of diabetics thereby enabling a
measure of comparison of the effectiveness of
healthcare provided.
more than three doses of medication in a week.
[12]
Quality of life was measured using a 8 item
questionnaire which included questions relating
to general health, activity limitation, financial
burden, pain and discomfort, energy and
vitality, emotional functioning, psychological
distress and social functioning. Responses
graded from 0 to 4 on a Likert scale with higher
scores indicating poor quality of life.
Data entry and statistical analysis was done in
PASW (SPSS) software, version 18. Statistical
methods used included means, measure of
dispersion, proportions, confidence intervals,
chi square test.
RESULTS
MATERIALS AND METHODS
A cross sectional descriptive study was
conducted among diabetic patients attending
outpatient department in hospital of Prathima
Institute of Medical Sciences, Karimnagar. The
study was conducted over a period of three
months. A semi structured questionnaire was
administered via a face to face interview and
responses were recorded by the interviewer.
Informed consent was obtained from the
participants and confidentiality was assured.
The questionnaire consisted of five parts, 1)
Socio-demographic information 2) Diabetes
specific information including duration since
initial diagnosis and nature of therapy 3)
Compliance with diabetic therapy 4) Quality of
life
Socio-demographic
information
collected
included the age and gender of the respondents.
Socio-economic classification was done based
the Kuppuswamy classification [11] based on
education, occupation and total family monthly
income. Respondents were then classified into
three classes of socio-economic status, upper
class, middle class which included upper and
lower middle class and lower class which
included upper lower and lower class.
Diabetes
specific
information
including
duration since initial diagnosis and nature of
therapy, whether the respondents were using
oral hypoglycemic drugs or injectable insulin
was obtained. Compliance with therapy was
evaluated; a patient was considered non
complaint with therapy if the patient missed
A total of 103 respondents consented and
participated in the study. The sample consisted
of 58 (56.31%) men and 45 (43.69%) women. 47
(45.63%) of the respondents were aged between
45 – 55 years, followed by 33 (32.03%) in the age
group of 55 – 65 years, 15 (14.57%) in the age
group of 35 – 45 years and 8 (7.77%) aged above
65 years. 68 (66.01%) belonged to the lower
socio-economic class, 27 (26.21%) to the middle
class and 8 (7.77%) belonged to the upper socioeconomic class. These socio-demographic
characteristics are depicted in table 1.
Table 1: Sociodemographic characteristics of
Study Population
Characteristic
Age in
35-45
years
45-55
55-65
>65
Gender
Male
Female
Socio Upper
economic
Middle
Status
Lower
Total
Number
15
47
33
08
58
45
08
27
68
103
Percentage
14.57
45.63
32.03
7.77
56.31
43.69
7.77
26.21
66.01
100
Diabetes specific information was collected. The
duration since initial diagnosis was 1 – 5 years
for 49 (47.57%) of the respondents, 5 – 10 years
for 35 (33.99%) of the respondents while it was
less than one year for 11 (10.68%) and more than
ten years for 8 (7.77%) of the respondents. 92
(89.32%) of the respondents were using oral
hypoglycemic agents and 11 (10.68%) used
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injectable insulin. The clinical characteristics of
respondents are reported in table 2.
association between compliance and socioeconomic status in presented in table 3.
Table 2: Clinical characteristics of Study
Population
Table 3: SES v/s drug compliance
Characteristic
Drugs
OHA
Insulin
Duration in
<1
years
1-5
5-10
>10
Total
Number
92
11
11
49
35
8
103
Percentage
89.32
10.68
10.68
47.57
33.99
7.77
100
In the lower class, 40 respondents were
complaint with therapy whereas 28 were not. In
the middle class, 22 and 5 were complaint and
non complaint respectively. In the upper class, 7
and one respondents were complaint and non
complaint respectively. Socioeconomic status
was significant for the number of missed doses
(Yates corrected X2 = 6.137, P < 0.04). The
Characteristics Compliant Non compliant
Lower class
40
28
Middle class
22
05
Upper class
07
01
Total
69
34
Yates corrected X2 = 6.137 p value < 0.04
Quality of life was measured on a 8 item
questionnaire and the most affected domains
when compared across socioeconomic status
were financial burden, general health and
psychosocial burden. The mean scores for
upper, middle and lower class on the items of
financial burden were 3.99 ± 0.906, 3.37 ± 1.079,
3.00 ± 0.756, for general health were 3.49 ± 0.837,
2.96 ± 0.706, 2.63 ± 0.744 and for psychological
distress were 3.56 ± 0.835, 2.70 ± 0.609 and 2.75
± 0.707 respectively. The quality of life scores
are depicted in table 4.
Table 4: SES versus quality of life
General Health
Activity limitation
Financial burden
Pain and discomfort
Energy and vitality
Emotional functioning
Psychological distress
Social functioning
Range
0-4
0-4
0-4
0-4
0-4
0-4
0-4
0-4
Lower class
3.49 ± 0.837
3.51 ± 0.743
3.99 ± 0.906
3.43 ± 0.759
3.35 ± 0.768
3.26 ± 0.725
3.56 ± 0.835
2.38 ± 0.519
DISCUSSION
Quality of life is a direct measure of the impact
of healthcare services and provision of
treatment which is more relevant with increased
life expectancy in diabetic people due to newer
methods of management. It helps us assess the
overall impact of the disease and enables a
comparison of the ability to cope with disease.
The measurement of quality of life is multifactorial and factors affecting disease also affect
quality of life. Social class is a strong
determinant of both occurrence of disease and
quality of life in diabetes. In comparable
methods of treatment, the impact of social class
on the disease and the burden on quality of life
can be measured.
In our current study, most respondents
belonged to the age group of 45 – 55 years
which is the peak age for the onset of
complications of diabetes, had an equitable
Middle class
2.96 ± 0.706
3.07 ± 0.675
3.37 ± 1.079
2.85 ± 0.77
3.04 ± 0.759
3 ± 0.877
2.70 ± 0.609
2.15 ± 0.362
Upper class
2.63 ± 0.744
2.87 ± 0.641
3 ± 0.756
2.87 ± 0.641
2.75 ± 0.707
2.75 ± 0.707
2.75 ± 0.707
2.63 ± 0.744
distribution of gender and predominantly
belonged to lower socio-economic class. Most
respondents had duration since initial diagnosis
of 5 to 10 years. This socio-demographic
distribution reflects the occurrence of disease in
India and has been seen in larger studies such as
the study by Mohan et al [13] who measured the
prevalence of diabetes and metabolic syndrome
in South India.
The study measured the nature of therapy,
whether oral hypoglycemic drugs or injectable
insulin and compliance with therapy. People in
the lower socio-economic strata are more likely
to be non complaint towards treatment as
evidenced in the study. These finding are
similar to the findings by Kalyango et al, [12]
Oladele et al [14] and Piette et al [3] who also
studied diabetes and the impact of social class
differentiation on the disease.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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Elaboration into the causal mechanism of this
and an explanation of the numerous variables
involved requires further study with a larger
sample size in the non complaint group.
The study measured quality of life over eight
domains and the most significantly affected
domains were financial burden, general health
and psychological distress. In addition, quality
of life across all eight domains had a lower
mean in the lower socio-economic class when
compared to the middle and upper class.
Similar impact on quality of life in diabetes
varying by the socio-economic status has been
seen in other studies. Larsson et al [15] obtained
lower scorings for physical functioning, general
health, vitality and mental health on the
domains for quality of life using SF-36 and they
also observed more disability and higher
complications in patients with lower social class
and educational level. Hassan et al [16] studied
the role of socioeconomic status, quality of life,
and glycemic control in diabetic patients and
found that quality of life deteriorated with
socioeconomic status and non- compliance and
poorer diabetic control. Chronic diseases such
as diabetes have a varying effect on quality of
life which is dependent on the social class of the
patient which needs to be addressed in primary
intervention for the disease.
CONCLUSION
Social class has a significant impact on quality
of life and therapy compliance and measures to
address this must be undertaken while
providing comprehensive healthcare in diabetes
for an optimal outcome.
LIMITATIONS
Quality of life measures were obtained through
an oral questionnaire and only the subjective
perception of the sample respondents was
sought.
Cost analysis of the prescriptions in the diabetic
regimens which would have added to the
strength of the study with comparisons of the
social class, average drug expenditure and
compliance, was not performed
due to
incomplete availability of prescriptions and lack
of manpower.
1.
Sicree R, Shaw J, Zimmet P. Diabetes and impaired
glucose tolerance. In: Gan D, editor. Diabetes Atlas.
International Diabetes Federation. 3rd ed. Belgium:
International Diabetes Federation; 2006. p. 15-103.
2.
Health inequalities: Europe in profile. An independent
expert report commissioned by and published under
the auspices of the United Kingdom Presidency of the
European
Union.
Available
at:
http://www.ec.europa.eu/health/ph_determinants/s
ocio_economics/documents/ev_060302_rd06_en.pdf,
Accessed October 12th, 2008.
3.
Piette JD, Wagner TH, Potter MB, Schillinger D: Health
insurance status, cost-related medication underuse,
and outcomes among diabetes patients in three
systems of care. Med care. 2004; 42: 102-9.
4.
Kim HY, Yun WJ, Shin MH, Kweon SS, Ahn HR, Choi
SW, Lee YH, Cho DH, Rhee JA. Management of
diabetic mellitus in low-income rural patients. J Prev
Med Public Health. 2009 ;42:315-22.
5.
The WHOQOL Group. The World Health Organization
Quality of Life Assessment (WHOQOL). Development
and psychometric properties. Soc Sci Med
1998;46:1569-1585.
6.
McHorney CA. Health status assessment methods for
adults: past accomplishments and future directions.
Annual Rev Public Health 1999; 20:309-35.
7.
Selim AJ, Rogers W, Fleishman JA, Qian SX, Fincke BG,
Rothendler JA, Kazis LE. Updated U.S. population
standard for the Veterans RAND 12-item Health
Survey (VR-12). Qual Life Res. 2009;18:43-52.
8.
Testa MA, Simonson DC: Health economic benefits and
quality of life during improved glycemic control in
patients with type 2 diabetes mellitus: a randomized,
controlled, double-blind trial. JAMA 280:1490-96, 1998.
9.
Andersson PO, Wikby A, Stenstrom U, Hornquist JO:
Pen injection and change in metabolic control and
quality of life in insulin dependent diabetes mellitus.
Diabetes Res Clin Pract 36:169-72, 1997.
10. Hornquist JO, Wikby A, Andersson PO, Dufva AM:
Insulin-pen treatment, quality of life and metabolic
control: retrospective intra-group evaluations. Diabetes
Res Clin Pract 10:221-30, 1990.
11. Kumar N, Shekhar C, Kumar P, Kundu AS.
Kuppuswamy's socioeconomic status scale-updating
for 2007. Indian J Pediatr. 2007;74:1131-2.
12. Kalyango JN, Owino E, Nambuya AP. Non-adherence
to diabetes treatment at Mulago Hospital in Uganda:
prevalence and associated factors. Afr Health Sci. 2008 ;
8: 67–73.
13. V. Mohan, S. Shanthirani, R. Deepa, G. Premalatha, N.
G. Sastry, R. Saroja. Intra-urban differences in the
prevalence of the metabolic syndrome in southern
India – the Chennai Urban Population Study. Diabet
Med. 2001; 18:280-7.
14.
Oladele CR, Barnett E. Racial/Ethnic and social class
differences in preventive care practices among persons
with diabetes. BMC Public Health 2006, 6:259.
15. Larsson D, Lager I, Nilsson PM. Socio-economic
characteristics and quality of life in diabetes mellitus-relation to metabolic control. Scand J Public Health.
1999 ;27:101-5.
16. Hassan K, Loar R, Anderson BJ, Heptulla RA. The role
of socioeconomic status, depression, quality of life, and
glycemic control in type 1 diabetes mellitus. J Pediatr.
2006 ;149:526-31.
REFERENCES
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ORIGINAL ARTICLE .
PERSUADE MOTHERS IN POST NATAL WARD FOR
TIMELY INITIATION OF BREASTFEEDING.
Mamtarani1, Ratan K Srivastava 2, B.Divakar3
1Assistant
Professor, Department of Community Medicine, Government Medical College, Surat
& Head, Department of Community Medicine, Banaras Hindu University, Varanasi
3Assistant Professor, Department of Pharmacology, MP Shah Medical College, Jamnagar
2Professor
Correspondence:
Dr. Mamtarani Verma
B-13 AP Quarters, New Civil Hospital, Majura Gate
Surat (Gujarat) 395001, India.
E-mail: [email protected]
Mobile-09374545911,
ABSTRACT
Objective: Timely initiation of breast feeding has been an important issue since last many decades.
However, encouragement and early initiation of breast feeding gained momentum since last 20 years.
The traditional wisdom and scientific research have proved that mother’s milk is the best.
Design: It is a Cross sectional study conducted in urban tertiary care teaching hospital.
Methods: a pretested semi-structured questionnaire was used to interview hospitalised mothers. This
paper is the result of the interview of 600 women who delivered babies in the hospital. Their Details
of socio-demographic features were enquired in addition to the questions related to their initiation of
breast feeding after the birth of baby. Timely initiation of breast-feeding was calculated in this paper
as percent of infants (0 - <12 months) who were put to the breast within one hour of delivery.
Results: Out of all deliveries, breast feeding was timely initiated with in one hour only by 1.0 percent
of mothers. However 30 percent mothers initiated breast feeding within two hours. Conclusion: The
observations of the present study supports that the health functionaries must utilise the opportunity
to persuade mothers in the postnatal ward after delivery of their babies for early initiation of breast
feeding.
Key Words: Timely initiation, breast feeding, postnatal ward, urban area.
INTRODUCTION
Timely initiation of breast feeding has been an
important issue since last many decades in
India. In the field of medical research, many
studies were carried out and suggestions were
made time and again to improve the situation.
The suckling reflex is another very important
parameter and is found to be very active during
the first half hour after birth (1). If the infant is
not fed then the reflex diminishes rapidly only
to reappear adequately forty hours later (2). This
may be called “The fourth stage of labour”
which includes putting the baby to breast after
birth and ensuring the intake of colostrums by
the neonate. The exact time of initiation of breast
feeding has been suggested right from birth in
the delivery room itself to within one hour after
delivery.
In order to ensure success in breastfeeding, it is
important that it be initiated as early as possible
during the neonatal period (3). This study was
planned to understand the current situation of
women of lower social class belonging to urban
areas of Surat district about their practices and
factors influencing the initiation of breast
feeding after the delivery of their babies. So that
effective strategy may be planned to persuade
mothers for timely initiation of breast feeding
who are coming for institutional delivery.
MATERIALS AND METHOD
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This study was carried out from June 2006 to
October 2006 for a period of 5 months in an
urban area of Surat district, Gujarat. The subjects
of the present study were hospitalised women
who delivered babies in the postnatal ward of
New Civil Hospital, Surat. Pre-tested semistructured questionnaire was used. The
information was collected using interview
technique within 8-12 hours of delivery to
reduce the effect of recall bias. More than half of
the women (60.5%) who came for delivery in a
tertiary care hospital were covered. Their details
of socio-demographic features were enquired in
addition to the questions related to their
initiation of breast feeding after the birth of
baby. The data of this study was collected by
cross sectional technique and did not represent
any particular cohort of mothers and their
babies. The data was analysed by EpiInfo 3.2
(window based) software.
The following WHO definitions were used (4):
1. Initiation of breast-feeding: It is the time
when baby is placed “skin-to-skin” with the
mother and offered the breast milk for the first
time after birth.
2. Timely initiation of breast-feeding: Refers to
percent of infants (0 - < 12 months) who were
put to the breast within one hour of delivery.
Calculated as: Number of infants (0< 12 months)
put to the breast within 1 hour of delivery x 100
Total number of infants (0< 12 months)
RESULTS
About half of mothers (51.5%) were young (2024 years) followed by one-third mothers (33.8%)
who were 25-29 years old. Two-fifth mothers
were illiterate & were from all age groups. Very
few mothers (5%) were educated up to higher
secondary school & more. Majority (83.2%) of
mothers were housewife and 17.8% were
working. Most of the mothers (83.7%) were from
lower social class III to V as per BG Prasad’s
modified classification for the year 2006. Threefourth of the mothers (77.2%) gave birth to
babies by normal delivery & 22.8% by caesarean
section. More than three-fourth mothers (83.6%)
were of the young age group of 20-29 years who
delivered babies weighing less than 2.5 kg. Most
of the mothers (89.5%) gave colostrums to their
babies. Out of those 205 babies to whom Prelacteal feed was given, honey was the
commonest and was given to 50.2 % of babies.
Out of all deliveries, breast milk was initiated
within one hour only by 1.0 percent of mothers
(Table1).
Breast feeding was initiated by 1.2% Hindu
mothers within one hour. Anyway 38.3% of
Muslim mothers initiated breast feeding within
two hours.
The percentage of mothers
belonging to General, SC, ST and SEBC who
initiated breast feeding within one hour was
0.6%, 0.5%, 1.8% and 1.6% respectively. Even so,
one-fourth mothers of all caste started breast
feeding within two hours. Out of total 463
normal deliveries, only six mothers initiated
breast feeding within one hour whereas none of
mothers who delivered by caesarean section. In
any way it was encouraging to note that almost
all mothers (100%) initiated breast feeding
within ten hours in the hospital. Those who
were illiterate mothers (1.2%) initiated the breast
feeding within one hour of delivery compared to
those (0.9%) literate mothers but the difference
was not significant. Out of 102 working mothers
nil had initiated breast feeding within one hour
of delivery.
DISCUSSION
Mothers are more likely to successfully initiate
lactation and maintain optimal breast-feeding
behaviour if they initiate breast-feeding shortly
after birth. Breast-feeding should begin no later
than one hour after the delivery of the infant (4).
For Assessing “timely initiation of breastfeeding” (1998-99) the percent of infants (0 - <12
months) who were put to the breast within one
hour of delivery was calculated as suggested by
WHO (4).
Table1. depicts the influence on the timing of
initiation of breast feeding in relation to the
different variables. All the mothers had initiated
breast feeding within first ten hours. This
finding showed an improvement as compared to
the past but it cannot be called timely initiation.
Hence, one has to measure initiation of breast
feeding within one hour of delivery. Very few
Hindu mothers (1.2%) initiated breast feeding
within one hour but none of the Muslim
mothers. Somehow most of the mothers (92.7%)
initiated breast feeding within six hours of
delivery. NFHS-2 (1998-99) study for Gujarat
revealed that 10% mothers out of 1,324 under
three children initiated breast-feeding within
one hour of birth, while 36.6% mothers initiated
breast-feeding on the same day. However in this
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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case of institutional delivery all mothers
initiated breast feeding within 10 hour. This
improvement could be due to the on going
IMNCI training at this instituition since 2004.
Table 1: Influence of different variables on the timing of initiation of breast feeding of mothers who
delivered babies at a teaching hospital
Variables
Within 1 hr
No.
%
Religion
Hindu
Muslim
Caste
General
Schedule caste
Schedule tribe
SEBC
Type of delivery
Normal
Caesarean
Education of mother
Illiterate
Literate
Occupation of mother
Working
Housewife
Prelacteal feed
Given
Not given
Colostrums
Given
Not given
Parity
Primipara
Multipara
Antenatal care
Received
Not received
Premature baby
Yes
No
Total
Timely initiation of breast feeding
Within 2 hr
Within 6 hr
Within 10 hr
No.
%
No.
%
No.
%
Total
n
6
nil
1.2
Nil
149
31
28.7
38.3
485
71
93.4
87.7
519
81
100.0
100.0
519
81
1
1
3
1
0.6
0.5
1.8
1.6
50
58
54
18
30.5
27.9
32.5
29.0
159
193
151
53
97.0
92.8
91.0
85.5
164
208
166
62
100.0
100.0
100.0
100.0
164
208
166
62
6
nil
1.3
Nil
147
33
31.7
24.1
431
125
93.1
91.2
463
137
100.0
100.0
463
137
3
3
1.2
0.9
62
118
24.3
34.2
238
318
93.3
92.2
255
345
100.0
100.0
255
345
nil
6
Nil
1.2
28
152
27.5
30.5
95
461
93.1
92.6
102
498
100.0
100.0
102
498
2
4
1.0
1.0
58
122
28.3
30.9
194
362
94.6
91.6
205
395
100.0
100.0
205
395
6
nil
1.1
Nil
164
16
30.5
25.4
498
58
92.7
92.1
537
63
100.0
100.0
537
63
1
5
0.5
1.2
51
129
27.3
31.2
174
382
93.0
92.5
187
413
100.0
100.0
187
413
6
nil
1.1
Nil
168
12
29.9
31.6
519
37
92.3
97.4
562
38
100.0
100.0
562
38
1
5
6
2.8
0.9
1.00
12
168
180
33.3
29.8
30.0
31
525
556
86.1
93.1
92.7
36
564
600
100.0
100.0
100.0
36
564
600
Most of the faculty of the paediatrics are trained
and are working as facilitator for the training.
But there is a scope of further improvement.
None of the working mothers in this study had
initiated breast feeding within one hour of
delivery. Among multiparous women initiation
of breast feeding within one and two hours was
observed to be earlier as compared to primipara.
The previous experience of delivery had lead to
a little rise in timely initiation of breast feeding
but is not appreciable and call in question about
the need of persuasion of mothers in postnatal
ward for timely initiation of breast feeding. The
recent finding of NFHS-3 (2005-06) ranked
Gujarat on 18th position in India by initiation of
breast feeding (27.1%) within 1 hour (5).
According to WHO’s indicator for assessing
breast feeding practices, timely initiation of
breast feeding rate(4) in the postnatal ward of
the hospital was very low (1.0%) whereas 30
percent of mothers had initiated breast feeding
within first two hours. The delay happened due
to occurrence of too many deliveries in the
labour room and the team of doctors and nurses
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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pISSN: 0976 3325 eISSN: 2229 6816
gave priority to the shifting of mother to the
indoor ward where they were finally motivated
for early initiation of breast feeding. But this
process of shifting use to take one hour leading
to delay in timely initiation of breast feeding
and thus important time was missed. Therefore
it is recommended that all mothers who deliver
their babies in hospital and are in labour room
must be encouraged for the commencement of
breast feeding as early as possible preferably
within one hour of delivery for better health of
mother as well as child.
Initiation of breast feeding within one hour of
birth was one of the Ten steps to successful
breastfeeding on which the BFHI was based and
implemented in 1992(6). The findings from a
Ghana study (2006) clearly showed for the first
time in the world, that ensuring initiation of
breast feeding within one hour could cut 22% all
neonatal mortality, assume great importance(7).
It calls for support to all mothers in the postnatal
ward during the first hour to ensure early
initiation of breast feeding.
Very few mothers (1.1%) initiated breastfeeding
within 1 hour in spite of receiving antenatal
care. This may be partially possible that the
antenatal care services received by the mothers
was not enough to educate them regarding
breast feeding practices. This was supported by
the fact that only 13.4 percent of mothers
received the right breast feeding advices out of
all those receiving the antenatal care in another
hospital of New Delhi(8).
On further enquiry it was brought to notice that
none of the mothers of this study was educated
about the early initiation of breast feeding
during antenatal check-ups. Whereas the breast
feeding policy of the UNICEFF and WHO
addresses issues to promote breast feeding right
from the antenatal period(9). Therefore, it is
again recommended to include the component
of timely initiation of breast feeding while
imparting health education to mother during
antenatal period.
Obstetricians and other concerned with
maternity care have key roles in promoting
breastfeeding (10). A pregnant woman has
confidence in her/his obstetrician and takes
her/his advice and even respects her/his
opinion regarding childbirth and care of the
neonate (11). The family Paediatrician can
influence a mother’s decision for timely
initiation of breastfeeding.
A significant difference on the aspect of early
initiation of breast-feeding (within one hour)
was noticed between mothers with normal
delivery and those who underwent caesarean
section. Similar findings have also been
observed in studies reported earlier (1,12). But in
this study the caesarean section delivery could
not reflect as barrier for initiation of breast
feeding within six hours as 91.2% mothers
initiated breast feeding by that time.
Early, successful initiation of breastfeeding gets
affected negatively by caesarean delivery was
reported in 1990(13). Mothers may be trained to
use pillows to provide support for the area of
incision. The efforts must be carried to promote
early initiation of breast feeding even after
caesarean delivery.
205 mothers gave pre-lacteal feed to the child.
The practice of pre-lacteal feeding was found to
be associated with delay in initiation of breast
feeding till within two hours of delivery. Ahmed
et al reported that type and duration of prelacteal feeding had significant negative influence
on milk secretion. Pre-lacteal feeding forms a
vicious cycle with ‘coming in’ of milk; it first
delays initiation, which later encourages prelacteal feeding (14).
The WORLD BREASTFEEDING WEEK (WBW)
2007 also aimed precisely towards this objective
(Breastfeeding: The Ist Hour-Save One million
babies!)(15) and also to raise public awareness
of the benefits of this achievable practice on
newborn and maternal health.
The observations of the present study supports
to frame a policy that the health functionaries of
postnatal ward (Paediatrician, obstetricians &
nurses) must utilize the opportunity to
persuade mothers for timely initiation of breast
feeding to the mothers who deliver their babies
in the hospital (institutional deliveries).
REFERENCES
1.
2.
3.
4.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Pandit N, Yeshwanth M & Albuquerque SR (1994)
Factors influencing initiation of breast feeding in an
urban setup. Ind J Paed, 31 (12): 1558-1560.
Arachavsky 1A. Immediate breastfeeding of newborn
infant in the prophylaxis of the so called physiological
loss of weight. Vopr Pediatric 1952, 20:45 Abstract in
courier 153, 3:170.
Sinusas K, Gagliardi A. Initial management of
breastfeeding. 2001 Sep; 64(6):981-8.
WHOs Indicators for Assessing Breast feeding
Practices, Wellstart International Tool Kit for
monitoring and Evaluating Breast feeding Practices and
Programs, 1998-99.
Page 369
pISSN: 0976 3325 eISSN: 2229 6816
5.
National
Family
Health
Survey
(NFHS-3),
http://www.nfhsindia.org.
6.
Evidence for the ten steps to successful breastfeeding:
Family and Reproductive health. Division of Child
Health and Development. World health Organization,
Geneva.
7.
Edmond K et al Delayed Breastfeeding Initiation
Increases Risk of Neonatal Mortality. Paediatrics 2006;
117:380-386.
8.
Kumari S et al (1988) Maternal attitude and practice in
initiation of newborn feeding. Ind J Paed, 55 (6): 905911.
9.
WHO/UNICEFF
Joint
Statement.
Protecting,
Promoting and supporting breastfeeding the special
role of maternity services. Geneva, WHO 1989.
10. Jellife DB, Jellife EP. Breastfeeding: world significance
in obstetric practice. J Trop Pediatr 1983; 29: 130-132.
11. Lawrence RA. Management of mother-infant nursing
couple. In :Breastfeeding –A Guide for the Medical
Profession. St. Louis, CV Mosby Company 1985; 1974179.
12. Rowe-Murray HJ & Fisher JR (2002) Baby –friendly
hospital practices: Caesaran section is a persistent
barrier to early initiation of breast-feeding. Birth, 29 (2):
124-131.
13. Kearney MH, Cronenwett LR, Reinhardt R. Cesarean
delivery and breastfeeding outcomes. Birth 1990; 17: 97103.
14. Ahmed FU, Rehman ME & Alam MS (1996) Prelacteal
feeding influencing factors and relation to
establishment of lactation. Bangladesh Med Res Counc
Bull, 22 (2): 60-64.
15. Available from: URL:
(http://worldbreastfeedingweek.org). Accessed
September 18, 2006.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
INVESTIGATION OF A CHOLERA OUTBREAK IN
KANPUR VILLAGE OF PANCHMAHAL, GUJARAT
Shroff Bhavesh D1, Mazumdar Vihang S2
1Assistant Professor, 2Professor & Head, Department of Community Medicine, Government Medical
College, Vadodara, Gujarat, India
Correspondance:
Dr. Shroff Bhavesh D.
Assistant Professor, Department of Community Medicine
Government Medical College
Vadodara, Gujarat, India – 390001
Email: [email protected]
Mobile: 9725518516
ABSTRACT
Introduction: Diarrhoeal disease outbreaks are causes of major public health emergencies in India.
We investigated such outbreak in Kanpur village of Panchmahal district, Gujarat to identify the
etiological agent, source of transmission and propose control measures. We also conducted casecontrol study to identify risk factors.
Results: The outbreak was caused by V. cholera 01. Cases were not localized to any specific area but
scattered in village depending on location of children who had eaten ice-cream from local vendor.
Contaminated water was not identified as possible source of the cholera outbreak.
Keywords: Cholera, outbreaks, local vendor
BACKGROUND
Cholera is a waterborne disease characterized by
severe diarrhea. The etiological agent is V.
cholerae O1 (more recently also V. cholerae O139),
which colonizes the small intestine and
produces an enterotoxin responsible for a
watery diarrhea. Without prompt treatment, a
person with cholera may die of dehydration in a
matter of hours after infection. Cholera
outbreaks
are
generally
associated
to
contaminated food and water supplies.
Until the 19th century, cholera was confined to
the Indian sub-continent1. There, cholera
outbreaks are seasonal with one or two peaks
per year2. From this region, cholera has spread
throughout the world seven times since 18173.
The last pandemic began in 1961 in Indonesia,
spread through the Asian continent during the
60's, reached Africa in 19704and Latin America
in 1991.
THE OUTBREAK
In May 2010, an outbreak of diarrhoea was
reported from Kanpur village of Panchmahal
district (Gujarat). A Rapid Response Team (RRT)
was constituted from Medical College, Baroda to
investigate the reported outbreak.
Kanpur had a population of 1950 with
approximately 170 Households (HH). Most of
the houses were scattered and people used hand
pump water for drinking purpose. There were
total 29 hand-pumps, there being at least one
hand-pump among 5-7 households.
As per the reports of Block Health Officer (BHO)
and Epidemic Medical Officer(EMO) of the area,
6 cases of nausea and 2 cases of diarrhea and
vomiting were reported and hospitalized at
CHC
Goghamba
and
simultaneously,
surveillance to find other cases was started.
During surveillance, a case of single episode
diarrhea was reported in a 12 year old female.
She had received ORS and Tab Metronidazole
(400mg) from the health worker. On the same
day, she developed severe diarrhea and
vomiting which was continuous in nature,
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lasting for 2 hrs. She succumbed within 2 hours
while on the way to the doctor.
After discussion with the BHO and the EMO at
the CHC, the team headed for Kanpur village.
On reaching the village, the team met medical
officer of the area who was engaged in
surveillance activities. After checking records of
surveillance teams, it was found that 3 cases of
diarrhea and vomiting had been detected. A
map of location all the hand pumps were made.
Children who had complaints of diarrhea and
vomiting were examined by the pediatrician and
their stool samples were collected by
microbiologist of the RRT. Three children were
referred to the CHC by the pediatrician for
treatment.
The team then headed to the house of girl who
had died due to diarrhea. Here, after verifying
the history, the surrounding area was examined;
water that they used for drinking and cooking
was checked. The stored grains and food items
were also checked. One significant finding in the
history was that the deceased had consumed ice
cream purchased from a vendor coming to the
village. The local people and the health
personnel of the area suspected the quality of
this ice-cream.
Out of the 742 children of the village, 38 children
had consumed ice-products from the vendor. A
day after, 15 had developed symptoms, among
them one died and 3 had severe symptoms.
A case control study was carried out to find out
the responsible risk factor/s for this outbreak.
The control group consisted of children who
belonged to the same village and were studying
in the same class as the patients. Subsequent to
enrollment of a case (total 15), eligible controls
of the same gender were approached until four
control children were individually matched to
each case because of the small number of the
cases. It was not possible to get suitable controls
for one case, so a total of 14 cases and 56 controls
were enrolled and the informed verbal consent
was obtained.
The study confirmed that ice cream
consumption from local vendor was associated
with the symptoms of the outbreak since odds of
having consumed the ice-cream among
symptomatics was 4.23 times that of those nonsymptomatics.
It was not possible to obtain the sample of icecreams, so couldn’t specify the responsible
type/ flavor of ice cream.
Table 1: Distribution of cases and controls based
on consumed ice-products
Cases
Controls
Total
Consumed ice
11
26
37
cream
Not consumed
03
30
33
ice cream
Total
14
56
70
X2 =4.64, p<0.05
Relative risk = 3.3, odds ratio= 4.23, 95%
CI=0.94-21.64
The EMO had also documented similar type of
out breaks from other areas of Panchmahal
district wherein, 8 cases of similar illness were
confirmed to be due to Cholera.
Reports of microbiological examination revealed
that of the samples taken by a Rapid Response
Team, 2 out of 3 were positive for V cholerae.
PREVENTIVE AND CONTROL MEASURES
TAKEN:
•
•
Family members of the deceased and other
persons of the village were made aware of
the reasons of Cholera in the given situation,
how it spreads, and importance of general
cleanliness and chlorination of water.
Distribution of chlorine tablets and
educating people how to use them was done
as well as prophylaxis with Doxycycline
was given to family contacts and in
neighboring houses when warranted. They
were also asked to adopt preventive
measures
for
averting
possible
contamination of drinking water.
CONCLUSION:
•
It was concluded from the investigations
that this outbreak of Cholera was caused by
V. cholera 01 and the source of the infection
was the consumption of the locally prepared
ice cream. Cases were not localized to any
specific area but scattered in village
depending on the consumption of the
contaminated product.
RECOMMENDATIONS:
•
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
It was recommended to halt and prevent the
further spread of this outbreak a ban on
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•
•
•
•
local vendor who was selling contaminated
ice-products specifically ice-cream. It was
also recommended to monitor other
producers of similar products as possible
potential sources of infection.
Monitoring of the quality of drinking water
also was recommended to be done by
sanitation staff.
Strengthening the surveillance in all villages
under the PHC was advised. Local health
workers were instructed to be vigilant for
unusual occurrences related to health and
report them immediately to their superiors.
Proper disposal and treatment of infected
fecal waste and all contaminated materials
(e.g. clothing, bedding, etc.) of cholera
patients as well as personal hygiene was
advised.
Medical officers were asked examine all
suspected cases of diarrhea/ vomiting, and
promptly manage the cases. If required,
immediate referral to higher centers must be
done. Continued surveillance to detect and
treat hidden cases in the community was
recommended.
ACKNOWLEGEMENT:
includes Dr.Amit Gamit (Assistant Professor,
Dept of Medicine) Dr.Vaishali (Assistant
Professor, Dept of Paediatrics) Dr. Sandeep
Nanda (Tutor, Dept of Microbiology),
Dr.Saurabh ( Resident, Dept of PSM) and
Dr.Mehul (Resident, Dept of Microbiolgy) for
their valuable activities during field visit.
We are equally thankful to Dr .Gohil, the Block
Health Officer, Dr.Patel, Emergency Medical
Officer of Panchmahal district and Medical
Officer and staff members of Kanpur PHC, for
their co-operation during field survey.
REFERENCES
1.
2.
3.
4.
We would like to express our gratitude to the
members of rapid response team of Medical
College and S.S.G. Hospital, Baroda , which
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Islam MS, Miah MA, Hasan MK, Sack RB, Albert MJ.
Detection of non-culturable Vibrio cholerae O1
associated with a cyanobacterium from an aquatic
environment in Bangladesh. Transactions of the Royal
Society of Tropical Medicine and Hygiene. 1994;88:298–
299
Faruque SM, Albert MJ, Mekalanos JJ. Epidemiology,
genetics and ecology of toxigenic Vibrio cholerae.
Microbiology and Molecular Biology Reviews.
1998;62:1301–1314. [
Morillon M, De Pina JJ, Husser JA, Baundet JM,
Bertherat E, Martet G. Djibouti, histoire de deux
épidémies de choléra: 1993-1994. Bull Soc Path Ex.
1998;91:407–411.
Islam MS, Drasar B, Bradley SR. Probable role of bluegreen algae in maintaining endemicity and seasonality
of cholera in Bangladesh: a hypothesis. J Diarrhoeal Dis
Res. 1994;12:245–256.
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ORIGINAL ARTICLE .
AN INVESTIGATION ON MEASLES OUT BREAK IN
NAVAGAM VILLAGE OF SURENDRANAGAR DISTRICT
OF GUJARAT, INDIA IN 2008
Jaydip R Oza1, Mallika Chavada1, Jagruti Prajapati1
1Resident,
Department of Community Medicine, B. J. Medical College, Ahmedabad
Address for correspondence:
Dr. Jaydip R Oza
24/Shrinath Residency, Near Swagat city,
Adalaj Gandhinagar
E mail: [email protected]
ABSTRACT
Background: An outbreak of measles was reported from a Navagam village of Surendranagar
District, Gujarat, in July 2008. The present study was conducted to investigate and assess various
epidemiological features associated with measles outbreak.
Methods: A community based cohort study was carried out in Navagam village of Surendranagar
district during month of June 2008. Suspected cases were detected through active case finding in the
community. Children <15 years of age with symptoms of Fever and rash and cough or coryza or
conjunctivitis (Red eye) in Navagam area of Kharaghoda PHC, Surendranagar district from 1st June,
2008 to 1st August, 2008 were identified as case in present outbreak. Blood samples were taken for
IgM antibody detection.
Results: The study covered 326 houses having 777children. An overall attack rate 11.17% was almost
equal in both male & female. Among measles cases, 45 (49.45%) had post measles complications. As
much as 69.23% children with measles had received measles vaccination in the past. Out of 11 blood
samples, 10 were positive for IgM antibody.
Conclusions: The outbreaks occurred due to poor vaccine coverage levels and an inefficient
surveillance system which failed to generate early warning signals.
Keywords: measles outbreak, measles vaccination, measles
INTRODUCTION
Measles is an acute, highly infectious disease of
childhood, characterized by fever, catarrhal
symptoms and typical rash1. World Health
Organization (WHO) has reported 31 million
cases and 7.77 lakh deaths in the year 20002.
Despite the availability of a safe and effective
vaccine, globally measles killed over 530,000
and 182,000 in South East Asian region as
reported in 20033. Outbreaks of measles in a
community tend to occur once the proportion of
susceptible reaches 40%4. In 2008, there were
2,81,972 reported cases and 164 000 measles
deaths globally – nearly 450 deaths every day or
18 deaths every hour. Most measles-related
deaths are caused by complications associated
with the disease. Complications are more
common in children under the age of five, or
adults over the age of 20. The most serious
complications of measles infection reported
from India include: severe diarrhea, otitis
media, bronchitis, pneumonia, meningoencephalitis, acute exacerbation of malnutrition,
blindness
and
subacute
sclerosing
panencephalitis. Infants and young children,
especially those that are malnourished, are at
highest risk of dying from measles. A review of
community based studies of published measles
outbreak investigations found a median case
fatality ratio of 3.7%, range 0 to 23.9%5.
Measles morbidity As high as 10% of measles
cases result in death among populations with
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high levels of malnutrition and a lack of
adequate health care. More than 20 million
people are affected by measles each year. The
overwhelming majority (more than 95%) of
measles deaths occurs in countries with low per
capita incomes and weak health infrastructures.
There for the fourth Millennium Development
Goal (MDG 4) aims to reduce the under-five
mortality rate by two-thirds between 1990 and
2015. Recognizing the potential of measles
vaccination to reduce child mortality, and given
that measles vaccination coverage can be
considered a marker of access to child health
services, routine measles vaccination coverage
has been selected as an indicator of progress
towards achieving MDG 46. Measles is an
important cause of morbidity and mortality
among the children of India with a median case
fatality rate of 2.5%2. The primary reason for
this high disease burden is inadequate
vaccination coverage due to under-utilization of
measles vaccine and weak immunization.
Services in many parts of the country. This is
unacceptable, because measles vaccine is highly
effective, safe, and cost-effective5.
BACKGROUND
On 29th July, 2008, one of the medical officers of
Patdi block, Surendranagar district, Gujarat
informed about cluster of measles cases in
Khara Ghoda village of Khara Ghoda PHC,
Surendranagar district, Gujarat. 36 cases of
measles were reported from Khara Ghoda
village. No children were reported to have died
from the disease. On 30th July, 2008, a team
from B. J. Medical College, Ahmedabad initiated
the investigation. This study was undertaken to
investigate the extent of the problem, possible
factors responsible for its occurrence and for
recommending
control
and
preventive
measures.
MATERIALS AND METHODS
Khara Ghoda PHC of the Patadi block
(Surendranagar district) situated at 67 KM away
from the Surendranagar with population of
29,914. Khara Ghoda. The block has the
population of 1, 68,062. Vaccination coverage of
overall Patadi block was reported 70% in 20072008. No previous year coverage data of measles
vaccination for the PHC was available.
A cross sectional survey was carried out during
the month of June-Aug, 2008 by the team from
the department of community medicine. The
team comprised of tutors and resident doctors
from the same department and paramedical
staff of kharaghoda PHC. The village is
comprised of 3 hamlets; Cases were reported
from Navagam hamlet of kharaghoda village.
There were usually 5 to 10 cases reported each
year in the Patdi block .36 cases were reported
from 3 villages of Kharaghoda PHC which was
clearly in excess that indicated existence of
epidemic.
The standard case definition was used for
diagnosis of measles. A combination of major
and minor criteria was used to clinically identify
the measles cases.
Major criteria: Fever, Rashes
Minor criteria: Presence of cough, or coryza, or
conjunctivitis
A study subject was considered to have measles
if he presented with major criteria and any of
the three minor criteria. Children <15 years of
age with symptoms of Fever and rash and
cough or coryza or conjunctivitis (Red eye) from
1st June, 2008 to 1st August, 2008 were
identified as case in present outbreak. We
searched for the cases by house to house visit.
Inquiries about measles cases were made from
the mothers or responsible persons. Inform oral
consent was taken of interviewee before
initiation of the survey.
We collected information about measles
vaccination, previous history of measles and
any complication of measles and outcome of
cases. Immunization status was assessed by
checking the cards where available or by a
convincing history of immunization given by
the mothers. “Unknown” was used to designate
patients with no knowledge of their
immunization status. Any episode of diarrhea,
pneumonia, ear infection (dummy for Ottitis
media) like complication asked
Blood samples were collected from 11 case
patients 4 to 28 days after rash onset. Samples
were sent to microbiology laboratory of B. J.
Medical College, Ahmedabad on 1st August,
2008 for detection of IgM antibody for measles
virus. Data was analyzed in the epi info version
4.1software. We described the outbreak through
time, place and person. Depend upon the
findings we made hypothesis.
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RESULTS & DISCUSSION
11 blood samples were sent to microbiology
department of B.J. Medical College, Ahmedabad
on 1st August, 2008 for IgM antibody for
measles virus. Out of 11 samples, 10 samples
were positive for IgM antibody. The other cases
were confirmed by epidemiological linkage.
We had surveyed 326 houses covering 809
children below 15 years of age. Children were
equally distributed in age group of 37 months to
144 months(22 to 23%) followed by 17.26% in
age group 10 months to 36 months. 55.75%
children were male and 44.25% female.The
outbreak
at
Kharaghoda
village
had
commenced in the first week of June, 2008,
reached a peak in the third week of July and
ended gradually in the first week of August.
(Figure 1)
Figure 1: Epidemic curve of measles outbreak in Navagam area, Kharaghoda PHC, Surendranagar
district, Gujarat, India, June-August, 2008
Table 1: Attack rate of measles by Age and Sex,
Navagam, Kharaghoda PHC, Surendranagar
district, Gujarat, India, June-August, 2008
Variable
Age
groups (In
months)
0-9
10-36
37-72
73-108
109-144
145-180
Sex
Male
Female
Total
No of
Cases
Population
(%)
Attack rate
(%)
2
21
26
27
11
5
35(4.33)
145(17.92)
183(22.62)
186(22.99)
177(21.88)
83(10.26)
5.71
14.48
14.20
14.51
6.2
6.02
50
42
92
451(55.75)
358(44.25)
809(100)
11.09(0.86p)
11.73(0.03x)
11.37
We identified 92 cases and no death with overall
attack rate of 11.37%. Attack rate was similar for
the age group 10 months to 108 months (14% to
15%). 6% attack rate was found in the children
less than 9 months and more than 108 months.
Attack rate was almost same between both the
sexes with no statistical significance. (Table 1)
Attack rate of measles was 9.22% amongst
vaccinated (Table 2). Vaccine efficacy was
turnout to be 45%.
CONCLUSION
A measles outbreak affected Navagam hamlet.
The most likely cause was low vaccine coverage
and low vaccine efficacy.The study highlights
the urgent need to raise the vaccine coverage
levels rapidly in all districts to achieve measles
control and prevent future outbreaks in UP.
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Table 2: Attack rate of measles by vaccination
status in children from 9-180 months of age,
Navagam, Kharaghoda PHC, Surendranagar
district, Gujarat, India, June-August, 2008
1)
2)
Vaccine
Measles
Given
Yes
49
No
51
Total
90
X2= 9.48, P =0.002
4)
Total
531
243
774
Attack
Rate (%)
9.22
16.87
11.62
3)
5)
6)
Indian Journal of Pediatrics, Volume 72—October, 2005
World Health Organization. Global measles mortality
reduction and regional elimination, 2000-2001. Part I,
Wkly Epidemiol Rec 2000, 77: 50-55.
Measles Mortality Reduction and Regional Elimination
Strategic Plan 2001- 2005 (WHO/V&B/01.13).
Park K. Mealses. In Park’s textbook of Preventive and
Social Medicine. 17th edn. Jabalpur; Banarsidas Bhanot
Publishers, 2002; 117-120.
Measles Mortality Reduction and Regional Elimination
Strategic Plan 2005- 2010 (WHO/V&B/01.13)
Singh J, Sharma RS, Verghese T. Measles mortality in
India: A review of community based studies. J Commun
Dis 1994; 26: 203-214.
REFERENCES
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ORIGINAL ARTICLE .
STUDY OF HEALTH PROFILE OF RESIDENTS OF
GERIATRIC HOME IN AHMEDABAD DISTRICT
Kavita Banker1, Bipin Prajapati2, Geeta Kedia3
1Tutor,
Community medicine department, B.J.Medical College, Ahmedabad 2Assistant Professor,
Community medicine department, Gujarat Adani Institute of MedicalSciencies,Bhuj 3Professor and
Head, Community medicine department, B.J.Medical College, Ahmedabad, Gujarat.
Correspondence:
Dr. Bipin Prajapati,
9,Radhe Bunglows, Opp.Amrut Party Plot,
Modhera Road,Mahesana-384002, Gujarat, India
E-mail - [email protected], [email protected] Mobile: 9904384100.
ABSTRACT
Background: Aging is a normal process. The modernization plays a vital role in aging process of an
individual. The aged feel a sense of social isolation because of disjunction from various bonds viz
work relationships, and diminish of relatives and friends, mobility of children to far off places for
jobs. The situation of the elderly still worsens when there is presence of chronic diseases, physical
incapacity and financial stringency.
Objective: To know the health profile and health related problems of the old age inmates residing at
geriatric homes.
Material and Methods: A cross sectional study was carried out in geriatric homes of urban and
periurban areas of Ahmedabad during January 2008 to January 2009.
Result: Out of total 530 inmates, 45.85% were males and 54.15% were females. 93.77% reported one or
more health related complaints. 37.4% were obese and 11.9% were underweight. Most common
presenting symptoms were: loss of teeth (70%), joint pain (60.2%), impaired vision (44.2%), weakness
(34.9%), and insomnia (34%). 82.3% were using spectacles followed by walking sticks (21.7%) and
denture (12.8%).The main health related problems were osteoarthritis (54.9%), hypertension (54.2%),
cataract(16%) and diabetes mellitus(14.9%).
Conclusion: The study highlighted a high prevalence of morbidity and health related problems in old
age groups. We need to strengthen geriatric health care services, social support by people, proper
implementation of geriatric related legislation by government and further research like qualitative
research to explore the problems of the elderly.
Key words: cross sectional study, Geriatric home, health profile.
INTRODUCTION
“Forty is the old age of youth; fifty is youth of
old age.”- a French phrase meaning that natural
process of waxing and waning of the body
ageing which start at very young age but is
visible only in old age1
There has been a progressive increase in both
the number and proportion of the aged in India
over time, particularly after 1951. Between 1901
and 1951, the proportion of population over age
60 years increased marginally from 5 percent to
5.4 percent, while by 2001 this had increased to
7.0 percent. The size of the elderly rose in
absolute terms during the last century from 12
million in 1901 to approximately 71 million in
2001 and is likely to reach 113 million in 2016.
The proportion of elderly is much higher in the
rural areas than in the urban areas and the
increase is greater among women 2. The
modernization plays a vital role in aging process
of an individual. The aged feel a sense of social
isolation because of disjunction from various
bonds viz work relationships, and diminish of
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relatives and friends, mobility of children to far
off places for jobs. The situation of the elderly
still worsens when there is presence of chronic
diseases, physical incapacity and financial
stringency3.
Presently, there are 1018 geriatric homes in India
today. Out of these, 427 homes are free of cost
while 153 geriatric homes are on pay and stay
basis, 146 homes have both free as well as pay
and stay facilities and detailed information is
not available for 292 homes. A total of 371
geriatric homes all over the country are available
for the sick and 118 homes are exclusive for
women. A majority of the geriatric homes are
concentrated in the developed states including
Gujarat 4.The present study is to understand the
health problems of elderly and analyse them.
Objective of the study is to know the health
profile and health related problems of the old
age inmates residing at geriatric homes.
MATERIAL AND METHODOLOGY
The cross sectional study was carried out in
geriatric homes of urban and periurban areas of
Ahmedabad. A list of geriatric homes of
Ahmedabad was obtained. The present study
was conducted from January 2008 to January
2009. All inmates more than 60 years of age were
included in study. Predesigned, pretested
questionnaire was used for the study. Prior
permission was taken from trusty/manager of
geriatric home. Before data collection informed
consent was taken from inmates. Each
individual in the study was subjected to
personal interview and clinical examination.
Complete general and systemic examination
was carried out for all the inmates of geriatric
homes, especially Respiratory, Cardiovascular,
Gastrointestinal, Genitourinary and Central
nervous system were examined and findings
were recorded on proforma. Information related
to chronic diseases was reported based on their
report of investigation done by their
physician/doctor or file of patient. Data entry
and data analysis was done in Epi-info software
version 3.5.Percentage and chi-square test was
applied.
RESULTS
530 inmates were examined in all 13 geriatric
homes in Ahmedabad district. Among them
45.85% (243) were males and 54.15% (287) were
females (Table 1). It was observed that
473(89.2%) of them were married, 86(78.8%)
were widows / widowers, 14(2.9%) were
separated and 57(10.8%) were unmarried.
497(93.77%) reported one or more health related
complain.
Table 1: Age and Sex wise distribution of
inmates of geriatric homes
Age
(in
years)
60-70
70-80
80-90
90-100
100-110
Total
Sex
Males
No. (%)
101(41.6)
110(45.3)
29(11.9)
3(1.2)
00(0)
243(45.85)
Females
No. (%)
145(50.5)
120(41.8)
19(6.6)
2(0.6)
1(0.3)
287(54.15)
Total
No. (%)
246(46.4)
230(43.3)
48(9.1)
6(1.1)
1(0.1)
530(100)
Half (50.7%) of inmates were having normal
Body Mass Index (BMI). 37.4% were overweight.
More female inmates (41.8%) were overweight
and more male inmates (16.0%) were
underweight but there was no significant
difference in the BMI among males and females
(Table 2).
Table 2: Distribution of inmates according
BMI
BMI
<18.5
18.5-24.99
≥ 25
Males (%)
Females
Total (%)
(n=243) (%) (n=287) (n=530)
39(16.0)
24(8.3)
63(11.9)
126(51.9)
143(49.5)
269(50.7)
78(32.5)
120(41.8)
198(37.4)
Most common presenting symptoms of the
elderly were: loss of teeth (70%), joint pain
(60.2%), impaired vision (44.2%), weakness
(34.9%), and insomnia (34%) (Table 3).
Most of inmates (82.3%) were using spectacles
for better vision followed by walking sticks
(21.7%) and denture (12.8%).There was no
significant difference among males and females
and use of supportive aids (Table 4).
More than half (61.3%) of patients were
suffering from morbidity of musculoskeletal
system (Table 5). Among them majority of
inmates were suffering from osteoarthritis
(54.9%).More females (62.0%) were suffering
from osteoarthritis than males (46.5%).
Significant difference was found among males
and females (x2=13.87, p<0.05) (Table 6).
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Table 3: Common presenting symptoms among inmates
Symptoms
Males (%) (n=243)
Females (%) (n=287)
Loss of teeth
163(67.1)
208(72.5)
Joint pain
117(48.1)
202(7(0.4)
Impaired vision
109(48.1)
125(43.6)
Impaired memory
79(32.5)
105(36.6)
Weakness
87(35.8)
98(34.1)
Insomnia
63(25.9)
117(40.8)
Constipation
50(20.6)
70(24.4)
Giddiness /Fainting
36(14.8)
36(12.6)
Poor appetite
32(13.2)
59(20.6)
Body ache
23(9.5)
53(18.5)
Frequency of fall
19(7.8)
22(7.7)
Pedal oedema
14(5.8)
23(8.0)
Cough
20(8.2)
17(6.0)
Headache
15(6.2)
21(7.3)
Loss of weight
16(6.6)
19(6.6)
Shortness of breath
13(5.3)
17(5.9)
Tremors of hand
13(5.3)
13(4.5)
Urinary problems*
13(5.3)
8(2.8)
Breathlessness
11(4.5)
9(3.1)
Diarrhoea
4(1.6)
10(3.5)
(Multiple Response)
*Urinary problems (incontinence, frequency of urination, hesitation)
Table 4: Use of supporting aids due to ageing
Use of
Males (%) Females(%)
aids*
(n=243)
(n=287)
Spectacles 198(81.5)
238(82.9)
Walking
52(21.4)
63(22)
sticks
Denture
38(15.6)
30(10.5)
Knee cap
6(2.5)
9(3.2)
Walker
3(1.2)
9(3.1)
Hearing
3(1.2)
3(1.0)
aids
Back belt
4(1.6)
5(1.7)
Wheel
0
1(0.003)
chair
(Multiple response)*
Total (%)
(n=530)
436(82.3)
115(21.7)
68(12.8)
15(2.8)
12(2.3)
6(1.1)
9(1.7)
1(0.001)
More than half 300 (56.6%) of inmates had one
or the other diseases of cardiovascular system
(Table 5). Hypertension was found in maximum
287(54.2%) inmates. Hypertension was more
common among females (59.6%) as compared to
males (47.7%). This difference was statistically
significant (x2=8.27, p<0.05) (Table 6). 9.4% of
inmates had diseases of respiratory system
(Table 5), and 7.9% had bronchial asthma (Table
6). Health related problems in relation to
dermatological disorders (10.9%), GI system
(7.4%), Psychiatric disorders (4%), GUT (1.2%),
Total (%)
371(70.0)
319(60.2)
234(44.2)
184(34.7)
185(34.9)
180(34.0)
120(22.6)
72(13.6)
91(17.2)
76(14.3)
41(7.7)
37(7.0)
37(7.0)
36(6.8)
35(6.6)
30(5.7)
26(4.9)
21(4.0)
20(3.8)
14(2.6)
CNS and thyroid disorders (1.7%) were found
(Table 5).
Table 5: Prevalence of morbidities of inmates
according to system affected
System
Males
Females
diseases
(n=243)
(n=287)
Musculoskelet 122(50.2) 193(67.2)
al system
Cardiovascular 121(49.8) 179(62.4)
system
Dermatological 22(9.1)
36(12.5)
disorders
Respiratory
27(11.1)
23(8.0)
system
GI system
15(6.2)
24(8.8)
Psychiatric
13(5.3)
8(2.7)
disorders
Central
4(1.6 )
5(1.7)
Nervous
Disorders
GUT
2(0.8)
4(1.4)
Thyroid
4(1.6)
5(1.7)
disorders
(Multiple morbidities present)
Total (%)
(n=530)
325(61.3)
300(56.6)
58(10.9)
50(9.4)
39(7.4)
21(4.0)
9(1.7)
6(1.2)
9(1.7)
The prevalence of cataract 16%, diabetes
mellitus 14.9%, deafness 12.5%, were also found
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in the present study (Table 6). One male (0.4%)
inmate was suffering from oral cancer and 2.8%
of the females were suffering from either of the
breast, uterine or cervix cancer. Over all
prevalence of cancer among the inmates was
1.7% in the present study (Table 6). 33(6.23%)
inmates were not suffering from any diseases.
Table 6: Prevalence of diseases among inmates
Disease condition Males(%)(n=243)
Osteoarthritis
113(46.5)
Hypertension
116(47.7)
Cataract
33(13.6)
Diabetes mellitus
40(16.5)
Deafness
32(13.2)
Bronchial asthma
22(9.0)
Cancer
1(0.4)
(Multiple morbidities present)
Females(%)(n=287)
178(62.0)
171(59.6)
52(18.1)
39(13.6)
34(11.8)
20(7.0)
8(2.8)
DISCUSSION
Old age is the last phase of human life cycle and
the duration of this period depends upon the
lifestyle enjoyed so far. Old age should be
regarded as normal, inevitable biological
phenomenon 5 .
In present study 37.4% inmates were obese and
11.9% were underweight (Table 2). This is in
contrast to findings of the study done by
G.K.Medhi et al6 (prevalence of obesity was
19.4% and of underweight was 23.6%).
70% of inmates had complains of loss of teeth.
Joint pain was the second common symptom,
comprising 60.2% individuals who had
restriction in mobility and limiting day to day
activities. Other common presenting symptoms
were impaired vision (44.2%), weakness (34.9%),
and insomnia (34%) (Table 3). In a study done
by H.M.Swami et al7 pain in joints (38%),
limitation
of
movements
(22.4%),
indigestion/heart burn (18.2%), backache
(15.3%), and excessive tiredness/weakness
(17.9%) were common finding. 93.77% had one
or more health related problems, whereas Ray8
observed same in 81.3% and SPS Bhatia9 in
86.1% aged persons.
54.9% of inmates were suffering from
osteoarthritis (Table 6). M.K.Sharma et al10
observed osteoarthritis in 57.2% individuals.
More females (62.0%) were suffering from
osteoarthritis than males (46.5%). The reason for
this may be that the post menopausal females
suffer more from osteoporotic and degenerative
changes due to hormonal withdrawal. High
prevalence of arthritis/joint pain among females
Total(%)(n=530)
291(54.9)
287(54.2)
85(16)
79(14.9)
66(12.5)
42(7.9)
9(1.7)
X2 value
13.87
8.27
2.01
0.86
0.21
0.78
4.45
P value
<0.05
<0.05
>0.05
>0.05
>0.05
>0.05
>0.05
was also reported by N.P.Das et al2 (Female57.1%, Male-43%).
In a study by Surekha Kishore et al11 prevalence
of hypertension in elderly persons was 41.4%. A
study conducted in Chandigarh by Kumar12
found 44.9% prevalence of hypertension. This is
comparable
with
present
study
(54.2%).Hypertension was more common
among females (59.6%) as compared to males
(47.7%) in present study. Chadha et al13 reported
prevalence rate of 58.8% and 52.2% among
females and males respectively. Similar results
were also reported by SPS Bhatia9 (Females46.4%, Males- 34.9%).
In this study dermatological problems were
found in 10.4% inmates (Table 5). Similar
finding was observed by the Kokhar14 (8.5%).
9.4% of inmates had diseases of respiratory
system (Table 5). Similar finding was reported
by H.M.Swami et al7(8.6%) and Kishore15 (7.3%)
. RB Gurav et al16 found prevalence of bronchial
asthma 7.92%, which matches with the present
study (7.9%) (Table 6).
The prevalence of diabetes mellitus was 14.9% in
present study (Table 6), similar finding was seen
in study conducted by H.M.Swami et al7
(12.2%).
Compared to our study results, higher GIT
morbidity was found amongst study conducted
by M.K. Sharma et al10(7.4% versus 31.9%)(Table
5).Prevalence of genitourinary disorder was
found 1.2% in present study, where as in the
study conducted in rural area of Varansi district
17 and Rajasthan based study18 prevalence of
genito urinary disorder was 5% and 2%
respectively.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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The presence of central nervous system
problems and psychiatric disorders among the
inmates were 1.7% and 4% respectively (Table
5). Rahul Prakash et al18 reported the prevalence
of disorders of nervous system to be 8.6% in
elderly persons which is much higher as
compared to the present study. 38.4%
prevalence of psychiatric disorders was reported
by Arvind Mathur 19. The rapid urbanization
and social modernization has brought
breakdown in family values and the framework
of family support, economic insecurity, social
isolation and elderly abuse leading to a host of
psychological illness20.
Eye problems were found to be present in 19.6%
of inmates. The leading cause of diminished
vision in developing countries is cataract, which
was found in present study in 16% of elderly
inmates (Table 5). SPS Bhatia9 observed same in
18.6% of aged persons. 12.5% inmates were
suffering from deafness (Table 6). This is in
agreement with a study conducted in
Pondicherry21 (15.4%).
RECOMMENDATION
The study highlighted a high prevalence of
morbidity and health related problems in old
age group. We need to develop geriatric health
care services, regular health check up, social
support by people, proper implementation of
geriatric related legislation by government and
training to health care providers and further
research like qualitative research to explore the
problems of the elderly.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
ACKNOWLEDGEMENT
We are thankful to trustee of geriatric home who
has given permission to us for this study and
geriatric people who had shared their valuable
experiences and spent precious time.
17.
18.
REFERENCE
1.
2.
Article in News Paper Divya Bhaskar,Women Bhaskar,
“Old age is not alternative of illness”. Tuesday-7th
April-2009;6.
N.P. Das, Urvi Shah, A study of old age homes in the
care of the elderly in Gujarat, Population Research
Centre, Department of Statistics, Faculty of Science,
M.S. University of Baroda, Baroda-390 002,December
2004.
prcsmohfw.nic.in/writereaddata/research/416.htm
19.
20.
21.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
J Sheela & M Jayamala, Health condition of the elderly
women: a need to enhance their well being, IJSAS 1(1)
2008, pp. Copyright © 2008 by Society for South Asian
Studies,Pondicherry,University.www.pondiuni.edu.in/jou
rnals/ssas/12_sheela_jayamala.pdf
Directory of Old Age Homes in India, Help Age India,
2002.
Park K. Park’s Text Book of Preventive and Social
Medicine,15th edition. Banarsidas Bhanot, Jabalpur.
1999; 388-90
G.K.Medhi , NC Hazarika, PK Borah, J Mahanta
,Health problems and disability of elderly individuals
in Two population group from same geographical
location JAPI, July 2006,Vol-54.
H.M. Swami, Vikas Bhatia, Rekha Dutt, SPS Bhatia. A
Community Based Study of the Morbidity Profile
among the Elderly in Chandigarh, India, Bahrain
Medical Bulletin, March 2002;24,(1).
Ray SC. A medico –social study of aged persons. A
thesis for MD (P and SM).AIIMS New Delhi;1975.
SPS Bhatia, HM Swami, JS Thakur, V Bhatia, A study of
health problems and Loneliness Among the Elderly in
Chandigarh,IJCM,Oct 2007;32,(4);255-258.
M.K. Sharma, H.M. Swami, Rajbir Gulati, Vikas Bhatia ,
Dinesh Kumar Life style and morbidity profile of
geriatric population in urban area of Chandigarh.
Journal of The Indian Academy of Geriatrics, Dec,
2005.Vol. 1(3),122-125.
Surekha Kishore, Ruchi Juyal, Jayanti Senwal, Ramesh
Chandra. Morbidity profile of elderly persons. JK
Science, April-June 2007;9(2);87-89.
Kumar R, Ahlawat SK, Singh MM, Thakur JS. Time
trends in prevalence of risk factors of cardiovascular
diseases in Chandigarh. IAPSM 3 rd conference (NZ)
Chandigarh; 2000.
Chadha SL, Radhakrishna S. Epidemiological study of
coronary heart diseases in urban population of Delhi.
Indian J. Med. Research 1990;92:424-30.
A Khokhar, M Mehera. Life style and morbidity profile
of geriatric population in urban area, Delhi. Indian
Journal of Medical science, 2001, volume-55, (11); 609615.
Kishore S, Garg BS. Sociomedical problems of aged
population in a rural area of Wardha. Indian J Public
Health 1997; 41:43-8.
RB Gurav, S Kartikeyan. Problem of geriatric
population in an urban area. Bombay hospital
journal,Jan-2001;44,(1).
Shankar R, Tandon.J, Gambhir.I.S., Tripathi.C.B. Health
status of elderly population in rural area of Varansi
district. Indian Journal of Public Health 2007; 51 (1):5658.
Rahul Prakash, S.K.Choudhary, Uday Shankar Singh. A
study of morbidity pattern among geriatric population
in an urban area of Udaipur Rajasthan, Dept of
community medicine, R.N.T. Medical college, Udaipur
Rajasthan, Indian Journal of community medicine, JanMarch-2004, Vol-29, No.1,35-40.
Arvind Mathur, Contemporary issues in the health of
elderly,
Chap-7,38-43
http://apindia.org/medicine_update_2007/7.pdf
Ingle GK, Nath A. Concerns and solutions for problems
in geriatric health in India. Indian journal of
community Medicine.2008;33:214-218.
Purty AJ, Bazroy J, Kar M, Vasudevan K, Veliath A,
Panda P. Morbidity Pattern among the elderly
population in the rural area of Tamil Nadu, India. Turk
J Med Sci 2006; 36: 45.50.
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ORIGINAL ARTICLE .
A STUDY ON AVAILABILITY OF BASIC CIVIC FACILITIES
IN URBAN SLUM AREA OF BHUJ, GUJARAT, INDIA
Bipin Prajapati1, Kavita Benker2, K N Sonalia3, Nitiben Talsania4, Siddharth Mukherjee5, K N
Trivedi6
1Assistant
Professor, Community medicine department, Gujarat Adani Institute of Medical
Sciencies,Bhuj 2Tutor, Community medicine department, B. J. Medical College, Ahmedabad,
3Professor, Community Medicine Department, Gujarat Cancer Society (GCS) Medical College,
AHmedabad 4Professor, Community medicine department, B. J. Medical College, Ahmedabad
5Medical Superintendent, Gujarat Cancer Society (GCS) Medical College, AHmedabad 6Professor,
Community medicine department, Gujarat Adani Institute of Medical Sciencies,Bhuj
Correspondence:
Dr. Bipin Prajapati,
9,Radhe Bunglows, Opp.Amrut Party Plot,
Modhera road,Mahesana-2,Pin-384002,Gujarat,India
E-mail - [email protected] or [email protected] Mobile no:9904384100
ABSTRACT:
Background: In cites of India, There is around 50-60% of the population of the urban areas that lives
in urban slums where basic facilities such as water, sanitation, health, electricity etc are poor. Disease
morbidity and mortality is high due to poverty, poor nutrition and poor education and children
living on payments slum are more exposed to drug abuse, child labour and sexual exploitation.
Objective: To study the availability of basic civic facilities in urban slums in bhuj city.
Materials and Methods: A cross sectional study was carried out between january 2011 to june 2011 on
randomly selected 109 households at ramdevnagar (urban slum) area located in the western part of
bhuj. House to house survey was carried out and information was obtained on predesigned and
pretested proforma by interviewing the head and or other members of family. Family details, ration
card, election card, water,gutterline, waste disposal, electric connection, education, availability of
basic health facility were included in the proforma. The data were analyzed in microsoft excel.
Results: 50.4% houses are permanent, 73% are having BPL ration card, 5.5 % houses is having
municipality water line connection, no house is having gutter connection and 58.7% houses are
having electricity connection, 60% houses don’t have toilet facility, No houses have the facility of
dumping solid waste. lack of basic infrastructure and primary health facilities in this area.
Conclusion: There are infrastructural issues like lack of permanent road, street light, dumping of
solid waste, drinking water facility and drainage of waste water facility. Proper implementation of
stretegy of town planning. Improve the efficiency of public health system in the cities by strenghthing
, revamping and rationalizing urban primary health structure.
Key words : Drinking water ,urban slum, basic facility.
INTRODUCTION
Slums are an urban phenomenon which comes
into existance on account of urbanization and
industrilization in and around cities thereby
attracting in migration of population in
countryside. Through slums are rich source of
unskilled and semiskilled manpower, they tend
to result in burden on the civic existing
amenities.Government agencies and NGO have
flung into action and initiated in several
measures to improve the plight dwellers and
make the slum areas livable for the habitants as
of late they are view as effective agents in the
process of urban development rather than
burden on urban infracture. A slum is a compact
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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pISSN: 0976 3325 eISSN: 2229 6816
settlement with a collection of poorly built
tenements, mostly of temporary nature, crowed
together usually with inadequate sanitary and
drinking water facilities in unhygienic
conditions in that compact area1. There is
around 50-60% of the population of the urban
areas that lives in urban slums where basic
facilities
such
as
water,sanitation,health,electricity etc are poor.
Disease morbidity and mortality is high due to
poverty, poor nutrition and poor education and
children living onpayments slum are more
exposed to drug abuse, child labour and sexual
exploitation. Urban growth has led to rapid
increase in number of urban poor population,
many of whom lives in slums and other sqatter
settlements. Slums are generally dirty and
unclean, and have shortage of water supply,
inadequate lighting and sanitation facilities. The
United Nations has been more concerned with
the slums of developing countries. The health
hazards of the urban slum dwellers are directly
related to poverty and a polluted and stressful
environment2. They are more prone to
communicable diseases and malnutrition and at
the same time exposed to greater risk of
accidents at work3.
In the last two decades, India's population has
increased by 2.25%, but the urban population
has increased by 3.8%4. An estimated 30% of the
population in 12 major cities of India lives in
slums and the proportion of slum dwellers and
squatters have been continuously increasing.
Therefore, the sanitary conditions and housing
conditions of slum dwellers are deteriorating
day-by-day, This calls for an urgent need for
evolving a rational policy on urban
resettlement5.
As per Census 2011- urban population 35.7 crore
in 2011 and 43.2 crore in 2021. National Family
Health Survey -3 revealed that Households
withaccess to piped water supply at home are
13%, Public tapehand pump for drinking water
are 72.4%, Using a sanitary facility for the
dispose of excreta are 40.5%, School
attendance6-17 years male- 67.3 %, School
attendance6-17 years female-61.4 %, Women age
15-49 yrs with no education – 60.9 %6. Under
Millenium development goals (MDG) all people
of the country have access to safe drinking water
and improved sanitation.
OBJECTIVE
To study the of availability of basic civic
facilities in urban slums in bhuj city.
MATERIALS AND METHODS
A cross sectional study was carried out in
january 2011 to june 2011 at ramdevnagar urban
slum area located in the western part of ward-1.
This area is well connected with kodki road and
bhuj city, Gujarat. The area was randomly
selected for ease of study. House to house
survey was carried out and information was
obtained on predesigned and pretested
proforma by interviewing the head and or other
members of family. Family details, ration card,
election card, water,gutterline, waste disposal,
electric connection, education, basic health
facility these information were collected in the
proforma.
Out
of
113
households,109
households were included in the study (4
households were not were not available/ not
cooperating).The data were analyzed in
microsoft excel.
RESULTS
Total area of Ramdevnagar is 1.83 hector.
Population density is 285 per hector which is
very less in comparison to other city areas.
1 room
+
kitchen
10
9%
1 room
+
kitchen
37
34%
1 room
+
kitchen
1
1%
1 room
only
61
56%
Fig 1: Distribution of households according to
number f rooms
Out of 523 population of 109 househods, 50.4%
houses are permanent. These permanent houses
are made of concrete blocks and cement,
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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remaining (49.6%) houses are temporary, these
houses are hut type made up of plastic sheets
(Figure-2).
Tempor
ary
14
13%
Hut
22
20%
Perman
ent
54
50%
Semiperman
ent
19
17%
Fig 2: Distribution of households according to
housing condition
Most of the people need permanent house and
most of the families reside in 1 room house
which is not enough for family size of 5 persons.
Infrastuctural facility is the main problem of
Ramdevnagar. Very few families are having
municipal water line connection (5.5 %) and
even though the main gutter line passes nearby
this area, no house is having gutter connection
and 58.7% houses are having electricity
connection. There is no facility for dumping
solid waste. Road condition is also not much
good. Inner roads of this area are taken care by
local people.
Access to drinking water is a major problem in
this area. Only 5.5% families are having
municipal water connection. From remaining
families, 55.5% families get drinking water from
neigbouring families who have acces to water
connection(Table 1). 40% families get drinking
water from private tankers by nagarpalika.
Daily 1 tanker is arranged/ ordered which
provides drinking water to the families of this
area. Majority families (60%) don’t have toilet
facility and go in open air defecation, 8%
families share the toilet facilities with neigbour
houses. Only 35(32%) families have toilet facility
in house. Similarly 75% families don’t have
bathroom facility and bath in open. While only
8(7%) families share bathroom facility, 19(17%)
families have bathroom in house. 16% families
have soak pit, 84% families do not have any
facility for removal of waste water (Figure - 3).
So the polluted water is thrown in open area
which leads to increase of contamination and
spread of diseases. No houses have the facility
of dumping solid waste. All families are
dumping their solid waste on roads, which leads
to increase in diseases and illness in the area.
Munici
pal
Connect
ion
11
9.24%
Table 1: Distribution of households according to
availability of Drinking water facility (n=120)
Source of Drinking
Water
In-home
Neighbor House
bore well
Dunky/ Hand pump
From other area
Municipality Tanker
Private Tanker
Public Stand
Public well
Number of Household
(%)
6 (5.00)
50 (41.67)
2 (1.67)
8 (6.67)
2 (1.67)
1 (0.83)
49 (40.83)
1 (0.83)
1 (0.83)
Soackpi
t
(khado)
16
13.45%
Nothin
g
92
77.31%
Fig 3: Distribution of households according to
availability of Drainage facility
According to age wise distribution- 18 to 59 year
old people are 48% (22.9% female, 25.1%
male),under five Children are 18.1% (9.9%
female, 8.2% male), 6 to 17 year old
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children/youth are 30.8% (15.7% female, 15.1%
male), above 60 years of age group are 3.5% (1%
female, 2.5% male). According to sex wise-50.4%
were male and 49.6% were female. Sex ratio is
981 females per 1000 males. All are hindus
family in studied area.
Out of 523people, 229 (43.7%) are married, 282
(53.9%) are unmarried, 4(0.7%) are widow and
6(1.1%) are widower, 1 (0.1%) divorced and 1
(0.1%) separated. According to type of family,86
(78.8%) families are nuclear, while 20 (18.3%) are
joint families and 3 (2.7%)are extended families
(Figure - 4). According to presence of ration
cards, 73% are having BPL ration card while
13% are having APL ration card and 14% do not
have ration cards.Information of voting list, 64%
families have their names in voting list, 36%
families do not have all family members names
in voting list.
According to educational level, 69% educated
population. Out of these, 18% of total
population gained primary education, while
28% gained secondary education. There are
more people illiterate in the age group of 25 to
59. The main reason for the low rate of
education is getting engaged with labour work
at an early age. Children above 15 years get
occupied in labour work to help in their family
economic condition and thereby their name
removed from school register.
Extende
d
3
2.75%
Joint
20
18.35%
Nuclear
86
78.90%
Fig 4: Distribution of households according
toType of family
We noticed that lack of basic infrastructure and
primary health facilities in this area. During ill
period, nearly 94% families take health services
from govt. hospital, 5% families can afford the
private medical services, and only 1% families
take benefit of camps organized by Charitable
Trusts. 12% families are covered under private
or Government insurance policies, 88% families
are not having insurance. while 96(88%) families
do not have bank accounts. So that 96 families
do not have any type of savings in bank and are
not accessing benefits of bank services.
According to occupational status, 46%
population is non working like – Students, aged
people, and diasbled. Remaining 49% working
population, most of them are associated with
daily labour and 5% population do their own
occupation (private and government). Females
are more occupied in handicraft and
houskeeping work. The average per family
income of this area is Rs.3000 per month. The
main reason for this is that the people are daily
wage earners and have no permanent
occupation. This income pattern restricts the
expenditure pattern in other activities. That is
why they are not able to fulfill their basic needs.
DISCUSSION:
In present study, 49.6% houses are temporary
which are hut type made up of plastic sheets.
5.5% families are having municipal water
connection, no house is having gutter
connection, 58.7% houses are having electricity
connection and 60% don’t have toilet facility and
go in open air defecation. Our findings are
compare with summary report of national
sample survey report, 65th round( 41.7% semi
pukka and 8.4% of slums were having katcha
structure,96.5% of slums, the major source of
drinking water was either tap or hand
pump,62.8%
are
having
toilet
facility,
underground sewerage existed in only about
23% slums,47.6% houses are having electricity
connection1.Here sex ratio is 981 females per
1000 males. Negative sex ratio is a feature of
current scenario in major part of india. As per
census 2011, 918 and 940 females per 1000 males
in gujarat and india. Our findings are compare
with study by Marimuthu P et al had reported
sex ratio at 789 per 1000 males in Delhi slums7.
CONCLUSION AND RECOMMENDATION
Even if slums are unauthorized settlements on
public land, local government should provide
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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facility of public latrines, total elimination of dry
latrines and manual scavanging, low cost on site
sanitation in unsewered parts of cities, improve
technology to reuse recycled waste, innvolve
NGO, Private sector and community for
prevention of water and land pollution.
Through National urban slum development
programme - Upgradation of urban slums by
providing physical amenities like water supply,
storm water drains, community bath, widening
and pavement of existing lanes, sewer drains,
community latrines and street light etc and
Provision of community infrastructure and
social amenities such as preschool education,
non formal education, immunization, primary
health care, reproductive and child health.
Strengthening of health education and family
planning services are required for control of
population explosion.
urban slum area of bhuj city for their help
during data collection and the people of this
area who had shared their valuable experiences
and spent precious time.
REFERRENCES
1.
2.
3.
4.
5.
6.
7.
ACKNOWLEDGEMENT
Directorate of economics& statastics (national sample
survey 65th round july 2008-july 2009) government of
india, website-http://des.delhi.gov.in
Schmid CF. Urban crime areas, Part II. Am Soc Rev
1966; 25:655-78.
Narain I, Mathur PC. Urban development and revitalization of local government institution. Indian J
Public Admin 1984; 30:4.
CBHI, Health Statistics of India, DGHS, MOHFW, GOI,
New Delhi: 1985.
Davis K. The urbanization of the human population.
Scientific American; Vol. 223. 1965.
National Family Health Survey, Delhi,Population
research centre and international institute for
Population sciencies,Bombay.1995.
Marimuthu P, Meitei MH, Sharma B.General morbidity
prevalence in the delhi slums India. Indian J
Community Medicine 2010;35:198-9.
We are thanksful to social worker, health staff
(Anganwadi workers and USHA workers) of
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ORIGINAL ARTICLE .
HEALTH STATUS OF RURAL GIRLS
Madhuri Inamdar1, Sameer Inamdar2, N. L. Sachdeva3
1Assistant
professor, 2Associate professor, Dept. of Medicine, Sri Aurobindo Institute of Medical
Sciences(SAIMS), Indore, MP, 3Retired as Professor and Head, Dept. of P.S.M., Rural Medical College,
Loni, Maharashtra
Correspondence:
Dr. Madhuri Inamdar22/10, Yeshwant Niwas Road,
Indore 452003, MP, India
Email: [email protected]
Phone no.- 8103576330
ABSTRACT
Background- In most of the developing countries, the girl child is ill fed and undernourished. 1 Quite
often the root cause of malnutrition among girls is not so much the lack of food as the lack of access to
food. Thus undernourished girls who grow into undernourished women perpetuate the
intergenerational undernourishment cycle.2
Aims and objectives- 1- To assess the health status of female child, 2- To compare the health status of
female child with that of male child and to determine if gender discrimination exists.
Material and Methods- Sixteen villages were selected by stratified sampling. Altogether 470
household were selected by systematic sampling method. Only those households which had at least
one male and one female child ( 0-14 Yrs.) were included in the study.
Observations- 44.63% of girls below 5 years of age were found to be malnourished in comparison to
15% of boys in the same age group ( P< 0.001). The percentage of stunted male children ( 6-14Yrs.)
was 14.78 while that of female children was 33.89. ( P< 0.001). While 3/4th of the boys received
complete treatment, it was only 2/3rd in case of girls.
Conclusion- Malnutrition was pronounced in girls as compared to boys.
Key words – Rural girls, Health status, malnourished, stunted, hygiene, complete treatment,
discrimination
INTRODUCTION
In most of the developing countries, the girl
child is ill-fed and undernourished.1 As per 2011
census the population of India is 1.2 billion. The
female child population is 75 million.3 The
steadily declining ratio of females to males in
India over the last 100 Yrs., has been the subject
of much speculation and investigation.4 It was
highlighted by the World Health Organization
that unless the girl child has a sound health, the
objective of “ Health for All by 2000 AD” cannot
be achieved. It was in this context that the “ year
of the Girl child” by the south Asian Association
of Regional co-operation (SAARC), at its summit
was
held
at
Islamabad
in
Dec.
19885.Subsequently, the decade 1991-2000 as the
SAARC Decade of the Girl child6 has been
dedicated for the girl child and to identify the
areas which need attention for the betterment of
the girl child.7
India is a signatory to a number of International
Instruments such as UN Convention on the
Rights of the Child, with its two Optional
Protocols, and Convention on the Elimination of
all Forms of Discrimination Against Women
(CEDAW), thereby affirming its commitment to
the growth and development of women and
children. Inadequate impact of programming
investment and achievement in overall
development of the child, and the adverse
influence of negative social attitudes towards
women and girls have left girl children in India
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disadvantaged. Their survival, development,
security and well-being as citizens of India, and
their participation as members of society is thus
officially recognized as a matter of serious
national concern.8
The girls in India do not achieve their full height
and weight potential on account of dietary
insufficiencies.2The rural adolescent population
lags behind its urban counterparts in all physical
growth characteristics.9 The rural girls are
shorter than their urban counterparts from
upper socio-economic group. 10,11,12
Quite often the root cause of malnutrition
among girls is not so much the lack of food as
the lack of access to food due to gender
discrimination. In addition to nutritional
stunting, undernourishment can lead to
cephalo-pelvic disproportion in adulthood- both
the factors are highly correlated with low birth
weight babies and perinatal complications. Thus
undernourished
girls
who
grow
into
undernourished
women
perpetuate
the
intergenerational undernourishment cycle.2
Number of health awareness and health
education programs have been introduced by
government and nongovernment agencies for
the welfare and empowerment of adolescent
girls as they are the future mothers. It will not be
wrong if we propose that girls need to be looked
after
optimally
from
birth
onwards.
Malnourished girls will continue to be
malnourished and stunted adolescents and
adults. These malnourished adolescents get
married early and give birth to small babies who
are vulnerable to become sick, malnourished
and death. Hence, it could be concluded that
removal of gender discrimination, along with
promotion of health, hygiene and nutrition is
needed throughout the life cycle of women.
MATERIAL AND METHODS
The study area comprised of 46 villages under
the three Primary Health Centres namely Loni,
Talegaon, and Guha located in the Talukas of
Shrirampur,
sangamner
and
Rahuri
respectively, which forms the field practice area
of Rural medical College of Pravara Medical
Trust, Loni, District Ahmednagar (Maharashtra)
All the villages were grouped in three strata on
the basis of population as underStratum A- <1000 population- Total villages
were 11, selected were 3.
Stratum B- 1000-2500 population- Total villages
were 22, selected were 8.
Stratum C- 2500+ population- Total villages
were 13, selected were 5.
Selection of villages (30%) from each strata was
done randomly keeping in mind that
representation from all the three PHCs be
possible. A total of 16 villages were selected by
stratified sampling method. The study
population comprises of 10 percent of the total
households in each village. Altogether 470
households were selected by systematic
sampling method. ( Every 10th house in each
village). Only those households which had at
least one male and one female child ( 0-14 Yrs.)
were included in the study.
A predesigned proforma was used to collect the
data from each household after having done the
pretesting.
The information regarding type, size, income, of
family was collected in proforma.
Proforma was used for assessing the health
status of the female child and to draw
meaningful comparison with male child
wherever possible. Information for proforma
was collected from mothers. As far as the age of
the child was concerned, the judgment of the
mother was relied upon.
Regarding treatment received by children in the
study, it was enquired whether they were
treated by private doctor/ govt. doctor/
indigenous practitioners. It was also enquired
whether the children took complete or
incomplete treatment if he/ she had not
completed the full course of drugs/ treatment
prescribed by their doctor.
General examination was done in detail
including nutritional deficiency signs and poor
hygienic conditions like louse infestation, dental
caries and wax in ear. Systemic examination was
done if required.
To find out the nutritional status of the child
standing height and weight were taken.
The children were made to stand erect against a
wall on a flat floor with heels closely placed, and
with the help of flat ruler a mark was made on
the wall and height was measured with
standard metal measuring tape in centimeters.
The infant was laid on the flat surface. Head was
positioned firmly with eyes looking vertically.
The knees extended, and the feet were flexed at
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right angles to the lower legs.13 Then, the length
was taken by metal measuring tape in
centimeters.
The weight of the children up to the age of 6
years was taken by Salter Baby Weighing
Machine ( dial type) and those above 6 years by
Bathroom Weighing Machine ( round shape).
The weighing machine were checked daily for
any possible error by comparing the results with
a standard caliberated beam type of weighing
machine available in Pravara Rural Hospital.
The weights were taken in kilograms. The
weight of children was taken after the shoes.
The weight of children from 0-6 years was taken
with them wearing minimal cloths, whereas the
weight of children more than 6 years, with them
wearing ordinary clothing.
Nutritional status of children ( 0- 5 Years) was
classified as per Indian Academy of Pediatrics
classification.14Nutritional status of children ( 614 years ) was classified as per waterlow’s
classification.15
For statistical analysis chi-square test was
used.16
RESULTS
Table 1 shows that 67% of male children and
43.01% of female children were healthy. As
many as 44.63 % girls were placed in grades II to
IV where as figure for boys was only 15 %.
Table 1: Nutritional Status of Children aging
less than five years
Nutritional status
Male (%)
Normal
138 (67)
Grade I
37 (17.96)
Grade II
26 (12.62)
Grade III
5 (2.42)
Grade IV
‐ Total
206 (100)
( x2= 35.28, d.f.=4, P< 0.001)
Female (%)
80 (43.01)
23 (12.36)
61 (32.79)
11 (5.92)
11 (5.92)
186 (100)
Table 2: Nutritional Status of Children aging 6
to 14 years
Nutritional
Male (%)
Status
Normal
115 (39.52)
Short
40 (13.74)
Wasted
93 (31.96)
Stunted
43 (14.78)
Total
291 (100.00)
( x2 = 32.24, d.f. = 3, P< 0.001)
Female (%)
121 (33.33
32 (8.81)
87 (23.97)
123 (33.89)
363 (100.00)
Table 2 shows that altogether 60.48% of male
children and 66.67 % of female children were
malnourished. The percentage of stunted male
children was 14.78 while that of female children
was 33.89.
Table 3: Level of Treatment in Boys and Girls
Level
of
Boys (%)
Treatment
Complete
255 (75)
Incomplete
85 (25)
Total
340 (100)
( x2= 4.63, d.f. = 1, P< 0.05)
Girls (%)
247 (67.67)
118 (32.33)
365 (100)
Table 3 shows that while 3/4th of the boys
received complete treatment, it was only 2/3rd in
case of girls.
Table 4: Comparison of Physical findings in
male and female
Physical Findings*
Deficiency of vit.A
Pallor
Hair Changes
Angular stomatitis
Scurvy
Dry scaly skin
Dental caries
Presence of ear wax
Louse infestation
*= multiple response
Male (%)
(n1=497)
2 (00.40)
39 (7.85)
11 (2.21)
5 (1.01)
4 (0.08)
84 (16.90)
106 (21.33)
5 (1.01)
Female (%)
(n2=549)
16 (2.91)
124 (22.59)
64 (11.66)
16 (2.91)
4 (0.73)
20 (3.64)
111 (20.22)
195 (35.52)
44 (8.01)
The table 4 shows that all deficiency states were
more common in girls as compared to boys. The
findings related to poor hygiene for ex. dental
caries, ear wax and louse infestation were more
frequent in girls as compared to boys.
DISCUSSION
The present study was conducted in a rural
community around Pravara Rural Medical
College, Loni. Total of 470 households were
studied which included 497 male and 549 female
children in the age group of 0- 14 years.
Distribution of households according to the type
of family, denotes that majority (70.63%) of the
households belonged to nuclear family followed
by joint or extended family (26.39%). However,
a total of 3% of households had broken families.
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A similar finding was observed by R. C. Goyal
et al17 whose study was conducted near Pravara
Rural Medical College, Loni. Similar findings
were also observed by Bhargava et al18 while
doing ICMR high risk study in three urban slum
centres at New Delhi, Calcutta and Madras and
three rural centres at Hyderabad, Varanasi and
Chandigarh. Bildhaiya et al19 observed that
81.44% families in rural area were of nuclear
type.
On analyzing the health care utilization, it was
found that 60.59% of the boys received
treatment from private doctors, which requires
monetary expenses while only 52.06% girls got
this privilege. There appears to be a uniform
difference, although a marginal one in seeking
health services from private/ government and
indigenous practitioners between boys and girls.
Ganatra and Hirve20 while analyzing their data
on health care utilization in a rural community
in Western India also pointed out a similar
discrimination. In their series 88.9% of male
children as compared to 76.5% of female
children were treated by registered private
medical practitioners. A study of Brown
Memorial Hospital of the Christian medical
college in Ludhiana ( Punjab) by Booth et al
revealed that families denied access to medical
care to about 75% of girls who needed
hospitalization just because of their sex. Lovel et
al21 in Pakistan found that private physicians
treated 58% of boys and only 37% girls. Likewise
in the urban slums of Delhi and Chennai
facilities used were governmental (43.8%),
private (47.2%), charitable (2.8%), chemist shop
(2.8%), faith healer (0.8%), home remedy (2.3%)
and combination (0.3%).22 Girls are usually
brought to the clinic or hospital in a worse
condition than boys. 23As far as level of
treatment is concerned the treatment was
complete in 75% of boys while it was only
67.67% in case of girls. This difference is
significant.
The children were divided on the basis of their
weight as recommended by Indian Academy of
Paediatrics. The ideal weight for age was taken
according to ICMR standards. 67% of male
children and 43.01% of female children were
within normal range. As many as 44.63% girls
were placed in Grade II to IV malnutrition
where as the figure for boys was only 15%. S. K.
Ray et al24 in a study of muslim community of
Burdwan in West Bengal found that all the
grades were more prevalent in females. Similar
findings were also observed by Sen and
Sengupta25 in two villages of West Bengal. As
per S. Rao Pune26, 40% urban slum children
were underweight and 55% were stunted.
Altogether 60.48% of male children and 66.67%
of female children were malnourished in age
group of 6-14 years. The percentage of stunted
male children was 14.78 while that of female
children was 33.89. 39.52% male and 33.33% of
female children were normal. Senapati et al27
found that total 45% children were normal (
46.2% female and 43.2% male). Goyal et al28 who
studied health status of school children in
Ahmednagar city, found that 15.6% children
were normal and 20% children were stunted.
According to K. Srinivasan et al 29 as many as
78.4 per cent children were found to be
malnourished. Malnutrition was higher in boys
(82%) as compared to girls (74.5%).In a study
conducted by Anita malhotra et al30 overall
29.7% of the subjects were found to be stunted.
Evidence of vit-A deficiency, Iron deficiency, Bcomplex deficiency and vit- C deficiency based
on physical findings was much higher in girls as
compared to boys. Similar findings were
observed by Senapati et al27, Gopaldas et al31
and P. B. Shetty32.In another study 80.4%
children were found to be anemic.29
Poor hygiene on the basis of physical findings
was observed in children. Dental caries was
found in 37.12% and ear wax in 56.85% of
children. Both the findings were more common
in females (20.22%, 35.52% respectively). Louse
infestation was found in 8.01% of girls and
1.01% of boys. The findings of R. C. Goyal et al28
in Ahmednagar city were in contrast. They
found only 1.5% children with wax in ear and
23.9% with dental caries. There is a possibility
that the subjects in the above study were mainly
from urban sector in contrast to our findings
from rural area.
CONCLUSION
In most of the developing countries gender bias
exists and the girl child does not get optimum
care and share in the family. The root cause of
malnutrition amongst girls is not just poverty
and lack of nutritious food, but also like lack of
value attached to girls. Discriminatory feeding
practices exist. Girl’s nutritional intake is
inferior in quality and quantity; boys have
access to more nutritious food. Boys are given
first priority with the available food within the
family. Female infants are breastfed less
frequently, for shorter duration and over a
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shorter period than boys.8 Malnutrition was
more pronounced in girls as compared to boys.
Deficiency states including protein- energy, vitA and iron were higher in female children than
in male children. It may therefore be concluded
that gender discrimination places girl child at a
lower level and recognizes her as a lesser sex.
Besides nutritional status, an attempt has been
made in the present study to determine the
health status of the girl child. Utilization of
health care system was fair by most of the
households, but it was noted that boys were
taken for treatment more promptly and
enthusiastically in comparison to girls.
Personal hygiene was worse with girls as
compared to boys. Lack of awareness along with
neglect of female child are responsible for poor
hygienic practices.
It is concluded that health and growth problems
of the female child arise from relatively lower
prenatal care and nutrition since infancy in
average female child. The girls were mostly
reared for getting them ready for marriage. The
high incidence of stunted growth around
puberty confirms the above statement.
Lot of studies have been done during
adolescence, like by government of India8 and
Anita Malhotra et al30 has also shown that
adolescent girls are more malnourished, anemic
in comparison to their counterpart boys.
It may therefore be concluded that as
malnutrition is also gender biased, it starts from
neonate through infancy, children continue up
to puberty and further to adulthood. The effects
of malnutrition on work capacity and cognition
are less well recognized but may be irreversible
and have direct negative impact on the economy
of
the
country. Moreover,
nutritional
improvement by food supplementation may
accelerate maturation but also increase the risk
of obesity.33 It may therefore be mentioned that
the objective and subjective studies need to
continue on various health parameters including
anthropometry, nutrition and hygiene amongst
girl children and adolescents from rural as well
as urban areas.
RECOMMENDATIONS
1.
General awareness should be created
through mass media about the positive
aspects of the girl child.
2.
3.
4.
5.
6.
The girls must be educated for improving
their health status as well as their future
generations.
The health status of the female children
should be improved. Sex discrimination
with regard to nutritional support should be
removed.
The
anganwadi
workers,
multipurpose health workers, ASHA and
school teachers can assist in this task.
Inclusion of hygienic practices in health
education should be stressed.
Family and community should create a new
culture where girl child is respected and
valued.
There should be congenial family life in
which both boys and girls are treated with
equal respect.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Proceedings of work-shop on girl child in West Bengal.
Child in Need Institute. Toka, West Bengal. 1988: 3-7.
Gopalan C, Kour S, editors, Women and nutrition in
India, NFI, New Delhi, 1989; 2.
Office of the Registrar General and census
commissioner. Government of India, Ministry of home
affairs, India.30.11.2011<Censusindia.gov.in>
Ghosh Shanti. A life time deprivation and
discrimination. In: Patnekar PN, Bhave Swati Y, Jayakar
Angha A, Potdar RD, editors, The girl child in Indiaissues and perspectives 1990: 1-16.
Taneja PN. The girl child in India. Indian pediatrics
1990; 27: 1151.
Ghosh S. Editorial, It is time we thought of youth.
Indian Pediatrics July 1992; 29: 821-823.
Xirsagar Sudha, Sahani Ashok. Health of the female
child – Perspectives and issues. In: Sahani Ashok,
editors, Health of the youth and female child.
Proceedings of the eleventh annual conference, 1991:
121-132.
Subgroup report, Girl child in the eleventh five year
plan. Ministry of women and child development,
Government of India, Shastri Bhawan, New Delhi:3-6.
Gupta V, Agrawal KN, Agrawal DK. Physical growth
characteristics in rural adolescent girls of Varanasi.
Indian pediatrics Dec. 1990; 27:1269-1274.
Agrawal KN, Tripathi AM, Sen S, Katiyar GP. Physical
growth at adolescence. Indian pediatrics 1974; 11:93297.
Pereira P, Mehta S, Khare BB. Physical growth
Characteristics in adolescent girls of upper socio
economic group in Varanasi. Indian Jr. of medical
Research 1983; 77:839-844.
Rath B, Ghosh S, Manmohan, Ramanujacharyulu TKTS.
Anthropometric indices of children (5- 15 Years) of a
privileged community. Indian pediatrics 1978; 15: 653666.
Jellife DB. The assessment of the nutrition status of the
community. WHO monograph series No.3, 1966: 64-69.
Ghai op. Essential pediatrics, Mehta offset works, New
Delhi, india 1990.
Waterlow JC, Rutishausen. Malnutrition in man in
early malnutrition and mental development. Cravioto J,
Hambroeus, vahlquist B, edirors, Stockholm- Quist
Page 392
pISSN: 0976 3325 eISSN: 2229 6816
16.
17.
18.
19.
20.
21.
22.
23.
AM, Wiksall, 13-27. Quoted in: Clinical nutrition
assessment. Practical pediatric nutrition. EME Poskitt,
editor, Butterworth and Company Ltd. 1988; 9.
Mahajan B. K. Methods in biostatistics. Jaypee brothers,
2010.
Goyal RC, Jejurikar ND, Bandgar BM. Infant Mortality
Survey in rural area. Agricultural Medicine and Rural
Health in India. 1991; 1:1;22-27.
Bhargawa SK, Singh KK, Saxena BM. ICMR task force
nutritional collaborative study on Identification of high
risk families, mother and out come of their offsprings
with particular Reference to problem of maternal
nutritional, low birth weight, prenatal and infant
morbidity and mortality in rural and urban slum
communities.
Summary,
conclusions
and
recommendations. Indian pediatrics Dec. 1991; 28:
1473-1496.
Bildhaiya GS, Bose C. A comparative study of health
status of infants and preschool children in Rural and
urban areas of Jabalpur MP. Indian Jr. of pediatrics
1977; 44:356:25-271.
Ganatra B, Hirve S. The lesser sex- bias against girl
child in health care utilization patterns for under fives
in a rural community in western India. Proceedings of
6th Asian Congress 1993; 212-220.
Lovel HJ, Sabir NI, Cleland J. Why are toddler girls at
risk death and undernutrition in a slum area of
Pakistan. Lancet 1984; 1: 797.
Sunder R, Mahal A, Sharma A. The burden of ill health
among the urban poor. The case of slums and
resettlement colonies in Chenni and Delhi. NCAER
2002; 25: 38-84
The girl child policy and research project. Florence
Nightingale International Foundation.8th sept. 2011. <
www.fnif.org/girlproject.htm>
24. Ray SK, Roy P, Deysarkari S, Lahiri A, Mukhopadhaya
BB. Across sectional study of Undernutrition in 0-5
years age group in an urban community. Indian Jr. of
Maternal and child H Health 1990; 1: 2: 61-62.
25. Sen A, Sengupta S. Malnutrition in rural children and
sex bias. Economic and Political weekly 1983; 18:
26. Sathe PV, Sathe AP. Primary health care and planned
development. In: Epidemiology and management for
health care for all. Bombay Popular Prakashan, 1991:
53-85.
27. Senapati SK, Bhattacharya S, Das DK. The girl child an
exposition of their status. Indian Jr. of Community
Medicine 1990; 15: 1: 15-19.
28. Goyal RC, Chavan UA. Health status of school children
in Ahmednagar city. Indian Jr. of Maternal and Child
Health 1993; 4:3:81-83.
29. Srinivasan K, Prabhu GR. A study of nutritional status
of the social welfare hostels in Tirupati, Andhra
Pradesh. The Indian Jr. of Nutrition and Dietetics, May
2004; 41: 5: 210-214.
30. Malhotra A, Jain Passi S. Diet quality and nutritional
status of rural adolescent girl beneficiaries Of ICDS in
north India. Asian Pac Jr. Clin Nutr 2007; 16: 1: 8-16.
31. Gopaldas T, Raghavan R, Kanani S. Nutritional impact
of antiparasitic drugs, prophylactic vit. A a and iron –
folic acid on underpriviledged school girls in India.
Nutritional Research 1983; 3: 831-844.
32. Shetty PB. School health program in municipal schools
of greater Bombay. In: Patnekar PN, Bhave Swati Y,
Jaykar Angha A, Potdar RD, editors, The girl child in
India-issues and perspectives 1990; 84-92.
33. Aneja S, Patwari AK. Malnutrition in Adolescence. In:
Bhave’s Textbook of Adolescent Medicine. Jaypee
brothers. 2006: 134-143.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 393
pISSN: 0976 3325 eISSN: 2229 6816
ORIGINAL ARTICLE .
MATERNAL RISK FACTORS FOR LOW BIRTH WEIGHT
NEONATES: A HOSPITAL BASED CASE-CONTROL
STUDY IN RURAL AREA OF WESTERN MAHARASHTRA,
INDIA
Deshpande Jayant D1, Phalke DB2, Bangal V B3, D Peeyuusha4, Bhatt Sushen4
1Associate
Professor 2Professor and Head, Department of Community Medicine, 3Professor and Head,
Department of Obstetrics & Gynecology, 4Third M.B.B.S. Student, Department of Community
Medicine, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
Correspondence:
Deshpande Jayant D.
Associate Professor, Department of Community Medicine(P.S.M.)
Rural Medical College, Pravara Institute of Medical Sciences,
Loni, Maharashtra, India
E-mail: [email protected] Mobile: 9762601050
ABSTRACT
Low birth weight (LBW) is a major determinant of infant mortality and morbidity. It is generally
recognized that the etiology of LBW is multifactorial. Present case control study was conducted with
the objective of studying maternal risk factors associated with full term LBW neonates. A total of 200
cases and 200 controls of age 18–35 years who delivered a live-born singleton baby were enrolled. The
data information was gathered from the maternal health records and interviewing the mothers of
these neonates. All the data were entered into the SPSS package (version 17). Association of the risk
factors under study was assessed by applying chi –square test. To assess the strength of association
the odds ratio and 95% confidence interval of odds ratio was calculated. Majority of the cases and
controls belongs to 20-29 years age group. The proportion of low income, illiterate/primary educated,
farm labourer mothers, primiparas, and women with Spacing < 2 years were higher among the LBW
newborns. LBW was strongly associated with anaemia [χ2=17.33, p<0.0001]. Significant risk factors
identified in univariate analysis included pregnancy-induced hypertension [OR=4.09(1.49-11.19)], pre
pregnancy maternal weight <45 kgs [OR=4.41(2.30-8.46)], maternal height <145 cms [OR=2.34(1.174.66)] and Inadequate antenatal care (χ2=24.81, p<0.0001). Large number of mothers from rural area
were not utilizing or inadequately utilizing antenatal care services. Many risks for LBW can be
identified before pregnancy occurs. Health education, socio-economic development, maternal
nutrition, and increasing the use of health services during pregnancy, are all important for reducing
LBW.
Key words: Low birth weight, risk factors, case control study
INTRODUCTION
Low birth weight (LBW) is an important
indicator of reproductive health and general
health status of population. LBW is considered
the single most important predictor of infant
mortality, especially of deaths within the first
month of life. 1 It continues to remain a major
public health problem worldwide especially in
the developing countries. The prevalence of low
birth weight in India was found to be 26%. As
per the WHO estimation about 25 million low
birth weight babies are born each year, nearly
95% of them in developing countries. 2 Across
the world, neonatal mortality is 20 times more
likely for LBW babies compared to heavier
babies (≤ 2.5 kg). 3, 4 LBW is a result of preterm
birth, intrauterine growth restriction, or a
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combination
of
both
pathophysiologic
conditions. There are numerous factors
contributing to LBW both maternal and fetal.
Weight at birth is directly influenced by general
level of health status of the mother. Maternal
environment is the most important determinant
of birth weight, and factors that prevent normal
circulation across the placenta cause poor
nutrient and oxygen supply to the fetus,
restricting growth. The maternal risk factors are
biologically and socially interrelated; most are,
however, modifiable. Krammer has identified 43
potential factors for low birth weight.4 Not that
all the factors, should be present in a given area.
The factors vary from one area to another,
depending upon geographic, socioeconomic and
cultural factors. The mortality of low birth
weight can be reduced if the maternal risk
factors are detected early and managed by
simple techniques. Thus it is necessary to
identify factors prevailing in a particular area
responsible for low birth weight. With this
background in mind the objective of the present
study was to identify the maternal risk factors
associated with LBW in rural area of western
Maharashtra.
MATERIAL AND METHOD
Present case control study was conducted in a
tertiary care teaching hospital in rural area of
western Maharashtra. The study data were
collected between March 2010-August 2010 by
interviews with the mothers, abstraction of
medical records and anthropometry. The World
Health Organization (WHO) definition of LBW
was used, i.e., birth weight less than 2500g. 5
Eligibility criteria for cases were: to deliver a live
newborn weighing less than 2,500 g. To be
eligible as a control, mothers should have
delivered a single newborn weighing more than
2,499g. Mother of babies with birth weights of >
2,499 g who were born consecutively after each
case, constituted the control group. Controls
were identified from birth records as the next
eligible delivery of a non-LBW baby after a
woman delivered an LBW baby. A total of 200
cases (vaginal delivery or caesarean section) and
200 controls of age 18–35 years who delivered a
live-born singleton baby through without
congenital malformation and with gestational
age 37–42 weeks were enrolled within one day
of delivery. Mothers who had multiple births
were excluded. All babies were weighed within
one hour after birth. The data were entered into
a standardized questionnaire after verbal
consent was obtained form the mother. The data
information was gathered from the maternal
health records and interviewing the mothers of
these infants.
Study variables: Study variables were maternal
age, height, pre-pregnancy weight, education,
occupation, socioeconomic status, type of
family, parity, interval between birth of the
newborn baby and the previous delivery,
Antenatal
care
(ANC)
during
current
pregnancy, iron and folic acid tablets consumed
and strenuous physical activity during
pregnancy. History was asked regarding
consumption of tobacco in any form regularly.
History of abortion was classified as ever/never
had abortion. Birth interval between the current
and last pregnancy was taken as a continuous
variable. Total numbers of ANC visits for the
current pregnancy were categorized as ≥ 4 visits
and < 4 visits, based on the WHO and United
Nations International Children's Emergency
Fund (UNICEF) criteria that women should
have ≥ 4 ANC visits with an appropriate health
care provider . Adequate antenatal care was
considered when the pregnant women was
registered at any time, had at least four
antenatal checkups, had adequately vaccinated
against tetanus, had consumed at least 100
tablets of iron and folic acid. Gestational age
was calculated from the first day of the last
menstrual period reported by the mother. 6
Illness developed during pregnancy was also
recorded; these include pregnancy-induced
hypertension (PIH), eclampsia / preeclampsia,
Rhesus problem, infections and others. Baby
characteristics included sex and the birth
weight. Physical examination was undertaken
after the interview was over. The available
health records were also reviewed. The
investigations such as haemoglobin, Blood
group, VDRL and urine sugar and albumin were
recorded from the case sheets. Socioeconomic
status as suggested by B.G.Prasad was adopted
and modified as per all India consumer price
index. 7
Statistical analysis: All the data were entered
into the SPSS package (version 17). Association
of the risk factors under study was assessed by
applying chi –square test taking a level of
significance of P < 0.05. To assess the strength of
association the odds ratio and 95% confidence
interval of odds ratio (O.R.) was calculated.
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RESULTS
of mothers in case group was 22.7±2.92 and in
control group 22.28±2.74. Majority of the cases
and controls belongs to 20-29 years age group.
The main maternal characteristics of the study
population are shown in Table 1. The mean age
Table 1: Comparison of basic variables of mothers between cases and controls
Variable
Mean age (years)
Height (cm)
Pre-pregnancy weight (kg)
Mean weight gain in pregnancy (kg)
Birth spacing (months)
Mean weight of newborn(gram)
Cases
22.7 ± 2.92
152.06±6.26
48.58±7.91
4.9±1.2
22.3±5.1
1864.97±465.06
The mean birth weight in LBW group babies
was 1864.97±465.06 g and in the control group
was 2848.355±298.53 g. Table 2 shows the
Control
22.28 ±2.74
153.62±5.31
52.35±6.3
6.9±1.5
30.2±6.2
2848.35±298.53
distribution of various factors among cases and
controls.
Table 2: Maternal risk factors for low birth weight
Variable
Age(years) <20/>30 years
Height <145cm
Lower socio-economic status (Class IV+V)
Maternal occupation farm labourer
Maternal education-illiterate/primary
Nuclear family
Pre pregnancy weight< 45 kg
Spacing < 2years
Primigravida
No ANC registration/late ANC registration
Inadequate ANC
Bad obstetrics history
Maternal Infections
History of infertility
Tobacco consumption
Heavy physical activity
PIH
Anaemia
Caesarean section delivery
The
proportion
of
low
income,
illiterate/primary educated and farm labourer
mothers were significantly higher among the
LBW newborns. Amongst the LBW there were
greater proportion of primiparas, mothers below
the age of 20 years and women with Spacing < 2
years. The ANC experience of the mothers in the
control group was significantly better than that
of cases. LBW was strongly associated with
inadequate antenatal care. [χ2=24.81, p<0.0001].
The haemoglobin status and daily intake of iron
supplements was better among the control
group. Mothers who had bad obstetric history
Cases (%)
(n=200)
31(15.5)
28(14)
54(27)
49(24.5)
71(35.5)
103(51.5)
47(23.5)
111(55.5)
71(35.5)
83(41.5)
107(53.5)
33(16.5)
9(4.5)
11(5.5)
23(11.5)
15(7.5)
19(9.5)
85(42.5)
59(29.5)
Control (%)
(n=200)
19(9.5)
13(6.5)
36(18)
19(9.5)
49(24.5)
97(48.5)
13(6.5)
83(42.5)
55(27.5)
49(24.5)
57(28.5)
18(9)
7(3.5)
9(4.5)
4(2)
5(2.5)
5(2.5)
45(22.5)
61(30.5)
Odds ratio
(95% CI)
1.74(0.95-3.91)
2.34(1.17-4.66)
1.68(1.04-2.71)
3.09(1.74-5.47)
1.69(1.1-2.61)
1.12(0.76-1.66)
4.41(2.30-8.46)
1.75(1.18-2.61)
1.45(0.94-2.21)
2.18(1.42-3.35)
2.88(1.90-4.36)
1.99(1.08-3.68)
1.29(0.47-3.5)
1.23(0.50-3.05)
6.36(2.15-18.77)
3.16(1.12-8.87)
4.09(1.49-11.19)
2.54(1.64-3.93)
0.95(0.61-1.46)
p value
0.09
0.021
0.04
0.0001
0.02
0.61
<0.0001
0.006
0.1064
0.0004
<0.0001
0.03
0.79
0.8185
0.0003
0.03
0.0062
<0.0001
0.91
showed poor outcome in their present
pregnancy also. A significant association was
found between bad obstetric history and birth
weight of baby. Anaemia, nonpregnant weight
below 45 kg, height less than 145 cm was
significantly more common amongst the
mothers of LBW babies. A significantly higher
proportion of mothers of LBW neonates had PIH
and eclampsia during the current pregnancy
than controls [O.R. = 4.09 (1.49-11.19)].
Furthermore, a significantly higher proportion
of mothers of LBW infants were having history
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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of tobacco
(p=0.0003).
consumption
than
controls
DISCUSSION
Factors associated with low birth weight, often
termed as ‘‘risk factors'' and their presence in an
individual woman indicates an increased
chance, or risk, of bearing a low birth weight
infant. Globally, LBW as indicator is a good
summary measure of a multifaceted public
health problem that includes long-term maternal
malnutrition, ill health, hard work and poor
pregnancy health care.
In present case control study from rural area,
lower socioeconomic status, maternal education,
maternal occupation farm labourer and having
heavy physical activity during antenatal period
were significantly associated with low birth
weight. However maternal age, having nuclear
family and parity has not identified as
significant risk factors for LBW babies. Krammer
4, Hirve and Ganatra 8 Deshmukh et al 9 also
found
significant
association
between
socioeconomic status and birth weight of baby.
The percentage of illiterate and primary
education was more in cases (35.5%) as
compared to control group (24.5%). Hirve and
Ganatra 8 found that the adjusted odds ratio for
delivering LBW decreases significantly with
increasing education status of the mother. In
rural area women from lower socioeconomic
status often continue strenuous physical work
through pregnancy. In our study, maternal age
had no significant association with LBW. Our
findings on maternal age as a risk factor is
consistent
with
studies
conducted
by
Mavalankar et al10 in India and Fikree et al 11 in
Pakistan. Anand and Garg 12 also found no
significant relationship between maternal age
and LBW. Proportion of primigravida was high
among cases as compared to control but the
difference was not statistically significant. In
contrast, previous studies have revealed that
primiparity is significantly associated with
LBW. 9, 13
This study has shown that low birth weight was
significantly
associated
with
inadequate
antenatal care, pre-delivery weight ≤45 kg,
height ≤145 cm, bad obstetrics history, tobacco
consumption, PIH and anemia. These findings
are consistent with Kramer's meta-analysis. 4
Malik et al 14 found a strong correlation between
birth weight and maternal height. Maternal
height < 145 cm contributed significantly to a
high rate of L.B.W. Effects of pre pregnancy
maternal weight; bad obstetrics history
(previous abortions) and anaemia were
consistent with another study in Ahmadabad. 10
In a hospital-based study in Calcutta Pahari et al
15 reported abortion as one of the main-causes of
adverse pregnancy outcomes in addition to
anaemia and hypertensive disorder. Anemia
was one of the common problems in the present
study from rural area. Almost 42.5% of mothers
who delivered LBW babies were anaemic.
Deshmukh et al 9 also found that anaemia was
significantly associated with LBW. Similarly,
Mavlankar et al 10 observed that pre pregnancy
maternal weight, and anaemia was important
determinant of low birth weight. The association
of tobacco consumption with low birth weight
observed in this study has also been reported by
Deshmukh et al. 9 and Gupta et al. 16 Antenatal
care had a strong influence on birth weight. In
present study it was found that most of mothers
from rural area start attending ANC clinics in
their sixth to seventh months of gestation.
Deswal et al 17 also reported that low maternal
weight, under nutrition, lack of antenatal care,
short inter-pregnancy interval, toxemia of
pregnancy were independent factors increasing
the risk of low birth weight significantly. Rural
women from lower socio-economic status are
more susceptible to poor diet and infection and
more likely to undertake physically demanding
work during pregnancy. Large number of
mothers from rural area are not utilizing or
inadequately utilizing antenatal care services.
Antenatal care for pregnant mothers is an
established factor to improve pregnancy
outcome, appropriate nutritional education and
food supplements must be given to the mothers
with poor weight gain. Access to quality
antenatal care should be viewed as potentially
important since it also offers opportunities for
counseling and risk detection apart from its
necessity for maternal health. It is generally
recognized that the etiology of LBW is
multifactorial. Special attention of health care
professionals is necessary for identification of
these risk factors for low birth weight. Various
factors are clearly and consistently linked to low
birth weight. Numerous opportunities exist
before pregnancy to reduce the incidence of low
birth weight, yet these are often overlooked in
favor of interventions during pregnancy.
CONCLUSION
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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Many risks for LBW can be identified before
pregnancy occurs. Health education, socioeconomic development, maternal nutrition, and
increasing the use of health services during
pregnancy, are all important for reducing LBW.
Acknowledgement: We acknowledge the
cooperation extended by Management of
Pravara
Medical
Trust,
Principal
and
Department of Obstetrics and Gynecology Rural
Medical College, Loni.
6.
7.
8.
9.
10.
11.
REFERENCES
12.
1.
13.
2.
3.
4.
5.
Ryan CA, Ryan F, Keane E, Hegarty H. Trend analysis
and socio-economic differentials in infant mortality in
the Southern Health Board, Ireland. Ir Med J 2000;
93:204-6.
Park K. Park’s Text book of preventive and social
medicine. 18th Edition. Jabalpur: M/s Banarsidas
Bhanot, 2005: 395-396.
UNICEF: Low Birth Weight, Country Regional and
Global
estimates.
[http://www.unicef.org/publications/index_24840.htm
l]. Accessed August12, 2011
Kramer MS. Determinant of low birth weight:
Methodological assessment and Meta analysis. Bull
WHO 1987; 65(5): 663-737.
World Health Organization. International Classification
of Diseases, Ninth revision,Vol. 1 Geneva, World
Health Organization, 1977.
14.
15.
16.
17.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Smith GC, Pell JP, Dobbie R: Caesarean section and risk
of unexplained stillbirth in subsequent pregnancy.
Lancet 2003, 362(9398):1779-1784
Kumar P. Social classification – Need for constant
updating. Indian J Commun Med 1993; 18:60-61.
Hirve SS, Ganatra BR. Determinants of low birth
weight: a community based prospective cohort study.
Indian Pediatr 1994; 31:1221-5.
Deshmukh JS, Motghare DD, Zodpey SP, Wadhva SK.
Low birth weight and associated maternal factors in an
urban area. Indian Pediatr. 1998; 35:33-6
Mavlankar DV, Gray Ronald H, Trivedi CR. Risk
factors for preterm and term low birth weight in
Ahmedabad, India. Int J Epidemiol 1992; 21:263-72.
Fikree FF, Berenes HW. Risk factors for term
intrauterine growth retardation Community based
study in Karachi. Bull WHO 1994; 72:581-87.
Anand K,Garg BS. A study of factors affecting low birth
weight. Ind j com med 2000;25:57-62
Nurul A, Abel R, Sampathkumar V. Maternal risk
factors associated with low birth weight. Indian J
Pediatr 1993; 60:269-274.
Malik S,Ghidiyal RG,Udani R, Waingankar R. Maternal
Biosocial factors affecting low birth weight.Indian
Journal of Paediatrics 1994;33:1222-25
Pahari K, Ghosh A: Study of pregnancy outcome over a
period of five years in a postgraduate institute of west
Bengal. J Indian Med Assoc 1997; 95:172-4.
Gupta PC, Sreevidya S. Smokeless tobacco use, birth
weight, and gestational age: population based
prospective cohort study of 1217 women in Mumbai,
India. BMJ. 2004; 328:1538.
Deswal BS, Singh JV, Kumar D. A Study of Risk Factors
for Low Birth Weight. Indian J Community Med.1999
;24 : 127-131.
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ORIGINAL ARTICLE .
A SOCIO- DEMOGRAPHIC PROFILE OF INFANT DEATHS
IN A TRIBAL BLOCK OF SOUTH GUJARAT
Amul Patel1, Pradeep Kumar2, Naresh Godara3, Vikas K Desai4
1Assistant
Professor, Community Medicine Department, GMERS Medical College, Gotri, Vadodra,
& Head, Community Medicine department, GMERS Medical College, Sola Ahmedabad
3Associate Professor, Community Medicine Department, Government Medical College, Surat 4Retired
Additional Director (FW), Commissionerate of Health, Medical Services & Medical Education,
Gujarat State, Gandhinagar
2Professor
Correspondence:
Dr. Pradeep Kumar,
A 1/7, Swagat City, Adalaj,
Gandhinagar 382421
E mail: [email protected]
ABSTRACT
With progressive reduction in infant mortality rate (IMR) and advent of technology, socio –
demographic determinants assume more importance (than biological), more so in remote and
inaccessible areas, which incidentally also record high IMR. Study was carried out in a tribal block of
South Gujarat to generate socio- demographic profile for 48 infant deaths reported during one year.
Data was collected through house to house survey on a designed questionnaire. Amongst 48 death
cases, literacy rates amongst mothers and fathers were 64.6 and 75% respectively. Occupation wise
81.3% fathers and 52.1% mothers were farm laborer. Joint families were in 81.3% cases and 85.4%
belonged to lower social class. Teenage pregnancy was found in 56.3% cases. Age of 25% mothers’ at
birth was below 20 years. First birth order was found in 47.9% cases. Birth spacing was less than 2
years in 60.4% cases. It is concluded that improving literacy, increasing age at pregnancy, increasing
birth spacing (> 2 years) along with overall socioeconomic improvement of community can help in
attaining the further reduction in infant mortality.
Key-words: Infant deaths, socio-epidemiological profile, socioeconomic status, literacy, teenage
pregnancy
INTRODUCTION
Infant mortality is not only an indicator of infant
health, but also of the entire population and of
their poverty ridden social status. 1 Infant
mortality rate (IMR) (infant deaths per 1000 live
births) has declined in last decades in India (50)
and in Gujarat (48) 2 though it is still high
compared to developed countries 3. With
decrease in IMR, it becomes important to find
out various types of determinants and their
interplay leading to the infant deaths. Research
studies in India so far have explored the causes
and determinants of infant mortality focusing
mainly on biological ones and the use of health
services. 1 In industrial world, dominant factor
of decline in infant mortality has been the social
and economic progress with medical services
playing the secondary role. 4 Therefore in a
scenario where the IMR is on decline, the social,
economic or demographic determinants assume
important role than the biological ones.
Elaboration of the social profile of the infant
deaths explains how social factors are the main
determinants of IMR. To our best of knowledge
no such community-based study has been
undertaken in Gujarat, with emphasis on sociodemographic aspects. Study was undertaken
with objective of generating socio-demographic
profile for all infant deaths.
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MATERIALS AND METHODS
Study was carried out in all 51 villages of 3
selected Primary Health Centers (PHCs) of a
remotely located, tribal dominated block from a
border district of South Gujarat. Purposive
sampling was done to select study populations
keeping in mind the resources, feasibility,
logistics and the availability of time. It was
thought that population of 3 PHCs would be
sufficient to meet the required sample size to
fulfill the objective of the study. The study
incorporated all the infant deaths, which
occurred during selected one year period (from
1st September 2004 to 31st August 2005). Field
based data collection was accomplished within
three months period. The infant deaths in which
the mother was daughter-in-law of the village
only, were included in the study. The
information regarding infant deaths was
gathered through 4 sources namely health care
system, Integrated Child development services
(ICDS) scheme, Civil Registration System (CRS)
and Investigator himself. The disparity in
reporting infant death by various agencies
during the same period and in the same study
area is reported elsewhere.5 Data collection was
done through house to house visits in study
area. For every infant death noticed, interview
was conducted at informant’s house in the local
language. First of all the purpose for study was
explained to the informant and his/ her consent
was obtained. Information about literacy and
occupation
of
parents,
basic
family
characteristics and maternal and birth related
characteristics were gathered by interviewing
the available parent (preferably mother), on a
designed verbal autopsy (VA) questionnaire developed with the help of VA questionnaire of
various agencies like WHO, SEARCH team,
Centre for Global Research and Aga Khan
foundation. Data was entered and analyzed
with Epi Info 6.04 version software.
RESULTS
A total of 48 infant deaths from the study area
during one year period were found. In all cases,
both parents were married and alive; living
together and in no case father was staying away
for job related or any other reason. Literacy rates
amongst mothers and fathers were 64.6 and 75
percent respectively. Very few (4 - 8%) had high
education (graduation & above). When literacy
was considered together, in 54.2% cases, both
parents were literate; while one of the parents
was literate in 31.2% cases and in rest (14.6%),
both parents were illiterate. Most common
occupation was farm labor for father (81.3%)
and mother (52.1%) (Table 1).
Table 1: Distribution of infant deaths according
to education and occupation of parents (N = 48)
Characteristics
Infant Deaths
Mother(%) Father(%)
Education
Illiterate
Up to primary
Up to higher
secondary
Graduate & above
Occupation
Farm laborer
Factory worker
Shopkeeper
Others*
Unemployed/
Housewife
*include milk seller and
office
17 (35.4)
14 (29.2)
15 (31.3)
12 (25.0)
15 (31.3)
17 (33.4)
2 (4.1)
4 (8.3)
39 (81.3)
3 (6.2)
3 (6.2)
2 (4.2)
1 (2.1)
25 (52)
23 (48)
helper in a newspaper
As per various family based characteristics, in
81.3% of infant deaths, families were of joint
type; rests (18.7%) were nuclear. Average family
size was 5.63 ± 2.4, while 60.4% had family size
of 1-5. Others (39.6%) had a family size of 6 or
more including 10.4% with 10 or more family
members.
Table 2: Distribution of infant deaths according
to family based characteristics
Characteristics
Infant Deaths (N = 48)
No.
%
Family type
Nuclear
9
Joint
39
Family size
29
1-5
14
6-9
5
10 & above
Social class
4
I & II*
3
III
17
IV
24
V
*No family belonged to social class I
18.7
81.3
60.4
29.2
10.4
8.3
6.3
35.4
50.0
Socio economical class of the families was
decided on the basis of per capita income
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according to modified Prasad’s classification 6.
No family belonged to social class I. Most
(85.4%) of them were from lower social class i.e.
class IV and V, while rest (14.6%) belonged to
class II and III (Table 2).
Mean age at marriage was 17.8 ± 3.03 years with
range, median and mode being 7 – 26, 18 and 16
years respectively. Considering the legal age at
marriage (18 years for female) 62.5 percent
mothers got married before attaining the legal
age of marriage. In more than half (56.3%) infant
deaths mother’s age at first pregnancy was
below 20 years. The mean age of mothers at first
pregnancy was 19.7 ± 2.7 years, with median
and mode as 19 and 17 years respectively. Mean
age for mothers at birth was 21.9 ± 3.5 years
while median and mode were 21 and 19 years
respectively.
Table 3: Distribution of infant deaths according
to maternal and birth related characteristics
Characteristic
Infant Deaths (N=48)
No.
%
Mother’s Age in years at Marriage
<15
2
4.2
15-18
28
58.3
19-21
13
27.1
> 22
5
10.4
Mother’s age (years) at first pregnancy
15-19
27
56.3
20-24
19
39.5
25-29
2
4.2
Mother’s age (years) at birth
15-19
12
25.0
20-24
29
60.4
25-29
4
8.3
>=30
3
6.3
Birth Order
1
23
47.9
2
20
41.7
3
4
8.3
6
1
2.1
Birth Spacing (years)
<2
29
60.4
2-<4
9
18.7
4-<6
7
14.6
>6
3
6.2
In one fourth (25%) of infant deaths, mother’s
age at birth was below 20 years and in 6.3%
cases it was 30 years or more. Regarding birth
order, first birth order was found in 47.9%
infants. While 41.7% cases had second order;
and in 10.4 % infants it was third or more. Birth
spacing ranged between 1- 9 years with median
and mode both being 2 years. It was less than 2
years in 60.4 percent infant deaths (Table 3), it
was worse for second birth order where spacing
was less than 2 years in 72% cases.
DISCUSSION
Present study aims to find out some known
socio - demographic determinants of infant
deaths in an area which is remote in location
and is inhabited largely by tribal population.
Children of illiterate mothers had higher risk of
dying during infancy compared to literate
mothers, as a strong link is seen between female
education and child survival.7-9 Literacy levels of
parents in our study are comparable with
literacy rates reported in Gujarat; though the
male literacy in the study was less (75%) than
figures of Gujarat (83%).7 Not much importance
can be attached to the literacy alone as what is
more relevant for preventing infant deaths is the
level of schooling. Educated women are likely to
marry at higher age, less influenced by
traditional practices inimical to health care,
more capable of dealing with modern
institutions and are able to alter the traditional
balance to favor children. A study from abroad10
reported that maternal and paternal education
were independent predictors of mortality
beyond the neonatal period.
All fathers were employed and dominant
occupation was farm labor. In case of mothers
too, more than half were employed all being
farm laborers. A study11 reported employed
mothers only in 13.3% early neonatal deaths and
a study from Lucknow12 found more such
deaths among families having agricultural work
as father’s occupation compared to other
occupations. Studies1, 9 reported that the impact
of the percentage of male laborers in non
agricultural work on IMR is negative and both
parents as skilled workers can help child
survival. Employment status of mother has two
way effects on mortality. Need to work outside
the house prevent the mother from caring for
the infant because of dual burden and thereby
increase the risk of infant death. On the other
hand, it leads to higher family income and gives
the mother a modern outlook, both of which
increase the probability of child survival.
Studies13-14 had reported that babies born in joint
and large sized families had greater risks of
neonatal and overall infant mortality. Families
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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in our study were mainly joint (81.3%), almost
two times more than rural Gujarat7 (43.4%).
Studies have reported that babies born in
families with low socioeconomic status1, 7-8, 15
had a higher risks of infant death as the capacity
(of families) for child care is minimal and child
survival depends on the ability to offer good
care. Majority (85.4%) of families in the study
belonged to lower social class (Class IV & V)
while none belonged to social class I.
The median age at marriage of mother was 18,
similar to Gujarat7. More than half of the
mothers got married before attaining the legal
age at marriage, higher compared to Gujarat
(39%) 7. High risk of infant deaths among
teenage pregnancy is due to biological and
psycho-social immaturity of mothers as well as
more chances of low birth weight babies. Infants
born to mothers above age 30 are also at risk of
congenital problems. Therefore, a U-shaped
pattern of mortality by mother’s age was seen
with higher infant mortality among mothers
below 20 years of age and above 30 years, is seen
everywhere 9, 16-18 including Gujarat7. Similar
was observed in relation of age of mother at first
pregnancy.
First birth order carries high risk of infant death
due to early age at marriage, teenage
pregnancy/ motherhood and associated reasons
as discussed above. In Gujarat 7, the same Ushaped relationship of infant mortality and birth
order was found with first and high order births
with high mortality as was with mother’s age.
Regarding birth orders in our study, first,
second and third or higher birth order was
found in 47.9%, 41.7% and 10.4 % infant deaths
respectively. Studies 8, 13-14 substantiate a strong
association between short birth intervals and
increased infant mortality. Birth spacing in our
study was less than 2 years in 60.4% infant
deaths. In second birth order, 72% had interval
to previous birth was less than two years. It
explains the relatively large proportion of deaths
in second birth order infants, which is otherwise
not a risk factor for infant death. In Gujarat 7 too,
the risk of death was higher for infants born
within birth intervals of less than two years
compared with those born beyond spacing of
two or more years.
CONCLUSION
Study has no control group so we cannot
attribute or quantify the role of various
attributes on infant mortality. Yet, by comparing
this profile with rural Gujarat, We can
summarize that improvement in education
especially amongst females, engagement of
people in skilled jobs along with overall
socioeconomic improvement of community are
essential in making further dent in existing
infant mortality. Efforts toward increasing the
woman’s age at marriage and spacing
pregnancies at least two years apart are needed.
Acknowledgement
We are thankful to medical officers and their
staff of 3 PHCs for help in carrying out this
study.
REFERENCES
1.
A study on the socio-economic determinants behind
infant mortality and maternal mortality. Available at:
http://planningcommission.nic.in/reports
/sereport/ser /study _immm.pdf. Accessed August
11th, 2011.
2.
Registrar General of India, Government of India. SRS
Bulletin
2011;
45(1):1.
Available
at:http://www.censusindia.gov.in/vital_statistics/SRS
_Bulletins/SRS_Bulletin_ January 2011.pdf. Accessed
May 10th, 2011.
3.
The world fact book - country comparison: infant
mortality
rate.
Available
at:
https://www.cia.gov/library/publications/the-worldfactbook/rankorder/2091rank.html. Accessed August
11th, 2011.
4.
K Park. Park’s Textbook of Preventive and Social
Medicine, 21st Edition, Jabalpur: Bhanot Publishers;
2011. Page 523-24.
5.
Patel Amul, Kumar Pradeep, Godara Naresh & Desai
Vikas K. Infant deaths – data disparity and use of ante,
intra and post-natal services utilization: an experience
from tribal areas of Gujarat. Submitted at Indian
Journal of Community Medicine; 2011.
6.
Kumar P. Social Classification- Need for Constant
Updating. Indian Journal of Community Medicine
1993; 18(2): 60-61.
7.
International Institute for Population Sciences and
Macro International. National Family Health Survey -3
Gujarat (2005-06). IIPS: Mumbai; 2008.
8.
Correlates of Infant Mortality in India and sub-Saharan
Africa.
Available
at:
http://www.
socstats.soton.ac.uk/choices/Factsheet
34
Infant
Mortality.PDF. Accessed August 11th, 2011.
9.
Infant Mortality Rates in India: District Level Variations
and Correlations. Available at:
10. http://www.isid.ac.in/~pu/conference/dec_10_conf/
Papers/ShrutiKapoor.pdf.Accessed August 11th, 2011.
11. Katz J, Keith P, Subarna K, Christian P, Steven C,
Pradhan E, Shreshta S. Risk factors for early infant
mortality in Sarlahi district, Nepal. Bulletin of the WHO
2003; 81(10): 717-725.
12. Aggarwal A, Kumar R, Kumar P. early neonatal
mortality in a hilly north Indian state: Sociodemographic factors and treatment seeking behavior.
Indian Journal of Preventive and Social Medicine 2003;
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 402
pISSN: 0976 3325 eISSN: 2229 6816
34(1&2): 46-52.
13. Srivastava J. Correlates of perinatal mortality in
Lucknow city: repeat study of a hospital’s experiences.
The Journal of Family Welfare 1992; 38(4): 42-52.
14. Muzibar Rahman M, Kabir M, Salam M. The influence
of socioeconomic characteristics on subsequent infant
and child mortality. The Journal of Family Welfare
1993; 39(3): 28-34.
15. Proximate Correlates of Infant Mortality in
Maharashtra: Experience of a developed State in India.
Available
at:
http://www.longwoods.com/content/17581. Accessed
August 11th, 2011.
16. Hosseinpoor AR, Reza A, Kazem M, Reza M et al.
Socio-economic inequality in infant mortality in Iran
and across its provinces. Bulletin of the World Health
Organization 2005; 83(11): 837-44.
17. Lawn J, Simon C, Jelka Z. Why are 4 million newborn
babies dying each year? Lancet 2004; 364:399-401.
18. Kapoor RK, Srivastava AK, Misra PK, Sharma B,
Thakur S, Srivastava KI, Singh GK. Perinatal mortality
in urban slums in Lucknow. Indian Pediatrics 1996;
33(1): 19-23.
19. Kusiako T, Ronsmans C, Vanderpaal L. Perinatal
mortality attributable to complications of childbirth in
Matlab, Bangladesh. Bulletin of the World Health
Organization 2000; 78(5): 621-627.
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ORIGINAL ARTICLE .
ASSESSING PATIENT SATISFACTION FOR
INVESTIGATIVE SERVICES AT PUBLIC HOSPITALS TO
IMPROVE QUALITY OF SERVICES
P.R.Sodani1, Kalpa Sharma2
1Dean (Training) & Professor, 2Research Officer, Institute of Health Management Research, Jaipur,
India
Correspondence:
Dr. P.R. Sodani
1, Prabhu Dayal Marg
Sanganer Airport
Jaipur – 302011
Email: [email protected], Mobile: 098291-20956
ABSTRACT
Objective: The main objective of the paper is to assess the satisfaction level of investigative patients at
public health facilities of Madhya Pradesh, a State of India.
Methods: Data were collected from investigative patients through structured questionnaires at public
health facilities in the sampled eight districts of Madhya Pradesh.
Settings: Data were collected from District Hospitals, Civil Hospitals and Community Health Centers
of the eight selected districts of Madhya Pradesh.
esults: A total of 280 investigative patients were included in the study to know their perceptions
about the services at the public health facilities. It was found that most of the respondents belong to
rural areas (53.9%) and majority (82.1%) lies within the age group of 16-50. 56.4% were male having
low level of literacy. 90% of the respondents who availed ultrasonography services and nearly 70% of
the investigative patients who have utilized ECG facility found the problem of overcrowding but
found the test facility good. However, 67.3% and 76% of the patients reported that the test facility was
good who availed the services of laboratory and X-Ray. More than 80% of the total investigative
patients reported the behavior of the technicians as good. Nearly 50% of the respondents who availed
the services of laboratory and X-ray, reported that privacy and confidentiality was good whereas rest
found it satisfactory.
Key Words: Investigative Services, Patient satisfaction, quality of care, public health facilities.
INTRODUCTION
Patient satisfaction is one of the established
yardsticks to measure success of the services
being provided in the health facilities. But it is
difficult to measure the satisfaction and gauze
responsiveness of the health systems as not only
the clinical but also the non-clinical outcomes of
care do influence the customer satisfaction [1].
Satisfaction has been defined as a consumer’s
emotional feelings about a specific consumption
experience [2, 3]. It is judgment that a product or
a services feature, or the product or service
itself, provide a pleasurable level of
consumption related fulfillment. The main
beneficiary of a good health care system is
clearly a patient. As a customer of healthcare,
the patient is the focus of the health care
delivery system.
Patient’s perceptions about health care system
seem to have been largely ignored by the health
care managers in the developing countries.
Patient satisfaction depends upon many factors
such as: quality of clinical services provided,
availability of medicine, behavior of doctors and
other health staff, cost of the services, hospital
infrastructure, physical comfort, emotional
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support and respect for patient preferences [4].
Mismatch between patient expectation and the
service received is related to decreased
satisfaction [5]. Therefore, assessing patient
perspectives gives them a voice, which can make
public health services more responsive to
people’s need and expectations [6, 7].
In the recent past, studies on patient satisfaction
gained popularity and usefulness as it provides
the chance to health care providers and
managers to improve the services in the public
health facilities. Patient’s feedback is necessary
to identify problems that need to be resolved in
improving the health services. This type of
feedback triggers a real interest that can lead to
a change in their culture and in the perception of
patients [8].
However, there are recent studies that are
conducted in India such as those of Sharma et
al., (2011); Sodani (2010) both of which have
been conducted among patients’ of out patient
department.[9,10] Few studies has been carried
out in India for measuring satisfaction of
patients in “Indoor Patient Department” at
public health facility. [11, 12, 13].
Hence our study attempts to highlight the
patient satisfaction among the investigative
patients who have availed the services such as
laboratory, X-Ray, ultra sonography, and ECG
services. The aim of our study is to identify the
key factors that affect patients’ satisfaction
among the investigative patients in the nonclinical services.
The purpose of present study is to carry out the
evaluation of public health facility by getting
feedback from investigative patients. The
present paper is based on a comprehensive
study conducted at the public health facilities in
the State of Madhya Pradesh to measure patient
satisfaction in the respondents who have availed
services of Outdoor Patient Department, Indoor
Patient
Department
and
Diagnostic/Investigative. The main objective of
this paper is to share the findings on patient’s
satisfaction about various components of
investigative services. In the study, the
investigative services are “An examination, test,
study, or procedure performed to identify the
condition that is causing symptoms or to
determine the status of a condition”. Most
diagnostic services take place in an outpatient
setting, although some may require a hospital
admission or overnight stay in a hospital or
diagnostic facility.
MATERIALS AND METHODS
The state is divided into eight administrative
divisions. To have a representative sample of the
state, one district has been identified from each
of the division. The identified districts were
Vidisha, Morena, Gwalior, Indore, Jabalpur,
Sidhi, Sagar, and Ujjain. To select the
investigative patients from each district, a
sample of investigative patients were drawn
from the public health facilities i.e. District
Hospital (DH), Civil Hospital (CH) and
Community Health Centers (CHC). From each
of the selected district, one DH, one CH and one
CHC were identified. Table 1 shows the
distribution of 280 investigative patients covered
from the 24 public health facilities of the state.
Table 1: Distribution of Investigative Patients
according to the type of Public Health Facilities
Sample Unit
DH CH CHC Total
No. of Facilities
8
8
8
24
No. of investigative
170 69
41
280
patients
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
To carry out the proper scientific study, a set of
well structured questionnaire containing closed
ended questions were developed. The
questionnaire was pre tested. The finalized
questionnaire was translated into Hindi, the
state language for administering purposes. The
questionnaire covered the information related to
the patient’s socio-economic characteristics and
perception towards laboratory, X-Ray, ultra
sonography and ECG services. The data were
collected with the help of trained field
investigators during the months of September
and October 2007. The state government
facilitated data collection from the various
facilities.
RESULTS AND DISCUSSIONS
Background Characteristics of the
Investigative Patients
The
characteristics
details
include
the
information on sex, age groups, place of
residence and education level of the
investigative patients in the hospital. It can be
observed from table 2 that out of 280
investigative patients, 158 (56.4%) patients were
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male and rest 122 (43.6%) were female. The
interviewed patients were further divided into
different four age groups i.e. 0-15 years, 16-30
years, 31-50 years and 50 years and above.
Findings depict that number of investigative
patients belonging to the age group of 0-15 years
were 8 (2.9%) and 118 (42.1%) belongs to the age
group of 16-30 years. However, number of
investigative patients belongs to the age group
of 31-50 years and 50 and above were 112
(40.0%) and 42 (15.0%) respectively. Data shows
that 151 (53.9%) patients were from rural areas
while rest 129 (46.1%) were from urban areas. It
can be observed that the proportion of rural and
urban areas is almost equal in the case of District
Hospital and Civil Hospital. However, the
proportion of patients belongs to rural areas
were high at community health centers. The
main reason of this is because the CHC is
situated in the rural areas. Findings shows that
the education level of the patients were very low
and 86 (30.7%) were illiterate; 42 (15.0%) were
primary passed and 44 (15.7%) were middle
passed.
Table 2: Sex, Age and Education Level of the
Investigative Patients at Public Health Facilities
Indicators
DH
N=170
CH
N=69
CHC
N=41
Total
N=280 (%)
Sex
Male
97
40
21
158 (56.4)
Female
73
29
20
122 (43.6)
Age Group (in years)
0-15
5
1
2
8 (2.9)
16-30
70
28
20
118 (42.1)
31-50
72
27
13
112 (40.0)
≥50
23
13
6
42 (15.0)
Place of Residence
Urban
86
35
8
129 (46.1)
Rural
84
34
33
151 (53.9)
Education Level
Illiterate
51
25
10
86 (30.7)
Primary
26
10
6
42 (15.0)
Middle
23
11
10
44 (15.7)
Secondary
30
7
6
43 (15.4)
Higher
40
16
9
65 (23.2)
Secondary
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
From rest of them 43 (15.4%) were secondary
passed and 65 (23.2%) were higher secondary
and above passed. The place of residence and
poor socio-economic background was the main
reason of lower level of literacy among the
investigative patients.
Laboratory Services
Data were collected on overall perception of
investigative patients regarding the laboratory
services including problem of overcrowding,
test facility, behaviour of lab technicians, and
maintaining privacy and confidentiality. Out of
280 investigative patients only 162 have availed
laboratory services.
Regarding the problem of overcrowding in the
laboratory, 98 (60.5%) of the respondents said
that there was no over-crowding. Data were also
collected to know the perception of patients
about the test facilities at public health facilities.
Findings shows that 109 (67.3%) patients
reported that the test facility was good and rest
53 (32.7%) reported it satisfactory. 144 (88.9%)
patients found the behavior of lab technician
good and rest 18 (11.1%) reported it satisfactory.
Findings on privacy and confidentiality at
laboratory shows that most of the patients
(50.6%) reported it good and 71 (43.8%) said it
satisfactory. However, rest 9 (5.6%) considered it
poor.
Table 3: Perception of the Investigative Patients
Regarding the Laboratory Services at Public
Health Facilities
DH CH CHC Total (%)
n=162
N=82 N=41 N=39
Problem of Over-crowding
Yes
44
13
7
64 (39.5)
No
38
28
32
98 (60.5)
Test Facility
Good
54
28
27
109 (67.3)
Satisfactory
28
13
12
53 (32.7)
Behaviour of Lab Technician
Good
70
37
37
144 (88.9)
Satisfactory
12
4
2
18 (11.1)
Maintaining Privacy and Confidentiality
Good
40
23
19
82 (50.6)
Satisfactory
37
15
19
71 (43.8)
Poor
5
3
1
9 (5.6)
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
Variables
X-Ray Services
Table 4 explains the perception of patients
regarding the X-Ray services in the public
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hospitals. Out of 280 patients who have used the
investigative services only 100 have used the XRay services in the hospital. Out of these 100
investigative patients, almost half of them
(51.0%) reported the problem of overcrowding.
Regarding the test facilities, 76 respondents
(76.0%) considered it good and the remaining 24
% said it satisfactory. 92 respondents out of 100,
reported that they like the behavior of
radiographer and rest 8 % said it satisfactory.
Regarding maintaining privacy and
confidentiality, 55 found it good while rest 45
respondents reported it satisfactory.
Table 4: Perception of the Investigative Patients
Regarding the X-Ray Services at Public Health
Facilities
Variables
DH
CH
CHC
Total
N=72 N=27 N=1
(%)
Problem of Overcrowding
Yes
41
10
0
51 (51.0)
No
31
17
1
49 (49.0)
Test facility
Good
53
22
1
76 (76.0)
Satisfactory
19
5
0
24 (24.0)
Behaviour of Radiographer
Good
66
25
1
92 (92.0)
Satisfactory
6
2
0
8 (8.0)
Maintaining privacy and confidentiality
Good
38
16
1
55 (55.0)
Satisfactory
34
11
0
45 (45.0)
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
Ultra Sonography Services
Table 5 shows the perception of patients
regarding ultra sonography services. It can be
observed from the table that only 10 patients
used ultra sonography services out of 280
investigative patients. It is because the ultra
sonography facility was only available in the
District Hospital (DH).
Majority of the patients who have used the ultra
sonography services only 9 (90.0%) said that
there is a problem of overcrowding. Regarding
the test facility, data depict that 90%
respondents who have used the ultra
sonography service found the test facility good
and rest found it satisfactory. Regarding the
behavior of ultra sonography technician 80.0%
respondents reported that the behavior was
good and remaining 20.0% said it satisfactory.
Half of the respondents reported that the
privacy and confidentiality was good while rest
found it satisfactory.
Table 5: Perception of the Patients Regarding
the Ultra sonography Services at Public Health
Facilities
Variables
DH (%)
Problem of Overcrowding
Yes
9 (90.0)
No
1 (10.0)
Total
10 (100.0)
Test facility
Good
9 (90.0)
Satisfactory
1 (10.0)
Total
10 (100.0)
Behaviour of Ultrasonography Technician
Good
8 (80.0)
Satisfactory
2 (20.0)
Total
10 (100.0)
Maintaining Privacy and Confidentiality
Good
5 (50.0)
Satisfactory
5 (50.0)
Total
10 (100.0)
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
ECG Services
ECG services were not available in all the health
facilities. It was available only in district
hospitals and civil hospitals. Out of 280
interviewed investigative patients, only 16 (15 in
DH and 1 in CH) have used the ECG facility
from these hospitals. 11 (68.8%) patients out of
16 who have availed the ECG facility reported
that test facility was good but found the
problem of overcrowding. Regarding the
behaviour of the ECG Technicians, 13 (81.2%)
respondents found the behavior good and the
remaining 3 (18.8%) reported it satisfactory.
Findings
on
maintaining
privacy
and
confidentiality in ECG services, half of the
respondents found it good while rest reported it
satisfactory.
Table 6: Perception of the Patients Regarding
the ECG Services at Public Health Facilities
Variables
DH
Problem of Overcrowding
Yes
11
No
4
Total
15
Test facility
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
CH
Total (%)
0
1
1
11 (68.8)
5 (31.2)
16 (100.0)
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Good
10
1
11 (68.8)
Satisfactory
5
0
5 (31.2)
Total
15
1
16 (100.0)
Behaviour of ECG Technician
Good
12
1
13 (81.2)
Satisfactory
3
0
3 (18.8)
Total
15
1
16 (100.0)
Maintaining privacy and confidentiality
Good
8
0
8 (50.0)
Satisfactory
7
1
8 (50.0)
Total
15
1
16 (100.0)
DH – District Hospital, CH – Civil Hospital,
CHC – Community Health Center
1.
2.
3.
4.
5.
6.
CONCLUSION
The study findings suggest that the following
measures may be taken by the policy makers
and hospital administrators to increase the
patient satisfaction at the public health facilities:
1). Efforts should be made to reduce the patient
load at the higher level facilities by made
services available at lower level public health
facility; 2). Efforts are also needed to strengthen
the infrastructure and human resources at the
public health facilities. The findings of the
present study can be utilized to improve the
investigative services at public health facilities of
the state resulting in the more satisfaction of the
patients availing such facility.
7.
8.
9.
10.
11.
Acknowledgements
Thanks are due to the Directorate of Health
Services, Government of Madhya Pradesh for
sponsoring the study. We also express our
gratitude to the patients for providing their
valuable time for interview.
12.
13.
Agrawal D. Health Sector Reforms: Relevance in India.
Indian Journal of Community Medicine 2006; 31:220-2
Oliver, R.L. (1977), “Effects of expectation and
disconfirmation on post-exposure product evaluations:
An alternative interpretation”, Journal of Applied
Psychology, Vol. 64 No. 4, pp. 246-50.
Spreng, R.A., MacKenzie, S.B. and Olshavsky, R.W.
(1996), “A re-examination of the determinants of
consumer satisfaction”, Journal of Marketing, Vol. 60,
July, pp. 15-32.
Jenkinson C, Coulter A, Bruster S, Richards N,
Chandola T. Patient’s experiences and satisfaction with
healthcare: Results of a questionnaire study of specific
aspects of care. Qual Saf Health Care 2002; 11:335-9
McKinley RK, Roberts C. Patient’s Satisfaction with out
of hours primary medical care. Qual Health Care 2001;
10:23-8
World Health Organization. The World Health Report
2000- Health Systems: Improving Performance. Geneva:
WHO, 2000.
Rao KD, Peters DH, Bandeen-Roche K. Towards
patient-centered health services in India- a scale to
measure patient perceptions of quality. Int J Qual
Health Care 2006; 18:414-21
Boyer L, Francois P, Doutre E, Weil G, Labarere J.
Perception and use of the results of patient satisfaction
surveys by care providers in a French Teaching
Hospital. Int J Qual Health Care 2006; 18:359-64.
Sharma Raman, Sharma Meenakshi, Sharma R.K.,
(2011) "The patient satisfaction study in a
multispecialty tertiary level hospital, PGIMER,
Chandigarh, India", Leadership in Health Services, Vol.
24 Issue 1, pp. 64-73.
Sodani P R, Kumar RK, Srivastava J, Sharma L (2010),
“Measuring patient satisfaction: A case study to
improve quality of care at public health facilities”,
Indian Journal of Community Medicine, Vol.35, pp. 5256.
Yogesh Pai P, Gaurav Ravi. Factors affecting In-patient
Satisfaction in Hospital - A Case Study. International
Conference on Technology and Business Management
2011; 1025-31
M V Kulkarni, S Dasgupta, A R Deoke1, Nayse. Study
of Satisfaction of Patients Admitted in a tertiary Care
Hospital in Nagpur. National Journal of Community
Medicine 2011; 2:37-39.
Laila Ashrafun, Mohammad Jasim Uddin. Factors
Determining Inpatient Satisfaction with Hospital Care
in Bangladesh. Canadian Center of Science and
Education 2011; 7: 15-24.
REFERENCES
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
IMPACT OF SCHOOL HEALTH PROGRAM –A
RETROSPECTIVE ANALYSIS OF PEDIATRIC ECHO’S
DONE IN A TERTIARY SET-UP
Poonam Singh1, Dorothy Sengupta2
1Associate
Professor, 2Tutor, Department of Pediatrics, Surat Municipal Institute of Medical Education
and Research (SMIMER), Surat.
Correspondence:
Dr. Poonam Singh,
Associate Professor, Department of Pediatrics,
SMIMER, Umarwada, Surat, Gujarat.395010
E-mail: [email protected], Mobile: 9374717453
ABSTRACT
This study was conducted to find out the efficacy of the school health program in picking up heart
diseases and hence providing benefit to the patients. The patients were screened on the basis of
degree of murmur and any abnormal ECG and X-ray findings and then subjected to
echocardiography. Total no of patients screened were 18721 of which 100 were detected to have heart
murmur. The incidence of heart disease found in our setup is 0.42% over six month’s duration. 57.5%
of patients were <5 yrs followed by 38.7% in 5-15 yrs age group. VSD (22.86%), ASD (21.4%) were the
most commonly diagnosed acyanotic congenital heart diseases and TOF (5.7%) was the commonest
cyanotic CHD. Pericardial Effusion (60%) was the commonest acquired heart disease.23.75% of these
were referred to higher centre for further management and 37% of patients with a school health card
have availed these facilities for free. 62.6% patients from the community were referred through school
health for heart disease.
Key words: School health program, Heart disease
INTRODUCTION
Heart diseases may be symptomatic or
asymptomatic in children. Cardiac murmurs can
be easily picked up and hence the presence of a
CHD can be diagnosed early. The incidence of
CHD in general population is about 1% of live
births. Congenital cardiac defects have a wide
spectrum of severity in infants: about 2-3 in 1000
newborn infants will be symptomatic with
disease in the 1st year of life. Diagnosis is usually
established by 1st week of age in 40-50% of
patients with CHD and by 1 month of age in 5060%
Despite all advances in management and
treatment, CHD remains the leading cause of
death
in
children
with
congenital
malformations. VSDs are 35-30% of all lesions
followed by ASDs in 6-8%.Gender differences in
the occurrence of specific cardiac lesions have
been identified. Acquired heart lesions can
present in varied forms like rheumatic heart
disease, cardiomyopathy, infective endocarditis,
pericardial effusions etc. Heart diseases may
present with varied symptoms such as not
feeding well, failure to thrive, murmur,
breathlessness, cyanosis, etc. and hence can be
diagnosed early1.
Innocent heart murmurs or functional murmurs
arise from cardiovascular structures in the
absence of anatomic abnormalities2. They are
common in children; more than 80% of children
have innocent murmurs of one type or another
sometime during childhood. A heart murmur
heard within a few hours of birth usually
indicates a stenotic lesion (AS/ PS), AV valve
regurgitation or small Lt →Rt shunt (PDA /
VSD). A murmur on a routine examination of a
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healthy-looking child is more likely to be
innocent. Patients with a murmur of grade 3/6
or more, systolic or diastolic murmur are more
likely to have some anatomic lesion.
Echocardiography is extremely useful, safe and
non invasive test used for the diagnosis and
management of heart diseases with the
advantage of reproducibility of results, instant
images and reliable level of accuracy2.
School Health program is a program for school
health service under National Rural Health
Mission (NRHM) which has been necessitated
and launched to provide effective health care to
population throughout the country. The School
Health Program intends to cover 12,88,750
Government and private aided schools covering
around 22 Crore students all over India.
Developing “Human Capital” of Nations,
especially the social, intellectual, mental and
physical abilities of children and adolescents is
fundamental to the improvement of quality of
life of the citizens. Children must be at the very
heart of development – their well being,
capabilities, knowledge and energy will
determine the “Future of Nation”. School health
program is a single, largest time framed health
program operating in the state of Gujarat since
1997. In 2009-2010, it was planned that, SHP will
cover ≈1.4 crore children, i.e. ≈25 % population
of Gujarat. SHP covers all 26 districts and 18568
villages (including 7 corporations) of the state3.
Our hospital is a tertiary level referral centre.
We receive the referred cases of SHP of Surat
city. The cardiac patients are screened for the
murmur, ECG changes and X-Ray findings and
then if necessary subjected to ECHO.
MATERIAL AND METHODS
This is a retrospective analysis of 100 patients
between the age group of 0 -18 years; carried out
over a six months duration i.e. from January
2011 – June 2011. The total number of pediatric
patients examined on indoor and outdoor basis
was 18721. The cardiac patients were either
referred from SHP or were picked up in routine
clinical examination in OPD or IPD. The patients
with an abnormal ECG / CXR &/or with a
murmur of 3/6 (Nadas criteria) were subjected
to ECHO.
The echocardiography machine (by Esaote) with
colour Doppler, having two probes namely
neonatal and pediatric was used. The ECHOs
were done by trained staff and patient data was
filled on a specific performa. The patient was
also given one copy of the same for his record.
For the children who required sedation,
Trichlorophos syrup (Pedichloryl) was used in
dose of 50 mg/kg, half hour before procedure.
After the ECHO was over these patients were
kept under observation till they are fully awake,
after which they were allowed to go home. The
Echo was done free of cost for patients with a
school health card. Of the 100 patients whose
Echo was done, 80 were abnormal and analysis
of these 80 is given below.
RESULTS
Result of the ECHO findings of 100 children
were shown in table 1. Out of these 100 children,
20 children were having normal ECHO
(innocent murmurs) which were not analyzed
further.
Table 1: Echocardiography findings (n=100)
Echo finding
Normal
Abnormal
Congenital defects
a) Acyanotic Heart disease
b) Cyanotic Heart disease
Acquired defects
Children (%)
20 (20)
80 (80)
70 (87.5)
62 (88.6)
08 (11.4)
10 (12.5)
Age and gender distribution of the children with
abnormal ECHO findings were shown in table 2
and table 3.
Table 2: Age distribution of patients (n=80)
Age of patients
0 -1mth
1mth – 1 yr
1 – 5 yrs
5 -10 yrs
10 – 15 yrs
>15 yrs
No. of Children (%)
10 (12.5)
12 (15)
24 (30)
14 (17.5)
17 (21.2)
03 (3.75)
Table 3: Gender distribution (n=80)
Gender distribution
Male
Female
No. of Children (%)
41 (51.25)
39 (48.75)
Higher rate of CHD is noted in males (51.25%)
and in age group of 1-5 years (30%)
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Table 4: Types of Congenital Heart Diseases
diagnosed (n=70)
Children (%)
Acyanotic Heart Disease (n=62)
Ventricular Septal Defect (VSD)
Atrial Septal Defect (ASD)
Patent Ductus Arteriosus (PDA)
Patent Foramen Ovale (PFO)
Pulmonary Stenosis (PS)
Coarctation Of Aorta (COA)
Endocardial Cushion Defect
(ECD)
Cyanotic Heart Diseases (n=8))
Tetralogy Of Fallot (TOF)
Tricuspid Atresia (TA)
Double Outlet Right Ventricle
+ECD+PS
16 (22.86)
15 (21.4)
07 (10)
08 (11.4)
03 (4.2)
02 (2.8)
01 (1.4)
4 (5.71)
1 (1.4)
1 (1.4)
Out of 80 children with abnormal ECHO, 87.5%
had congenital defects, of which 88.6% were
acyanotic. Among acyanotic CHD (n=62),
majority had VSD(22.86%) followed by ASD
(21.4%) and PFO (11.4%). Out of the 11.4% of
cyanotic CHD, 4 (5.7%) were found to be TOF.
Total 47 (58.75%) patients had multiple lesions
and 33 (41.25%) had a single lesion.
Table 5: Types of Acquired lesions diagnosed.
Acquired defects
Pericardial effusion
Cardiomyopathy
Rheumatic heart disease
Children (%) (n=10)
6 (60)
2 (20)
2 (20)
Table 5 shows distribution of children with
diagnosed acquired lesions. Pericardial effusion
(60%) was the most common diagnosis of the
Acquired Heart disease.
Table 6: Presence of school health card
School health card
Yes
No
Don’t know
Children (%) ( n=100)
37 (37)
50 (50)
13 (13)
23.75% were referred to higher centre for
surgical intervention and further management.
The patients with a school health card were
referred to U.N.Mehta Cardiology Institute,
Ahmedabad, where they were operated free of
cost, as and when needed.
37% of the patients had come with a school
health card and were able to avail these facilities
for free.
DISCUSSION
As per the Mohfw- Gujarat data, in the year
2009-2010 almost 1,31,27,064 children were
examined; of these 15,99,194 received spot
treatment and 82,470 children were referred for
further management. An estimated 4176
children received cardiac care, 544 received
kidney
care
and
182
received
cancer/malignancy care specialist services all
over Gujarat.
Table 7: Comparison of Current study with other studies
Total pts (n)
<1 yr
<5 yrs
VSD (%)
ASD (%)
PDA (%)
TOF (%)
Mad.Sani et al4
122
33.6%
69%
45.9
12.3
-26.2
Kapoor et al5
281
--21.3
18.9
14.6
4.6
A total of 111 children had come to our institute
with school health cards covering all types of
diseases, within this time frame, and 69 of these
were subjected to Echo from the OPD. This
shows that heart diseases are still the most
commonly diagnosed anomaly in children.
In our study the incidence of CHD is 0.37% and
prevalence is 3.7, which is similar to that seen in
the Ashraf study. The abnormal echo’s in <1yr is
Ashraf et al6
221
--31.2
11.3
16.3
7.8
This study
80
27.5%
57.5%
22.86
21.4
10.0
5.71
27.5% and <5yrs is 57.5% in our study which is
almost similar to that found in Mah.Sani et al
study. VSD (22.86%) was most commonly
diagnosed in our study, as is seen in all the other
three studies. VSD was followed by ASD and
then PDA, which is same as all the other studies.
TOF was found to be 5.71% which is comparable
to the Kapoor Study and other Indian studies.
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CONCLUSION
The incidence of heart disease found in our
setup is 0.37% (80/18721) over a time span of six
months. The pick-up rate of heart murmur and
referral is 62.6% (69/111) in the community. A
good number of the patients (23.75%) were
referred to higher centre for further intervention
and management, and around 31% could be
managed medically early in the course of the
disease.
KEY MESSAGE
School health program is very effective in
picking up the cardiac murmurs and in turn the
patients with some cardiac anomaly, improving
the overall lifestyle of the patient because of
early detection and management. It is also cost
effective for the patients.
REFERENCES
1.
2.
3.
4.
5.
6.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Nelson Textbook of Pediatrics, 18th ed, India, 2008,
Elsevier:1857-1864
Myung.
K.
Park,
Pediatric
Cardiology
for
practitioners,5th ed, India,2009, Elsevier:81-96
Mohfw, Government of India- Gujarat data.
Mahmoud U Sani, Mariya Mukhtar-Yola,Kamilu M
Karaye. Spectrum of Congenital Heart Disease in A
Tropical Environment: An Echocardiography study. J
Natl Med Assoc.2007 June; 99(6):665-669
Rashmi Kapoor, Shipra Gupta. Prevalence of
Congenital Heart Disease, Kanpur, India. IP 2008
April;45: 309-311
Mohd.Asraf, J Chowdhary,K Khajuria et al. Spectrum
of Congenital Heart Diseases in Kashmir, India. IP 2009
Dec;46:1107-1108.
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ORIGINAL ARTICLE .
EFFECT OF DAILY VERSUS WEEKLY IRON FOLIC ACID
SUPPLEMENTATION ON THE HAEMOGLOBIN LEVELS
OF CHILDREN 6 TO 36 MONTHS OF URBAN SLUMS OF
VADODARA
K Sharma1, P Parikh2, F Desai3
1PhD
Advisor, 2Doctoral Student, 3Masters Student, Department of Foods and Nutrition, Faculty of
Family and Community Sciences, The Maharaja Sayajirao University of Baroda, Gujarat, India
Correspondence:
Dr. Kavita Sharma, PhD Advisor,
Departments of Foods and Nutrition, Faculty of Family and Community Sciences,
The Maharaja Sayajirao University of Baroda, Gujarat, India
Email - [email protected]
ABSTRACT
Objective: To assess the effect of daily versus weekly iron folic acid (IFA) supplementation on the
haemoglobin levels of children 6 to 36 months of urban slums of Vadodara
Design: Non Randomized control supervised trial
Setting: Five out of 40 anganwadi centres were randomly selected. The centres were randomly
divided into 3 groups i.e., daily, weekly and control.
Participants: All children age 6 to 36 months were selected
Intervention: Subjects of daily group (n=31) received one IFA tablet (19.8 mg of elemental
iron/tablet) daily for 60 days; weekly group (n=30) received one IFA tablet per week for 19 weeks;
control group (n=31) did not receive any supplementation.
Main Outcome Measure(s) included impact on haemoglobin levels, anemia prevalence.
Results: A significant rise in the hemoglobin levels of 2.03g/dl and 1.75g/dl was observed in daily
and weekly group respectively, with anaemic subjects showing a higher rise. Overall prevalence of
anemia reduced significantly by 35% and 43% respectively in daily and weekly group. Weekly
supplementation showed fewer side effects and more reduction in anemia compared to daily.
Conclusions: IFA supplementation significantly increased haemoglobin levels of underprivileged
children below 3y of age, irrespective of dose and regimen (daily or weekly). Weekly
supplementation with medicinal iron can be used as a strategy for improving haemoglobin levels and
anemia reduction among children 6 to 36 months with fewer side effects.
Key words: Under 3, IFA supplementation, anaemia, weekly vs. daily supplementation, low socio
economic group
INTRODUCTION
Iron deficiency anemia (IDA) is a public health
problem of staggering proportions affecting 2050% of world’s population 1. It is the most
common nutritional disorder in the world
affecting particularly pregnant and lactating
women and preschool children 2.
Infants and young children are highly
vulnerable to IDA because of depletion of iron
stores due to rapid growth, low iron content of
most infant diets and early initiation of top milk.
According to WHO (1991), 48% of children
<3years of age have IDA 3. In India nearly 6070% of all children below 6 years suffer from
varying degree of anemia 4.
The results of the National Family Health
Survey III (NFHS-3) show almost 40% of all
children below three are underweight and
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almost 80% of children in the age group of 6-35
months are anaemic 5.
In India, 57 of every 1000 children die before
they reach the age of one year. 6. Iron deficiency
anaemia is associated with impaired motor
development, physiological and behavioural
effects, reduced physical activity and poor
scholastic performance in children 3 7.
Iron supplementation has successfully proved to
be a short term strategy to combat anaemia. But
daily iron-folic acid (IFA) supplementation has
shown to have certain limitations like rapid
decline in iron absorption due to high dose and
gastrointestinal side effects. On the other hand
weekly iron supplementation has advantage
over daily iron supplementation like – lower
side effects, cost effectiveness and improved
compliance.
The National anemia control program
recommends supplementation of 100 IFA tablets
every year for all children 6 to 36 months.
However, this has failed to make any dent in
anemia control among under 3 with latest NFHS
III data showing increase in anemia from 74.3%
to 78.9%, the reasons for this are many
predominantly poor compliance. Fewer then
one in ten children were given IFA
supplementation in last seven days (4.7 %) as
per NFHS III. The operational success of this
strategy needs to be examined and redefined. 5
While the effectiveness of weekly regimen of
iron
supplementation
in
improving
haemoglobin levels has been established in older
children and adolescents 8 9, very few studies
have addressed this issue in infant and young
children (< 3 years)
Therefore, the present study was undertaken
with the major objective of assessing the
effectiveness of weekly versus daily iron
supplementation in improving the haemoglobin
levels of young children (6 months – 3 years)
and reducing the prevalence of anemia.
METHODOLOGY
The prospective study was undertaken in the
areas of anganwadi centres managed by a
children’s hospital of Baroda, in 2004. Five out of
40 anganwadi centres were randomly selected
and a total of 158 subjects (6– 36 months of age)
were enrolled for the study. The anganwadi
centres were randomly divided into three
groups, with a minimum of 50 subjects in each.
The three groups were – daily group (n=55) and
weekly group (n=51), each of which served as
experimental groups and a control group (n=52).
Daily group received one iron folic acid (IFA)
tablet/day for 60 days, whereas weekly group
received one IFA tablet/week for 19 weeks.
Control
group
did
not
receive
any
supplementation. It was a supervised trial.
Chemical analysis of the IFA tablets was done
using Wong’s method.
Baseline data were collected on socio-economic
status, dietary intake, hemoglobin levels, red cell
morphology and morbidity profile. Hemoglobin
levels and red cell morphology were again
measured at the end of the intervention period.
Socio-economic status: Information on socioeconomic profile of the subjects was collected
using a pre-tested structured questionnaire.
Dietary intake: Data on dietary intakes was
collected using 24 hour dietary recall method
and food frequency questionnaire.
Haemoglobin estimations: Haemoglobin levels
were
measured
using
standard
cyanmethemoglobin method.
Red cell morphology: The red cell morphology of
all the subjects was studied using peripheral
blood smear.
Morbidity Profile: Data on morbidity profile was
collected using a reference period of two weeks,
both at baseline and after intervention.
Ethics: Before starting the study, consent was
taken from the social welfare officer of the
hospital, supervisors of the anganwadi centres
and the parents of all the subjects.
Statistical analysis: Data was analysed using the
SPSS package. Frequency distribution and
percentages were calculated for all parameters
while means and standard errors were
calculated for all numerically expressed
parameters. Independent‘t’ test were used to
compare the difference between the means in
different groups. Paired‘t’ test were used to
assess the differences between the means of
same group before and after the study period.
Chi-square test was used to test difference
between the frequency distribution.
RESULTS
Out of the 158 enrolled children, 92 children – 31
each in daily and control groups and 30 in
weekly group, completed the study, for analysis
the subjects were classified into two categories.
The subjects in the two categories were not
mutually exclusive.
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All subjects – Total 92 (daily =31, weekly=30 and
control =31) subjects who participated and
completed the study, including both anaemic
and non-anaemic subjects.
Anemic subjects – Total 80 subject with initial
Hemoglobin levels below 11g/dl including 28
from daily, 25 from weekly and 27 in control
group.
Table 1: Mean Dietary Iron Intake of the Subject in Three Groups
Age group
6 to 12 m
12 to 24 m
Daily (A)
Mean ± SE
7.42 ± 1.33
5.9 ± 0.8 9
Weekly (B)
Mean ± SE
5.85 ± 1.47
5.11 ± 0.38
Control (C)
Mean ± SE
6.61 ± 0.99
5.38 ± 0.44
The results of chemical analysis showed that the
IFA tablets contained 19.8 mg of elemental
iron/tablet. The daily group was supplemented
1 tablet/day for 2 months (60 days) thus
consuming a total of 1188 mg of iron through
supplements, while the weekly group was
supplemented 1 tablet/week for 19 weeks thus
consuming a total of 376.2 mg iron.
A v/s B
‘t’ value
0.78
0.82
B v/s C
‘t’ value
0.43
0.464
A v/s C
‘t’ value
0.47
0.529
The data on the dietary intakes obtained both
through the 24 hour dietary recall method and
the food frequency method showed that the
dietary iron intake was very low in all three
groups and was statistically non significant
(Table 1).
Table 2: Impact of IFA Supplementation on Haemoglobin levels of Children (6 to 36 months)
Groups
Haemoglobin Levels (g/dl) Mean ± SE
A v/s B
‘t’ Value
Daily (A)
Weekly (B)
Control (C)
(31)
(30)
(31)
All Subjects
1.56
8.73±0.284
9.59±0.251
9.06±0.23
Initial
0.68
8.68±0.256
11.27±0.22
11.09±0.79
Final
-0.06±0.23
1.75±0.24
2.03±0.25
Difference
Paired ‘t’ Value
7.9***
7.7***
0.316
Anaemic Subjects
(28)
(25)
(27)
9.19±0.22
8.27±0.19
1.24
Initial
8.81±0.205
0.57
Final
10.97±0.12
10.98±0.21
18.36±1.19
Difference
2.16±0.26
1.87±0.25
0.1±0.22
Paired ‘t’ Value
8.13***
7.42***
0.48
*** Significant at p<0.001, Figures in parenthesis indicates no of subjects
The effect of iron supplementation on the mean
haemoglobin levels of the subjects is shown in
Table 2. The initial hemoglobin level of the three
groups was not different significantly. However,
B v/s C
‘t’ Value
A v/s C
‘t’ Value
2.23
7.65***
0.875
8.252***
3.08
8.33***
1.91
10.09***
the mean final hemoglobin level of “All
subjects” of the daily and weekly groups was
significantly higher than the control group.
Table 3: Effect of IFA Supplementation on Change in the Percent Prevalence of Red cell Morphology
among Children (6 to 36 months)
Daily
Weekly
Control
Normocytic Normochromia
Initial (%)
Final (%)
9 (29)
28 (90)
10 (32.2)
22 (70.9)
7 (22.5)
7 (22.5)
Microcytic Hypochromia
Initial (%)
Final (%)
17 (54.8)
1 (3.3)
16 (53.3)
5 (16.6)
15 (50)
16 (53.3)
When the different levels of change in
hemoglobin levels was seen for all subjects, 39%
of subjects from daily group and 33% of subjects
Macrocyctic Hypochromia
Initial (%)
Final (%)
5 (16.1)
2 (6.4)
4 (12.1)
3 (9.6)
9 (29.0)
8 (25.8)
from weekly group showed an increase in
hemoglobin levels between 1.51g/dl to 2.5g/dl.
A total of 29% and 20% subjects from daily and
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observed in the subjects with hemoglobin level
below 10g/dl in both daily (2.43g/dl) and
weekly (2.03g/dl) groups.
weekly group respectively showed an increase
greater than 2.51g/dl (Figure 1). Sixty one
percent subjects in the control group showed a
drop in hemoglobin levels. The data when
analysed for anemic subjects showed a similar
trend.
With respect to the impact of supplements on
the percent prevalence of anemia, the results
showed that the overall percent prevalence of
anemic subjects reduced from an initial 89% to
55% in the daily and 83% to 40% in the weekly
group, whereas it increased from initial 87% to
93% in the control group.
Percent Subjects
The impact of supplementation on the final
haemoglobin levels of all subjects in relation to
initial hemoglobin levels is shown in Figure 2. A
higher increase in hemoglobin levels was
45
40
35
30
25
20
15
10
5
0
39
37
0
3.3
< -0.5
33
32
29
6
10
3.3
3
0.01 - 0.5
0
Daily
20
16
13
10
Weekly
Control
10
3.3
0
29
3
0
0.01 - 0.05 0.51 - 1.50 1.51 - 2.50
>2.51
Change in hemoglobin levels (g/dl)
Figure 1: Percent of All Subjects Showing Different Level of Change in Hemoglobin Levels – After
Supplementation
Change in hemoglobin levels (g/dl)
Analysis of hemoglobin levels of the subjects
according to the initial red cell morphology
showed that irrespective of the type of red cells,
significant increase in hemoglobin levels from
initial to final was seen in all the three categories
i.e. Microcytic, Hypochomic, Normlcytic,
Normochromic and Macrocytic Hypochromic in
the daily and weekly groups. Normocytic
Normochromic subjects showed rise in
hemoglobin levels but lower in comparison to
the other two deficient cell morphologies.
3
2.5
Daily
2.43
Weekly
2.03
2
1.44
1.39
1.5
1
0.6
0.5
Control
0.81
0.19
0
-0.5
-1
-1.5
<10.0
-0.6
10.0 - 10.99
>11.0
-1.13
Initial hemoglobin levels (g/dl)
Figure 2: Effect of Supplementation on Change in Hemoglobin Levels of Subjects in Relation to Initial
Hemoglobin Levels
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Moreover the impact of supplementation
brought about a drastic shift in the red cell
morphology of the experimental group subjects
with majority of subjects having normal red cell
morphology in these groups after the
intervention as shown in Table 3.An assessment
of the physiological effects experienced on
consumption of the supplements as reported by
the subjects showed that majority of the subjects
(90.3%) in daily group reported to have side
effects as against only 9.6% in the weekly group.
DISCUSSION
Supplementation with medicinal iron in the
present study led to a significant rise in the
haemoglobin levels of the subjects in both the
daily (2.03 g/dl) and weekly (1.75 g/dl) groups.
The anemic subjects showed a higher increase in
hemoglobin levels as compared to the normal
subjects, in both supplementation groups.
A rise of 2.43 g/dl and 0.6 g/dl respectively was
observed in daily group among subjects with
hemoglobin levels <10g/dl and 10-10.9g/dl, and
2.03 g/dl and 1.39 g/dl in the weekly group. On
the other hand no change in the mean
hemoglobin levels was observed in the control
group.
Studies in literature have shown a significant
increase in haemoglobin levels on weekly
supplementation to different age group thus
showing it to have a comparable effect on
hemoglobin levels. While studies have been
carried out to assess the effect of daily
supplementation of iron on hemoglobin levels of
children, the effect of daily versus weekly iron
supplementation on hemoglobin levels have
been studied in few.
In a study by Sungthong et al (2002) in Thailand,
397 primary (6-13yr) school children were
supplemented 60 mg of elemental iron, either on
daily or weekly basis for 16 weeks. An increase
in hemoglobin levels of 0.65 g/dl in daily group
and 0.57 g/dl in weekly group was observed 9.
A study in North-East Delhi on 2210 girls aged
10-17 years assessed the effect of supplementing
100mg elemental iron and 500 mg folic acid for
100 days to the daily group and for 230 days to
the weekly group. The haemoglobin levels
significantly increased from pre to post, 11.7 to
12.2 g/dl in daily group and 11.7 to 12.1 g/dl in
weekly group 10.
In the present study, overall 91% and 93%
subjects from daily and weekly group showed
improvement in haemoglobin levels. Further
39% and 33% of subjects respectively from daily
and weekly group showed an increase in
hemoglobin levels between 1.51 g/dl to 2.5 g/dl,
while 29% subjects from daily and 20% subjects
from weekly group showed an increase greater
than 2.51 g/dl. As against this, 61% of control
group subjects showed a drop in hemoglobin
levels with 29% showing drop of over 0.5 g/dl.
A study conducted in Andhra Pradesh 8, to
assess the effect of daily versus weekly iron
supplementation on 244 girls (13-15 yrs) with
different degrees of anemia, showed that rise in
hemoglobin levels observed increased with the
severity of anemia in both the groups. The
results in the present study also showed a
similar trend. The highest rise in hemoglobin
levels of 2.43 g/dl and 2.03 g/dl was observed
in severely anemic subjects from daily and
weekly group respectively. Over all there was
35% and 43 % reduction in anemia among the
daily and weekly group respectively.
To conclude, the results of the present study
have shown that supplementation with IFA
(19.8 mg elemental iron) brought about a
significant rise in the haemoglobin levels and
the rise was comparable between both the
groups i.e. daily and weekly. Also weekly
supplementation was reported to have fewer
side effects and better anemia reduction than
daily supplementation.
Thus, weekly supplementation with iron-folic
acid tablets can be recommended as a strategy
for improving haemoglobin levels of young
children (6 to 36 months). Further research
needs to be carried out to test the long-term
effect of IFA supplementation on hemoglobin
levels, anemia prevention, compliance and
growth of young children.
What is already Known
IFA supplementation can cause a significant rise
in the haemoglobin levels in different age
groups.
What this Study Adds
Irrespective of dose and regimen (daily or
weekly) IFA supplementation significantly
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increases haemoglobin levels in young children
(6 to 36 months).
Weekly supplementation shows fewer side
effects.
REFERENCES:
1.
2.
3.
4.
Stoltzfus R, Dreyfuss M. Guidelines for the use of iron
supplements to prevent and treat iron deficiency
anemia. WHO/INACG/UNICEF, 1997.
Sharma KD, Naidu AN. Anemia in Children, National
Institute of Nutrition, India. 1984.
Gillispie S. Major issues in the control of iron
deficiency. The micronutrient initiative, Canada.
UNICEF, New York, 1998.
Kapur D, Agarwal K, Sharma S. Iron status of children
aged 9 to 36 months in an urban slum: Integrated Child
Development Service Project in Delhi, Indian Pediatrics
2000; 39: 136-144.
5.
Pollit E. Development and Probabilistic nature of the
functional consequences of iron deficiency anemia in
children. American Society for Nutritional Sciences,
2000.
6.
International Institute for Population Sciences (IIPS)
and Macro International. National Family Health
Survey (NFHS-3), 2005–06, 2007.
7.
Office of the Registrar General. SRS Bulletin. Volume
42, No. 1. New Delhi: India, 2007.
8.
Shobha S, Sharad D. Efficacy of twice weekly iron
supplementation in anemic adolescent girls. Indian
Pediatrics 2003; 40: 1186-1190.
9.
Sungthong R, Mo-Suwan L, Chongsuvivat Wong. Once
weekly is superior to daily iron supplementation on
height gain but not on Haematological improvement
among school children in Thailand. Journal of Nutrition
2002; 132: 418-422.
10. Agrawal KN, Gomber S, Bisht H, Sorn M. Anemia
prophylaxis in adolescent school girls by weekly or
daily iron folate supplementation. Indian Pediatrics,
2003: 40: (17) 296-301.
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ORIGINAL ARTICLE .
SOCIO-DEMOGRAPHIC CHARACTERISTICS OF POSTMENOPAUSAL WOMEN OF RURAL AREA OF
VADODARA DISTRICT, GUJARAT
Donald Christian1, Manish Kathad1, Bharat Bhavsar2
1Assistant
Professor, 2Professor & Head of Dept., Department of Community Medicine, SBKS Medical
Institute & Research Center, Piparia
Correspondence:
Dr. Donald Christian
Assistant Professor, Department of Community Medicine,
SBKS Medical Institute & Research Center, Piparia,
Taluka Waghodia, District- Vadodara(Gujarat) - 391760
E-mail: [email protected], Mobile: +91 9825888630
ABSTRACT
Background: With the growing aged population in the country, postmenopausal health problems and
needs are likely to become a great challenge to public health. This is more so related to the women
with poor social background like those residing in rural areas.
Material & Methods: Design: Cross-sectional study, Participants: 147 post-menopausal women
residing in Piparia village of Vadodara district were involved in the study, based on sample size
calculation and necessary assumptions. Information was filled up in a pre-tested questionnaire.
Objective: To study the social and demographic characteristics of the post-menopausal women in
rural areas of Vadodara district, Gujarat.
Results: Among a total of 147 respondents, the mean age was 58.32 (48-68) years, while the mean age
of inception of menopause was 47.74 (44.84-50.64) years. Labor work (n=37, 25.2%) was the most
common occupation. Among all the respondents, 98.5% belonged to social class 4 or below, 18.4%
were widow and 40% were below poverty line (BPL). 74.8% were not literate and 42.9% were
dependent on their children for daily living.
Conclusion: Rural post-menopausal women in India suffer many social disadvantages which could
make them more vulnerable to experience more frequent and more severe of menopausal symptoms.
Along with geriatric care, this special group of women also needs a separate focus for health care
provision.
Key words: post menopausal women, socio-demographic profile, rural area, menopause, menopausal
symptoms.
INTRODUCTION
While women of reproductive age group (15-45
years) are covered under the Reproductive and
Chile
Health
(RCH)
program,
the
postmenopausal women ageing 45 and above,
are not covered in any specific health program
in the country. This is especially important as
the country is facing the challenges of growing
aged population and provision of health
services to those people, which has already
become a challenge. It has been estimated that in
2025, the geriatric population in India would
reach the mark of 168 million, which was only
81 million in 2002. 1.The second issue here is the
lack of standard data related to postmenopausal women in India, especially rural
areas, where lack of services has been a huge
issue and where most of the women of this agegroup are expected to reside. 2. It is also
important to study the women in sociodemographic context, as they are closely related
with regards to perceptions-positive or negative-
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by the woman.3. It has been emphasized to
study social factors along with medical
problems of postmenopausal women, to derive
at valid conclusions. 4. Though there are few
studies in India, several local contexts need to be
studied well in every part of the country. 5.
The study was conducted with an objective to
study the social and demographic characteristics
of the post-menopausal women in rural areas of
Vadodara, Gujarat.
MATERIAL & METHODS
A cross sectional study was conducted during
2009-10 in rural area of Vadodara district of
Gujarat state. Sample size calculation was done
using average prevalence of some of the major
postmenopausal symptoms affecting Indian
women found from various studies. Here the
prevalence rate of the major menopausal
symptoms (like, hot flushes, anxiety, depressive
episodes etc.) was considered to be about 40% 1-7
on an average, based on various studies in India,
and the maximum allowable error was kept at
5%. The desired sample size (600 samples) was
modified, as the survey included all the women,
who reported as having crossed menopause and
who also gave informed consent. Institutional
ethical committee approved the project and
informed written consent was taken from the
participant during the conduct of the study in
vernacular language.
The study population was rural women aged 45
and above who had undergone menopause from
the information provided by themselves. The
study was carried out in village Piparia of
Waghodia taluka of Vadodara district of Gujarat
state. The inclusion criteria were any woman,
aged 45 and above and who reported to have
experienced menopause in recent or remote past
and who gave informed consent to participate in
the study. Postmenopausal women who were
seriously ill due to reasons associated or not
associated with menopause were excluded from
the study. The study was carried out in the
village by searching in all the four corners of the
village, the desired samples, conducting house
to house survey. Those women fulfilling
inclusion criteria were interviewed using predesigned questionnaire. The information was
collected by considering a particular symptom if
it was present since at least 5 days at the time of
interview. The data was collected by the intern
doctors posted in the department. The data were
analyzed using SPSS software and appropriate
statistical tests were applied.
RESULTS
A total of 176 women were found having
undergone menopause, out of which 29 subjects
were excluded from the study due to not
satisfying the inclusion criteria. (not giving
consent and/or seriously ill). The mean age of
the rest (n=147) subjects was 58.32 (48-68)
years.[Table 1]. Importantly, the mean age of
menopause came out to be 47.74 (44.84-50.64)
years. The mean gravida was 2.69 children and
mean parity was 2.61 children per woman.
Table 1: Statistics related to age of various events among postmenopausal women (N=147)
Statistics
Age
Age of Menarche
Age at Marriage
Age at Menopause
Minimum (yrs)
Maximum (yrs)
Mean (yrs)
45
12
12
40
85
17
23
55
58.32
13.39
17.80
47.74
The results of the study shows that among a
total of 147 women, the majority of the women
were not engaged in any work and were
housewives (n=108, 73.5%), while few of them
were laborer (n=37, 25.2 %). [Table 2]. Majority
of the women (n=118, 80.3%) were married and
living with the partner at the time of the study
while some were widow (n=27, 18.4%). Most
(98.5%) of the women belonged to either class IV
or class V according to modified Prasad
Standard
Deviation
9.858
1.107
2.358
2.905
classification. (58.5% and 40% respectively).
While socio-economic class signifies the said
amount of income of the family, the study also
took into account the distribution of BPL
families which was 40 %.( n=59). Most of the
BPL women were laborer by occupation (34/37),
which was found to be highly significant in
comparison
to
non-laborers.
(25/110).
(p<0.001)[Table: 3]
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Table 2: Distribution of various social
characteristics among post menopausal women
(n=147)
Characteristics
No. of Women (%)
Level of Education
Illiterate
110 (74.8)
Primary School
26 (17.7)
High School
3 (2.0)
SSC
4 (2.7)
Above SSC
4 (2.7)
Types of Occupation
Farmer
2 (1.4)
Housewife
108 (73.5)
Laborer
37 (25.2)
Socio-economic Class
Class III
1 (0.7)
Class IV
86 (58.5)
Class V
60 (40.8)
Marital Status
Unmarried
2 (1.4)
Married
118 (80.3)
Widow
27 (18.4)
Nature of Dependency
Self
42 (28.6)
Spouse
42 (28.6)
Children
63 (42.9)
Whether belonged to Below Poverty Line
Not BPL
88 (59.9)
BPL
59 (40.1)
Table 3: Distribution of occupation type among
BPL-non BPL respondents (p<0.001)
Occupation
BPL
APL
Total
Farmer
1
1
2
Housewife
24
84
108
Laborer
34
3
37
Total
59
88
147
BPL=Below Poverty Line , APL= Above Poverty
Line
The most common mode of dependency was
dependent ‘on children’ (42.9%, n=63) followed
by both ‘on self’ and ‘on husband’. (n=42, 28.6%
for each category).l
The education level showed following
distribution. It shows that most of them (n=110,
74.8%) were not literate, while only 17.7% (n=26)
had an education level of primary school. Rest
of the categories did not form significant
proportions.
DISCUSSION
The mean age of the study was 58 (48-68) years,
which is higher than the studies conducted by
Kapur et al (45.02 years) Kakkara et al (48.0
years) and Bairy et al (48.70 years) which
probably explains that chances of getting
premenopausal women were very less. 5, 10, 11
This can be accepted because the reported age of
menopause was quite similar (47.74 years) in
present study.
The study showed that a majority of the women
were housewives (n=108, 73.5%) and only few
were laborer (n=37, 25.2%). Importance of the
type of occupation lies in the fact that, several
studies have shown an association of the nature
of the work done by the women and severity of
the complaints after menopause. For example, a
study by Kakkara V. et al showed that working
women had a higher proportion of
psychological symptoms while the non-working
women had higher proportions of somatic
symptoms among the study subjects. 5. To live
with the partner (n=118, 80.3%) has got some
positive implications on the perception of
symptoms as social factors do play in here.
Most (98.5%) of the women belonged to either
class IV or class V according to modified Prasad
classification. (58.5% and 40% respectively).
While socio-economic class signifies the said
amount of income of the family, the study also
took into account the distribution of BPL
families, as reported, which was 40 %.( n=59).
Poor socio-economic conditions predisposes to
higher rates of menopausal complaints as
evident by a study conducted by Aaron et al,
which showed higher proportions of depressive
symptoms.2 Poor social-economical status is also
associated with higher chances of getting early
menopause11. The study shows that most of
them (n=110, 74.8%) were not literate. A study
conducted in Turkey showed that the level of
education has got a positive influence on the
perceptions of symptoms by menopausal
women. The role of social factors also plays part.
Thus it recognizes the need of such studies in
rural and backward areas of country like us 4.
CONCLUSION
Post-menopausal women in India, particularly
in rural areas, pose a challenge to public health
as well as to society, as most of India resides in
villages and geriatric population is also
increasing day by day. It is evident that these
women also suffer added social disadvantages
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like poor social status, hard physical working
conditions, poor economic conditions and low
level of literacy. Although age of menopause is
not affected by such conditions, these
disadvantages certainly make them more
vulnerable to various menopausal symptoms
with increased severity, for which various
preventive and curative solutions are yet to be
sorted out.
Acknowledgement: The authors would like to
acknowledge the help of the intern doctors
during the study.
REFERENCES
1.
2.
3.
4.
Report of the United Nations, 2004, UN- United
Nations, "World Population Prospects," The 2004
Revision.
Aaron R, Muliyil J, Abraham S, Medico-social
dimensions of menopause: a cross-sectional study from
rural south India, Natl Med J India. 2002 Jan-Feb;
15(1):14-7.
Liu J, Eden J., Experience and attitudes toward
menopause in Chinese women living in Sydney--a cross
sectional survey, Maturitas, 2007, Dec 20; 58(4):359-65.
Uncu Y., Alper Z., Ozdemir H., Bilgel N. & Uncu G.,
The perception of menopause and hormone therapy
among women in Turkey,2007, 10 (1) , 63-71 . Online
linkhttp://informahealthcare.com/doi/abs/10.1080/13697
130601037324?select23=Choose
5.
Kakkara V, Kaurb D., Chopraa K., Kaura A., Kaura I.,
Assessment of the variation in menopausal symptoms
with age, education and working/non-working status
in north-Indian sub population using menopause rating
scale (MRS), Maturitus, 57, (3), Pages 306-314.
6.
Simon T., Why is cardiovascular health important in
menopausal women?, Climacteric.-The journal of the
International Menopause Society 2006 Sep;9 Suppl 1:138.
7.
Gupta P, Sturdee DW, Hunter MS., Mid-age health in
women from the Indian subcontinent (MAHWIS):
general health and the experience of menopause in
women. Climacteric, 2006 Feb; 9(1):13-22.
8.
Reena C, Kekre AN, Kekre N., Occult stress
incontinence in women with pelvic organ prolapsed,
Int J Gynaecol Obstet., 2007, Apr; 97(1):31-4,
9.
Avis NE, Stellato R, Crawford S, Bromberger J, Ganz P,
Cain V, Kagawa-Singer M., Is there a menopausal
syndrome?-Menopausal status and symptoms across
racial/ethnic groups, Soc Sci Med. 2001 Feb; 52(3):34556.
10. Bairy L, Adiga S, Bhat P, Bhat R., Prevalence of
menopausal symptoms and quality of life after
menopause in women from South India, Aust N Z J
Obstet Gynaecol., 2009, Feb 49(1):10611. Kapur P, Sinha B, Pereira BM, Measuring climacteric
symptoms and age at natural menopause in an Indian
population using the Greene Climacteric Scale, 2009,
Mar-Apr; 16(2):378-84.
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ORIGINAL ARTICLE .
A STUDY ON STATUS OF EMPOWERMENT OF WOMEN
IN JAMNAGAR DISTRICT
Yadav Sudha B1, Vadera Bhavin2, Mangal Abha D3, Patel Neha A3, Shah Harsh D3
1Professor
and head, 2Assistant professor, 3Resident, Department of Community Medicine, Shri MP
Shah Medical College, Jamnagar,Gujarat
Correspondence:
Dr. Harsh Dilipkumar Shah
Near Mahila Mandir, Kothariwada, Modasa-383315,
Dist- Sabarkantha, Gujarat
E-mail address: [email protected], Mobile: 9925220545
ABSTRACT
Background: Empowerment of women is important for decision making in relation to health seeking,
family planning, nutrition and economic issues, for her as well as for the family.
Aim: To assess the level of empowerment of women in Jamnagar district.
Settings and design: A cross sectional study was designed in rural and urban areas of Jamnagar
district.
Material and methods: An open-ended questionnaire was used for data collection on parameters
relating to women empowerment through house-to-house survey.
Statistical analysis: Chi-square was used.
Results: Mean age of participants was 30.74 ± 7.65 years, 14.77% were illiterate, majority of women
were housewives, 28.86% were not involved in decision regarding their marriage and 14.09% were
not involved in household decisions. About quarter had no say in financial matters of family and 57%
didn’t hold any bank account. The condition was worse for rural and urban slum women. 21% of the
women had experienced some kind of domestic violence, which was higher in case of urban women.
About one fifth of the women had no role in decisions related to reproductive health viz; spacing and
of number of children, methods of family planning.
Conclusion: one fifth of the women had no say regarding the reproductive issues and similarly a
quarter had no participation in financial decisions. One in every five (21.47%) had faced domestic
violence in some form. Education, employment had a positive impact on status of women in relation
to empowerment.
Keywords: women empowerment, domestic violence, participation in financial decision
INTRODUCTION
The empowerment of women occurs when
women are involved in decision making, which
leads to their better access to resources, and
therefore improved socio-economic status. In
recent years, gender equality and women’s
empowerment have been recognized as crucial
to the health and socio-economic development
of entire country, not just individual families.
This is evident in the fact that promotion of
gender equality and empowering women is one
of the eight Millennium Development Goals1.
Gender based inequalities stem from greater
value being placed on the health and survival of
males than of females2. At the household level,
disempowerment of women results in their
lower access to education, employment and
income and limits their participation in decision
making2. Men’s power over women’s lives can
be measured by the extent to which women
suffer from spousal violence2. Disempowerment
of women also affects their health as their health
needs are often ignored even by themselves as
well as by their families.
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The UNDP has developed a gender
empowerment measure (GEM) which focuses on
three
variables
that
reflect
women’s
participation in society-political power or
decision-making, education, and health 3. The
indicators of empowerment are designed to
measure roles, attitudes, and rights of women in
society2.
the participants verbally before the interview.
We could interview 149 women as one woman
refuse to partake in the study.
In this backdrop, the present study was
endeavored to find out the quantum of
participation of women in decisions affecting
their own lives, as well as that of their families
in Jamnagar district of Gujarat, India.
RESULTS
OBJECTIVES
The study was undertaken to find out
1) Participation of women in household
decisions about reproductive health affecting
their lives including age at marriage and
financial decisions.
2) Prevalence of domestic violence.
3) Association of socio demographic factors with
participation in decision making and domestic
violence.
MATERIALS AND METHODS
A community based, cross sectional study was
conducted during December 2009 in the selected
villages, urban slums, and urban areas of
Jamnagar district in Gujarat state.
The study population comprised of married
women of reproductive age group (15-49 years)
residing in the study area. Sample size for the
study was estimated using proportion of women
taking part in household decision making
reported in (57%) in NFHS 3 for Gujarat state4.
With relative precision of 15% and assuming
10% non-response rate, sample size was
estimated. It was decided by multistage random
sampling method to study 50 women each from
rural, slum and non-slum area of urban
population of Jamnagar district to make the
sample. In each area, the survey was initiated
from the household selected from the list by
random method and continued in consecutive
houses until the required numbers of women
were surveyed.
A pre-tested, semi-structured questionnaire was
used for data collection by interviewing the
women from each household through house-tohouse survey. Informed consent was taken from
The data was entered and analyzed in SPSS
version 17. The chi-square applied where
required.
Table 1: Socio demographic characteristics of
the study population
Characteristics
Age in years
15-25
25-35
35-49
Residence
Rural
Urban
Slum
Type of family
Nuclear
Joint
Religion
Hindu
Muslim
Others
Socio-economic
class
Upper
Middle
Lower
Education
Illiterate
Primary
Secondary
Higher secondary
Graduate and
above
Occupation
Help her husband
Job
Self employed
Unemployed
Age at marriage
Less than 18
18-24
25-35
Frequency (%)
45 (30.2)
66 (44.2)
38 (25.5)
52 (34.9)
50 (33.5)
47 (31.5)
86 (57.7)
63 (42.2)
127 (85.2)
18 (12.0)
4 (2.6)
2 (1.3)
77 (51.6)
70 (46.9)
22 (14.7)
41 (27.5)
51 (34.2)
7 (4.6)
28 (18.7)
8 (5.3)
7 (4.7)
12 (8)
122 (81.8)
20 (13.4)
122 (81.8)
7 (4.7)
Table 1 shows the socio-demographic
characteristics of the study population. The
mean age of the study participants was 30.74 ±
7.65 years. Majority of the women were
educated up to secondary level, while 14.77 %
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women were illiterate. Among the study group,
only 40.94% women were satisfied with their
educational status. Reasons for leaving studies
were enquired into from those who left the
studies (n=88). The most common reason for
leaving school was denial by parents and
housework (39.77%). The next important reason
was poverty accounting for 27.27% of the study
group. As many as 11.36 % women got married
at an early age due to which they could not
complete studies. The other reasons were weak
in study (11.36%), school not approachable
(7.95%) and others (2.27%).
The majority of the women were housewives
(81.88%). On enquiring about their wish to
engage in gainful employment 57.38% women
were willing to work but could not due to
family responsibility of small children and
elderly relatives (35.71%), while 32.85% women
could not spare time from house hold work. The
other reasons were family denial (11.43%), low
education status (8.57%), and others (11.43%).
The mean age at marriage was 20.36 ± 3.15
years. As many as 28.86% women were not
involved in the decision regarding their
marriage. Rest 71.14% were involved in some
way but not fully in the decision related their
marriage.
Table 2: Women’s participation in decision
making
Decisions
Decision of marriage
Yes
No
In household decisions
Yes
No
Major financial
decisions of family
Yes
No
Rights over
reproductive health
Say no for sex
Yes
No
Can’t say
Decision on family
planning
Yes
No
Can’t say
Frequency (%)
106 (71.1)
43 (28.8)
128 (85.9)
21 (14.0)
116 (77.8)
33 (22.1)
124 (83.2
21 (14.0)
4 (2.6)
116 (77.8)
30 (20.1)
3 (2.0)
Table 2 shows the participation of women in
decision making regarding different aspects of
their life. Majority of the women (85.91%)
participated in making household decisions.
Woman’s age affects their participation in
household decision making (Table 3). Older
women (mean age 31.61± 7.66 years) have more
say in these matters compared to younger
women (mean age 25.42 ± 5.06 years).The
difference observed was statistically significant
(p<0.0001).
Table 3: Women’s participation in household
matters
Variables
House hold decision p value
Yes (%)
No (%)
Area of study
Rural
42(80.8)
Slums
41(87.2)
Urban
46(92.0)
Education
Above secondary 33(94.28)
Secondary
46(90.2)
primary
35(85.4)
illiterate
15(68.2)
Employment
Yes
25(92.6)
No
104(85.2)
10(19.2)
6(12.8)
4(8.0)
0.248
2(5.7)
5(9.8)
6(14.6)
7(31.8)
0.032
2(7.4)
18(14.8)
0.311
When the participation of the women in house
hold decision making compared to their place of
residence, an interesting trend emerged. More
women living in urban areas (92%) participate in
these decisions compared to those living in
urban slums (87.2%) and in rural areas (80.8%),
however the difference was not statistically
significant (p= 0.24).
With education, there is marked improvement
in their participation in household decision
making, with almost 100% women educated up
to higher secondary or more participating in
household decision making. The participation of
women decreases with decrease in the number
of years of schooling they have received, 90.2%
secondary educated women, 85.4% primary
educated women, 68.2% illiterate women had
some say in household decision (p<0.059).
Employment increases the participation of
women in household decision making. 92.6%
employed women participated in household
decisions, while 85.2% housewives were
participating in these decisions. The difference
was not statistically significant ( p=0.31).
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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More than three fourth (77.85%) women had
some say in decisions related to financial
matters. Most women (89.93%) could make
purchases for daily needs by themselves. On
enquiring about having a bank account in their
name or a joint account with their husband, it
was found that only 42.95% women had such an
account. Rest of the women (57.05%) did not
have any bank account. On enquiring about
having some money to spend by them, it was
found that 26.17% women had no money which
they could spend according to their wish. Rest
(73.83%) had some money which they could use
according to their wish. Only 51.68% women
had say in the decision on how the household
earnings should be spent (Table 4).
Table 4: Women’s participation in decision on
earning spent
Variables
Area of study
Rural
Slums
Urban
Education
Above secondary
Secondary
primary
illiterate
Employment
Yes
No
Decision on earning
p
spent
value
Yes (%)
No (%)
24(46.2)
18(38.3)
35(70.0)
28(53.8)
29(61.7)
15(30.0)
0.005
25(71.42)
28(54.9)
16(39.0)
8(36.4)
10(28.58)
23(45.1)
25(61.0)
14(63.6)
0.016
22(81.5)
55(45.1)
5(18.5)
67(54.9)
0.001
On looking at the distribution of women
according to place of residence and their
participation in how household earnings are
spent, it was found that majority of the urban
(70%) women had some say in it, while only
38.3% women residing in slums and 46.2% in
villages participated in this decision. This
difference is statistically significant (p< 0.005).
When the same decision was seen against the
educational status of the women it was found
that, the participation increases with the increase
in level of education,71.42% women with
education of Higher secondary and above
participated in the decision, compared to
women having secondary (54.9%) or primary
level of education (39%),and those who are
illiterate (36.4%). This difference was found to be
statistically significant (p<0.002).
Employment status of women has significant
impact on decision regarding spending on the
household activities. Majority of the employed
women (81.5%) participated in this decision,
while less than half of the un-employed women
(45.1%) had any say in this decision (p<0.001).
The women in our study were asked about their
experience of domestic violence. One in every
five (21.47%) women admitted having suffered
from some kind of domestic violence. One in
four women suffered physical violence (n= 32)
and the rest (75%) non physical i.e. mental
and/or emotional violence.
On looking at the distribution of women
according to place of residence and their
experiencing domestic violence(table-5), we
found that more urban women (36%) have
suffered from domestic violence than women
living in urban slums (12.8%) and villages
(15.4%) and the difference is statistically
significant( p<0.001).
Table 5: Prevalence of domestic violence
Variables
Area of study
Rural
slums
urban
Education
Above secondary
Secondary
Primary
Illiterate
Employment
Yes
No
Domestic violence
Yes (%)
No (%)
p
value
8(15.4)
6(12.8)
18(36.0)
44(84.6)
41(87.2)
32(64)
0.009
11(31.42)
8(15.7)
8(19.5)
5(22.7)
24(68.57)
43(84.3)
33(80.5)
17(77.3)
0.364
1(3.7)
31(25.4)
26(96.3)
91(74.6)
0.013
When we distribute the study subjects according
to their education and domestic violence, we
found that domestic violence is most prevalent
among women having education of higher
secondary and above and in illiterate women. It
decreases with rise in education level except in
women having education level of Higher
secondary and above in whom the prevalence is
31.42%, which is higher than in any of the other
classes, however the difference is not significant
(p <0.36).
Experience of domestic violence is related with
employment status of women. We found that
being employed accords some protection to
women against domestic violence, as only 3.7%
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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employed women suffered from some kind of
domestic violence, whereas almost a quarter
(25.4%) of the housewives reported suffering
from some kind of violence. This difference was
found to be statistically significant (p< 0.013).
Women’s participation in decision making in
matters related to their reproductive health was
explored. It was found that about 1 in every 5
women (18.79%) had no participation in
decision regarding spacing of children, number
of children (19.46%) and use of contraceptive
methods (20.13%). On asking the women about
whose responsibility family planning is, 73.82%
women said it was the woman’s responsibility.
This is further reflected in the finding that only
10.06% women felt that their husbands could
also go for the family planning operation
instead.
Lastly, the women were asked about their wish
to be reborn as a female child. Only 21.48%
women did not wish to reborn as a girl child.
Although 6.04% did not comment on this while
72.48% women expressed a desire to be reborn
as a female child.
DISCUSSION
Society in India has traditionally been
patriarchal, except a few communities in south
India where it is matriarchal. Traditionally
women are considered subordinate to men and
incapable of taking any major decisions. Their
role in family is that of a home maker and it is
expected of them to leave the decision making
regarding finances, major purchases and other
household issues as well as health to men. The
study of Kishor and Gupta (2004) revealed that
average women in India were disempowered
relative to men, and there had been little change
in her empowerment over time.5
In this study, majority of women were found to
be having limited access to education. They
were pushed into assuming responsibilities of
the family from a very young age due to family
circumstances. Less education means less
opportunity for employment and early
marriage. Though the mean age at marriage in
India has increased from 16.1 yrs (NFHS 1) to
16.8 years (NFHS 3), still there is scope for much
improvement2. The situation among the study
group was slightly better with the mean age
being 20.36 years, still as many as 13.42%
women got married before legal age of marriage
18 years. Past studies have shown that the mean
age at marriage in various parts in India is still
less than 18 years6. As many as 29% women had
no say in the decision of their marriage. Their
decision is still the prerogative of elders in the
family. The observation of 71% women having
at least some say in the decision is encouraging
which should be promoted.
Less education is both the cause and effect of
early marriage. Other reasons include negative
attitude of family members towards women’s
education, economic pressures, non-availability
of schools and academic failure etc. these
findings
corroborate
the
youth
study
undertaken by IIPS7.
Past studies have confirmed that women have
limited access to knowledge, restricted control
over resources and constrained authority to
make independent decisions. They lack physical
mobility and are unable to forge equitable
power relationship within families8.
Similarly, in this study it was found that though
majority of women were participating in various
decisions, they were not taking these
independently. In addition, it is well recognized
that employment leads to empowerment. In
general, employed women have a greater say in
family matter and in financial decision also.
Employed women are as better educated so
aware of health issues. In this study, majority of
the women were housewives who wished to
work but were unable to do so due to various
familial and household pressures.
We have seen education and employment
together lead to increased participation of
women in various household, financial decisions
with decreased occurrences of domestic
violence. Our study also suggests that older
women have greater say in household decisions
than younger women. This is keeping line of the
nature of joint family system in India wherein
the wife of the head of the family has more
decision making power. And also more urban,
educated, and working women participate in
these decisions. This may be due to greater
awareness of their rights and duties.
While still men make most of the financial
decisions in our society, our study found that
most women had some say in these matters. Still
majority of women did not have any bank
accounts,
which
reveal
their
financial
dependency on other family members. It was
observed that education, employment as well as
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urban residence have better association with
financial decision making.
Domestic violence is a violation of a woman’s
basic human rights. Accordion to NFHS 3, the
prevalence of domestic violence in Gujarat is
27.6%2. However, in the present study, the level
is little less than NFHS 3, still 21% is an
unacceptable number. Only being gainfully
employed, living in rural areas accorded some
protection against acts of violence by husband.
Contributing to the family’s income; increases
the respects for women in family. Perhaps stress
and strain of urban living, with breaking up
joint families, migration from villages and race
for materialistic things have led to lesser
tolerance for erring spouse9.
Family planning is not discussed openly among
couples. It is seen as a woman’s prerogative.
Even women seem to believe so, which reflects
their acceptance of subordinate role of wife.
Various studies have also shown that age group
of women, education, occupation, place of
residence, standard of living were major factors
affecting awareness on reproductive health
issues including Family planning10.
CONCLUSION
The study concluded that though the situation
of women employment in Jamnagar District is
better than rest of Gujarat, there is scope for
improvement. Better education, opportunities
for employment and a shift in the attitude of
society in general towards women will lead to
their empowerment. Education of girls should
be made national priority. Men often ignore
women’s issues. Empowerment of women will
go a long way in improving the health and
quality of life of women and families and will
lead to accelerated development of our society.
REFERENCES
1.
Millennium Development Goals, United Nations, Goal
3.
Available
from:
unstats.un.org/unsd/mdg/Resources/attach/indicato
rs/Officiallist2008.pdf [updated 2008 Jan 15; last cited
on 2011 Feb 21]
2.
International Institute for Population Sciences. National
Family Health Survey 2005-06 (NFHS-3). Mumbai: IIPS;
2007. Gender equality and women empowerment in
India.
IIPS,
2005-2006
Available
from:
www.nfhsindia.org/a_subject_report_gender_for_web
site.pdf. [updated 2009 Dec;last cited on 2011 Feb 21]
3.
United
Nations
Development
programme
(www.undp.org.in)
available
from:
hdr.undp.org/en/statistics/indices/gdi_gem/
[last
cited on 2011 Feb 21]
4.
Gujarat fact sheet. National Family Health Survey 200506 (NFHS-3). International Institute for Population
Sciences.
Mumbai;
2007.
Available
from:
www.nfhsindia.org/pdf/gujarat.pdf [last cited on 2011
Feb 21]
5.
Sunita Kishor and Kamla Gupta. Women’s
empowerment in India and its states: Evidence from the
NFHS. Economic and Political Weekly 2004;39:694-712
6.
Neeraj K Sethi, Sarah S Rao, O.P Aggarwal, A
Indrayan, C.S Chuttani. Age At Marriage, Gauna
(Effective Marriage) And First Child Birth In Rural
Women- Changing Pattern In Various Marriage
Cohorts by decades. Indian J Community Med
1988;13:166-69
7.
Youth in India: Situation and Needs Study, Ensuring
education for all in India: Highlighting the obstacles,
International Institute for Population Sciences (IIPS);
Population Council. Policy Brief no. 31. Available from:
www.popcouncil.org/pdfs/2010PGY_YouthInIndiaBri
ef31.pdf (updated 2010, last cited on 2011 Feb 21 ).
8.
Jejeebhoy SJ. Convergence and divergence in spouses'
perspectives on women's autonomy in rural India. Stud
Fam Plann 2002;33:299-308.
9.
Umesh Kamat, AMA Ferreira, DD Motghan, Neeta
Kamat, NR Pinto. A cross sectional study of physical
spousal
violence
against
women
in
Goa.
Healthline 2010;1:34-40
10. C.T. Vinitha, Saudan Singh, A.K.Rajendran. Level of
reproductive health awareness and factors affecting it
in a rural community of South India. Health and
Population 2007;30:24-44.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
PATTERN OF OCULAR MORBIDITY IN SCHOOL
CHILDREN IN CENTRAL INDIA
Harpal Singh1
1Department
of Ophthalmology, People’s College of Medical Sciences and Research Center, Bhanpur,
Bhopal (M.P)
Correspondence:
Dr. Harpal Singh
Assistant Professor
25 A-Sector Sarvadharm colony Kolar Road Bhopal,
M.P- 462040
Email – [email protected], Mobile no. 9826859233
ABSTRACT
School eye health services is one of the important aspect of school health services in which children
can be screened for various systemic and eye diseases such as refractive error, squint, amblyopia,
cataract ,vitamin deficiency etc .
The basic aim of this study was to assess the prevalence and pattern of visual impairment amongst
school children of central India and to recognize avoidable causes of ocular morbidity. School surveys
were conducted in various government schools of rural, urban and semi urban areas of Bhopal
between Nov-2004 to Dec-07. A total of 20,800 school children between age group 5 to 16 years had
under gone the complete ocular examination. Prevalence of Ocular morbidity was found in 14.5%.
Refractive error was found to be the most common cause of ocular morbidity (47.91%) followed by
vitamin A deficiency (13.66%) and strabismus (2.08%).
Key words: Refractive error, Night blindness, Cataract and Trachoma.
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 2020. 2
Although blindness in children is relatively
uncommon, this age group is also considered a
priority as severe visual loss in children can
affect their development, mobility, education,
and employment opportunities. This has farreaching implications on their quality of life and
their affected families. In terms of the 'blind
person years' they form the maximum burden of
blindness on the community, next only to
cataract, which is the commonest cause of
avoidable blindness. 3 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. 3 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 eye health services is one
of the
important aspect of school health services in
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with pin hole and no organic lesion was
detected after complete ocular examination.
which children can be screened for diseases
such as refractive error, squint amblyopia,
trachoma etc.
The basic aim of this study was to assess the
prevalence and pattern of visual impairment
amongst school children of central India and to
recognize avoidable causes of ocular morbidity.
MATERIAL AND METHODS
School surveys were conducted in various
government schools of rural, urban and semi
urban areas of Bhopal between Nov-2004 to
Dec-07. A total of 20,800 school children
between age group 5 to 16 years had under gone
the complete ocular examination. The School
was informed well in time for appropriate
arrangements at a given date and time.
Informed consent was obtained from the parents
or guardian.
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. Fundus
evaluation with dilated pupil was done where
vision was not improving with pinhole.
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
OBSERVATION AND RESULTS:
A total of 20,800 children were screened, Out of
them 12130 were boys (58.31%) and rest 8670
(41.68%) were girls. Ocular morbidity was found
in 3016(14.5%) children out of which
1617(7.77%) were boys and 1399(6.72%) were
girls.
Table-1: prevalence of various ocular
morbidities
Causes
Refractive Error
Vitamin A
Deficiency
Strabismus
63 (2.08)
Infective Condition
439 (14.55)
Corneal Opacity
177 (5.86)
Developmental
108 (3.58)
Cataract
Traumatic Eye
161 (5.33)
Injury
Miscellaneous
211 (6.99)
*Out of total children population
%
(n=20800)*
6.94
1.98
0.30
2.11
0.85
0.51
0.77
1.01
Refractive error was found to be the most
common cause of ocular morbidity (47.91%)
followed by vitamin A deficiency (13.66%) and
strabismus (2.08%).
Table 2: Age Wise Distribution of Ocular
Morbidity
5 – 8yr
9-12yr
13-16yr
Total no of
children examine
4234
8562
8004
Children with
ocular morbidity
476
1423
1117
The most common age group affected was 8 to
12 years followed by 13 to 16 years.
Table 3: Visual acuity in children with refractive
error
Visual Acuity
6/9 – 6/18
6/24 -6/60
<6/60
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Total children
((3016) (%)
1445 (47.91)
412 (13.66)
No of Children (n=1445) (%)
947 (65.53)
416 (28.78)
82 (5.67)
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It was observed that 65.53%of children with
refractive error had uncorrected visual acuity
between 6/9 – 6/18 while 5.67%had uncorrected
vision < 6/60 causing severe visual impairment.
Out of 412 children with vitamin A deficiency,
125 (30.33%) were boys and 287(69.66%) were
girls. Most affected age group was 5-8 years
(44.90%) followed by 9-12 years (34.70%) and 1316 years (20.38%)
Table 4: Types of strabismus
Type
Exotropia
Esotropia
Exophoria
Esophoria
Vertical squint
Cases (63) (%)
13 (20.63 )
09 (14.28 )
28 (44.44 )
11 (17.46 )
2 (3.17 )
Latent squint was found to be more common
than manifest squint, exodeviation being more
prevalent.
DISCUSSION
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 was found to be
14.5 %. Results were comparable to the study of
Kalikivayi et al (1997). 4
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.
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.
The Vitamin A deficiency was found in 13.66 %
of children screened. The highest prevalence
was found in the age group of 5-8 yrs. A study
conducted by committee on preventable
childhood blindness found the proportion of
childhood blindness attributable to Vitamin A
deficiency ranged from 7.5 % in Kerala to 26.7 %
in M. P. Though there is marked variation in the
geographical distribution, but high prone areas
needed to be identified and focused.
CONCLUSION
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.
Realizing that with a significant proportion of
children are not going to school in India, a more
complete assessment of visual impairment in
children could be assessed by general
population based studies and not restricted to
school children
Screening of school children for ocular diseases
should be made a key component of an effective
blindness prevention program. In the context of
Vision 2020, the priorities of action to reduce the
childhood ocular morbidity in India should be
directed towards refractive error and vitamin A
deficiency.
REFERENCES
1.
2.
3.
4.
Increase parental awareness of symptoms in
a child suggestive of poor vision.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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.
World Health Organization, Global initiative for the
elimination of avoidable blindness. WHO/PBL/97.61.
Geneva: WHO; 1997.
Rahi JS, Gilbert CE, Foster A, Minassian D. Measuring
the burden of childhood blindness. British journal of
ophthalmology 1999;83:387-8
Kalikivayi V, Naduvilath TJ, Bansal AK, Dandona L:
Visual impairment in school children in southern India,
Indian Journal of Ophthalmology, 1997; 45 (2):129-134
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ORIGINAL ARTICLE .
A STUDY ON THE KNOWLEDGE OF TETANUS
IMMUNIZATION AMONG INTERNEES IN A
GOVERNMENT MEDICAL COLLEGE OF KOLKATA
Ranadip Chowdhury1, Abhijit Mukherjee1, Saibendu Kr Lahiri2
1Post graduate trainee, 2Professor & Head of Dept, Department of Community Medicine, RG Kar
Medical College & Hospital, 1, Khudiram Bose Sarani, Kolkata 700004
Correspondence:
Dr Ranadip Chowdhury,
Department of Community Medicine,
3rd Floor Academic Building RG Kar Medical College & Hospital,
1, Khudiram Bose Sarani, Kolkata 700004.
E- mail: [email protected] Mobile: +91 9836685913
ABSTRACT
The current study was undertaken to assess the knowledge of the internees regarding tetanus
immunization in children, pregnant women and adults as per the NIS and the guidelines regarding
tetanus immunization in relation to the wound categories depending on the immunisation status of
the patients. A pre tested questioner used to access knowledge among 108 internees. 57.4% internees
were not aware of the number of doses of tetanus vaccine recommended for children under the age of
16 years and 76.8% internees were not aware of the number of doses of tetanus vaccine recommended
for adults over the age of 16 years. More than 90% of the internees considered contaminated wounds,
animal bites, burn injuries and wounds greater than 6 hours old to be tetanus prone. 91.7% of
internees had considered wounds greater than 6hours old as tetanus prone and 5.6% did not consider
this wound to be tetanus prone. On the other hand 97.2% of internees had considered contaminated
wounds and animal bite to be tetanus prone and 2.8% did not consider. While 93.5% of internees
considered burn injuries to be prone to the development of tetanus, 6.5% of internees thought
otherwise. 13% of the internees did not consider human bite to be tetanus prone. 25% of the
internees considered every cut injury to be tetanus prone. Better TT awareness of tetanus prophylaxis
recommendations is necessary and tetanus prophylaxis recommendations may be more effective if
they are better adhered to at the ED and the other departments that are involved in providing tetanus
prophylaxis to their patients.
Keywords: Tetanus, internees, immunization, knowledge, wound
INTRODUCTION
Tetanus is an acute, often fatal, disease caused
by an exotoxin and highly potent neurotoxin,
tetanospasmin, which is produced during the
growth of the anaerobic bacterium Clostridium
tetani. Cl. tetani is not an invasive organism;
infection with Cl. tetani remains localized.
Tetanus spores are widespread in the
environment. Tetanus bacilli can also enter the
body through contaminated puncture wounds
and sometimes seemingly trivial injuries.1 Once
inside neurons, tetanus toxin cannot be
neutralized by tetanus antitoxin. Toxin
accumulates in the central nervous system,
where it prevents the release of inhibitory
neurotransmitters, such as glycine and gammaaminobutyric acid, thereby leaving excitatory
nerve impulses unopposed.2
In neonates, tetanus occurs as a result of
unhygienic birth practices, most commonly
when tetanus spores contaminate the umbilical
cord at the time that it is cut or dressed after
delivery. It is a deadly disease for newborns,
with a case fatality rate of 70 to 100 per cent.3
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Most neonatal deaths due to tetanus occur at
home before the baby reaches two weeks of age
with neither the birth nor the death being
reported. The number of cases of tetanus
reported also remains low, representing only the
tip of the iceberg.3
Behaviours such as safe delivery practices,
training of the traditional birth attendants (TBA)
and immunization with tetanus toxoid (TT) are
important factors affecting the incidence of
tetanus.4 Immunisation of pregnant women with
TT induces the formation of antibody, primarily
of the immunoglobulin G (IgG) class, which
passes to the foetus through the placenta and
prevents neonatal tetanus. Without that
protection and if a birth takes place in
unhygienic conditions, the newborn child may
get tetanus through infection of the umbilical
cord stump. Immunisation is more effective than
comprehensive perinatal health care in the
prevention of neonatal tetanus. 5 Thus the
primary focus of the neonatal tetanus
elimination program is the immunization of
women of childbearing age with tetanus toxoid.6
Prevention of wound related tetanus is
primarily through the administration of the
toxoid along with the use of Human Tetanus
Immunoglobulin (HTIG) depending on the risk
of the wound to develop tetanus. Tetanus
immunoglobulin is necessary for immediate
protection to tide over the period that the toxoid
needs to achieve levels of protective immunity.
Wounds can be divided into categories A and B
based on the type and duration of wounds.
Category A wounds are defined as wounds that
were less than 6 hrs old, clear, non-penetrating
and with negligible tissue damage & category B
included all other types of wounds.4 The
schedule recommends the use of TT for Cat A
wounds and TT and HTIG for Cat B wounds.
The schedule also considers the immunization
status of the patient while planning tetanus
prophylaxis.
It is difficult to justify the fact that despite the
disease being entirely preventable through
immunisation and the availability of a safe and
potent vaccine for the last 82 years the burden of
tetanus worldwide still remains high. 7
Following widespread use of tetanus toxoid-containing vaccine during the 1940s, tetanus has
become uncommon in the United States,
particularly in children and adolescents. During
1990-2004, a total of 624 tetanus cases were
reported; 19 (3%) cases were among adolescents
aged 11-18 years.8
The National immunisation Schedule (NIS) has
been running successfully in the country since
1986. Despite the apparent success of the
programme, tetanus remains an important
endemic infection in India.4 and the goal of
elimination of neonatal tetanus by 2005 remains
elusive. Infact, the Central Bureau of Health
Intelligence (CBHI) has reported an increase in
the total number of neonatal tetanus cases from
625 in 2006 to 937 in 20079and an increase in the
incidence of total tetanus cases from 2815 in
2006 to 7005 in 2007.9
Immunisation against tetanus is also the most
effective tool for controlling the disease in
children and adults.5 According to the World
Health Organisation (WHO), six doses of TT
containing vaccine within the age of 16 years
provide life long immunity against the disease.2
The NIS in India advocates the administration of
7 doses of TT by the age of 16 years. It provides
protection that lasts 3 weeks, throughout the
duration of the disease incubation period.10
Knowledge regarding TT vaccination as per the
NIS among all levels of health care personnel is
important not only for the prevention of
neonatal tetanus but also tetanus in the children
and adults. A thorough knowledge of the
tetanus immunisation in wounds is also
necessary to prevent the occurrence of wound
related tetanus.
In West Bengal the internees constitute the first
tier of health care providers in almost all
departments of the medical college, more so in
the emergency departments. They take down
the detailed history of the patient at entry and
give out the preliminary treatments. In the
emergency departments they are the ones
responsible for arranging for immunisation of
the patients with injuries before definitive
management is instituted. So it is important that
they are well aware of the exact guidelines in
dispensing the vaccines and immunoglobulin
for their patients. Improper or inadequate
knowledge would result either in excessive or
under utilisation of the vaccine and
immunoglobulin putting patients at risk of
developing tetanus or unnecessary adverse
effects of hyper immunisation.
In their study from Karachi, Ahmed et al
reported that, 11 among general practitioners in
Pakistan, it was observed that doctors had poor
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knowledge of tetanus immunization. In another
study on doctors in Delhi, Rajesh K and co
workers found low knowledge levels regarding
tetanus immunization.12 Studies conducted at 5
university-affiliated emergency departments
(ED) in the United States found substantial
under immunization in the ED (particularly
with regard to use of tetanus immunoglobulin),
leaving many patients, especially those from
high-risk groups, unprotected. Better awareness
of
tetanus
prophylaxis
schedules
was
recommended. 10
The present study was undertaken to assess the
knowledge of the internees, who comprise an
important category of service delivery at all
departments of RG Kar Medical College,
Kolkata regarding tetanus immunization in
children, pregnant women and adults as per the
NIS 13 and the guidelines regarding tetanus
immunization in relation to the wound
categories depending on the immunisation
status of the patients.
ETHICAL CONSIDERATION
The study employed a, cross-sectional
questionnaire, which was approved by the
Ethical Committee of the R.G.Kar Medical
College, Kolkata. Before commencement of
interviews, the objectives of the study and the
contents of the questionnaire were explained to
each of the subjects and consent for participation
obtained. Participants were assured that the
data which was gathered would be used only
for research purposes.
METHODS
It is a descriptive observational cross-sectional
study conducted among internees of 2010-2011
batch of R.G. Kar Medical College and
Hospitals, Kolkata during March 2011.
An extensive search of the literature available on
the internet did not reveal any information
regarding the prevalence of knowledge
regarding
tetanus
immunization
among
internees in a medical college. The sample size
calculations were thus based on the assumption
that 50% of the internees had the correct
knowledge
regarding
the
immunization
guidelines. 14 With a 95% confidence limit and
10% allowable error and applying the formula
[z2 p(1-p)/d2]14
the sample size(n) was calculated to be 400.
However since the study population (N) was
150, the revised sample size calculation with
finite population correction given by the
formula
Nz2 p(1-p)/[d2(N-1)+z2p(1-p)]14
[Where N= study population, z=1.96 for 95%
confidence, p=estimated proportion in study
population, d=acceptable margin of error] gave
the corrected sample size of 108. These 108
internees to be interviewed were selected by
Simple Random Sampling (SRS) from a total of
150 internees after complete enrolment.
A pre-tested, pre-designed questionnaire was
adapted. Before adaptation of the questionnaire
a thorough peer review and discussions were
undertaken. The questionnaire was then pretested on a group of 20 internees not included in
the final study. Corrections and modifications
were incorporated following the pretesting
procedure to develop the final questionnaire.
The questionnaire consisted of four parts
namely; the internees’ profile, evaluation of the
internees knowledge on the number of doses of
tetanus vaccine in children, adult and pregnant
women as per the National Immunisation
Schedule as followed in India, the types of
injury that are tetanus prone and TT and HTIG
administration in relation to various types of
wounds according to the immunization status of
the patient.
Analysis
The collected data were entered in the Epi Info
software (version 3.5.2, CDC Atlanta) by a RC
and double checked by AM for errors in data
entry. All calculations were done with the help
of the Epi-info software.
RESULTS
All the 108 internees participated in the study.
Out of 108 internees, 72 were males and 36 were
females. The mean age of the internees was 23.8
± 1.2 years. The mean age of the male internees
was 24.0 ± 1.4 years and that of female internees
was 23.4 ± 0.9 years.
57.4% internees were not aware of the number
of doses of tetanus vaccine recommended for
children under the age of 16 years and 76.8%
internees were not aware of the number of doses
of tetanus vaccine recommended for adults over
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the age of 16 years. All the internees that
participated in the study knew the correct
schedule of tetanus immunisation for pregnant
women with no history of previous
immunisation. However 18.5% of the internees
are not aware of the correct number of doses to
be administered to pregnant mother who had
their last child birth within the last 3 years.
Table 1: Knowledge of correct doses as per National Immunisation Schedule
Correct Answer
45(41.66)
25(23.15)
108(100)
Children<16 years
Adults>=16 years
Pregnant women with no
previous history of TT
Pregnancy within last 3 years
88(81.48)
Figure in parenthesis indicate percentage
Incorrect answer
62(57.41)
83(76.85)
0
Don’t Know
1(.001)
0
0
Guidelines
6 doses
1dose
2doses
9(.09)
11(1.02)
1dose
Table 2: Number of internees who considered a particular wound to be tetanus prone
Type of wounds
Any cut injury
Wounds >6 hrs old
Contaminated wounds
Human bite
Animal bite
Burn
Yes
27(25%)
99(91.67%)
105(97.22%)
90(83.33%)
105(97.22%)
101(93.52%)
No
80(74.07%)
6(5.55%)
3(2.78%)
14(12.96%)
3(2.78%)
7(6.48%)
More than 90% of the internees considered
contaminated wounds, animal bites, burn
injuries and wounds greater than 6 hours old to
be tetanus prone. 91.7% of internees had
considered wounds greater than 6hours old as
tetanus prone and 5.6% did not consider this
wound to be tetanus prone. On the other hand
97.2% of internees had considered contaminated
wounds and animal bite to be tetanus prone and
Does not Know
1(.9%)
3(2.78%)
0
4(3.70%)
0
0
Guideline
No
Yes
Yes
Yes
Yes
Yes
2.8% did not consider. While 93.5% of internees
considered burn injuries to be prone to the
development of tetanus, 6.5% of internees
thought otherwise. 13% of the internees did not
consider human bite to be tetanus prone. 25% of
the internees considered every cut injury to be
tetanus prone. There were several internees with
no responses to some of the questions asked.
(Table 2)
Table-3: Knowledge of internees of tetanus immunization in Cat-A wound according to
immunization status of the patients
Immunisation Nothing
TT 1
TT 1 +
status
required
HTIG
<5 years
100(92.6)
6(5.5)
1(.9)
5-10 years
21(19.4) 84(77.8)
3(2.8)
>10 years
9(8.3)
74(68.5) 10(9.3)
No history of
0
1(0.9)
2(1.8)
Immunization
Figure in parenthesis indicate percentage
TT
TT complete Can’t
complete
+HITG
say
1(.9)
0
0
0
0
0
13(12.0)
2(1.85)
0
81(75.0)
23(21.27)
1(0.9)
Respondents
were
questioned
on
the
recommendations for tetanus immunization for
category A and Category B wounds. Table 3
and Table 4 show the responses for Category A
and Category B wounds respectively.
In case of Cat-A wound with a history of
complete immunisation within the last 5 years,
Nothing required
TT 1 dose
TT 1 dose
TT complete dose
almost 7% of internees recommended a single
dose of Tetanus toxoid. For patients who
received a full course of tetanus within the last 5
to 10 years, almost 20% internees had
recommended nothing and also 35 internees had
recommended tetanus immunoglobulin. Again
in patients where complete immunisation had
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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been done 10 years back and where one dose of
TT is sufficient almost 32% internees had not
recommended that. And 11% internees had
recommended tetanus immunoglobulin. Where
no previous history of immunisation is present
complete dose of TT is sufficient in Cat-A
wound but 23% internees had recommended
tetanus immunoglobulin. Thus there is a lacunae
of knowledge regarding wound related tetanus
immunisation among internees in Cat-A wound
,the patients may not get TT where they
shouldn’t or vice versa or would get tetanus
immunoglobulin where it is not recommended.
Table-4: Knowledge of internees of tetanus immunization in Cat-B wound according to
immunization status of the patients
Immunisation Nothing
TT1
TT1+
TT
TT complete
Status
Required
HTIG complete
+HITG
<5 Years
80(74.1) 19(17.6) 4(3.7)
1(.9)
4(3.7)
5-10 Years
12(11.1) 52(48.1) 33(30.6)
5(4.6)
5(4.6)
>10 years
1(.9)
6(5.6) 69(63.9) 12(11.1)
20(18.5)
No history of
0
0
2(1.8)
2(1.8)
104(96.3)
immunisation
Figure in parenthesis indicate percentage
In Cat-B wound if the patient had taken
complete immunisation within last 5 years there
is nothing required while 25.9% internees had
not recommended that. In case of complete
immunisation done within 5-10 years where just
one TT dose is sufficient just 48.2% internees
had recommended that and 35% internees had
recommended tetanus immunoglobulin in this
sub-group of patients. In another sub group of
patient where complete immunisation was done
10 years back and TT one dose and tetanus
immunoglobulin is recommended 17% internees
didn’t recommended tetanus immunoglobulin
and 18.5% internees recommended complete
dose of TT. But contrary to all in case of no
previous history of immunisation in Cat-B 96.3%
internees had recommended correct schedule.
DISCUSSION
The objectives of this study was to evaluate the
knowledge among internees in tetanus
immunization in children, pregnant women and
adults as per the NIS13 and the guidelines
regarding tetanus immunization in relation to
the wound categories depending on the
immunisation status of the patients. The present
study reveals that among the internees the
knowledge regarding immunization of pregnant
women during their first pregnancy was
universal. Better health care provider education
regarding immunization in subsequent
Pregnancies is needed to fill the gaps in their
knowledge as they have lacunae of knowledge
Guideline
Nothing Required
TT1
TT 1+HTIG
TT complete +HITG
in non immunised pregnant mothers but they
have lacunae of knowledge regarding tetanus
immunisation in children and pregnancy within
last 3 years.
A quarter of the internees seemed to be
overcautious in their use of tetanus vaccination
for cut injuries considering any cut injury to be
tetanus prone. Similar result was found in a
study in UK among various staff members in the
accident and emergency (A&E) departments,
where 22.1% of respondent considered any cut
injury to be tetanus prone.1
Many of the internees did not know the
appropriate course of action regarding tetanus
immunization in wounds and either did not
recommended booster doses of TT when needed
or
recommended
TT
and
tetanus
immunoglobulin unnecessarily.
Mortality from neonatal tetanus still remains an
important but preventable, cause of neonatal
mortality in India. 15 The Government of India
had set the goal of neonatal tetanus elimination
by the year 2005 through the coverage of all
pregnant women with 2 doses of tetanus toxoid.
A single booster dose of the toxoid is
recommended for repeat pregnancies within a
period of 3 years since the last pregnancy.16
Vaccination with two doses of TT immunization
given at least 4 weeks is the chief priority in
preventing neonatal tetanus. The vaccine is
cheap and available at the government
subcentres for free. It is indeed surprising that
even then the goals of elimination of neonatal
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Can’t
Say
0
1(.9)
0
0
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tetanus in India are yet to be achieved. In
addition to proper knowledge of the
immunization schedule among all levels of
health care workers including internees, it is
imperative that access to the health care delivery
systems for all mothers is ensured.
Although not specified in the NIS in India the
WHO 17 states that three doses of TT gives 5
years protection, four doses of TT gives 10 years
protection and five doses of TT gives lifelong
protection against neonatal tetanus starting from
15 days after the date of dose in each cases. So
tetanus immunisation schedule for pregnancies
after the second need to be planned based on the
number of vaccines received and the timing of
the subsequent pregnancies.
WHO 2 updated its tetanus policies and
recommendation to achieve and sustain a high
coverage of 3 doses of tetanus containing
vaccine (DPT) in infancy and of appropriate
booster doses in order to prevent tetanus in all
age groups. The primary series of DPT coverage
in infancy only gives protection for
approximately 5 years and reinforcing doses of
TT in children of school age and adolescents are
critical in maintaining antibody levels which can
persist for decades.2 Evidence of this is supplied
by serological surveys of countries with an
established
programme
of
tetanus
immunization. Based on the recommendations
of the WHO the National Immunisation
Schedule of India has proposed 3 doses of DPT
in the first year of life as primary immunisation
and then one booster of DPT at 16-24 months
and then at 5-6 years one dose of DT and at 10
years and 16 years one dose of TT respectively.18
Immunisation with TT in HIV positive patients
is safe as the vaccine is an inactivated toxoid.
HIV-positive children given three doses of TT
(DTP) at 6, 10 and 14 weeks had similar
proportions protected at nine months of age as
HIV-negative children.19 Moss et al 20 concluded
that 40%–100% of HIV-infected children develop
protective levels of tetanus antitoxin following
primary immunization in infancy. HIV-infected
children appear to respond well to booster
immunization with between 74%–90% reported
to have protective antibody levels following a
booster dose at various ages and times since
primary series.21,22, 23. In HIV-infected adults the
response to a booster dose induces protective
levels; 24 however the response tends to be lower
than in uninfected controls. 25, 26,27
Tetanus toxoid, as a monovalent vaccine or as a
component
of
combined
vaccines,
is
recommended for HIV-infected children or
adults, regardless of the presence or absence of
symptoms of AIDS, as most vaccine recipients,
both children and adults, appear to achieve
protective antitoxin levels
However, there are many barriers preventing
successful immunization throughout infancy,
childhood, and adolescence in some regions,
including cost, logistics, and rate of school
attendance. In addition to imparting knowledge
regarding the number of doses of vaccines to the
care providers and beneficiaries it is equally
important that availability and access to the
health care facilities be ensured.
Considering a cut injury to be tetanus prone can
result in the unnecessary use of toxoid and
tetanus immunoglobulin. Although both the
toxoid and HTIG are considered relatively safe,
there have been reports of adverse reaction in
the form of Arthus type of hypersensitivity
following the use of tetanus toxoid–containing
vaccine. 28 A large number of respondent
internees considered contaminated wounds,
animal bites, and burn injuries to be tetanus
prone, many did not consider human bites to be
tetanus prone 29 , putting patients with such
injuries at risk of developing tetanus. Talan et
al10 reported that in about one third of patients
with baseline “nonprotective” tetanus antitoxin
titers, toxoid boosters increase antibody titres to
protective levels within 7 days, leaving these
patients vulnerable to develop tetanus. Tetanus
immunoglobulin provides immediate protection
that lasts 3 weeks, throughout the duration of
the disease incubation period.
Immediate
protection
through
passive
immunization by tetanus immunoglobulin is of
utmost importance in the prevention of tetanus
in heavily contaminated wounds. Tetanus
immunoglobulin is given to neutralize
circulating toxin and unbound toxin in the
wound, antitoxin effectively lowers mortality.
The present guidelines regarding the use of
tetanus immunoglobulin and TT in injuries are
rather complicated. In case of Cat-A wound with
complete course of TTor booster within last five
years nothing is required, within five to ten
years TT one dose, more than ten years TTone
dose and if no previous history of immunisation
then TT complete dose. In case of Cat-B wound
with complete course of TT or booster within
last five years nothing is required, within five to
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ten years TT one dose, more than ten years TT
one dose and tetanus immunoglobulin and no
previous history of immunisation TT complete
dose and tetanus immunoglobulin.4
This could be because of the non adherence to
the guidelines by the medical officers and senior
doctors at the ED where tetanus immunizations
are mainly given. Majority of the patients
needing tetanus for injuries cannot remember
their last dose of tetanus immunisation. The
dangers of under immunisation probably
outweigh those of extra doses. Although
considered generally safe HTIG still carries the
risk of local and generalised side effects and
therefore unwarranted use of the same should
never be encouraged. Some of the reported side
effects are short term discomfort at the site of
injection. Very rarely a hardened area may
develop where the injection was givenchest
pain, shortness of breath, shaking, dizziness,
swelling of the face, coating of the tongue,
mouth ulcers, joint pains and fever.30
Talan et al,10 while reporting on tetanus
immunity and physician compliance with
tetanus prophylaxis practices among emergency
department patients presenting with wounds
identified certain subpopulation in the United
States that were relatively unprotected. This
subpopulation comprised specifically the
elderly, immigrants, and persons with education
limited to grade school. The existence of similar
subpopulation in patients from the country need
to be examined through further research.
Better TT awareness of tetanus prophylaxis
recommendations is necessary and tetanus
prophylaxis recommendations may be more
effective if they are better adhered to at the ED
and the other departments that are involved in
providing tetanus prophylaxis to their patients.
National recommendations should be followed
at all times while administering the vaccine. An
immunisation card containing the details of
tetanus immunisation can be kept with the
patient at all times. This will enable the health
care personnel to know the immunization status
of the patient when needed. In the absence of
such a health card the use of rapid tests for
tetanus immunity can be used for appropriate
wound management in the emergency
department.
Acknowledgement
All the internees who had participated in the
study had been acknowledged.
Competing Interest
The author’s declare that they have no financial
and personal relationship(s) which may
inappropriately influenced them in writing this
paper.
Authors’ Contribution
R.C has contributed in concepts, design,
definition of
intellectual
content,
data
acquisition and manuscript preparation. A.M
has contributed in literature search, data
analysis, statistical analysis and manuscript
preparation.
S.K.L
has
contributed
in
manuscript editing and manuscript reviewing.
REFERENNCES
Savage EJ, Nash S, McGuiness A, Crowcroft NS. Audit of
tetanus prevention knowledge and practices in accident
emergency departments in England. Emerg Med J
2007;417-421
2 Borrow R, Balmer P, Roper HM. Tetanus Update. The
immunological basis for immunisation series Module 3:
Tetanus update 2006.WHO; 2006.
3 WHO. Maternal and Neonatal Tetanus Elimination by
2005.WHO
2000
(Available
at
www.who.int/vaccines_documents last accessed on
1.10.2011)
4 Park K. Park’s Textbook of Preventive & Social Medicine
20th Edition Banarsidas Bhanot Publishers 2009:272
5 Peeters RF, Alisjahbana, Meheus AZ. Preventing neonatal
tetanus: traditional birth atetanus toxoidendants or
immunization.
Downloaded
from
www.heapol.oxfordjournals.org on January 17, 2011
6 Neonatal Tetanus Elimination. Pan American Health
Organization
2005.
Available
at
htetanus
toxoidp://www.paho.org/english/ad/fch/im/FieldGui
de_NNT.pdf last accessed on 1.10.2011)
7 Abrutyn E. Principles of Harrison’s Internal Medicine 17th
Editiion Mcgraw hill Medical 2008:898-900
8 Srivastava P, Brown K, Chen J, Kretsinger K, Roper MH.
Trends in tetanus epidemiology in the United States,
1972--2001. 39th National Immunization Conference,
Washington, DC,2005; March: 21--24
9 Kishore J. National Health Programmes of India 9th Edition
Century Publications 2011:158
10 Talan DA, Abrahamian FM, Moran GJ,
Mower WR,
Alagappan K, Tiffany BR, Pollack CV, Steele MT, Dunbar
LM, Bajani MD,
Weyant RS, Ostroff SM. Tetanus
immunity and physician compliance with tetanus
prophylaxis practices among emergency department
patients presenting with wounds. Annals of Emergency
Medicine 2004: 43(3):305-14
11 Ahmed SI, Baig L, Thaves IH, Siddiqui MI, Jafery SI, Javed
A. Knowledge atetanus toxoiditude and practices of
general practitioners in Karachi District Central about
tetanus immunization in adults. J Pak Med assoc
2001;367-369
12 Dabas P, Agarwal CM, Kumar R, Taneja DK, Ingle GK,
Saha R. Knowledge of general public and health
professionals about tetanus immunization. Indian J
Paediatr 2005;1035-1038
1
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 438
pISSN: 0976 3325 eISSN: 2229 6816
Ministry of Health & Family Welfare, Government of
India. Review of Universal Immunisation Program in
India 2004. New Delhi, 2005.
14 Abramson JH, Abramson ZH. Survey Methods in
Community Medicine 5th edition Churchill Livingstone
1999:102
15 Blencowe H, Lawn J, Vandelear J, Roper M, cousens S.
tetanus toxoid immunisation to reduce mortality from
neonatal tetanus International Journal of Epidemiology.
2010:102-109
16 Kishore J. National Health Programmes of India 9th
Edition. Century Publications 2011:158
17 Monitoring immunization services using the lot Quality
technique. Department of Vaccines and Biologicals. WHO
18 Govt. of India (2006). Health information of India 2005,
Ministry of Health & Family Welfare, New Delhi.
19 Ryder RW et al. Safety and immunogenicity of bacille
Calmette-Guérin, diphtheria-tetanus-pertussis, and oral
polio vaccines in newborn children in Zaire infected with
human immunodeficiency virus type 1. The Journal of
Pediatrics 1993; 122:697–702.
20 Moss WJ et al. Immunization of children at risk of
infection with human immunodeficiency virus. Bulletin,
Geneva, World Health Organization 2003;81:6170
21 Borkowsky W et al. Cell-mediated and humoral immune
responses in children
infected with human
immunodeficiency virus during the first four years of life.
The Journal of Pediatrics 1992; 120:371–375.
22 Rosenblatt HM et al. Tetanus immunity after diphtheria,
tetanus toxoids and acellular pertussis vaccination in
children with clinically stable HIV infection. The Journal
of Allergy and Clinical Immunology 2005;116:698–703.
23 Melvin AJ, Mohan KM. Response to immunization with
measles, tetanus, and Haemophilus influenzae type b
vaccines in children who have human immunodeficiency
virus type 1 infection and are treated with highly active
antiretroviral therapy. Pediatrics 2003; 111:641–644.
24 Kurtzhals JAL et al.. Immunity against diphtheria and
tetanus in human immunodeficiency virus —infected
Danish men born 1950–1959. APMIS: acta pathologica,
microbiologica, et immunologica Scandinavica 1992;
100:803–808.
25 Kroon
FP et al. Immunoglobulin (IgG) subclass
distribution and IgG1 avidity of antibodies in human
immunodeficiency virus-infected individuals after
revaccination with tetanus toxoid. Clinical and Diagnostic
Laboratory Immunology, 1999; 6:352–355.
26 Dieye TN et al. Immunologic and virologic response after
tetanus toxoid booster among HIV-1 and HIV-2-infected
Senegalese individuals.Vaccine 2002;20:905–913
27 Bonetti TCS et al. Tetanus and diphtheria antibodies and
response to a booster dose in Brazilian HIV-1 infected
women. Vaccine 2004; 22:3707–3712.
28 Immunisation Practice advisory Commitetanus toxoidee
(CIP), CDC Atlanta. Diptheria, tetanus and pertusis:
Recommendations and other preventive measures.
MMWR 1991;1-28
29 Eilbert WP. Dog,Cat and human bites: Providing safe and
cost effective Treatment in the ED. Emergency Medicine
Practice 2003;5(8)
30 Downloaded from [email protected]. Last accessed on
1/10/2011.
13
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ORIGINAL ARTICLE .
SPECIFICITY AND SENSITIVITY FOR MALARIA
DETECTION BY RAPID (PARAHIT) DETECTION TEST
AND MICROSCOPIC METHOD
Pankaj P. Taviad1, T.B. Javdekar2, Bhavna A. Selot3, Vipul P. Chaudhari4
1Assistant
Professor, Department of Microbiology, Government Medical College, Surat 2Professor &
Head, 3Assistant Professor, Department of Physiology, Government Medical College, Baroda
4Assistant Professor, Department of Community Medicine, Government Medical College, Surat.
Correspondence:
Dr. Vipul P. Chaudhari
D-1/2, New Assistant Professor Quarter
New Civil Hospital Campus, Majuragate
Surat (Gujarat) INDIA, Pin: 395001
E-mail: [email protected], Mobile: 09925033488 / 09374717162
ABSTRACT
Malaria continues to be a major killer of mankind, especially in developing countries.1 It is a disease
of antiquity, has proved to be a formidable deterrent to the cultural and socio-economic progress of
man in tropical, subtropical and monsoon prone zones of world.2 One of the most pronounced
problems in controlling the morbidity and mortality caused by malaria is limited access to effective
diagnosis and treatment in areas where malaria is endemic.3 100 cases were analyzed in respect of
clinical presentation by routine microscopic methods and the immune assay techniques namely
pLDH antigen detection for rapid P. falciparum and P. vivax detection. More than two third (67%)
positivity rate for P. falciparum blood smear. The pLDH antigen detection was positive in 58% of P.
falciparum cases while 22% of P. vivax cases. Also pLDH antigen detection immunoassay gives 100%
specificity and 85.42% sensitivity.
Key Words: Malaria detection, Specificity and sensitivity of rapid test, ParaHIT
INTRODUCTION
Malaria continues to be a major killer of
mankind, especially in developing countries.1 It
is a disease of antiquity, has proved to be a
formidable deterrent to the cultural and socioeconomic progress of man in tropical,
subtropical and monsoon prone zones of world.2
The Causative agents in humans are four species
of plasmodium protozoa-P.falciparum, P.ovale
and P.Malariae. Of these, P.Falciparum account
for majority of morbidity and is most lethal.
The disease now occurs in more than 90
countries worldwide. It is estimated that there
are over 500 million clinical cases and 2.7 million
malaria –caused deaths per year. Being
associated with most serious complications,
diagnosis of P.falsiparum malaria constitutes a
medical emergency. One of the most
pronounced problems in controlling the
morbidity and mortality caused by malaria is
limited access to effective diagnosis and
treatment in areas where malaria is endemic.3
Microscopic examination of blood smears is the
widely used routine method for detection of
malaria parasite and remains the gold standard
for malaria diagnosis. But microscopic
examination is laborious and requires
considerable expertise for its interpretation,
particularly at low levels of parasitaemia. In
addition, in patients with plasmodium
falciparum malaria, sometimes the parasites can
be sequestered and are not present in peripheral
blood. Thus, a P. falciparum infection could be
missed due to absence of the parasite in the
peripheral blood film. Besides these, majority of
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malaria cases occur in rural areas where there is
little of no access to reference laboratories and in
many areas, microscopy is not available.
Because of the non-specific nature of the
symptoms and signs of malaria, this results in
considerable mistreatment, both over-treatment
with antimalarial agents and under-treatment of
those with non-malarial illness. Keeping all
these in mind, the World Health Organization
has recently reiterated.4 The urgent need for
simple and cost effective diagnostic tests for
malaria to overcome the deficiencies of light
microscopy and clinical diagnosis.
Recently, rapid non-microscopic tests for the
detection of plasmodium falciparum infection
have been introduced to overcome problems
associated with time constraint and low
sensitivity in diagnosing malaria infections with
a low level of parasitaemia by microscopy.
These rapid tests are based on the detection of
antigens
released
from
parasitezed
erythrocytes.5 One of them is paraHIT f test.
This test utilizes the detection of Histidine Rich
Protine II which is species specific test for
P.falciparum malaria.1 The other is Plasma
Lactate
Dehydrogenase
(pLDH)
antigen
produced by all four species of genus
plasmodium which infect humans.6
Similar test for P.Vivax is also available now
commercially in developing countries like ours,
if the cost becomes reasonable then it can be
beneficially used as an adjunct to microscopy
especially in endemic areas, peripheral and
tertiary centers and for rational use of
antimalarials.
MATERIALS AND METHOD
The present study has been carried out from
April 2006 to October 2006 in Sir Sayajirav
Gyakwad Hospital, Vadodara. The study was
done on the cases of fever admitted in the
hospital & suspicious of having fever on the
basis of clinical findings. The study included 100
cases. Rapid dipstick test and smear
examination were done. The cases with smear
positive for P.falciparum and P.vivax malaria
were used for calculation of sensitivity and
specificity. Positivity of thick and thin smear &
positive ParaHIT test are compared for
sensitivity and specificity. Data entry and
analysis was undertaken by EpiInfo software
(version 6.04).
RESULTS
During the present study 100 cases were
analyzed in respect of clinical presentation by
routine microscopic methods and the immune
assay techniques namely pLDH antigen
detection for rapid P. falciparum and P. vivax
detection.
Table 1: Distribution of malarial cases according
to their result by Dipstick with Microscopy
Results
Positive
cases by
Microscopy
(%)
P. falciparum
67 (69.8)
P. vivax
27 (28.1)
Mixed
02 (2.1)
Total
96
Positive
Negative
cases by
cases by
Dipstick
Dipstick
(%)
58 (70.8) 09 (64.3)
22 (26.8) 05 (35.7)
02 (2.4) 00 (Nil)
82
14
The careful thick and thin peripheral blood
smear examination made it easy, with the fact
that, it was correlated well with serological
marker i.e. pLDH antigen detection. Our casestudy showed 67% positivity rate for P.
falciparum blood smear. The pLDH antigen
detection was positive in 58% of P. falciparum
cases while 22% of P. vivax cases were positive
by same technique.
Table 2: Dipstick and microscopic result wise
comparison of cases
Dipstick
Test
Positive
Negative
Total
Positive
82 (a)
14 (c)
96 (a + c)
Microscopy
Negative
00 (b)
04 (d)
04 (b + d)
Total
82 (a + b)
18 (c + d)
100
The present study evaluates the comparison of
methodology used for definite diagnosis of
specific parasite by conventional method such as
the thick and thin blood smear examination with
the serological marker viz. pLDH antigen
detection immunoassay which gives 100%
specificity and 85.42% sensitivity along with its
other merits explained earlier and documented.
DISCUSSION
Newer, more advanced malaria diagnostics
based on fluorescent microscopy and detecting
of nucleic acid (PCR) are well known, but there
are limitations for these newer techniques viz.
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require skill, equipments and are it universally
available in many malaria-endemic countries.
Recently introduced diagnostic tests based on
immune assays solve this problem, since they
are easy to run and interpret and do not require
complex equipment or technical support. They
are also rapid (20 min / test) and at least having
comparable
sensitivity
with
traditional
microscopy7.
The present study evaluates the comparison of
methodology used for definite diagnosis of
specific parasite by conventional method such as
the thick and thin blood smear examination with
the serological marker viz. pLDH antigen
detection immunoassay which gives 100%
specificity and 85.42% sensitivity along with its
other merits explained earlier and documented.
CONCLUSION
Comparing ParaHIT Total test with microscopy
the sensitivity is 85.42% and specificity of test is
100%. Positive predictive value is 100% and
Negative predictive value is 63.16%.
Thus, concluding that in contrast to light
microscopy, the ParaHIT Total test is rapid and
technically easy to perform. It takes
approximately 10 minutes to perform a single
test and we can perform many tests
simultaneously. Minimal training is required to
perform the assy. No equipment is required. It
require little space and no electricity supply. As
it is rapid method, it helps in management of
sever cases of malaria particularly at peripheral
health centres. Both specificity and sensitivity of
this test is comparable to the microscopy which
is considered as ‘Gold standard’ currently. So,
this test is very useful in rapid diagnosis of
complicated falciparum cases, partially treated
cases, at peripheral health centers, was
microscopy is not feasible.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Kaushik A. et al –Rapid manual test for falciparum
Malaria Indian Pediatrics Jun 2001; 38 -650-654
Lal Shiv. Dhillon G P S and Aggarwal C S
Epiderniology and control of malaria. Indian J Pediatr
1999:66:547-554
Palmer C J et al –Evaluation of the optimal test for
Rapid diagnosis of plasmodium vivax and plasmodium
falciparum malaria. Journal of Clinical Microbiology
Jan.1998:36 No 1: 203-206
Chayani N et al –Comparision of Parasite lactate
dehydrogenase
based
immunochromatographic
antigen detection assay (Optimal) with microscopy for
detection of malaria parasites. Indian Journal of
Medical Microbiology 2004: 22(2) : 104-106
Iqbal J et al –Plasmodium Falciparum Histidine Rich
Protein . it based immunocapture diagnostic assay for
malaria :Cross Reactivity with Rheumatoid factorsHJournal of clinical Microbiologgy Mar 2000 ;38 No 3:
1184-1186
Afzaal S et At –Rapid Diagnostic Tests fro malaria,
JAP/Feb 2001:49:261 -264
Gilles H M –Historical Outline. In Gilles H M & Warreli
D A (Eds) Bruce-Chwatt’s Esential malariology. Third
Edn. Arnold ;1993 : 1-4.
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ORIGINAL ARTICLE .
MAGNITUDE AND LEADING SITES OF CANCER IN A
TERTIARY CANCER CARE HOSPITAL OF WESTERN
MAHARASHTRA
Kapil H Agrawal1, S.S. Rajderkar2
1Assistant Professor, Dept. of Community Medicine, A.C.P.M. Medical College, Dhule 2Dean,
Government Medical College, Miraj, Maharashtra
Correspondence:
Dr. Kapil H. Agrawal
2, Nagai colony, Deopur, Dhule-424002, Maharashtra
E-mail: [email protected], Mobile: 9422824600
ABSTRACT
Context: It is observed that cancers are increasingly seen in both genders and all the age groups due
to a complex interaction of various risk factors. To implement the Public health intervention measures
it is essential to have the baseline data regarding frequency, distribution of cancers in the population.
Aims: To study the magnitude of cancers by obtaining a baseline data regarding the frequency,
distribution, leading cancer sites among the patients in a tertiary cancer care hospital of Western
Maharashtra.
Study settings: Shri Siddhivinayak Ganapati Cancer Hospital, Miraj
Study Design: Hospital based, Cross sectional study involving retrospective information of patients
from 1st March 2005 to 28th February 2006.
Methods and Material: Retrospective, questionnaire study of patients from 1st March 2005 to 28th
February 2006. Out of the total 2168 new patients registered, 1891 patients were detected to be
malignant and included in the study.
Results: 63.5 % Males and 67% Females in the age group 35-64 years had cancer. The sex ratio percent
was 1.01%. Top five Cancer in males in our study were Oral Cavity, Oesophagus, Lung, Larynx and
NHL. Top five Cancer in females in our study were Cervix, Breast, Ovary, Oral Cavity and
Oesophagus. 27% were TRCs (Tobacco Related Cancers) in males while 9.6% were TRCs in females.
34% cancers were in easily accessible parts of body.
Conclusions: The Tobacco Related Cancers represent the most preventable form of cancer in our
society. It was 27% in males and 9.6% in females in our study. Additionally 34% cancers were in
easily accessible parts of body. It highlights the possibility of easy and early detection of cancers in the
population thus decreasing the cancer burden in the community.
Key-words: Magnitude, Leading sites, Cancer, Western Maharashtra.
INTRODUCTION:
It is observed that cancers are increasingly seen
in both genders and all the age groups due to a
complex interaction of various risk factors. The
prevalence pattern, type of cancers differs in
various part of same country1. This is due to
interaction between geological, meteorological,
nutritional, cultural and behavioural factors2. To
implement the Public health intervention
measures it is essential to have the baseline data
regarding frequency, distribution of cancers in
the population.
Studying the magnitude and patterns of cancer
helps in determining clues to the cause of cancer
and undertake studies in disease aetiology.
Epidemiologic study based on this help in
knowing what is happening and what can be
done3. The present study was undertaken at
Miraj which is in Western Maharashtra.
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Another reason to carry out this study is that,
the available literature indicates no such study
in Western Maharashtra. Thus this study may be
considered as a baseline enquiry into the subject.
Objectives:
1. To study the age and gender distribution of
cancers.
2. To study the distribution of various cancers.
3. To determine the leading cancer sites in the
present study.
4. To comment on TRC (Tobacco Related
Cancers).
SUBJECTS AND METHODS
The study was conducted at Shri Siddhivinayak
Ganapati Cancer Hospital, Miraj. It is a private
hospital run by a trust since 1997 and is one of a
leading tertiary care institution for Cancer in
Western Maharashtra. It has a significant turn
over of patients from Sangli district as well as
from adjacent areas within and outside the state
of Maharashtra.
The present study is a Hospital based, cross
sectional study carried out for the period of one
year from 1st March 2005 to 28th February 2006.
Retrospective
questionnaire
study
was
conducted on the patients after taking their
consent. Out of the total 2168 new patients
registered from 1st March 2005 to 28th February
2006, 1891 patients were detected to be
malignant and thus included in the study
(n=1891). The data was collected in a predesigned and pre-tested proforma. The data so
collected was fed in the computer, analyzed and
presented in the form of figures, tables and
percentages. Only the data on age, gender and
sites involved are analyzed in this study.
Statistical analysis included calculation of
percentages and proportions.
RESULTS
Table 1.1: Sex-wise distribution of New cases of
Cancer (2005-2006)
No. of Case (%)
Total Cases
1891 (100)
Male
950 (50.23)
Female
941 (49.77)
Sex Ratios%
101
S Number of male patients per 100 female
patients
Table 1.2: New Cases of Cancers by Broad Age Groups (2005-2006)
Sex
Males
Females
Total
0-14 (%)
53 (5.6)
38 (4.1)
91 (4.8)
15-34 (%)
105 (11)
128 (13.6)
233 (12.3)
Out of the 1891 patients the relative proportion
of male patients were 50.23% and female
patients were 49.77% while the sex ratio percent
was 101. The minimum age of the patient was 3
months and the maximum age of the patient
was 100 years.
63.5% males and 66.8% females belonged to age
group 35-64 years. Almost 2/3rd of cases
occurred in this age group. Males predominate
in the age group 0-14 and above 65 years, while
females predominate age group 15-34 years
(reproductive age group). However, the
frequency of cancers reduced at the extreme of
ages in both the sexes.
In males Oral Cavity (13.2%) was the leading
site of cancer followed by Oesophagus (4.9%),
Lung (4%), Larynx (3.9%) and NHL (3.4%). Top
five male cancers accounted for 279 cases from
Age Groups
35-64 (%)
603 (63.5)
629 (66.8)
1232 (65.1)
65+ (%)
189 (19.9)
146 (15.5)
335 (17.7)
All Ages
950
941
1891
total male cases of 950. The proportions of these
cancers were 29%.
In females Cervix (22.1%) was the leading site of
cancer followed by Breast (13.1%), Ovary (5.8%),
Oral Cavity (3.7%) and Oesophagus (3.7%). Top
five cancers in females accounted for 454 cases
from total female cases of 941. The proprotions
of these cancers were 48%.
The table depicts leading sites of cancers in
broad age groups (0-14, 15-34, 35-64 and 65 and
above years of age). In age group 0-14
Lymphoid Leukemia and Eye were the leading
sites in males, while Lymphoid Leukemia and
Bones were the leading sites in females. In age
group 15-34 Myeloid Leukemia and NHL were
the leading sites in males, while Cervix and
Breast were the leading sites in females.
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Table 1.3: Leading Sites of and Rank (R) of
Cancers (2005-2006) in Males and Females
Sites
No. of Case (%)
R
In Male
Oral cavity+
125 (13.2)
1
Oesophagus
47 (4.9)
2
Lung
38 (4)
3
Larynx
37 (3.9)
4
NHL
32 (3.4)
5
Rectum
19 (2)
*
Stomach
17 (1.8)
*
Hypopharynx
10 (1.1)
*
Prostate
5 (0.5)
*
Myeloid Leukaemia
4 (0.4)
*
Total
334 (35)
All Sites
950 (100)
In Female
Cervix
208 (22.1)
1
Breast
123 (13.1)
2
Ovary
55 (5.8)
3
Oral Cavity+
35 (3.7)
4
Oesophagus
33 (3.5)
5
Rectum
11 (1.7)
*
Stomach
10 (1.1)
*
Lung
10 (1.1)
*
NHL
8 (0.85)
*
Larynx
5 (0.53)
*
Total
498 (53)
All Sites
941 (100)
* Rank not within first five + Includes Cancers of
lips, Tongue, gum, Floor of mouth, Cheek,
Palate
In age group 35-64 Oral Cavity and Lung were
the leading sites in males, while Cervix and
Breast were in females. In 65 and above age
group Oral Cavity and Oesophagus were the
leading sites in males, while Cervix and Breast
were in females. Its worthwhile to take a note
that from 15-34 years age group onwards Cervix
and Breast predominates the leading sites in
females.
Table 1.4: commonest cancers in different age
groups
Age
groups
0-14
(n=91)
Sex
Males
(n=53)
Females
(n=38)
15-34
Males
(n=233) (n=105)
Females
(n=128)
35-64
Males
(n=1232) (n=603)
Females
(n=629)
65+
Males
(n=335) (n=189)
Females
(n=146)
Most Common Cancers (%)
Lymphoid Leukemia (5.6)
Eye (3.8)
Lymphoid Leukemia (10.5)
Bones (7.9)
Myeloid Leukemia (3.8)
NHL (3.8)
Cervix (24.2)
Breast (18.8)
Oral Cavity (15.1)
Lung (5.7)
Cervix (22.7)
Breast (11.4)
Oral Cavity (15.9)
Oesophagus (10)
Cervix (23)
Breast (18.5)
Table 1.5: Comparison of leading sites of Cancer found in various study
Rank
1
2
3
4
5
Males
Current Study Mumbai HBCR
2004-2005
Oral Cavity
Oral Cavity
Oesophagus Lung
Lung
NHL
Larynx
Hypopharynx
NHL
Oesophagus
Barshi PBCR
2004-2005
Hypopharynx
Oesophagus
Larynx
Mouth
Stomach
Females
Current Study Mumbai HBCR
2004-2005
Cervix
Breast
Breast
Cervix
Ovary
Ovary
Oral Cavity
Oral Cavity
Oesophagus Gall bladder
Barshi PBCR
2004-2005
Cervix
Breast
Oesophagus
Ovary
Lung
\5 Leading cancers in males in our study were:
Oral Cavity, Oesophagus, Lung, Larynx and
NHL. Whereas, it was Hypopharynx followed
by Oesophagus for Population Based Cancer
Registry (PBCR), Barshi4, it were Oral Cavity
and Lung for Hospital Based Cancer Registry at
Mumbai6.
Cervix, Breast4 and Breast, Cervix for HBCR at
Mumbai6.
5 Leading cancers in females in our study were:
Cervix, Breast, Ovary, Oral Cavity and
Oesophagus. Whereas for PBCR, Barshi it was
DISCUSSION
Out of the 950 male cases, 27% were TRCs,
similarly out of 941 female cases 9.6% were
TRCs.
Cancer is predominantly a disease of middle
and old age5. Almost 2/3rd of all cases among
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males and females in our study occurred in the
age group 35-64 years, comparable to the
findings at all the Hospital Based Cancer
Registries for 2004-2006 in India6. In our study
we found the male female ratio to be almost
equal (1.01).
Table 1.6: Tobacco Related Cancer (TRCs)*
Sites
Male
(n=950)(%)
Female
(n=941)
(%)
Oral Cavity+
125 (13.2)
35 (3.7)
Pharynx
9 (0.9)
8 (0.9)
Oesophagus
47 (4.9)
33 (3.5)
Larynx
37 (3.9)
5 (0.5)
Lung
38 (4)
4 (0.4)
Urinary Bladder
3 (0.3)
2 (0.2)
Total
259 (27)
89 (9.6)
*Sites of Cancer included in TRCs* (Tobacco
Related Cancers): Lips, tongue, mouth, Pharynx,
Oesophagus, Larynx, Lung and Urinary
Bladder. (Source: International Agency for
Research on Cancer monographs (IARC), 1987).
+ Includes Cancers of lips, Tongue, gum, Floor of
mouth, Cheek, Palate
In the present study top 5 cancer sites in males
were Oral Cavity, Oesophagus, Lung, Larynx
and NHL. Based on IARC cancer monographs,
1987 Oral Cavity, Oesophagus, Lung and
Larynx are Tobacco Related Cancers. In our
study it constitutes 27% of all cancer in males.
Tobacco use is a major cause of cancers of Oral
Cavity, Lung, Pharynx, Oesophagus and
Larynx7-11. In 2004, IARC (IARC 2004) in a newer
monographs states, that, there is there is
sufficient evidence to establish a causal
association between cigarette smoking and
cancers of the nasal cavities and nasal sinuses,
stomach, liver, kidney, uterine cervix and
myeloid leukaemia apart from the sites in earlier
monograph of 19876. It represents the most
preventable form of cancer in our society. NHL
also finds place in first five leading sites in
Mumbai HBCR. It is 2nd leading site in 15-34 age
groups among males in the present study. NHL
is more common in developed countries.
Top 5 cancer sites in our study were Cervix,
Breast, Ovary, Oral Cavity and Oesophagus.
Cervix together with Breast constituted 1/3rd of
all cases among the females. Cancer of Cervix is
more common in developing countries5. Early
marriage, age of 1st pregnancy, multiple
pregnancies, decreased genital hygiene, sexual
behaviour
influence
the
cancer
of
cervix12,13.WHO has recommended screening of
every woman between 35-40 years of age for
cancer cervix14. Breast cancers also find place in
top 5 sites in Mumbai HBCR and Barshi PBCR.
The survey of literature reveals that
development of Breast cancer in many women
appears to be related to female reproductive
hormones. Many Epidemiological studies have
consistently identified a number of risk factors,
each of which is associated with increased
exposure to endogenous estrogens15-17. Tobacco
Related Cancers in females (Oral Cavity and
Oesophagus) were 9.6% of all the cancers among
them.
Leukaemias were leading among childhood
cancers (0-14) among males and females. It also
occupies the 1st place among the childhood
cancers at all the HBCRs6 (2004-2006).
34% cancers were in easily accessible parts of
body. It highlights the possibility of easy and
early detection of cancers in the population thus
decreasing the cancer burden in the community.
Limitation of the present study: This being the
first study of its kind in the south-western
Maharashtra, it was imperative that a cross
sectional study was done than going for indepth probing of any specified parameter.
CONCLUSIONS
The Tobacco Related Cancers represent the most
preventable form of cancer in our society. It was
27% in males and 9.6% in females in our study.
Additionally 34% cancers were in easily
accessible parts of body. It highlights the
possibility of easy and early detection of cancers
in the population thus decreasing the cancer
burden in the community. This study also
reinforces the fact that about 1/3rd of all cancers
are preventable and further 1/3rd are potentially
curable if diagnosed sufficiently early.
Acknowledgement:
Shri
Siddhivinayak
Ganapati Cancer Hospital, Miraj for allowing
me to conduct the study.
REFERENCES
1.
Sir Richard Doll. The Epidemiology of Cancer. Cancer
1980; 45: 2475-2485
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 446
pISSN: 0976 3325 eISSN: 2229 6816
2.
3.
4.
5.
6.
7.
8.
Park K. Park’s Textbook of Preventive and Social
Medicine, 18th edition. Jabalpur: Banarsidas Bhanot
Publications; 2005. P302-310
Population Based Cancer Registries Reports-2004-2005.
Available
at
http://www.pbcrindia.org/Pbcr_map1.htm
(Last
accessed Oct 2 2011)
Individual Registries write up- Barshi. Available at
http://www.pbcrindia.org/Pbcr_map1.htm
(Last
accessed Oct 6 2011).
R Kalyani, S Das, MS Bindra et al. Cancer profile in
Kolar: A ten years study. Indian J Cancer 2010; 47:160165
Consolidated Report of Hospital Based Cancer
Registries
2004-2006.
Available
at
http://www.pbcrindia.org/HBCR_Report_2004-06.pdf
(Last accessed Oct 6 2011)
Cancer
fact
sheet.
http://www.who.int/mediacentre/factsheets/fs297/e
n/ (Last accessed Oct 6 2011)
Park K. Park’s Textbook of Preventive and Social
Medicine, 18th edition. Jabalpur: Banarsidas Bhanot
Publications; 2005.p304
9.
10.
11.
12.
13.
14.
15.
16.
17.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Eaton Lynn. World cancer rates set to double by 2020.
Br Med J 2003; 326:728
Scully C, Porter S. ABC of oral health. Br Med J 2000;
321:97-100
Rao DN, Epidemiological observation on cancer of
oesophagus-A review of Indian studies. Indian J Cancer
1996; 33:55-75
Malhotra V, Shah BS, Sabharwal S. Pattern of cancer in
Dayanand Medical College & Hospital, Ludhiana (A
ten year retrospective study). Indian J Pathol Microbiol
2001; 44:27-30
Rao DN, Ganesh B. Estimate of cancer incidence in
India in 1991. Indian J Cancer 1998; 35:10-8.
Sharma RG, Maheshwari MS, Lodha SC.Cancer profile
in Western Rajasthan. Indian J Cancer 1992; 29:126-132.
Apter D, Vinko R. Early menarche, a risk factor for
breast cancer. Journal of Clinical Endocrinology and
Metabolism 1983; 57:82-86.
W.H.O.’s Manual on the Prevention and Control of
Common Cancers: New Delhi. Prentice Hall of India;
1998: 252-253.
Gilani GM, Kamal S. Risk factor for breast cancer in
Pakistani women aged less than 45 years. Ann Hum
Biol 2004; 31:398-407.
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ORIGINAL ARTICLE .
ASSESSMENT OF PERSONAL HYGIENE OF CANTEEN
WORKERS OF GOVERNMENT MEDICAL COLLEGE AND
HOSPITAL, SOLAPUR
Anant Arunrao Takalkar1, Anjali P. Kumavat2
1Associate Professor, Department of Community Medicine, Kamineni Institute of Medical Sciences,
Narketpally 2Professor and Head, Department of Community Medicine, Dr. V. M. Government
Medical College, Solapur
Correspondence:
Dr. Anant Arunrao Takalkar
Associate Professor, Department of Community Medicine,
Kamineni Institute of Medical Sciences,Narketpally.
Sreepuram, Narketpally- 508254 Nalgonda district, Andhra Pradesh
Email: [email protected] Mobile No. 09704823229
ABSTRACT
Background: Major risk of food contamination lies with the food handlers. Pathogenic organisms
present in or on food handlers’ body multiply to an infective dose when come in contact with food
and could be a potential source of food poisoning to its clients.
Methodology: Cross sectional observational study involving all 83 food handlers presently working
were included. With structured proforma, details of socio-demographic data, general physical
examination for personal hygiene and assessment of knowledge about food hygiene carried out.
Results: 45.8% were from 15 to 35 years age group while child labours were found to be 6.0%. Only
28.9% were having good personal hygiene whereas 32.5% were having poor personal hygiene.
Commonly observed dermatological morbidities were fungal infection (21.4%), dermatitis (20.4%)
and scabies (9.3%). 95.2% were aware about food borne diseases. 86.7% responded that contaminated
foods transmit disease. 56.6% responded role of vectors in disease transmission. Conclusion: There is
lot of scope for improving the standards of personal hygiene of canteen workers. Owners of
establishments should be made aware of importance of pre-placement and periodical medical
examination in order to protect the health of consumer.
Key words: hotel workers, food handlers, personal hygiene, food establishments etc.
INTRODUCTION
Food-borne illnesses have an impact in both
developing and developed countries. Most of
the annual 1.5 billion episodes of diarrhoea in
children under five years of age occur in
developing countries. A significant proportion
of diarrheal cases are food-borne in origin, and
the more than 3 million resultant deaths per
year are an indication of the magnitude of this
problem. Moreover, in developing countries, up
to an estimated 70% of cases of diarrheal disease
are associated with the consumption of
contaminated food. 1, 2
Though reliable statistics on food borne diseases
are not available due to poor or non-existent
reporting systems in most developing countries,
such diseases take a heavy toll in human life and
suffering, particularly among infants and
children, the elderly and other susceptible
groups. They also create an enormous social,
cultural and economic burden on communities
and their health systems. 3
Food handler is any person who handles food,
regardless whether he actually prepares or
serves it. Food handlers are the most important
sources for the transfer of microorganisms to the
food from their skin, nose, and bowel and also
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from the contaminated food prepared and
served by them. 4 Food handlers may transmit
pathogens passively from a contaminated
source, for example, from raw poultry to a food
such as cold cooked meat that is to be eaten
without further heating. They may also,
however, themselves to be sources of organisms
either during the course of gastrointestinal
illness or during and after convalescence, when
they no longer have symptoms. During the
acute stages of gastroenteritis large numbers of
organisms are excreted and by the nature of the
disease are likely to be widely dispersed; clearly,
food handlers who are symptomatically ill may
present a real hazard and should be excluded
from work. Good hygiene, both personal and in
food handling practices, is the basis for
preventing the transmission of pathogens from
food handling personnel to consumer.5
Medical and paramedical staffs, students,
patients and their relatives were consuming
food from the messes and canteens, so they
should be aware of health status of food
handlers in order to prevent food borne
diseases. Few studies were conducted in past
focusing the hygienic aspect of food handlers
and eating environment. Therefore this study
was aimed at assessing personal hygiene of food
handlers presently working in different eating
establishments of medical college and hospital
as well as their knowledge in the areas of food
borne diseases and food hygiene.
MATERIALS AND METHODS
The present cross sectional observational study
was conducted amongst 83 food handlers
working in various canteens and messes that
come under Dr. V. M. Government Medical
College and Hospital, Solapur city during year
2005.
Total 83 food handlers were included in our
studies who were presently employed. All food
handlers working in college and hospital
canteens, boys and girls hostel messes and
resident doctors mess. Data regarding sociodemographic profile, general and clinical
examination for personal hygiene was collected
by using pretested and predesigned proforma.
Assessment of personal hygiene was done by
using Jacob M. scoring system (which includes
condition of hairs, hands, nails, use of gloves,
apron, cap, bathing etc.)6. Maximum score for
assessment was 10 (Good = 8-10, Average = 5-7
and Poor = 0-4) Social class grading was done by
using modified B. G. Prasad’s classification.
Knowledge about food borne diseases and food
hygiene was assessed with the questionnaire.
Data thus collected was entered and analyzed
by using appropriate statistical tool.
RESULTS
Table 1: Distribution according to sociodemographic variables (N=83)
Variables
Age (years)
Below 14
15-25
26-35
36-45
46-55
Above 55
Sex
Male
Female
Socio-economical status
Lower class
Upper lower
Lower middle
Upper middle
Upper class
Educational status
Illiterate
Primary
Secondary/High. Secondary
Graduate
Number (%)
05 (6.0%)
19 (22.9%)
19 (22.9%)
21 (25.3%)
14 (16.9%)
05 (6.0%)
51 (61.4%)
32 (38.6%)
29 (34.9%)
35 (42.2%)
14 (16.9%)
05 (6.0%)
00 (00%)
19 (22.9%)
17 (20.5%)
46 (55.4%)
01 (1.2%)
Maximum numbers of food handlers 45.8% were
from 15 to 35 years age group while child
labours were found to be 6.0%. 61.4 % were
males and 38.6% were females. 77.1% were from
lower socioeconomic class. 22.9% were illiterate
and 55.4% were studied up to Secondary School.
Table 2: Distribution according to grade of
personal hygiene
Grade
Good
Average
Poor
Total
Number (%)
24 (28.9)
32 (38.5)
27 (32.6)
83 (100)
Personal hygiene grading revealed that only
28.9% were having good personal hygiene
whereas 32.5% were having poor personal
hygiene.
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Table 3: Dermatological morbidities amongst
food handlers
Skin morbidity
Scabies
Boils and furunculosis
Fungal infection
Dermatitis
Number (%)
08 (9.6)
14 (16.7)
20 (24.1)
17 (20.4)
General examination of study population with
respect to personal hygiene revealed some
dermatological morbidity. Prevalence of fungal
infection was 24.1%, dermatitis (20.4) and
scabies (9.6%).
Table 4: Knowledge of study population
regarding food borne diseases and personal
hygiene
Knowledge
Have you ever heard about food
borne diseases?
Yes
No
What is your source of
information?
Mass media
Health professionals
Formal training and written display
$How can food borne diseases be
transmitted?
Contaminated foods
Contaminated hands
Contaminated water
Vectors
Don’t know
$How disease can be prevented
from food handlers to consumers?
Washing hands before serving
Washing hands after defecation
Regular trimming of nails
Minimum handling of cooked food
Keeping unhealthy food handlers
away from service
($ indicates multiple responses)
No. (%)
79 (95.2)
04 ( 4.8)
58 (69.9)
14 (16.9)
11 (13.2)
72 (86.7)
25 (30.1)
28 (33.7)
47 (56.6)
11 (13.2)
80 (96.4)
83 (100)
72 (86.7)
36 (43.4)
55 (66.3)
95.2% were aware about food borne diseases.
Main source of information was mass media
(69.9%). 86.7% responded that contaminated
foods transmit disease. 56.6% responded role of
vectors in disease transmission. Almost all food
handlers were aware about importance of hand
washing before serving and after defecation in
prevention of food borne diseases (96.4% and
100% respectively). Only 43.4% were aware
about minimum handling of cooked food.
DISCUSSION
The food handler in restaurants are the sensitive
group of population that can be a focus for
contamination by various infectious agents as
they are in direct contact with the clients
especially when they are in asymptomatic stage.
Table 1 revealed majority i.e.45.8% were in
young age group (15-35 years), followed by
middle age group (25.3%) i.e.36-45 years. Chitnis
UKB7, Kale AB8 and Sangole SS9 stated that
majority of population in their study were from
15 to 35 years age group.
Prevalence of child labour in our study was
6.0%. In India, according to Factory Act (1948),
Sec.172 of Bombay Factories Rules (1950)
prohibits employment of young person below 14
years of age.10 In spite of various acts/rules,
prohibiting employment of child labour; they
are still being exploited in many countries
including India and are frequently to be found
in eating establishments.
77.1% food handlers were from lower
socioeconomic class. 22.9% were illiterate and
55.4% were studied up to Secondary School.
Many of the food handlers are from poor
families, jobless and with low level of education
whereas a job of food handler in such hotels
offers them some income, free food and shelter.
Table 2 depicts personal hygiene status of food
handlers. Personal hygiene was graded based on
the scoring system of Jacob M.6 and revealed
that only 28.9% were having good personal
hygiene whereas almost one third i.e. 32.5%
were having poor personal hygiene. Our
findings are consistent with findings of other
authors7,9,12. However Rathore AS11 observed
60% food handlers with good personal hygiene.
Mohan V, Mohan U and Raj K 13 observed far
better personal hygiene among their study
subjects in Amritsar city.
Poor personal hygiene in our study can be
attributed to lack of sanitary facilities and
majority from lower socio-economical class. A
high standard of personal hygiene is expected
that will reduce the risk of contamination and
help to prevent food poisoning.
Table 3 depicts dermatological morbidities
amongst food handlers. Prevalence of fungal
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infection was 24.1%, dermatitis 20.4% and
scabies 9.6%. Mudey A et al14 observed same
prevalence of scabies (9.25%) amongst food
handlers in their study from Maharashtra.
Pawar AT 15 carried out health survey of hotel
workers in Pune and observed that prevalence
of fungal infection is most common (15.1%) that
matches with our findings. However, Kale AB 8
observed less prevalence of skin morbidities
comparatively eczema & scabies 3.5% each,
furuncle 1.4%, fungal infection1.9%. This means
good
personal
hygiene
and
stringent
supervisory control on food handlers.
Skin diseases are direct reflection of lack of
personal hygiene. Since majority of workers in
our study were from rural area with lower
socioeconomic status, there was gross
negligence regarding minor skin ailments. Also
they were afraid of losing the job if found by
hotel owner, and so use to hide it.
Table 4 depicts Knowledge of study population
regarding food borne diseases and personal
hygiene. 95.2% were aware about food borne
diseases. Main source of information was mass
media
(69.9%).
86.7%
responded
that
contaminated foods transmit disease. 56.6%
responded role of vectors in disease
transmission. Almost all food handlers were
aware about importance of hand washing before
serving and after defecation in prevention of
food borne diseases (96.4% and 100%
respectively). Only 43.4% were aware about
minimum handling of cooked food.
Since they were working in institutional
establishments, knowledge about food hygiene
and personal hygiene was found satisfactory,
but there is a vast gap between knowledge and
their practices. Same observations were made by
different authors 16, 17. Very few Indian studies
conducted knowledge survey of food handlers
regarding personal and food hygiene.
CONCLUSION
There is lot of scope for improving the standards
of personal hygiene of hotel workers. Owners of
eating establishments should be made aware of
importance of pre-placement and periodical
medical examination in order to protect the
health of consumer. Health education in these
areas will help to early detection of any morbid
state. Child labour should be strictly prohibited.
Though it is not risky to work in hotels for
children, they should be prohibited because
their educational and other rights are hampered.
So parents and general population should be
made aware of it.
REFERENCES
1. World Health Organization. Removing obstacles to
healthy development. WHO, Geneva.1999
2. World Health Organization. Food borne Disease: A focus
for Health Education. WHO, Geneva. 2000
3. Theo Van de Venter. Emerging Food-borne Diseases: a
global responsibility, Food, Nutrition & Agriculture,
FAO corporate document repository, 2009.
4. Mohan V. et al. An evaluation of health status of food
handlers of eating establishments in various educational
and health institutions in Amritsar City. Indian Journal
of Community Medicine.2001; 26(2): 80-84.
5. Murat B, Azmi S, Ersun, Gokhan K. The evaluation of
food hygiene, knowledge, attitudes, and practices of
food handlers in food businesses in Turkey. Food
Control. 2006;17:317–322
6. Jacob M. Safe food handling- a training guide for
manager of food service establishments. WHO, Geneva,
1989.
7. Chitnis UKB. An evaluation of health status of workers
in eating establishments in Pune Cantonment. Medical
Journal of Armed Forces. 1986; 2: 34-5.
8. Kale AB et al. Prevalence of intestinal parasites in food
handlers. Indian Medical Gazette, September 1989, 289291.
9. Personal communication: Sangole SS. Study of health
status of food handlers working in “Zunka Bhakar”
Center in Nagpur City. A Dissertation submitted for MD
(PSM), Nagpur University 1999.
10. World Health Organization. Children at work-special
health risks. Report of WHO study group, WHO TRS
No.756, WHO, Geneva, 1987.
11. Rathore AS et al. An evaluation of health status of food
handlers and sanitary status of messes of a training
establishment in Karnataka. Indian Journal of
Community Medicine.1993; 18 (1): 21-25.
12. Gupta s, Kelkar YA. Health and hygiene status of food
handlers. Indian Medical Gazette.1981; 15(8): 295-298
13. Mohan V, Mohan U and Raj K.A study of carrier state of
S.Typhi, intestinal parasites and personal hygiene of
food handlers in Amritsar city. Indian Journal of
Community Medicine. 2006;31(2): 60-61
14. Mudey A et al. Health status and personal hygiene
among food handlers working at food establishment
around a rural teaching hospital in Wardha district of
Maharashtra, India. Global Journal of Health Science.
2010; 2(2): 198-206
15. Pawar AT, Kakrani VA. Health status of hotel workers
with special reference to high risk practices and STDs.
Indian Journal of Public Health.2007;51(1): 51-52
16. Udgiri R, Yadavnnavar MC. Knowledge and food
hygiene practices among food handlers employed in
food establishments of Bijapur city. Indian Journal of
Public Health 2009; 53: 240-241.
17. Santos MJ, Nogueira JR, Patarata L, Mayan O.
Knowledge levels of food handlers in Portuguese school
canteens and their self-reported behavior towards food
safety. Int J Environ Health Res. 2008; 18:387-401.
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ORIGINAL ARTICLE .
BIOMEDICAL WASTE MANAGEMENT: AWARENESS
AND PRACTICES IN A DISTRICT OF MADHYA PRADESH
Manoj Bansal1, Ashok Mishra2, Praveen Gautam3, Richa Changulani3, Dhiraj Srivastava4, Neeraj
Singh Gour5
1Assistant
Professor, Department of Community Medicine, Bundelkhand Medical College, Sagar
(MP) 2Professor 3Assistant Professor, Department of Community Medicine, G.R Medical College,
Gwalior (MP) 4Lecturer, Department of Community Medicine, UP RIMS&R, Saifai, Etawah (UP)
5Assistant Professor, College of Medicine, JNM Hospital, Kalyani, (AP)
Correspondence:
Dr. Manoj Bansal
Assistant Professor, Department of Community Medicine
Bundelkhand Medical College, Sagar (M.P.)
E-mail: [email protected], Phone no. 09907542382
ABSTRACT
Background: A hospital is an establishment that provides medical care facilities. Since the majority of
the persons receiving treatment in the hospital are suffering with infectious diseases therefore, the
waste generated in hospital has potential to transmit infections and other hazards to hospital staff and
nearby community, if not managed adequately. Adequate awareness in the hospital staff and
practices regarding the biomedical waste management is crucial to prevent these hazards.
Objective: To assess the awareness and existing practices regarding biomedical waste and its
management in a district of Madhya Pradesh.
Material And Methods: The present study was a cross sectional study carried out in both urban and
rural health facilities of Gwalior district from Jan to Jun 2008. Only those hospitals having indoor care
facility were included randomly. Medical, para-medical and non-medical personnel working at their
current position for at least 6 months were included as study participants to assess awareness.
Statistical Analysis: Percentage and Proportion were applied to interpret the result.
Results: Awareness regarding biomedical waste management was highest among doctors followed
by para-medical staff and least among non-medical staff. Practices of waste management in hospitals
were grossly inadequate, particularly in rural area.
Conclusion: The present study concludes that regular orientation and re-orientation training
programs should be organized for hospital staff and strict implementation of guidelines of biomedical
waste management, to protect themselves and hospital visitors.
Key Words: Biomedical Waste, Hazards, Health care personnel
INTRODUCTION
A hospital is an establishment that provides
medical care facilities to persons suffering or
suspected to be suffering from any disease or
injury. The medical facilities available in a
hospital may be diagnostic, therapeutic or
rehabilitative. Hospital wastes have always been
considered as potentially hazardous. The major
identified hazard is infection, because most of
the persons receiving medical care in the
hospital are suffering from communicable
diseases.1 Other hazards associated with poor
waste management includes injuries from
sharps, risks associated with hazardous
chemicals or drugs and disposables being
repacked and sold without being washed. Waste
piles also attract variety of disease vectors,
including mosquitoes and flies. 2 It is important
to note that not all hospital waste has the
potential to transmit infection. It is estimated
that 80–85% is non-infectious general waste, 10%
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is infectious and 5% is other hazardous waste. 3
However, if the infectious component gets
mixed with the general non-infectious waste, the
entire bulk of hospital waste potentially
becomes infectious.4
The management of hospital waste requires its
segregation and removal from the health- care
establishments in such a way that it will not be a
source of health hazards to those who are
directly or indirectly related to hospital
environment. The Ministry of Environment and
Forest, Government of India promulgated “Biomedical Waste (Management and Handling)
Rules” in July 1998 and amended on 2nd June
2000 with the objective to promote scientific and
systematic management of health care waste.
These rules apply to all those who generate,
collect, receive, store, transport, treat, dispose, or
handle bio-medical waste in any form.5,6
Any carelessness in the management of wastes
generated in a hospital tends to spread
infections and contaminate the entire living
environment prevailing in a hospital. Thus,
improper waste management practices are a
serious problem that involve not only to the
hospital staff but society at large. In developing
countries, however, medical waste materials
have not received sufficient attention therefore
the management of bio-medical waste is still a
major challenge to the hospitals. 7
Thus present study was conducted with the
following objectives:
• To assess the awareness in hospital
personnel regarding bio-medical waste and
its management.
• To know the existing practices of biomedical waste management in the health
facilities of Gwalior district.
MATERIALS AND METHODS:
The present study was a cross-sectional study
carried out in government and private hospitals
of Gwalior district for a period of six months
from Jan-Jun 2008.
The study was conducted in both urban and
rural health facilities of Gwalior district. From
urban area, two government and two private
hospitals were selected randomly. Rural area
was further divided into four blocks. From each
block one government and one private health
facility included in the study. Only those health
facilities having indoor care were included in
the study. Informed consent from the hospital
authorities and health personnel of respective
health facility was taken for the study and they
were assured that confidentiality would be
strictly maintained. Staff and students of
Department of Community Medicine, G.R.
Medical College, Gwalior, visited to selected
hospital one by one.
In the first stage, investigators conducted
interviews and in the second stage, existing
practices of biomedical waste management were
assessed. Observation of health facility was
done to confirm the response of hospital
authority about existing practices, using
separate structured proforma. From each health
facility, medical (doctors), para-medical (nurses
and lab. technicians) and non-medical (waste
handlers and sweepers) personnel, working at
their current position for at least 6 months, were
interviewed to find out the awareness about
biomedical waste management
by using
purposive sampling method.
Pre-designed, pre-tested study tool consists of
two sections. First section contains a total of ten
questions, of these six were multiple choice
questions with one correct option and four were
answered as true or false. The second section
contains questions regarding the existing
practices of various steps involved in the
biomedical waste management in respected
health facility. Data collected was compiled and
analyzed manually. Percentage and proportion
were used for the interpretation of findings.
RESULTS:
A total of 12 hospitals were selected, of which
four were from urban area and eight were from
rural area of Gwalior district. Out of 246 health
personnel interviewed, 116 (47.15%) were
doctors, and para-medical and non-medical staff
were 29.26% and 23.57% respectively. (Table I)
Table 1: Distribution of different health care
personnel interviewed.
Type of
Hospital
Medical
(%)
76 (47.50)
Government
Private
Total
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
40 (46.51)
116
(47.15)
Paramedical
(%)
48 (30.00)
Nonmedical
(%)
36 (22.50)
34 (39.53)
72 (29.26)
22 (25.58)
58 (23.57)
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In this study, the overall awareness was found
maximum among doctors followed by paramedical workers and least among non-medical
workers. Majority of the medical workers were
found aware about the biomedical waste
management. Awareness regarding colour
coding and segregation was little bid greater
among para-medical workers than doctors.
Regarding composition of hospital waste, only
32.75% medical, 25% para-medical and 3.44%
non-medical workers gave correct answer.
(Table 2)
Table 2: Showing awareness regarding biomedical waste and its management among health care
personnel.
Question regarding
Hazards associated with BMW† Management &
Handling
Prevention of hazards associated with BMW†
Management & Handling
Colour coding
Segregation of BMW†
Segregation of sharp waste such as contaminated
needle
Transportation of BMW† for terminal disposal
Open unused sharps are not considered as BMW†.
Any item which has had contact with blood
or any other fluid is considered as BMW†
Untreated BMW* can be stored maximum for 48 hrs.
About 10-25% of total waste generated in a hospital is
hazardous
†Biomedical Waste
As far as practices of biomedical waste is
concerned, in our study only one hospital of
urban area adequately segregating the hospital
waste while pre-treatment was done in only 33%
hospitals under study. Transportation of
biomedical waste out side the hospital was
adequate in almost all the urban health facilities
but none of the rural health facility shows
adequate transportation. In urban area, all the
hospitals were using Common Biomedical
Waste Treatment Facility (CBWTF) for terminal
disposal of waste. In rural area, the health
facilities were using deep burial, burning and
open dumping, either single method or in
combination for terminal disposal. (Table 3)
Medical
(n=116) (%)
116 (100)
Correct Response
Paramedical
Nonmedico
(n=58) (%)
(n=72) (%)
69 (95.83)
25 (43.10)
116 (100)
67 (93.05)
22 (37.93)
64 (55.17)
52 (44.82)
83 (71.55)
44 (61.11)
37 (51.38)
43 (59.72)
06 (10.34)
04 (6.89)
06 (10.34)
112 (96.55)
78 (67.24)
115 (99.13)
54 (75.00)
30 (41.67)
63 (87.50)
27 (46.55)
05 (8.62)
30 (51.72)
70 (60.34)
38 (32.75)
31 (43.05)
18 (25.00)
07 (12.06)
02 (3.44)
was found highest among medical professionals.
Almost all the doctors and majority of the paramedical workers were quite aware about
hazards and method of prevention of hazards of
biomedical waste management and handling
while it was least among non-medical workers.
Similar observations were noted by Deo et al 8
and Pandit NB et al 9
DISCUSSION:
The knowledge regarding segregation is
important to prevent the mixing of hazardous
and non-hazardous or domestic waste which
has to be disposed off with municipal waste. In
this study, knowledge about colour coding and
segregation was more among para-medical than
medical staff. These findings were supported by
studies done by various researchers. 8, 10
The present study was conducted in
government and private hospitals of both urban
and rural area to find out the awareness and
existing practices regarding biomedical waste
management in the district. Awareness among
health care workers is essential for the adequate
management of biomedical waste. The overall
awareness about biomedical waste management
Our study reveals that knowledge about
transportation of waste for terminal disposal
was highest among doctors than para-medical
staff and least among non-medical staff. In our
study, only 32.75% doctors, 25% para-medical
and 3.44% non-medical staff were agree with the
fact that about 10-25% of total waste generated
in a hospital is hazardous. This may be because
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of there low level of education. Saini et al found
that person with higher education level were
more aware regarding the issue.11
Segregation is the most important step in the
entire process of biomedical waste management.
Segregation not only reduces the risks
associated with the biomedical waste but also
the cost of handling, treatment and disposal. As
per the findings of this study, majority of the
hospitals using two or three colour coded bags
to segregate the waste and the practices of waste
segregating were not adequate and mixing of
waste was found. Pandit NA et al in his study in
Srinagar and Gupta et al in Lucknow also
reported that there was no mechanism for waste
segregation of infectious and non-infectious
waste.12,13
rural health facilities. This may occur because in
urban area, all the hospitals under study have a
contract with Common Biomedical Waste
Treatment Facility for transportation and
terminal disposal. Persons working with
CBWTF collect waste from these hospitals daily
by separate vehicle used only for transportation
of biomedical waste.
The health facilities of rural area were using
deep burial, burning and open dumping near to
hospital premises for terminal disposal. Pandit
NB et al in his study carried out in a district of
Gujarat and Rijal et al in Kathmandu valley also
noted that there were no effective waste
segregation, collection, and transportation and
disposal system in most of the health care
institutions. 9, 14
Storage and transportation of waste were found
adequate in hospitals of urban area, while not in
Table 3: Showing existing practices of biomedical waste management in urban and rural hospitals.
Step of BMW† Management
Urban Hospitals
(n=04) (%)
Segregation
Adequate
01 (25)
Notadequate
03 (75)
Pre-treatment
Yes
02 (50)
No
02 (50)
Storage at site of production
<=1day
04 (100)
>1day
00 (00)
Frequency of removal
<=1day
04 (100)
>1day
00 (00)
Transportation
Adequate
04 (100)
Notadequate
00 (00)
Method used for terminal disposal
CBWTF#
04 (100)
Others
00 (00)
# Common Biomedical Waste Treatment Facility
CONCLUSION:
The present study concluded that the awareness
regarding biomedical waste management was
satisfactory in medical personnel while poor in
para and non-medical workers. As these
workers are regularly engaged in the process of
biomedical waste management and handling,
therefore there is an urgent need for orientation
training regarding the issue, to entire health care
personnel especially para and non-medical
Rural Hospitals
(n=08) (%)
Total (n=12) (%)
00 (00)
08 (100)
01 (8.33)
11 (91.67)
02 (25)
06 (75)
04 (33.33)
08 (66.67)
03 (37.50)
05 (62.50)
07 (58.33)
05 (41.67)
03 (37.50)
05 (62.50)
07 (58.33)
05 (41.67)
00 (00)
08 (100)
04 (33.33)
08 (66.67)
00 (00)
08 (100)
04 (33.33)
08 (66.67)
workers to protect themselves and people
visiting to hospital and nearby community.
Also, there is a need of strict implementation of
guidelines of biomedical waste management
and regular supervision and monitoring by a
separate committee, exclusively formed for the
implementation of rules related to the safe
management and handling of hospital waste in
entire district.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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REFERENCES:
1.
2.
3.
4.
5.
6.
7.
8.
Standard operative procedure, Manual for Control of
Hospital Associated Infections, NACO New Delhi; p.066.
Acharya DB & Singh M. The Book of Hospital waste
Management. Minerva Press, New Delhi; 2000:p.5-47.
Manual on Hospital Waste Management. Central
Pollution Control Board, Delhi; 2000.
http://pib.nic.in/infonug/infaug.99/i3008991.html,
accessed on May 25th 2008. Info Nugget. 2003 Hospital
Waste Management and Biodegradable Waste.
The Bio Medical Waste (Management & Handling)
Rules. Ministry of Environment and Forest, Govt. of
India, 1998.
The Gazette Notification. Ministry of Environment and
Forest, Govt. of India, June 2000.
Silva CE, Hoppe AE. Ravanello MM & Mello N.
Medical waste management in the south of Brazil.
Waste Management. 2005;25: p.600-05.
Deo D, Tak SB & Munde SS. A study of Knowledge
Regarding Biomedical Waste Management among
Employees of a Teaching Hospital in Rural Area. J of
ISHWM. April 2006;(1):p.12-16.
9.
10.
11.
12.
13.
14.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Pandit NB, Mehta HK, Kartha GP & Choudhary SK.
Management of bio-medical waste: awareness and
practices in a district of Gujarat. Indian J Public Health.
Oct-Dec 2005; 49(4): p.245-47.
Mathur V, Dwivedi S, Hassan MA, Misra RP.
Knowledge, Attitude and Practices about Biomedical
Waste Management among Health Care Personnel: A
Cross-sectional Study. Indian J Community Medicine.
Apr 2011;36(2):p.143-145.
Saini S, Nagarajan SS & Sharma RK. Knowledge,
attitude and practices of bio-medical waste
management amongst staff of a tertiary level hospital in
India. J of the Academy of Hospital Administration.
2005;17(2):p.1-12.
Pandit NA, Tabish SA, Qadri GJ & Mustafa A.
Biomedical waste management in a Large Teaching
Hospital; JK-Practitioner,2007;14(1)57-59.
Gupta S, Boojh R. Waste Management and
Research,2006;24:584-591.
Rijal K, Deshpande A. Critical Evaluation of Biomedical
Waste Management Practices in Kathmandu Valley.
Proceedings of the International conference on
Sustainable solid Waste Management, 5-7 September
2007, Chennai, India: 142-147.
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ORIGINAL ARTICLE .
KNOWLEDGE & PERCEPTIONS OF ICDS ANGANWADI
WORKERS WITH REFERENCE TO PROMOTION OF
COMMUNITY BASED COMPLEMENTARY FEEDING
PRACTICES IN SEMI TRIBAL GUJARAT
Purvi Parikh1, Kavita Sharma2
1PhD
Scholar, 2PhD Advisor, 1Department of Foods and Nutrition, WHO Collaborating Centre for
Research and Training in Promoting Nutrition in Health and Development, Faculty of Family and
Community Sciences, the Maharaja Sayajirao University of Baroda, Gujarat, India.
Correspondence:
Ms Purvi Parikh,
Department of Foods and Nutrition,
Faculty of Family and Community Sciences,
The Maharaja Sayajirao University of Baroda, Gujarat, India
Email: [email protected]
ABSTRACT
Objective: To assess ICDS anganwadi workers’ knowledge and perception regarding promotion and
enhance community based complementary feeding practices.
Methodology: Total 17 anganwadi workers’ (AWWs) from one semi tribal sector (covering
approximately 850 children under three two years) of Vadodara district in Gujarat state, India were
purposely selected. This study employed interview with AWWs as a principal method of data
collection using a pretested semi-structured interview schedule. The entire interview was divided
into 8 themes.
Results: The knowledge of AWWs with regard to key IYCF practices was average. None of the
AWWs knew the complete rationale for promoting breastfeeding till 2 years and beyond. Merely 65%
AWWs recommended food with thick consistency while 47% recommended liquid diets for children.
These practices in fact are one of the primary reasons which can be attributed to low energy and
protein intake during complementary feeding. As low as 18% AWWs advised giving small frequent
feeds during illness and only 6% advised additional meal after illness. None of the AWWs
recommended persistence in feeding the child with required quantity of food. Total 41% listed
sickness as key reason for child not feeling hungry, missing out on the other two imperative reasons
i.e. micronutrient deficiency and mouth lesion.
Conclusion: Overall knowledge and perceptions for promoting of community based CF practices
was average amongst the ICDS AWWs with a percent score of 40%. The AWWs were aware of key
IYCF practices, however the AWWs perceptions and knowledge with regard to the rationale
applicable to the appropriate recommended CF practices being promoted was rather poor. This is
noted to be a critical gap and needs to be addressed for equipping the ICDS frontline workers for
effectively promoting successful adoptions of CF practices by community.
Key words: Complementary Feeding (CF) Practice, Anganwadi worker (AWW) Integrated Child
Development Services (ICDS)
INTRODUCTION
Globally under nutrition contributes to nearly
35% i.e. three million deaths of children below
five years of age 1. Malnutrition among children
below five years of age can only be prevented
when policy, program, and budgetary actions
are directed to children during prenatal life and
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the first two years of life. Any intervention later
will be ineffective. Moreover, there is now
evidence that rapid weight gain after first two
years of life increases the risk of chronic disease
later in life 2. The National Family Health Survey
(NFHS) – III shows 40.4% of children below
three years of age are underweight in India 3.
Stuting and wasting are mainly due to
suboptimal
complementary
feeding
and
improves in most settings with focus on feeding
frequency, energy density and adequacy of
nutrients in the diet 4. It has been established
that early childhood nutrition is the single most
important child survival intervention 5.
Improvement of complementary feeding (CF)
through strategies such as counseling about
nutrition for food-secure populations and
nutrition counseling could substantially reduce
stunting and related burden of disease 5.
Translating these two optimal infant and young
child feeding practices (IYCF) to coverage of
90% is estimated to contribute to 19% reduction
in deaths of children below five or saving
450,000 deaths in India6,7.
In Gujarat state of India, although 41.1% of
children below three are underweight 49.2% are
stunted and 19.7% are wasted i.e. poor feeding
practices is recognized to be a primary reason
for the high level of malnutrition in Gujarat. In
Gujarat state, as per the District Level
Household & Facility Survey-III 8, only 19.5
percentage children 6-24 months met all the
three following criteria of appropriate feeding
i.e. of being breastfed within one hour of birth,
exclusive breastfed (EBF) for the first six months
and presently receiving solid and semi sold
food. For those children who had started food
supplementation while still breastfeeding, the
median age in months at the time of other fluids,
semi-solid food and solid food supplementation
were 6.2 months, 8.3 months and 11.3 months
respectively 8. Further the NNMB 9 study
showed that in Gujarat among children 1-3 years
there is a wide gap in consumption of food
against RDA ICMR. None of the vital food
groups are consumed above 40% of RDA. There
is a deficit of over 500 calories in the intakes of
1-3 years old, resulting in only 24% of calorie
and protein adequacy.
In India ICDS anganwadi workers (AWWs),
play a vital role in promotion of community
based optimal CF practices in India. The present
study was conducted to assess the knowledge
and perceptions of AWWs in enhancing
community based complementary feeding
practices.
MATERIALS AND METHODS
The paper is a part of operational research study
on “Capacity Building of ICDS Functionaries in
Growth Monitoring and Promoting (GMP) &
IYCF Practices: Impact on Nutritional Status of
under Twos”.
Total 17 AWWs of one semi tribal sector of
Vadodara district were purposely selected for an
in-depth interview. These AWWs catered to a
population of approximately 850 children below
2 years of age. This study employed interview
with AWWs as a principal method of data
collection using a pretested semi-structured
interview schedule. It included items which
elicited responses in the form of pre-coded
responses as well as those which had to be
recorded
by
verbatim.
The
latter
were subsequently coded into themes and subthemes.
“This provided
a
combination
of structure and flexibility and hence a scope for
bringing out standardized as well as unexpected
responses". The questionnaire was prepared
using the formats of the Breastfeeding
Promotional Network of India (BPNI) for
conducting in-depth interviews for community
workers 10. The terms and definitions for IYCF
used were as per the National Guidelines on
IYCF, 2nd edition (2006) 11. The knowledge and
perceptions of AWWs on CF was assessed based
on the WHO ten guiding principles for CF 12.
The responses were quantified into number and
percent score wherever possible and presented
in tabular form. For these the entire interview
was scored, 1 point (score) per AWW for each
preferred response. Score for all 17 AWWs for
each response was clubbed and percent score
was calculated. Similarly average score for all
themes and sub themes were calculated taking
average of all response.
Each interview was scored of total 90 points (92
positive - 2 negative). Negative marking was
done only in CF section while assessing
knowledge and perceptions about type and
consistency of food. These were only when
AWWs listed thin liquid foods as CF. Further
the score was divided into key 8 themes and
converted into percentages score of total score
i.e. 90 points.
Observation and discussion was based on
important, essential, critical messages which
needs to be communicated by community based
change agents like AWWs in order to motivate
and convince community to follow optimal CF
practices.
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OBSERVATIONS
Profile of AWWs
The 17 AWWs covered had varied profile with
education ranging from 7 to 12 grades, age
ranging from 29 to 53 years and experience
between 1 to 25 years. All AWWs had received
ICDS job & 11 were trained in IMNCI. The
supervisor of sector has 24 years of experience
and also had also received ICDS job and
refresher training.
Key IYCF Practices
The knowledge of AWWs with regards to the
three IYCF practices was average (Figure 1). The
major gap was with respect to the knowledge
related to CF. Many AWWs mentioned starting
CF with thin liquid diet and most of them state
partially, missing to mention continuation of
breastfeeding till two years and beyond.
Complementary Feeding (CF)
The knowledge and perceptions of AWWs on
CF was assessed based on the WHO ten guiding
principles for CF
• Initiation of Complementary Feeding &
Continuation of Breastfeeding
Initiation of CF on completion of 6th month is
vital for prevention of undernutrition. All
(100%) AWWs mentioned correct age of
initiation of CF. Continuing breastfeeding till
two years and beyond along with CF is equally
important, however only 6% AWWs had
knowledge
regarding
continuation
of
breastfeeding. None of the AWWs knew the
complete reason behind continuation of
breastfeeding which further represented a very
poor capacity of AWWs to convince community
to continue breastfeeding till two years (table 1).
Table 1: Complementary Feeding
Indicators
AWWs %
Score (N=17)
Age of Initiation of CF
After six months, seven months onwards
100 (17)
Reasons
After 6 month of age mother milk only is not sufficient to meet growing infant needs.
76 (13)
Appropriate age of initiation of Family foods - Around 1 year
35 (6)
% Average Score
70
Continuation of Breastfeeding along with CF
Two years and beyond
6 (1)
Up to 2 years
59 (10)
Reasons
Provides vital source of energy and nutrients into 2nd year of life
1.1. Child can’t eat everything so child gets all missing nutrients from mother’s
6 (1)
milk/child may not like all the kind of CF which is being offered to him
Provides fluids and nutrients during infection
1.2. child gets healthy / does not feel sick
12 (2)
% Average Score
10
Note: Only essential perceptions are presented in the table. The responses may add up to more than 100% due
to multiple responses.
In midst of this one AWW did mention “Child
gets vitamins from mother's milk; child cannot
have everything & might not like all kind of
food”
• Type and Consistency of Foods to be
served as Complementary Foods
The AWWs listed 9 out of 14 food groups listed
in complementary foods list. A majority of
AWWs recommended cereals (53%), pulses
(71%), fruits (65%), and milk (41%) as CF. Food
available at anganwadi centre (AWC) were also
mentioned by 29% AWWs.
•
Frequency, Quantity and Consistency of
Complementary Foods
Although 65% AWWs recommended food with
thick consistency, a large percent of AWWs
(47%) also recommended liquid diets for
children. The low energy and protein density in
CF normally observed could be attributed to
these perceptions.
The AWWs knowledge was average due to two
major gaps in perceptions (table 2). Most of the
AWWs recommended
− Introducing liquid diet at 6 month in place
of dense food
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−
Recommending lesser quantity of food for
children above 1 to 2 years
Table 2: Frequency, Quantity and Consistency
of Complementary foods
Indicators
AWWs %
Score
(N=17)
Frequency of CF - 6 to 12 months
Three times
47 (8)
If not breast feed than five times
47 (8)
Quantity of CF - 6 to 12 months
One bowl (250 ml) each time
24 (4)
Consistency of CF - 6 to 12 months
Mashed &/or thick / dense
76 (13)
Finger food by 8 months
Frequency - 1 to 2 years
Five times
65 (11)
Quantity - 1 to 2 years
One and half bowl each time
6 (1)
Half of adults
6 (1)
Consistency - 1 to 2 years
Family food
94 (160
Quality of Complementary food for
6mts to 2 yrs
1. Right consistency
12 (2)
2. Soft
76 (13)
3. Nutritious / calorie dense
29 (5)
4. Hygienic/boiled
47 (8)
Incorrect Response** - Thin/
Liquid/fruit juice
6 (1)
% Average Score
37
Note: Only essential perceptions are presented in the
table. The responses may add up to more than 100%
due to multiple responses.
• Feeding Children during and after Illness
The WHO guiding principles for CF
recommends: Increase fluid intake during
illness, including more frequent breastfeeding,
and encourage the child to eat soft, favorite
foods.
During illness only 18% AWWs stated giving
small frequent feeds and 6% advised on
continuing breastfeeding. With regards to
feeding after illness, only 6% AWWs advised an
additional meal (table 3) which was very
important as per the guiding principle of CF.
• Methods to Promote/Encourage
Complementary Feeding
None of the AWWs demonstrated persistence in
feeding the child with required quantity of food.
Further none of them advised on experimenting
with taste, consistency, food items to ensure that
a child consumes required quantity of food.
Most of AWWs only suggested that a child
needs to be encouraged to eat (42%) e.g. with
play, songs and story, comparing with other
child who are eating, feeding child in company
of other kids.
Showing affection, love, bribing child with ice
cream, chocolates and toys, feeding in company
of other or older kids, comparing and relation
with other kids were most common methods
(82%) recommended by AWWs to encourage
child to eat.
Table 3: Feeding Children During and After Illness
AWWs % Score (N=17)
Knowledge on Feeding Child During Illness
Encourage the child to drink and to eat - with lots of patience, toys
Feed small amounts frequently
Give foods that the child likes
Give GLVs, Milk, fruits
Continue to breastfeed
Easily digestible foods like “khichadi*”
Soft
Hygienic & fresh
Knowledge on feeding a child recovering from illness
Feed an extra meal
Give an extra amount
Use extra rich foods / nutritious food/ fruits/ GLVS/ milk
Give extra breastfeeds as often as child wants
Continue breastfeeding
Routine food/ homemade food
Hygienic (food, hands and utensils)
% Average Score
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
12 (2)
18 (30)
24 (4)
41 (7)
6 (1)
29 (5)
24 (4)
24 (4)
6 (1)
18 (3)
29 (5)
6 (1)
0 (0)
24 (4)
12 (2)
18
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Note: Only essential perceptions are presented in the table. The responses may add up to more than 100% due
to multiple responses.
*Khichadi means a dish of rice and pulses
Table4: Methods to Promote/Encourage Complementary Feeding
Indicators
AWWs %
Score (N=17)
12 (2)
18 (3)
6 (1)
82 (14)
Feed infants directly
Assist older toddlers eat
Feed patiently
Encourage, show affection / love/ Bribe child with ice cream, chocolates and toys
/Feed in company of other / older kids, comparing and relation with other
kids/learns from other kids
Talk to child during feeding
6 (1)
Behaviors regarding complementary feeding Appropriate
Milk in cup rather than bottle to 2 year old
88 (15)
Talking to a 10-month-old child during meal
76 (13)
Showing affection to a 15 month old child know that he/she is loved while feeding
82 (14)
him
Inappropriate
Giving a 10-month child own bowl and spoon to eat alone
76 (13)
Keeping a 12-month old child from touching her food and plate
71 (12)
Spoon feeding and holding a cup for a 24-month-old, not allowing child to touch
100 (17)
spoon
Knowledge on Encouraging Child to Completing The Served Portion
Do not force feed the child
12 (2)
Try giving child food with different type
6 (1)
Encourage the child to eat eg with play, songs and story , compare with other child
29 (5)
who are eating, feed child with other kids
% Average Score
44
Note: Only essential perceptions are presented in the table. The responses may add up to more than 100% due
to multiple responses.
The methods not listed included feed infants
directly, assist older toddlers eat, being sensitive
to hunger, being sensitive to satiety cues,
feeding patiently, do not force the child,
minimizing
distractions
during
meals,
maintaining eye contact while feeding. Further
the AWWs were asked to grade various feeding
behavior as appropriate and inappropriate.
None of the AWWs could grade all 6 behaviors
correctly. Most of the AWWs could grade 2-3
behaviors correctly (table 4). A very limited
approach, knowledge and involvement of
AWWs in promoting CF was evident.
• Care during feeding
All AWWs (100%) listed crying as an indicator
of hunger, which showed that the awareness on
earlier signs of hunger were not very good, since
crying is one of the late signs of hunger.
AWWs listed sickness as the key reasons for
poor appetite. Fever and micronutrient
deficiency were listed by one AWW each.
One AWW state “Poor appetite is due to delay
introduction of complementary, child not used to
eating”
Total 11 care practices were identified which the
caregivers could ensure while feeding the child
(table 5). When assessed the AWWs on an
average listed 2 practices.
DISCUSSION
In the current study, at first instance, looking at
the responses of AWWs with regard to the key
IYCF practices, it was noted that the AWWs
have knowledge regarding the key IYCF
practices. However the study indicates that the
knowledge of AWWs is superficial which may
not be helpful to the community to promote and
enhance the key CF practices to its optimal level.
The knowledge of AWWs with regard to the
three IYCF practices was average; many AWWs
mentioned starting CF with water and most of
them failed to mention continuation of
breastfeeding till two years and beyond.
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Table 5: Care during Feeding
Care during feeding
AWWs % Score (N=17)
Notices progress and how much is eaten
47 (8)
Should not be throwing food on floor/eating from floor
18 (3)
Ensures cleanliness of dishes and utensils; the child’s face, fingers,
76 (13)
clean after eating; free from flies
Child has own bowl and utensil
6 (1)
Assists in self-feeding /completing food*
29 (5)
Provides a sociable setting, good environment
24 (4)
Provides physical support/contact
6 (1)
Expresses affection / Encourage and feed
6 (1)
Gives child time to eat at his/her pace / child should chew well
6 (1)
Signs or Actions of infant showing child is hungry
Cries
100 (17)
Child sucks fingers
6 (1)
Reasons for child not feeling hungry
Fever
6 (1)
Micronutrient deficiency
6 (1)
Child sick
41 (7)
% Average Score
20
Note: Only essential perceptions are presented in the table. The responses may add up to more than 100% due to
multiple responses.
1) Early Innitiation of Breastfeeding*
41
2) Exclusive Breast Feeding **
88
3a) Appropriate and adequate CF from six
months of age
88
All 3 correct
24
3b) Continued BF up to the age of two years or
beyond
18
All 4 correct
AWWs % Score (N=17)
6
% Average Score
59
0
40 50 60 70 80 90 100
Percent Score
FIGURE 1: Knowledge on Key IYCF Practices
*Preferably within one hour (includes half hour responses).
** For the first six months i.e., the infants receives only breast milk and nothing else, no other milk,
food, drink or water.
Note: Percent score is % of total sum score of all AWWs out of 17 @ 1 point per AWW. Average Score is
average of percent score
Inappropriate CF is one of the major causes of
malnutrition in young children in developing
countries. Education about food recommended
for young children is of great importance in the
prevention of chronic malnutrition 13. With
regard to CF all AWWs (100%) stated the correct
age of CF. However, only 6% knew the fact
regarding of continuation of breastfeeding till
two years. None of the AWWs knew the
10
20
30
complete reason behind breastfeeding till 2
years and beyond, which further represented a
very poor capacity of AWWs to convince
community to continue breastfeeding till two
years. Listing the type of food recommended as
CF, AWWs listed 9 out of 14 food groups
identified. Although 65% AWWs recommended
food with thick consistency to be fed and a large
percent of AWWs (47%) also recommended
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gap in knowledge of AWWs needs to be
addressed to bring about transformation in
community based CF practices.
liquid diets for children. These incorrect
perceptions are possibly the contributory
reasons for reinforcing incorrect belief of feeding
liquid foods as CF to children resulting in low
energy and protein density in CF. This immense
Key IYCF Practices
59
Age of Initiation of Complementary Feeding
71
List of Complementary Food Items & Reason
37
Frequency, Quantity and Consistency of
Complementary Foods
33
Knowledge on Feeding Child During Illness
18
Techniques for Encourage Child to Eat
44
Care during feeding
20
Total percent score
40
0
20
40
Percent Score
60
80
Figure 2: Knowledge and perceptions Score of AWWs
WHO recommends encouraging child to drink
and eat during illness and provide extra food
after illness to help child recover quickly 14. In
this
study 12% AWWs
recommended
encouraging child to drink, 6% advised on
continuing breastfeeding and 18% advised on
giving small frequent feeds. Further only 6%
AWWs advised on additional meal after illness.
There was a very limited approach, knowledge
and involvement of AWWs in promoting CF.
None of the AWW recommended persistence
required by caregivers while feeding a child
with required quantity of food.
According to UNICEF conceptual framework
food, health, and care are all necessary, but none
alone is sufficient for healthy growth and
development 15. All three elements must be
satisfactory for good nutrition. Behaviors or
practices related to how food is provided to
children and fed to them have been found to
influence nutrient intake 16. Programmes that
include care are likely to be effective in
increasing nutrient intake and improving
growth and development of children from birth
to three years of age 17.
The knowledge on care during feeding was poor
with AWWs listing average 2 of the 11 care
practices identified. The perception of AWWs on
early signs of hunger was limited to crying,
which was in fact the last sign of hunger and at
time not at all related to hunger. Prolonged EBF
leading to micronutrient deficiency could be one
of the reasons for poor appetite in child. Total
41% listed sickness as key reason for child not
feeling hungry, and almost none listed the other
two imperative reasons i.e. micronutrient
deficiency and mouth lesion.
Overall the knowledge and perceptions of
AWWs was very poor with average score of 40%
(Figure 2). Similar study conducted in rural
Vadodara also revealed similar average score of
42% among AWWs 17.
STRENGTHS
Although pre-coded, the questionnaire was
open ended, so that the validity of data is high.
LIMITATIONS
Each AWW was interviewed only once at one
point of time. In such a process AWW might
have missed out sharing some knowledge and
perceptions. To neutralize this as much a
possible the observation and discussions are
considered after clubbing the knowledge and
perceptions of all AWWs and not based on one
single AWW.
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CONCLUSION & RECOMMENDATIONS:
Overall knowledge and perceptions for
promoting of community based CF practices
was average amongst the ICDS frontline
workers (AWWs) with a percent average score
of 40%. The AWWs were aware of key IYCF
practices. However the AWWs perceptions and
knowledge with regard to the rationale
applicable to the appropriate recommended CF
practices being promoted was rather poor. This
is noted to be a critical gap and needs to be
addressed for equipping the ICDS frontline
workers for effectively promoting successful
adoptions of optimal CF practices by
community.
Regular reinforcement of training with on-job
capacity building, follow-ups with regards to CF
rather than just IEC (Information education and
communication) on key IYCF messages is
recommended. These might bring about
discretion among the change agents (AWWs)
between simply giving messages and science
behind ‘bring about behavior change’ in any
community. This probably would accelerate
prevention and reduction of undernutrition in
community.
ACKNOWLEDGEMENTS
Our sincere thanks to
− All AWWs, Supervisor for cooperation in
conducting the study.
− PO-ICDS of ICDS Baroda and specially
CDPO (Ms Nayan Pargi) for her support in
conducting this study.
REFERENCES
1.
2.
3.
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis
M, Ezzati M, Mathers C, Rivera J. Maternal and Child
Undernutrition Study Group. Maternal and child
undernutrition: global and regional exposures and
health consequences. The Lancet 2008; 371:243-260.
Shrimpton R, Victora CG, de Onis M, MD, Costa Lima
R, Blossner M, Clugston G. Worldwide Timing of
Growth Faltering: Implications for Nutritional
Interventions. Pediatrics 2001, 107(5):E75.
N.F.H.S. 3rd National Family Health Survey for India
conducted by Mumbai, India: International Institute for
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Population Science (IIPS) and Macro International.
2007.
Brown KH, Dewey KG, Allen L. Complementary
feeding of young children in developing countries: A
review of current scientific knowledge. Geneva: World
Health Organization, 1998.
Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K,
Giugliani E, Haider BA, Kirkwood B, Morris SS,
Sachdev HPS, Shekar M. What works? Interventions for
maternal and child undernutrition and survival. Lancet,
2008; 371: 417 - 440.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS
and the Bellagio Child Survival Study. How many child
deaths can we prevent this year. The Lancet 2003; 362 :
65-71.
BPNI bulletin. From the Desk of the National
Coordinator;
Repositioning
Integrated
Child
Development Scheme; Breastfeeding Promotion
Network of India (BPNI); Number 28, February 2006.
International Institute for Population Sciences (IIPS),
2010. District Level Household and Facility Survey
(DLHS-3), 2007-08: India. Gujarat: Mumbai: IIPS.
NNMB. Diet and nutritional status of rural population,
Technical Report 21. NIN, ICMR, Hyderabad 2002.
Breastfeeding Promotion Network of India (BPNI).
Tools
for
investigating
IYCF.
(http://www.bpni.org/research.html, accessed July 31
2007)
Ministry of Women and Child DevelopmentGovernment of India. National Guidelines on Infant
and Young Child Feeding 2006.
(http://wcd.nic.in/infantandyoungchildfeed.pdf,
accessed August 1 2007)
PAHO/WHO. Guiding Principles for Complementary
Feeding of the Breastfed Child. 2003
Van der Crabben SN, Heymans HS, van Kempen AA,
Holman R, Sauerwein HP. Qualitative malnutrition due
to incorrect complementary feeding in Bush Negro
children in Suriname. Ned Tijdschr Geneeskd. 2004
May 29; 148(22):1093-7.
WHO, UNICEF. Infant and young child feeding
counseling – an integrated course. World Health
Organization, UNICEF, 2006.
UNICEF. UNICEF Conceptual framework for nutrition.
New York: UNICEF, 1990.
Gittelsohn J, Shankar AV, West KP, Faruque F, Gnywali
T, Pradhan EK. Child feeding and care behaviors are
associated with xerophthalmia in rural Nepalese
households. Social Science & Medicine 1998; 47:477-86.
Engle, P.L., and Lhotska, L. The role of care in
programmatic actions for nutrition: Designing
programmes involving care. Food Nutrition Bulletin.
1999; Volume 20, Number1: 121-135.
Karkar P & Sharma K. Capacity Building of ICDS
Functionaries in Growth Monitoring and Promoting &
Infant and Young Child Feeding Practices: Impact on
Nutritional Status of under Twos. PhD Thesis,
Department. of Foods and Nutrition, M. S. University,
Baroda. Under preparation.
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ORIGINAL ARTICLE .
ATTITUDE TOWARDS JOINT FAMILY SYSTEM AMONG
UNDERGRADUATE STUDENTS OF A MEDICAL
COLLEGE IN RURAL AREA
C.L.Prasher1, A.K. Bhardwaj2 Sunil Kumar Raina3, Vishav Chander4, B.P.Badola5, Abhilash Sood4
1Health
educator, 2Professor & Head, 3Associate Professor, 4Assistant Professor, Department Of
Community Medicine, Dr. R.P. Government Medical College, Tanda, Himachal Pradesh, India.
5Associate Professor, College of Education, Kangra, Himachal Pradesh,
Correspondence:
Dr. Sunil Kumar Raina
Associate Professor, Department Of Community Medicine
Dr. R.P. Government Medical College, Tanda
Himachal Pradesh, India.
Email: [email protected] Phone No: 094180-61066 (Mobile)
ABSTRACT
Introduction: Since more women in India are joining the labor force without proper support and
assistance often in the face of extended family and community opposition, an increase in family
difficulties is to be expected. Aim: To assess the attitudes of MBBS students towards joint family.
Material and methods: A cross-sectional study using a prestructured questionnaire was used for
conducting this study. Results: Out of 118 respondents, a majority, 66.95 percent expressed their
preference in it. 58 percent female respondents do not prefer the joint family living, only 42 percent
women respondents preferred it.
Keywords: Attitude, Joint family, medical students
INTRODUCTION
More recent crises in Indian families encompass
many of the same kinds of problems that have
plagued countries in the West at least since the
1960s. These include marital strain and
dissolution, parent-child conflicts and various
forms of family violence. Given these conditions
and difficulties the future and well-being of the
Indian family is uncertain. 1,2
Subtle changes in family patterns especially with
regard to the use of authority within the family
as well as an increased focus on individual
autonomy 3,4 are also likely to influence
members' expectations of marriage and their
choice of marriage partner. Educated middle
class families are now more hesitant to make
decisions for their offspring with regard to
marriage, education, and employment. 4 With an
increased onus of responsibility falling on the
individual rather than on the entire family,
young Indian adults today face what Dr. Gore
calls "choice anxiety" - increased autonomy and
increased choice that have led to increased
anxiety. 4
Since more women in India are joining the labor
force without proper support and assistance
often in the face of extended family and
community opposition, an increase in family
difficulties is to be expected. 5,6,7,8
With these facts in mind a study among
undergraduate students of Dr. RP Government
Medical College to assess their attitude towards
joint family system was planned.
MATERIAL AND METHODS
The present study was carried out in the state of
Himachal Pradesh at Dr. Rajendra Prasad Govt.
Medical College, Kangra at Tanda. The students
of this college hail from the different parts of the
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state representing all the communities and
cultures of the state.
The Dr. Rajendra Prasad Govt. Medical College,
Kangra at Tanda has on its rolls 250 students
belonging to different levels of education viz.
semester 1 to 9. The number and list of medical
students in each year was procured from the
office record. After this uniform proportionate
sample of 50% from each semester was drawn
by simple random technique using random
table. Thus the total number students included
in study were 118. For collection of information
on personal and sociological background of the
respondents included in the study an interview
schedule was developed. It consisted of two
parts: the first part contained questions on the
personal and sociological background of the
subjects, and second part contained questions on
various aspects of the family such as reference
for particular type of family living, marriage,
divorce,
kinship,
identity,
obligation,
socialization,
residence
and
household
maintenance etc. attitudes towards these
elements of family culture constitutes area of
concern for research in family. The response to
each question of the interview schedule was
further divided into three categories i.e. “yes”
“No”, “No response”.
The responses to each questions (contained in
the interview schedule), it was thought, may not
provide in a comprehensive way the attitudes of
individuals toward joint family. Therefore, to
overcome this attitudinal inventory was
developed on the lines contained in the Likert
method of scaling. For this purpose a pool of 29
statements on various aspects of joint family
were prepared, each statement was assigned
three response categories (i) “Strongly agree”,
(ii) “Disagree”, (iii) “No definite opinion”. The
responses were given weights 1, 2 and 3 for
positive statements and 3, 2 and 1 for negative
statement.
The interview schedule and the attitudinal
inventory so developed were pre-tested on
twenty five respondents. On the basis of pretesting ambiguous question were excluded and
some others were reworded. Similarly some of
the statements not understood by the
respondents were excluded and some others
reframed. The final version of the interview
schedule and the attitudinal inventory was used
to collect the data.
For the purpose of collecting data the
respondents were contacted personally in their
respective departments after establishing
rapport with them each respondent was
interviewed personally. The responses of
subjects were recorded in the interview
schedule. A similar technique was adopted with
regard to collection of information on attitudinal
inventory. At the end of each interview, the
schedule was thoroughly checked and the scores
allotted to the responses of statements to yield
total score.
In case of any inconsistency further probe for
clarification was done. In case respondent gave
response to question in terms of “no response”,
then the question was restated.
The questions in the interview schedule were
coded and classified into various categories
depending upon their frequencies. The data
were accommodated in tables after decoding. To
measure attitudes the mean and standard
deviation of total Obtained by each respondent
on the attitudinal inventory were computed on
the basis of mean (64.40) and standard deviation
(9.27) three attitudinal categories were made, as
follows:
Category 1 = mean + I.S.D.
64.40 + 9.27 =
73.67 = 74
Category II = (Mean + I.SD) to (Mean-I.S.D.) =
74 = 74to 55
Category III = Mean –I.S.D.
64.40-9.27 =
55.13 =55
Category I, II and III for the purpose of
convenience were designated as strongly
favourable, favorable, as under: strongly
favorable = score above 74
Favorable = score less than 55.
Each respondent was accommodated in the
attitude category depending upon the total score
obtained.
RESULTS
Regarding preference for living in joint family,
data cited in table 4 reveals that out of 118
respondents, a majority, 66.95 percent expressed
their preference in it. This indicates that a large
number of MBBS students are joint family
minded as they wish to live in joint
households.58 percent female respondents do
not prefer the joint family living, only 42 percent
women respondents preferred it. Conversely
which 67.65 percent respondents opted for joint
family and only 32.35% men respondents voted
against it. It is seen that there is a difference,
though very slight between the respondents
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whose parental families are in rural areas and
those whose are in urban areas (Table 4.2)
Amongst the former category 74 percent are in it
favour and the member of respondents who do
not desire to live in joint family is higher
(54.41%) in urban area as compared to 26% in
the rural area.
Table-1: Age and gender wise distribution of
respondents
Variables
Age group (Years)
18-19
20-21
22-23
24-25
Sex
Male
Female
No. of Students (%)
19 (16.1)
39 (33.1)
32 (27.1)
28 (23.7)
68 (57.6)
50 (42.4)
Those who were born in village, 71.70 percent
regard joint family as good arrangement, against
28.30% who consider that it is not good. Of those
who were born in town 55.88% respondents
considers joint family good where as 44.12% do
not. Similar observation is made with regard to
those born in city as 67.74% of them are in
favour of joint living. The data pertaining to
‘caste and preference for joint living’ indicates
that lower caste subjects though less in number
(37) in our study sample prefers joint living. Of
81 respondents of higher caste barring 62.96%
preferred joint living as good arrangement, thus
shows that both higher and lower caste persons
(66.10%) prefer predominantly joint family.
Out of those who lived in joint family 92.31%
favoured it while 7.69% did not. Of those who
belonged to nuclear families as lesser number
46.97% stood for joint living, while a majority,
53.93%, opposed it. Those who lived in large
families prefer joint family living and of those
who belong to medium sized family 72% wish
for joint living and only 28% oppose it.
Conversely, of those who lived in small family
58.73% prefer it and 41.27% did not.
Preference for joint family is much higher
among respondents whose parents are
agriculturists and horticulturists and low in case
of employees’ category (in both cases i.e. father
and mothers occupation). Moreover in case of
respondents whose mothers are housewives,
majority (73.53%) do not prefer joint living. 55.55
percent of those whose families are in the lowest
income group (Rs. 2001-5000 P.M), 66.67 of those
in the income group Rs. 5001-10,000 P.M. and
63.63% of those in the income group of Rs.
10,000-20,000 P.M and 71.42% of those with very
high incomes prefer joint family living.
Table-2: Family profile of respondents
Family Profile
Type of family
Nuclear
Joint
Place of Birth
Village
Town
City
No. of family members
3-5
6-8
≥9
Education of Father
Illiterate
Matriculation
Graduation
Post graduation
Education of Mother
Illiterate
Middle
Matriculation
Graduation
Post graduation
Occupation of Father
Agriculture
Business
Govt. Service
Occupation of Mother
Agriculture
Housewife
Govt. Service
Income
2001-5000
5001-10000
10001-20000
20,001 and above
Students (%)
62 (52.5)
56 (47.5)
53 (44.9)
34 (28.8)
31 (26.3)
63 (53.4)
50 (42.4)
5 (5.2)
27 (22.9)
61 (51.7)
30 (25.4)
10 (8.5)
22 (18.6)
35 (29.7)
40 (33.9)
11 (9.3)
26 (22.0)
19 (16.1)
73 (61.9)
26 (22.0)
68 (57.6)
24 (20.4)
9 (7.6)
24 (20.4)
64 (54.2)
21 (17.8)
DISCUSSION
Most of the studies undertaken so far seem to
have been obsessed with a single question “ is
the joint family in India breaking down or its
existence ( importance) and undergoing a
process of nuclearization at least some of them
seem to have accepted the assumption that a
general tendency exists towards the breakdown
of the joint family and some other seems to have
rejected this assumption by putting forward the
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argument that the joint families are still intact
i.e. this institution is as strong today as it was .
Kapadia pointed that any analysis of
institutional change must examine its three
phases : attitudinal change , structural change
and ideological change.10 The western contact
has brought about remarkable attitudinal
change in respect of some of our social and
cultural institutions. As a result of it and under
the impact of various other forces the structural
change is also evident in some respects.
Table-3: Reasons for the preference for living in
Joint Family
Reason
Mutual help in difficulties and
necessities
Better economic progress, mutual
love, cooperation , help in
difficulties, better division of labor
and better care of children
Mutual love and cooperation
Help in difficulties and better
economic progress
N (%)
32 (40.5)
20 (25.3)
18 (22.8)
9 (11.4)
Table-4: Reasons for non preference for living in
Joint Family
Reason
Conflict among family member
Negligence towards children
Lack of freedom
N (%)
22 (56.4)
10 (25.6)
7 (18.0)
Male students in larger number, no doubt, still
hold traditional attitude toward joint family.
This is perhaps due to the fact that female
respondents for certain reasons do not like to
live in joint family therefore tendered
preferences against it. Rural born student hold
more traditional attitude than the urban ones, in
matters of liking for joint terms of place of
residence i.e. those MBBS students who live in
rural areas were more prone to joint living than
those who live in urban areas. This reflection
may be due to the impact of education and
urbanization on urban youths who do not prefer
to live in joint family.
Furthermore, caste seemed to be a more
important factor in determining individual’s
preference for type of family and in this regard
it was observed that both higher and low caste
respondents expressed their preference for joint
family. This may be attributed to the persistence
of influence of caste on the members of society
in Himachal Pradesh. However among higher
caste subjects a significant number voted against
joint family, this indicates the departure from
traditional pattern and emergence of nontraditional attitude. This again is attributable to
diversities of occupation to which different
castes are exposed to.
Family type-wise preferences show that the
students living in joint family wish to continue
in it while those having experienced
nuclearisation do not prefer jointness. It was
also found that higher the educational level of
parents of respondents lesser is the preference
for joint family. Preference for joint living was
also noticed among certain occupational groups
such as agriculture and horticulture but those
whose parents were in service significantly
disliked joint living. It was found that
preference for joint living is much frequent
among almost all income groups (high & low).
However the number of those who do not prefer
joint living though not large, but are
considerable in each income category.
Reasons advanced by those who prefer joint
family were; mutual love and cooperation, help
in difficulties and necessities, better economic
progresses and better division of labour, etc. on
the other hand reasons tendered by respondents
for not preferring joint living include; lack of
freedom, conflict among family members and
negligence toward children.
The cumulative attitude toward joint family in
terms of three categories i.e. strongly favorable,
favorable and not favorable, revealed the
traditional attitude of majority of respondents.
In other words attitude of larger number of
graduates was in favour of joint family.
REFRENCES
1.
2.
3.
4.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Chowdhury A. Employed mothers and their families in
India. Early Child Dev Care 1999;113: 65-75.
Das RC. Marriage in transition: A biosocial approach.
In: Baral AK, Chowdhury A, editors. Family in
transition: Power and democracy. New Delhi: Northern
Book Centre; 1999. p. 16-20.
Sinha D. The family scenario of a developing country
and its implications for mental health: The case of
India. In: Dasen PR, Berry JW, Sartorius N, editors.
Health and cross cultural psychology: Towards
application. Newbury Park: Sage Publications; 1988.
Gore MS. Key note address. In: Bhatti RS, Varghese M,
Raguram A. Editors. Changing Marital Family SystemsChallenges To Conventional Models in Mental Health.
Proceedings of the National Symposium on Changing
Marital and Family Systems held during August 1994
at NIMHANS, Bangalore. NIMHANS Publication; 2003.
Page 468
pISSN: 0976 3325 eISSN: 2229 6816
5.
6.
7.
Chowdhury A, Carson DK, Carson CK, editors. Jaipur:
Rawat Publications; 2006. Family Life Education in
India: Perspectives Challenges and Applications.
Parameswaran U. Indian families in the world. In:
Dasgupta S, Lal M, editors. The Indian family in
transition. New Delhi: Sage Publications; 2007.
Sengupta J. Society, family and the self in Indian fiction.
In: Dasgupta S, Lal M, editors. The Indian family in
transition. New Delhi: Sage Publications; 2007.
8.
Walsh JE. As the husband, so the wife. In: Dasgupta S,
Lal M, editors. The Indian family in transition. New
Delhi: Sage Publications; 2007.
9.
http://himachal.nic.in/tour/glance.htm
10. Kapadia, K.M. in The family in India: Structure and
Practice. Sage publications 2005
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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ORIGINAL ARTICLE .
A STUDY ON KNOWLEDGE, ATTITUDE AND PRACTICE
OF LABORATORY SAFETY MEASURES AMONG
PARAMEDICAL STAFF OF LABORATORY SERVICES
Hansa M Goswami1, Sumeeta T Soni2, Sachin M Patel3, Mitesh K Patel4
1Professor,
Dept of Pathology 2Assistant Professor, Dept of Microbiology, B.J. Medical College,
Ahmedabad 3Assistant Professor, Dept of Microbiology, GMERS. Medical College, Sola, Ahmedabad,
Gujarat, India 4Assistant Professor , Department of Preventive & Social Medicine, B.J. Medical
College, Ahmedabad, Gujarat, India
Correspondence:
Dr Sumeeta T Soni,
J/4, Vikram Apartments, Nr Shreyas Crossing ,
Ambawadi, Ahmedabad-380015
Email.- [email protected] Mob- +91-9428043531
ABSTRACT
Purpose: A lot of accidents occur in the laboratory due to lack of proper knowledge regarding
laboratory safety measures, indifferent attitude & improper implementation of safe laboratory
practices. In view of this, the present study on knowledge, Attitude & Practice (KAP) of laboratory
safety measures was carried out among paramedical staff of laboratory services of tertiary care
teaching hospital, western India.
Method: This was a comparative study which used a standardized, structured self-administered
questionnaire to survey knowledge, attitude and practice of paramedical staff. The KAP study
enrolled 81 respondents.
Results: Regarding knowledge- the majority knew the very important issues related with laboratory
safety like Post Exposure Prophylaxis (96.55%) & discarding of blood samples (93.10%) etc. In regard
to attitude towards the scientific process, all are very much aware about importance of protective
devices (i.e. Wearing Gloves) and Biomedical waste management. In regard to the practice in
laboratory, the entire study subject group (100%) replied “YES” in each question that shows the good
quality work of the laboratory. Conclusion: The induction training on Laboratory safety is very
important and motivating exercise for improving the laboratory safety measures.
Key words: KAP Study, Laboratory safety, Training
INTRODUCTION:
The technological advances of the past 150 years
have transformed medicine from an art to a
modern science. A growing number of clinical
investigations are available to the physician and
there is an increasing need for technicians to
perform these laboratory tests. Current
knowledge of safe working practice in
laboratories leaves much to be desired and there
are an urgent need for both nationally &
internationally agreed codes of safe practice and
the development of guidelines for the medical
surveillance of laboratory workers1. The World
Health Organization is developing such
guidelines in an attempt to protect the health of
workers employed in the investigation of ill
health in others. Laboratory hazards are
something which may cause injury or damage.
These hazards fall generally into one of five
categories- Biological, Chemical, Physical,
Electrical/Mechanical, high voltage apparatus,
machinery with moving parts, Psychological.
Every Laboratory worker should be aware of the
potential hazards in their workplace. It is
important for them to ensure safety in their
practice.Personnel must be trained in safe
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pISSN: 0976 3325 eISSN: 2229 6816
working, provided with appropriate protective
clothing, and subjected to agree monitoring
procedures to ensure that they are healthy when
they start work and remain so during the course
of their employment. Due to lack of knowledge
of safety precautions, injuries can happen.
Safety in laboratory is responsibility all the
employees and employer. This study was
undertaken to evaluate the knowledge, attitudes
and practices of paramedical staff regarding the
laboratory safety measures.
METHODS:
Study Design: This was a comparative study
which used a standardized, structured selfadministered
questionnaire
to
survey
knowledge, attitude and practice of paramedical
staff of Laboratory services of tertiary care
teaching hospital, western India.
Study
Setting
&
Study
Population:
Paramedical staff of Laboratory Services,
Laboratory services of tertiary care teaching
hospital, western India, for the Laboratory
Safety measures. The questionnaire was self
generated and adapted from the literature. It
was self-administered, and consisted of twenty
standardized questions. Before questionnaires
were handed out to participants, the aims and
objectives of the study was explained to them.
Questionnaires were handed out to a group of
Paramedical staff under the supervision of the
laboratory Incharge so that they don’t consult
each other and go through the literature. A post
education (after training on Laboratory safety)
Questionnaires that one is same as Pre
Education Questionnaires was administered to
all enroll Paramedical staff after Induction
training on Laboratory safety.
Study Sample: Sampling was not feasible in
such a small target population, as this would
have limited the generelizability of the findings.
Upon completion of data collection, data were
coded, captured on Excel and then imported
into the EpiInfo software for analysis.
RESULTS
Out of 81 respondents 44(54.32%) were females
and 37 (45.68%) were males. Regarding age 50
respondents were in the age group 21- 35 years.
The first part of the questionnaire for this study
was to assess knowledge of paramedical
workers regarding laboratory safety. Correct
response to the questions differs in before and
after training of laboratory safety. The
knowledge increased after training. The vast
majority knew the very important issues related
with laboratory safety like Post Exposure
Prophylaxis2 (96.55%) & discarding of blood
samples (93.10%) etc. (Table -1)
Table 1: Knowledge about Laboratory safety
Question
Laboratory Safety starts before entering and starting the
laboratory work
Mentions the name the various Barrier protection equipments
Protective clothing should be decontaminated in 0.1% sodium
hypochlorite for 10 minutes before washing
Write two physical/mechanical hazards of laboratory
Write the full form of MSDS
Mention the three common causes of Fire
First Aid kits are available for the emergency conditions in
laboratory
Mention the equipment of Face protection
What is PEP
How blood samples discarded after serum separation?
Ergonomics concerned with how the workplace “fits” the worker.
The graph shows the correct response from the
participants in Pre-test and Post-test period. In
Correct Response (%)
Before
After
Training
Training
82.76
89.66
79.31
37.93
82.76
72.41
62.07
48.28
48.28
82.76
79.31
82.76
65.52
89.66
68.97
86.21
68.97
68.97
72.41
96.55
93.10
68.97
Pre-test, 41% of participants gets score more
than 8 (i.e. >=70% correct responses).In Post-test,
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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score more
m
than 8 was achiev
ved by 90%
% of
Participaants which suggest Ind
duction Train
ning
y Safety is benefited for the
on Laboratory
Participants.
In regaard to attitu
ude toward
ds the scien
ntific
process, all are very much
h aware ab
bout
importance of proteective devices (i.e. Weaaring
Gloves) and Biomedical wastte managem
ment.
Attitudee about the blood bornee infections and
imp
portance of Primary Prevention through
Vacccines (I.e. Hepatitis B Vaccines) were
observed chang
ge after trainiing follow up
p. (Table
-2)
Table 2:: Attitude about Laborato
ory Safety
Question
n
Before
B
Trainiing (%)
Agree
A
Diisagree
34.48
3
6
65.52
75.86
7
2
24.14
00.00
0
100
I am nott at risk of geetting Blood borne
b
infectiions
Hepatitiis B Vaccine is essential fo
or me
Wearing
g Gloves at the time of Phlebotomy
y is just
wasting time
Biomediical waste management is
i very imporrtant
100
0
00.00
After trainiing (%)
A
Agree
Diisagree
227.59
72.41
7
889.66
10.34
1
100
000.00
100
00.00
0
Table 3:: Practice abo
out laboratorry safety
DIS
SCUSSION:
I wear a gloves at thee time of blo
ood collection
n
I alway
ys wash my
m hand before
b
invaasive
procedu
ure
I report needle stick injury
I alwaays follow the biom
medical waste
w
managem
ment rules
I alwayss categorize the biomediical waste beefore
disposall
In above stud
dy, there was not mucch more
diffference in the percentagee of female and
a
male
sub
bjects (54.322% were feemales and 45.68%
malles) & 50 resspondents w
were in the ag
ge group
21- 35 years. Gupta et al (22006) in theiir similar
kno
owledge, attiitude and p
practice (KAP) study
amo
ongst HCWss in teaching
g hospital fo
ound that
the mean age off participants was 33+/- 6 years3.
In the
t
study Kormed
K
et all (2005) amo
ongst the
NG
GO run clinicss of Rural So
outh India fo
ound that
the mean age of responden
nts were 30.5 +/- 10.3
years4.
In the questions related
r
to the practicee in
laborato
ory, the entiree study subjeect group (1000%)
replied “YES” in eaach question
n that showss the
good qu
uality work of
o the laborattory. (Table 3)
3
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The comparison of Knowledge, with Attitude
and Practice of Paramedical workers in pre and
post education shows that the induction training
on Laboratory safety is very important and
motivating exercise for the improving the
laboratory safety measures. We find that
paramedical persons had good knowledge,
almost similar in many aspects therefore;
attitude and practice percentage is also very
high. Study by Gurubacharya DL (2003)
revealed that 46% of the nurses and Lab
Technicians had correct knowledge regarding
universal precautions5. The result in this study
has been mainly attributed to the instruction
manual and the responsibility given to the
paramedical staff for implementation of rules by
the authorities. In above study, subjects has a
knowledge of PEP is very satisfactory. In the
study by Rao & Konanur (2004), 81 % of the
Doctors had knowledge about PEP6. None of the
Doctors had knowledge regarding PEP in the
study by J. Parra-Ruiz et al (2004) 7.
Paramedical staff though had very poor
knowledge about the BMW Act and rules before
training, but a good percentage of this category
has positive attitude and practice habits.
Maqbool Alam (2002) in his study found that 27
% of the respondents (Nurses, Technicians &
Health workers) were using gloves regularly8.
Thus, a safety-conscious staff, well informed
about the recognition and control of laboratory
hazards, is key to the prevention of laboratory
acquired infections, incidents and accidents. For
this reason, continuous in-service training in
safety measures is essential.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
NACO guideline (revised) March 2007 (based on CDC.
Public Health Service guidelines for management of
health-care
worker
exposures
to
HIV
and
recommendations for post exposure prophylaxis.
MMWR. September 30, 2005-54(RR09); p1-17.
NACO guidelines. Post Exposure Prophylaxis
Guidelines for Occupational Exposure available at
http://www.nacoonline.org/guidelines/guideline_7.p
df. Accessed October 15th, 2010.
Gupta V, Bhoi S, Goel A, Agarwal P. Universal
precautions: knowledge, attitude and practice of
healthcare workers regarding HIV, hepatitis B and C
European Society of Clinical Microbiology and
Infectious Diseases 16th European Congress of Clinical
Microbiology and Infectious Diseases Nice, France,
2006,April 1-4 .
Kermode M, Holmes W, Langkham B, Thomas MS,
Gifford S. HIV- related knowledge, attitudes and risk
perception amongst nurses, doctors and other
healthcare workers in rural India. Indian J Med Res.
2005 Sep; 122(3):258-64.
Gurubacharya DL, Mathura KC, Karki DB. Knowledge,
attitude and practices among health care workers on
needle stick injuries in Health Care Settings.
Kathmandu University Medical Journal. 2003; 1(2)9194.
Rao AS, Konanur HS. Knowledge about Occupational
risk of HIV infection and Post-exposure Prophylaxis
among Physicians. Electronic Journal of the
International AIDS Society. 2004.
Parra-Ruiz J et al. Knowledge of post-exposure
prophylaxis inadequate despite published guidelines
views on
http://www.springerlink.com/content/nhekx6lv4j5va
qg6/. Accessed October 18th, 2010.
Maqbool Alam et al. Knowledge, attitude and practices
among health care workers on needle-stick injuries.
Annals of Saudi Medicine. 2002; Vol 22, No 5-6: 396-99.
Page 473
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ORIGINAL ARTICLE .
MISSING GIRLS: LOW CHILD SEX RATIO - STUDY
FROM URBAN SLUM AND ELITE AREA OF NAGPUR,
INDIA- A CROSS SECTIONAL STUD
Sumit Dutt Bhardwaj1, Babusaheb Nagargoje2, Ashok Jadhao3, Jyoti Khadse4
1Assistant
Professor Department of Preventive and social Medicine, Chirayu Medical College, Bhopal
District Health Officer, Aurangabad 3Associate Professor, Dept. of Community Medicine,
Government Medical College, Nagpur 4Medical Officer, Amravati
2Assistant
Correspondence:
Dr Sumit Bhardwaj
3070/26, Shyam Bagh, Mandirwali Gali,
Near Everest Plaza, Bhadawas Gate,
REWARI, Haryana, Pin- 123401
Email: [email protected], Mob - +919826184148
ABSTRACT
Objectives: To find the Child Sex Ratio (CSR) in the urban slum and elite area of Nagpur and also to
compare child sex ratio according to birth order and sex of previous born child. Methods: Study
involved house to house interview of mothers of 0-6 year children from urban slum and elite area of
Nagpur. Information regarding all children born in last 6 years, their date of birth, birth order, sex
and information regarding any abortions was noted. . Results: CSR was 934 females per 1000 males
combined for both areas. CSR was significantly low (P<0.05) in elite area (904 females per 1000 males)
compared to slum area (964 females per 1000 males). In elite area, when first-born child was female,
in second birth order number of males was significantly higher than females (P<0.05). There was
significant difference between number of males and females of second birth order, when first-born
child was male compared to when it was female (P<0.001). Conclusion: There is missing of girl child
form the second and subsequent birth order, especially when the previous born child is female, which
is more evident in elite area.
Key words: Child sex ratio, urban slum, elite area, birth order, India.
INTRODUCTION
Sex ratio is an important social indicator to
measure the extent of prevailing equity between
males and females in a society. The sex ratio at
birth is slightly favourable to boys, which is a
natural phenomenon.1 India’s sex ratio, 933
females per 1000 males is lowest amongst the
ten most populous countries of the world. For
Maharashtra, the sex ratio has declined from 934
in 1991 to 922 in 2001. The child sex ratio, which
is the sex ratio for 0-6 years age group is an
important indicator of the social health of any
society. India’s child sex ratio has declined over
a period of time from 976 in 1961 to 927 in 2001.
Child sex ratio is declining in some of the most
progressive states and districts. According to
2001 Census, it declined to less than 900 in states
like Punjab (793), Haryana (820), Delhi (865), etc.
Maharashtra recorded a sharp decline from 946
in 1991 to 917 in 2001. The north Indian states of
Punjab, Haryana, Chandigarh and Delhi, as well
as Gujarat, surpassing in wealth with the rest of
India,
were
shown
to
be the
worst offenders.2 There are various possible
explanations for unequal sex ratios at birth,
including lower caloric intake by mothers,
Hepatitis B virus infection, father’s occupation
or his absence from the home, maternal
dominance, smoking, and hormonal factors,
time taken to conceive, female infanticide, and
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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under-reporting of female births.3,4 In India,
there is a cultural preference for boys,5 however,
and the most plausible explanation for fewer
female than male births seems to be prenatal sex
determination, followed by induced abortion of
female fetuses.4-6Anecdotal evidence suggests
that access to ultrasound is fairly widespread,
even in rural areas,4 and although prenatal sex
determination has been illegal since 1994 the law
is often ignored.7 With all these facts in hand
about child sex ratio, the present study was
undertaken in Slum and elite area of Nagpur to
compare child sex ratio in these areas.
METHODOLOGY
The present community based cross sectional
study was carried out in field practice area of
Urban Health Training Centre (UHTC), Ramna
Maroti, which is affiliated to Department of
Preventive and Social Medicine, Government
Medical College, Nagpur. Bhande plot slum
area and adjoining elite area namelyBapunagar, Mirey layout, Makade layout was
selected purposively for study. The data was
collected between June to August 2009.
Institutional ethical clearance was sought. Study
subjects were children less than six years of age
and their mothers. With expected proportion of
girls and boys as 50% each, and 5% precision at
95% confidence level, a sample size of 384 was
calculated for slum as well as elite area. Sex ratio
was defined as the number of females per 1000
males. Child sex ratio was defined as the
number of girls per 1000 boys in the age group
of 0-6 years. Slum is a compact area of at least
300 populations or about 60-70 households of
poorly built, congested tenements in an
unhygienic
environment,
usually
with
inadequate infrastructure and lacking in proper
sanitary and drinking water facilities.2
All the houses in selected area were visited.
Information was asked about number of persons
in the house and number of under six years age
children in the house. From those houses in
which 0-6 years age group children were
present, their mothers were interviewed by
using a predesigned and pretested proforma.
Questions were asked to mothers regarding all
children born in last 6 years, their date of birth,
birth order, sex, interval between two births,
ultra-sonography was done or not during
pregnancy and if yes- month of gestation when
ultra-sonography was done and its indication.
Information regarding any abortions was noted.
Advice about hygiene, nutrition, and family
planning was given to mothers. Treatment, if
required was given at Urban Health Training
Centre.
We considered differences to be statistically
significant when the P-value was below 0.05.
The analysis was performed using statistical
programme (SPSS Version10.0, SPSS Inc,
Chicago, USA). 95% confidence level for sex
ratios was calculated and Chi-square test was
used for comparing frequencies.
RESULTS
Total 1253 households with 6344 population
were surveyed. There were total 878 (13.8%)
children in 0-6 years age group, 440 (14.4%)
children in slum area and 438 (13.3%) in elite
area. There were 0.79 children and 0.63 children
per household in slum and elite area
respectively. Only 4.3% and 2.4% household in
Slum and elite area respectively were having ≥ 3
under 6 year children. Out of 878 children 454
(51.7%) were males and 424 (48.3%) were
females. In slum area, maximum males (23.2%)
were in 37-48 months age group and maximum
females (23.6%) were in 61-72 months age
group, while minimum males (12.9%) were in 012 month age group and minimum females
(11.1%) were in 13-24 months age group. In elite
area, maximum (21.7% males and 20.2%
females) children were in 61-72 months age
group.
Child sex ratio was 934 females per 1000 males
combined for both areas. Child sex ratio was
significantly low in elite area (904 females per
1000 males) compared to slum area (964 females
per 1000 males). (χ2=4.697, df =1, p<0.05)
Child sex ratio according to socioeconomic
status was highest for lower class in slum area
(1875) and for upper class in elite area (2857).
While child sex ratio was lowest for lower
middle class in both slum and elite areas.
Majority of study subjects i.e. 52.3% males and
56.9% females from slum area and 86.1% males
and 92.8% females from elite area were hindus.
Child sex ratio was highest for hindus (1051 in
slum area and 975 in elite area) and lowest for
others (778 in slum area and 375 in elite area).
Child sex ratio was highest for second birth
order (1132 for slum area and 1023 for elite area)
and lowest for fourth birth order (600 for slum
area) [Table 1].
Table 2 shows, child sex ratio according to birth
order and sex of previous siblings for birth order
upto three. For both areas combined upto birth
orders three, child sex ratio was 941 females per
1000 males (981 for slum area and 904 for elite
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area). In elite area, for second birth order,
number of males was significantly higher than
females, when first-born child was female
(χ2=5.697, df =1, p<0.05). There was significant
difference between number of males and
females of second birth order, when first-born
child was male compared to when it was female
(χ 2=14.025, df =1, p<0.001).
Table 1: Child Sex Ratio according to Birth
Order
Birth
Child sex ratio
order
Slum area Elite area Combined
1
900
893
896
2
1132
1023
1076
3
839
450
686
≥4
600
*
600
Overall
964
904
934
95% CI
(951-975)
(884-922) (917-949)
* Sex ratio could not be calculated, as there are
no children in that group.
When first-born child was female, number of
males was significantly high in elite area
compared to that in slum area, for second birth
order (χ 2=4.341, df =1, p<0.05).For birth order
two, child sex ratio was significantly low when
first-born child was female (1100 for slum area
and 545 for elite area) compared to that when
first-born child was male (1162 for slum area
and 1818 for elite area).
Child sex ratio was lowest (463 for slum area
and 839 in elite area) when mother was
educated more than secondary school level but
less than graduation. Child sex ratio again
increased slightly when mother was graduate or
educated more than that.
DISCUSSION
Our finding indicate that the child sex ratio is
not favorable to females in this part of the urban
slum and elite area, when compared among
these areas elite area found to have significant
lower Child sex ratio than slum area. In both the
area the proportion of 0-6 year children in the
surveyed population was 13.8%, this was
comparable to Census 2001 findings, where
15.9% population was under six years of age.2
In our study we found the child sex ratio for
both area combined was 934 girls per 1000 boys
which was similar to 2001 Census, child sex
ratio was 927 girls per 1000 boys for India and
913 girls per 1000 boys for Maharashtra.2
Similarly, other studies by Bhasin SK et al
(2006)8, Jha P et al (2006)3 and Sekher TV et al
(2005)10 in Mandya district showed similar
findings. CRY (Child Rights and You) also
reported that in 26 states of our country child
sex ratio in slum areas was 919 compared to 904
in non-slum areas. For slum areas of Nagpur
and some other cities, child sex ratio is more
than 950.11
Table 2: Child Sex Ratio according to Birth Order and Sex of Previous Child (upto third birth order)
Birth
Sex of
Number of subjects
Child sex ratio
order
previous
Slum area
Elite area
Slum area
Elite
Combined
child
area
Male (%) Female(%) Male (%) Female(%)
1
100 (46.7) 90 (42.9)
122 (53) 109 (52.4)
900
893
896
2
MALE
43 (20.1) 50 (23.8) 33 (14.3) 60 (28.8)
1162
1818
1447
FEMALE 40 (18.7)
44 (21)
55 (23.9) 30 (14.4)
1100
545
779
3
M+M
6 (2.8)
4 (1.9)
0 (0)
0 (0)
667
*
667
M+F
15 (7)
8 (3.8)
9 (3.9)
2 (1)
533
222
416
F+F
10 (4.7)
14 (6.6)
11 (4.9)
7 (3.4)
1400
636
1000
Overall † 214 (100) 210 (100) 230 (100) 208 (100)
981
904
941
(95% CI)
(970-989) (884-922) (925-955)
M = Male, F= Female, * Sex ratio could not be calculated, as there are no children in that group, † Overall sex
ratio for birth orders up to three.
In present study it was found that, as the
education of mother increases, child sex ratio
decreases, except when mother was graduate or
postgraduate. This finding is comparable to that
reported in report of ministry of health and
family welfare, which showed that as the
education of the mothers increases, child sex
ratio shows a declining trend except for
‘graduation and above’, where it improves
slightly.12
One interpretation of our findings is that
households are ensuring that at least one boy is
born. The deficit in the number of girls born as
second child is more than twice when first born
child was female, assuming equal births. This
dependence of child sex ratio on the sex of the
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previous born child was more evident in the
elite area. These differences noted for
educational level are not correlated with income
or measures of wealth. Nevertheless, we believe
they indicate cultural preferences and easier
access to, and greater affordability of prenatal
ultrasound in educated individuals.4 Although
further research is needed, in our opinion, the
most plausible explanation for the low femaleto-male sex ratios reported at birth is prenatal
sex determination followed by selective
abortion. Other explanations,3-4 including
infections, smoking, maternal nutrition, and
hormonal factors during pregnancy, might play
a part in reducing the overall sex ratios, but they
are unlikely to explain the discrepancies noted
for second-order and higher-order births and
there influence by the sex of previous born child.
The results of a US study13 of 6000 children born
indicate that sex of subsequent births is
independent of sex of earlier births. Moreover,
these alternative explanations cannot readily
explain the marked decline in female-to-male
sex ratios recorded for children aged 0–6 years
since the 1981 census, especially in urban areas.
In our survey, the differences in sex ratios
between slum and elite areas were significant
for third order female births if the first two were
also female. Female infanticide does seem to be
a major contributor to low sex ratios, although
we could only measure this practice indirectly.
Our results suggest that prenatal sex
determination and selective abortion probably
account for nearly the entire deficit in the
number of girls born as second or third children
after previous female births. However we
cannot directly estimate the degree to which
prenatal sex determination affects sex ratio for
the first child from our results. In our study this
decline in child sex ratio was not much evident
after 3rd birth order as there were very few
children in that category, hence a trend and
similar finding could not be shown.
CONCLUSION
Our study revealed that there is missing of girl
child form the second and subsequent birth
order, especially when the previous born child is
female. This missing girl is more evident from
the elite area as compared to slum area which
may reflect cultural preferences and easier
access to, and greater affordability of prenatal
ultrasound in educated individuals.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Jain S. Save Daughter, Come and Join the Fight Against
Female
Foeticide
and
“Son
Obsession”.
http://www.wowindia.info/social_health.asp
(accessed Oct 3, 2010)
Census of India 2001. Office of the Registrar General
and
Census
Commissioner,
India.
www.censusindia.gov.in (accessed Oct 9, 2005)
Jha P, Kumar R, Vasa P, Dingra N, Thiruchelvam D,
Moineddin R; Low male to female sex ratio of children
born in India: National Survey of 1.1 million
households. Lancet 2006; 367: 211 – 18.
International Institute for Population Sciences. National
family health survey (NFHS-2), India, 1998–99.
http://www.nfhsindia.org/ india2.html (accessed Oct
19, 2005).
Mutharayappa R, Choe MK, Arnold F, Roy TK. Effect
of son preference on fertility in India. National Family
Health Survey Subject Reports, 1997: report number 3.
Available
on
http://www2.
eastwestcenter.org/pop/misc/subj-3.pdf (accessed Oct
10, 2005)
Chaturvedi S, Aggarwal OP, Bhasin SK, Gupta P.
Prenatal sex determination: a Community-based
investigation in East Delhi. Trop Doct 2001; 31: 204–06.
UNFPA. Sex-selective abortions and fertility decline:
the case of Haryana and Punjab. New Delhi: United
Nations Population Fund, 2001.
Bhasin SK, Saini NK, Meena S. Missing girls in an area
of East Delhi: Possible role of female feticide. Indian
Medical Gazette 2006: 246 – 251.
Sekher TV, Hatti N, Vulnerable daughters, in a
modernising society: From son preference to daughter
discrimination in modern India. Paper presented in
Seminar on female deficit in Asia, Trends and
prospective, Singapore 5 – 7 Dec. 2005.
India's imbalance of sexes. CRY (Child Rights and You)
2007. www.cry.org (accessed 6 Oct 2007).
Annual Report 2006, On implementation of the PreConception and Pre-Natal Diagnostic Techniques
(Prohibition of Sex Selection) Act PNDT Division,
Ministry of Health and Family Welfare, Government of
India, New Delhi. ww.mohfw.nic.in.
Female foeticide rampant in Delhi: The Times of India
(New Delhi), July 15, 2005: 1.
Rogers JL, Doughty L. Does having boys or girls run in
the family? Chance 2001; 14: 8–13.
Page 477
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ORIGINAL ARTICLE .
A PREVALENCE STUDY OF IODINE DEFICIENCY
DISORDER IN CHILDREN OF PRIMARY SCHOOLS IN
GANDHINAGAR DISTRICT
Shridhar V Rawal1, Geeta Kedia2
1Epidemiologis
2Professor
cum Assistant Program Manager, RNTCP, Gujarat.
& Head, Department of Community Medicine, B.J. Medical College, Ahmedabad
Correspondence :
Dr. Shridhar V. Rawal,
729, Sanatan, someshwar society,
sector -27, Gandhinagar.
e-mail : [email protected], Mobile : 9824367567
ABSTRACT
Objective: To assess the magnitude of IDD in Gandhinagar region and also assess the salt
consumption patterns in the region.
Study Design: It is a Cross-sectional study conducted in primary schools of both urban and rural
areas. Clinical examination of study population for goiter, laboratory assessment of casual urine
sample for urinary iodine and estimation of Iodine in salt samples were done. School children in the
age group of 6-12 years were selected for study using WHO 30-cluster methodology. During the
school survey, 10 salt samples were collected from the students (preferably from all age group) and
tested on the spot with UNICEF kit. Iodine concentration recorded as 0, <15, > 15. Fourteen Samples
of Urine were obtained from students for Iodine estimation from each school.
Results: An overall goiter prevalence of 7.75% was observed in the district. Females had a prevalence
of 7.68% and males 7.82%. 78.57 percent of subjects had urinary iodine excretion >100mcg/l with
21.43% having moderate -mild iodine deficiency. In Gandhinagar region, 93.2% of households
consume powdered salt with 90.5% powdered salt samples having an iodine content of greater than
15 ppm.
Conclusion: Iodine deficiency remains a public health problem in kalol and dehgam taluka and
proper administrative action to enhance universal iodinization is recommended.
Key words: Iodine Deficiency Disorder, Prevalence, goiter, school age, Urinary Iodine excertion
INTRODUCTION
Iodine is one of the essential micronutrients
required for the normal mental and physical
well being of human. Iodine deficiency occurs
when iodine intake falls below recommended
levels. Iodine deficiency is an ecological
phenomenon occurring naturally in many parts
of world. The erosion of soils in many areas is
done for agricultural production, over-grazing
by livestock and tree - cutting for firewood,
which ensures a continued and increasing loss
of iodine from the soil. Available ground water
and locally grown plants in these areas also
lacking in iodine.
Iodine deficiency resulting from inadequate
dietary iodine intake is causally related to a
spectrum of diseases collectively referred to as
iodine deficiency disorders (IDDs)1. These
include preventable conditions such as impaired
mental function, goitre, hypothyroidism,
cretinism, and retarded physical development;
iodine deficiency also causes increased child
mortality. Iodization of salt is widely regarded
as the most effective and sustainable long term
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public health measure for the prevention and
control of IDDs.
The Govt. of India took a policy decision to
iodate the entire edible salt in the country by
1992. The program commenced in 1986 in
phased manner2. All states and cities have been
advised to ban sale of non-iodised salt under
Prevention of Food adulteration Act.
Iodine Deficiency Disorders (IDD) is a public
health problem in India. Iodized salt is one of
the approaches to control the problem had been
implemented for about two decades.
To assess the prevalence of Iodine deficiency
disorders current resurvey was carried out as
per the recent ‘Revised Policy Guidelines on
National Iodine Deficiency Disorders Control
Programme’, October 2006,by N R H M, I D D &
Nutrition Cell, D G H S, Ministry of health & F
W, G.O.I. New Delhi. Clinical examination,
iodine estimation in urine as well as raw salt at
consumer level and from the shops was done.3
Iodine status assessment requires conducting a
cross-sectional survey of a representative sample
of the entire target population. The
recommended survey method is multistage
“proportionate to population size” (PPS) cluster
sampling. This method has been in use for many
years for the evaluation of immunization (EPI)
coverage, and can be applied to many other
health indicators.
The school-based PPS cluster sampling method
is recommended as the most efficient and
practical approach for performing an iodine
status or an IDD prevalence survey.
METHODOLOGY
Research Methodology for conducting IDD
Resurvey has been mentioned in the National
guidelines. Following strategy was carried out
in Resurvey for IDD in Gandhinagar District.
Survey was done amongst school children
registered at various primary schools run by
zilla Panchayat and from the dropouts among
the community. Village wise list of population
for the entire district was obtained from the
CDHO. Also list containing number of students
enrolled in schools per village was obtained
from the District Education office. Cumulative
total of village wise population was calculated
then 30 clusters were selected by cluster
sampling technique, first cluster was selected by
random number method. As per the guidelines
from GOI, 70 children in the age group of 6 – 12
years were selected for the survey per cluster
(equal proportion from each gender and each
age group, i.e. 7 male and 7 female in each age
group in each cluster). Remaining 28 children
were attempted to get selected from community.
Out of which 14 were male and 14 were female
in each cluster.
School Survey
Survey began from school in the village selected
by cluster sampling and covered all children in
age group of 6-12 years till the 70 sample size is
achieved.
During the survey, investigators
ensured equal representation of both gender, i.e.
35 male and 35 female students in each cluster. If
desired sample size is not achieved in one
school, then children from the village were
examined to complete the sample size. Goiter
was assessed by palpation method and graded
as grade 0, I and II. During the school survey, 10
salt samples were collected from the students
(preferably from all age group) and tested on the
spot with UNICEF kit. Iodine concentration
recorded as 0, <15, > 15. Fourteen Samples of
Urine were obtained from students for Iodine
estimation. These samples were collected in
plastic bottles (50 ml capacity with screw cap
with Toludine as preservative) and a label
showing the details. These samples were sent to
Government Medical College, Surat for
quantitative estimation of iodine in urine at the
earliest. Remaining 28 children were selected
and examined for goiter from the community in
the particular village. The male female
proportion was maintained in each age group.
Study was carried out in rural population only;
city and urban area were excluded from study.
Students were examined by clinical method
(Thyroid palpation). In each cluster 98 students
were examined so sample size for each district
was 2940 out of which male and female
proportion were taken in equal number so, 1470
male children and 1470 female children were
studied for clinical examination. As per protocol
14 samples of urine were collected from each
cluster, from 7 male & 7 female children. From
every cluster salt samples from the market were
purchased unanimously and checked on the
spot and 20 gm. of salt were packed in sealed
polythene bag (PDU shop, Anganwadi center,
Mid-day meal, provision store in village) and
results were recorded. As per the guidelines, a
team of 2 members, one tutor/resident/intern as
clinical
expert
and
one
resident
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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doctor/Intern/Medical Social Worker, to assist
in survey was formed. One Tutor/A.P. was
designated as Team leader and coordinator for
IDD Resurvey. Data were collected in predesigned and pre-tested Performa. Data analysis
was done and tabulated data are presented here.
Training Program
A brief training session was arranged for
participating doctors in the Community
Medicine Department, B. J. Medical College,
Ahmedabad. Team members were explained
about detailed research methodology and
practical aspect of survey regarding palpation of
goitre with example and salt testing and
collection of urine samples, Performa etc.
Urine analysis report for the samples of
Gandhinagar district was carried out at Govt.
medical college, Surat.
OBSERVATIONS
Clinically, 7.75 % school children, with pick
being in the age group 8-9 years were found to
have goiter. The sex wise difference was not
found to be significant. Taluka wise analysis
suggested highly significant difference of goiter
prevalence (X 2 =30.25, p<0.001). Kalol taluka
was having prevalence of 16.32%. Age wise
analysis of UIE (Urinary Iodine excretion)
though did ot reveal significant difference, the
findings corroborated well with the clinical
findings.
Table 1: Age and Grade Specific Prevalence af Goitre in Gandhinagar District
Age
6
7
8
9
10
11
12
Total
Grade 1
24
29
37
37
27
32
24
210
Grade 2
3
3
2
3
2
2
3
18
Total
27
32
39
40
29
34
27
228
Total examined
420
420
420
420
420
420
420
2940
Prevalence rate (%)
6.42
7.61
9.28
9.52
6.90
8.09
6.42
7.75
Table 2: Sex and Grade Specific Prevalence of Goitre in Gandhinagar District
Sex
F
M
Total
Grade 1
108
102
210
Grade 2
5
13
18
Total
113
115
228
TABLE 3: Goitre Prevalence Rate in Various
Talukas of Gandhinagar District
Taluka
Dehgam
Gandhi
nagar
Kalol
Mansa
Chandk
heda
Total
Children
Examined
784
980
Goiter
cases
63
76
Prevalence
Rate(%)
8.03
7.75
196
784
196
32
53
04
16.32
6.76
2.04
2940
228
7.75
Overall goiter prevalence was found to be
7.75%(228/2940) in school children clinically.
Maximum affected were students of 9years of
age(9.52%). Prevalence was more among males
Total examined
1470
1470
2940
Prevalence rate (%)
7.68
7.82
7.75
(7.82%) as compared to females (7.68%). The
taluka wise analysis revealed that Kalol taluka
had very high prevalence (16.32%) , almost
double as compared to other talukas of district.
Chandkheda taluka had problem under control
(2.04%) with rate < 5%. The salt samples
revealed that out of 93.2% iodised salt samples
, 90.5% had iodine content of >=15ppm. The age
wise maximum Urinary Iodine Excretion was
found in 10 year age students, while minimum
value was observed in 9 years. This finding
corroborates well with the finding of highest
goiter prevalence on clinical examination found
in age group 9 years. (14 urinary samples were
not included for analysis where quantity was
not sufficient.) The median UIE was found to be
165 mcg/l.
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Table 4: Goitre Prevalence Rate among Males and Females In Various Talukas of Gandhinagar
District
Taluka
Sex
Dehgam
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
G’nagar
Kalol
Mansa
Chandkheda
Grade 1
Grade 2
Total cases
30
31
34
32
14
16
27
23
03
00
00
02
01
09
01
01
02
01
01
00
30
33
35
41
15
17
29
24
04
00
Table 5: Profile of Salt Sold at Shop (n=74)
Profile
Salt characteristic
Branded
Unbranded
Salt type
Crystal
Powdered
Claim of iodisation by
manufacturer/shopkeeper
Iodized
Non iodized
Iodine level
0
<15
>=15
Batch no.
Yes
No
Logo
Yes
No
Address of manufacturer
Yes
No
Salt sample
(%)
67 (90.5)
7 (9.5)
05 (6.8)
69 (93.2)
69 (93.2)
05 (6.8)
05 (6.8)
02 (2.7)
67 (90.5)
57 (77.0)
17 (23.0)
62 (83.8)
12 (16.2)
64 (86.5)
10 (13.5)
DISCUSSION
Total prevalence of goiter was 7.75%.This is
almost 50% as compared to findings of Sambit
Das et al. 4 in their study , which detected it to be
15.1%. Though the findings by Imtiyaz A bhat et
al. are comparable with the finding , as they
have detected the prevalence of goiter to be of
11.9% in Jammu region, with a range from 3.5 to
21.2% . 5 The study prevalence rate is more
comparable with international study, a study in
Total Children
examined
392
392
490
490
98
98
392
392
98
98
Prevalence
Rate (%)
7.65
8.41
7.14
8.36
15.30
17.34
7.39
6.12
4.08
0.00
Tanzania by Assey et al., where the prevalence
rate was found to be 6.9% . It should be
remembered that Tanzania has Iodinization of
salt since last 12 years, a period comparable with
India. 6 However, the state of Jharkand has, as
mentioned by B.K. Patro et al., very low
prevalence of Goiter(0.9%). 8 The prevalence rate
of Goiter as mentioned by Chudasama RK et al.
in Rajkot district of Gujarat, 8.8%, is little higher
than gandhinagar district. 9
Table 6: Age wise analysis of Urinary Iodine
excretion
Age
(years)
Urinary Iodine Excretion
>100 mcg/l
<100 mcg/l
Total
(%)
(%)
6
38 (77.55)
11 (22.45)
49
7
47 (78.33)
13 (21.67)
60
8
40 (85.10)
07 (14.9)
47
9
35 (71.42)
14 (28.58)
49
10
51 (91.07)
05 (8.93)
56
11
55 (78.57)
15 (21.43)
70
12
64 (85.33)
11 (14.67)
75
Total
330 (78.57)
76 (21.43)
406
X 2 =9.04, p=0.1711 at Df=6.
As per age groups the prevalence is highest
(9.52%) in age group of 9 year, where as lowest
(6.42%) in age group of 6 & 12 years. Sambit Das
et al. had detected higher prevalence among
adolescents (13 to 16 yr) as compared to young
children (6 to 12 yr) (17.7 and 13.9%, P=0.03).
Imtiyaz et al also had found the prevalence to be
higher in 9-12 year age group.
The prevalence was found to be more in males
(7.82%) as compared to females(7.68%). While in
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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Jammu, The prevalence of goiter was higher in
females than in males (16.12% vs 10.10%).
The prevalence was found highest in Kalol
taluka which is 16.32% . This finding is
corroborated by the fact that nearly 60% salt
samples collected from shops in Kalol taluka
had <15ppm iodine concentration.
Though overall ,90.5% of all salt samples from
shops had >=15 ppm of Iodine, which is less
than the findings of Sambit Das et al who
reported it to be 98.1% but far better than 70.9%
detected in salt samples collected from shops by
B.K. Potra et al.8
On Urinary Iodine Excretion analysis, 21.43%
of students had biochemical iodine deficiency of
mild to moderate severity as urinary iodine
excretion was <100 mcg/l. The prevalence was
max. in 9year age group and it corroborates well
with clinical goiter prevalence finding.
The median UIE was found to be 165 mcg/l.
This is far better than the findings in Surat
(90mcg/l) , valsad and Panchmahal (70 mcg/l) 7
as well in region of Jammu (96.5 mcg/l). The
result is comparable with result in jharkhand,
where the median UIE level is 173.2 mcg/l.
Median UIE was 170 mcg/l in females while it
was 160 mcg/l in males, which corroborates
well with sex wise goiter prevalence.
Hence it is concluded that prevalence rate in
Kalol taluka is
comparatively high. So
Promotion of iodized salts should be increased
in this taluka is recommended. Attention is also
required to be paid in age group 8-9 year having
higher prevalence rate. As this age marks the
beginning of adolescence, their physical and
psychological care is necessary. The measures
necessary to increase availability of iodised salt
at shops through food adulteration act should be
confirmed.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
K. Park. Park’s textbook of preventive and social
medicine. 18th edition;p 451.
Sundar lal et al. Texbook of community medicine.1st
edition ;p 180-181.
Govt. of India. Revised Policy Guidelines On National
Iodine Deficiency Disorders Control Program. NRHM.
IDD and Nutrition Cell. DGHS. MoHFW. GOI. New
Delhi; 2006.
Sambit Das et al. Persistence of Goitre in the postiodinization phase: micronutrient deficiency or thyroid
autoimmunity? The Indian Journal of Medical
Research. 2011 january ; 133(1): 103-109.
Imtiyaz A bhat et al . Study on Prevalence of Iodine
Deficiency Disorder and Salt consumption Patterns in
Jammu Region. Indian J Community Med. 2008
January; 33(1): 11–14.
Assey et al. Tanzania national survey on Iodine
deficiency : inpact after twelve years of salt
iodation.BMC Public Health. 2009; 9: 319.
Umesh Kapil. Successful efforts towards Elimination
Iodine Deficiency Disorders in India. Indian J
Community Medicine. 2010 oct-Dec; 35(4): 455-468.
Binod Kumar Patro et al. Tracking Progress toward
Elimination of Iodine Deficiency Disorders in
Jharkhand, India. Indian J Community Med. 2008 July;
33(3): 182–185.
Chudasama RK, Verma PB, Mahajan RG., Iodine
nutritional status and goiter prevalence in 6-12 years
primary school children of Saurashtra region, India.
World J Pediatr. 2010 Aug;6(3):233-7.
Page 482
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ORIGINAL ARTICLE .
HIV SENTINEL SURVEILLANCE AMONG HIGH RISK
GROUPS: SCENARIO IN GUJARAT
L B Chavan1, Prakash Patel2, Vaibhav Gharat3
1State
Epidemiologist, Gujarat State AIDS Control Society, Ahmedabad
Department of Community Medicine, SMIMER, Surat
2Assistant
Professor
3Resident,
Correspondence:
Dr. Laxmikant Chavan
State Epidemiologist, Gujarat State AIDS Control Society,
Block O-1, New Mental Hospital Compound,
Meghaninagar, Ahmedabad – 380016
Email: [email protected], Mob: 9904379545
ABSTRACT
Background: Surveillance is the ongoing systematic collection, collation, analysis and interpretation
of data so that appropriate action can be taken within time.
Aims and Objective: The present annual HIV sentinel surveillance (HSS) was carried out for
monitoring trends of HIV epidemic in high risk group populations in selected sites of Gujarat state..
Methodology: The HSS was carried out in representative populations from High Risk Group (HRG)
like Female Sex Workers (FSW), Man having Sex with Man (MSM) and Single Male Migrant. Target
sample size was 250 at each HRG site (Female Sex Worker, Male Sex Male & SMM). Consecutive
sampling was done at designated sentinel site for selecting the survey participants.
Results: Overall 3726 samples (1494 FSWs, 1732 MSMs & 500 SMM) were tested in the High risk
group of HSS 2008. The overall sero-positivity in samples from FSWs, MSMs sites was 4.5%. Seropositivity was more or less high (≥ 5%) among FSWs as well as MSMs irrespective of age, place of
residence, literacy level, occupation; and migration status.
Conclusion: The overall trend of sero-positivity in High risk groups shows decreasing trend of HIV
in the state from 2004 to 2008.
Keywords: HIV, Sentinel Surveillance, High Risk Groups, Prevalence
INTRODUCTION
Surveillance is the ongoing systematic collection,
collation, analysis and interpretation of data in
order that Action may be taken. Deriving
programmatic implications for further Action is
the main purpose of Surveillance system.
Surveillance is aimed to provide data within the
limitations of time and extent. Feasibility and
cost‐effectiveness to conduct the study every
year is an important aspect in planning the
surveillance activities. For HIV sentinel
surveillance, specific sites are selected across the
country for different target populations where
an annual exercise of collecting a stipulated
number of samples for HIV testing is
undertaken. Since data is collected from the
same selected sites every year, it provides
information to understand the spread and
trends of HIV epidemic in different
geographical regions as well as in different
population sub‐groups. In the absence of any
other information, the data is also used for the
purpose of estimation of HIV infected persons in
the country.1
Annual HIV sentinel surveillance (HSS) has
remained the mainstay for monitoring trends of
HIV epidemic in high and low risk populations
and also for HIV disease burden estimation in
India since its inception from 1998.2 HRGs are
very important for HIV epidemic in any locality,
not only for spread of infection but also to
curtail it. This study used a piece of data
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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collected during HIV sentinel surveillance in
2008 in Gujarat.
METHODOLOGY
The HSS was carried out in representative
populations from High Risk Group (HRG),
Bridge population as well as Low Risk group.
The HRG populations were represented by
patients attending STDs clinics (10 sites), FSWs
and MSMs at TI (15 sites). All individuals
attending the designated sentinel site during the
period of surveillance (June – August 2009 for
HRG sites) were recruited during the HSS.
Target sample size was 250 at HRG site (FSW,
MSM & SMM). The target sample size was
achieved by each of HRG sites.
Consecutive sampling was done at designated
sentinel site for selecting the survey participants.
The collections of participants at HRG site were
based on strict inclusion criteria. All Female sex
workers (FSW - a women aged 15-49 years who
have sold sex in the past one month) & Men
Having Sex with Men (MSM - an individual
who have sex with men in the past six months)
Single Male Migrants (SMM – Migrant who has
stayed away from his spouse/family for more
than 6 months in a year) were included in the
sample.
Availability of line list at TI-NGO site provides
an opportunity for random sampling. The
serially numbered line list of HRGs was
compiled by NGOs to use it as ‘sampling frame’.
This sampling frame was sent to Regional
Institute for randomization. If randomly selected
individual doesn’t found eligible or refuses to
give consent, reasons for the same were
documented in the register at site. In place of
random numbers of individuals who could not
be recruited from the first list will be replaced
with additional random numbers from the
second list of 150 by respective SST member
with weekly feedback and replacement.
As per HSS protocol, it’s mandatory to ensure
the confidentiality of the survey participants and
hence the HIV testing is unlinked to any
identifiers of the individual concerned. Each
questionnaire was given a unique code number
that linked it with the laboratory result.
The data collected from various sentinel sites
were entered into web-based software at SACS
level while second entry was done by Regional
Institute. The double entry process improved
the data minimizing errors which took much
time and delayed the receipt of final version of
HSS data to GSACS.
RESULTS:
Overall 3726 samples (1494 FSWs, 1732 MSMs &
500 SMM) were tested in the High risk group of
HSS 2008. Table 1 presents the percentage
distribution of survey participants by age group,
residence and education status. At MSM, FSW
as well as SMM site, majority of participants
were from the age group of 20-44 yrs (91%, 94%
and 96% respectively). Notably, of all MSMs
participants, 5% were aged less than 20 yrs.
In case of FSW and MSM sites, participants were
almost always from urban areas. Among SMM,
equal participation from urban & rural area. The
educational distribution of women participants
at different sites illustrates that almost half
(47%) of the FSWs participants were illiterate.
Notably, almost half (60%) of the MSMs & SMM
were educated till 12th standard. In case of
MSMs, almost one third of participants were
working as Industrial/Factory worker while
23% doing service in Govt. or private sector.
Table 1: Distribution of participants by age
group, residence and education status, HSS 2008
Characteristics
Participant (n)
Age Group (%)
Below 20
20-29
30-44
45 and Above
Missing
Place of Residence
Urban
Rural
Missing
Literacy
Illiterate
Literate and Till 5th
Till 12th
Till Graduation
Graduate and Above
Missing
MSM
1732
FSW
1494
SMM
500
4.50
59.47
31.58
4.04
0.40
1.54
34.87
59.10
4.48
0.00
1.80
63.60
33.00
1.40
0.00
94.92
1.44
3.64
96.79
2.34
0.87
49.80
50.00
0.20
13.80
24.25
58.37
1.62
1.62
0.35
46.79
33.60
18.54
0.67
0.40
0.00
0.20
32.40
59.40
7.00
1.00
0.00
The overall sero-positivity in samples from
FSWs, MSMs sites was 4.5%. Sero-positivity was
more or less high (≥ 5%) among FSWs as well as
MSMs irrespective of age, place of residence,
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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literacy level, or miigration statu
us. The detaailed
analysis is given in
n Table 2 above.
a
Typollogy
Wise Strreet based FSWs
F
& Kotthi among MSM
M
han 5% posiitivity. Amon
ng MSM,
showed more th
unp
protected anaal sex is the sexual behav
vior with
the highest risk for HIV tran
nsmission.3-7
Table 2:: Positivity att MSMs, FSW
Ws and SSMss site
Characteristics
Tested
d
MSMs
Positivee (%)
Testted
FSWs
Positiive (%)
Teested
SMM
Possitive (%)
Age Gro
oup
Below 20
2
78
5 (6.41)
23
3
0 (00.00)
9
0 (0.00)
1030
46 (4.447)
20-29
521
1
31 (55.95)
3319
7 (2.19)
547
30-44
35 (6.440)
883
3
21 (22.38)
1165
2 (1.21)
70
45 and Above
A
6 (8.57)
67
7
4 (55.97)
7
0 (0.00)
7
1 (14.229)
Missing
g
0
0 (00.00)
0
0 (0.00)
Place off Residence
1644
86 (5.223)
Urban
144
46
52 (33.60)
2249
6 (2.41)
25
Rural
3 (12.000)
35
5
4 (111.43)
2250
3 (1.20)
63
Missing
g
4 (6.355)
13
3
0 (00.00)
1
0 (0.00)
Literacy
y
239
11 (4.660)
1
Illiteratee
699
9
31 (44.43)
0 (0.00)
th
420
Literate and Till 5
22 (5.224)
502
2
15 (22.99)
1162
3 (1.85)
1011
Till 12th
57 (5.664)
277
7
10 (33.61)
2297
6 (2.02)
28
Till Grad
duate
2 (7.144)
10
0
0 (00.00)
35
0 (0.00)
28
Graduatte and Above
1 (3.57)
6
0 (00.00)
5
0 (0.00)
6
0 (0.00)
Missing
g
0
0 (00.00)
0
0 (0.00)
1732
93 (5.337)
Total
149
94
56 (33.75)
5500
9 (1.8)
Median Prevalence**
5.600
3.22
*Median
n Prevalencee is preferred
d for compariison with nattional and in
nternational d
data as well in
i
analysiss due to skew
wed distributtion of HIV positivity
p
in FSW
F
& MSM
M sentinel sitees.
Sexual transmission
t
n has been associated with
w
nondiscllosure of HIV
H
infectio
on with caasual
partnerss. Not discu
ussing HIV status and not
knowing
g a partn
ner's HIV status were
w
particulaarly common
n in the casu
ual partnersships
of the men surveyed. E
Efforts to improve
com
mmunication
n skills relateed to HIV sttatus and
con
ndom use wiith sexual paartners migh
ht reduce
8, 9
the sexual transmission of H
HIV among MSM.
M
Fig 1: Median Prev
valence of HIIV at FSWs (6), MSMs (7)) and Migran
nt (2) Sites, G
Gujarat HSS 2004-08
2
National Journal of Comm
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Site wise analysis revealed that HIV seropositivity was ≥ 5% at 2 FSW sites (Vadodara
and Ahmedabad). In case of MSMs, the seropositivity was ≥ 5% at Bhavnagar, Jamnagar,
Surat and Rajkot. The year wise trend in median
HIV positivity indicates a decreasing trend at
both FSWs and MSMs site. At FSW site, %
positivity has shown increased at Vadodara,
while it has increased at MSM site in district
Surat & Vadodara. However the change in
recruitment methodology for HRGs in 2008
necessitates interpreting the trend with caution
with support from TI/STI data and
triangulation.
2.
3.
4.
5.
6.
CONCLUSION
The overall trend of sero positivity in High risk
groups shows decreasing trend of HIV in the
state from 2004 to 2008. However the prevalence
in HRGs are still high and needs continuous and
accelerated efforts to achieve NACP III goal.
REFERENCES
1.
7.
8.
9.
HIV Sentinel surveillance and HIV estimation.
Available on www.nacoonline.org. Accessed on 20
Nov, 2011.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
HIV Fact Sheet Based on HIV Surveillance, Data in
India 2003-2006. National AIDS Control Organization,
Ministry of Health and Family Welfare, November
2007.
Available
at:
http://www.nacoonline.org/upload/NACO%20PDF/
HIV_Fact_Sheets_2006.pdf, accessed on May 28, 2010.
Koblin BA, Husnki MJ, Colfax G, et al. Risk factors for
HIV infection among men who have sex with men.
AIDS 2006;20:731--9.
Ekstrand ML, Stall RD, Paul JP, Osmond DH, Coates TJ.
Gay men report high rates of unprotected anal sex with
partners of unknown or discordant HIV status. AIDS
1999;13:1525--33.
Morin SF, Steward WT, Charlebois ED, et al. Predicting
HIV transmission risk among HIV-infected men who
have sex with men: findings from the healthy living
project. J Acquir Immune Defic Syndr 2005;40:226--35.
Chen SY, Gibson S, Katz M, et al. Continued increases
in sexual risk behavior and sexually transmitted
diseases among men who have sex with men: San
Francisco, Calif. 1999--2001. Am J Public Health
2002;92:1387--8.
Crepaz N, Marks G, Liau A, et al. Prevalence of
unprotected anal intercourse among HIV-diagnosed
MSM in the United States: a meta-analysis. AIDS
2009;23:1617--29.
Molitor F, Facer M, Ruiz JD. Safer sex communication
and unsafe sexual behavior among young men who
have sex with men in California. Arch Sex Behav
1999;28: 335--43.
Chesney MA, Koblin BA, Barresi PJ, et al. An
individually tailored intervention for HIV prevention:
baseline data from the EXPLORE Study. Am J Public
Health 2003;93: 933--8.
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ORIGINAL ARTICLE .
SEROPREVALENCE OF PRIMARY INFERTILITY AND
ACUTE PELVIC INFLAMMATORY DISEASE CAUSED BY
CHLAMYDIA IN AJMER REGION
Ashish Surana1, Prem Singh Nirwan2, Suchitra Gaur3
1Assistant
Professor, Department of Microbiology, Surat Municipal Institute of Medical Education &
Research (SMIMER), Surat, Gujarat, India 2Principal & Controller- JLN Medical College & Group of
Hospitals, Professor- Department of Microbiology, 3Associate Professor, Department of
Pharmacology, JLN Medical College, Ajmer, Rajasthan
Correspondence:
Dr. Ashish Surana
Department of Microbiology,
SMIMER, Surat
E-mail: [email protected] Mobile: 09426854701
ABSTRACT
Purpose: Chlamydia trachomatis is emerging as important pathogen of pelvic inflammatory disease and
acute salpingitis. These infections are major cause of financial losses and serious medical
complications as infertility.
Methods: In the present study, the diagnosis of chlamydial genital infections was made by detection
of antichlamydial IgM antibodies by E.L.I.S.A among a group of 50 females each with acute pelvic
inflammatory disease and primary infertility along with 50 healthy control females.
Results: The present study shows, high seroprevalence (45.33%) of C trachomatis infections. Strong
correlation of these chlamydial infections with age factor and socioeconomic status was observed.
These chlamydial infections presents in both clinical and sub-clinical form and also lack pathognomic
sign & symptoms.
Conclusion: This study emphasizes the need of strong clinical suspicion along with screening of such
subjects with a laboratory test which can provide rapid and specific diagnosis, thereby preventing
complications.
Keywords: Chlamydial seropositivity, primary infertility, acute pelvic inflammatory disease
INTRODUCTION
Chlamydia trachomatis is exclusively a human
pathogen and its infections have got increasing
trend1. The clinical spectrum of sexually
transmitted C trachomatis infection parallels that
of gonococcal infection however C trachomatis
infections produce fewer sign and symptoms 2. C
trachomatis has emerged as an important
causative agent of pelvic inflammatory disease
(PID) in females and its sequel includes ectopic
pregnancy and tubal obstruction secondary to
salpingitis leading to infertility3.
Acute salpingitis is the most serious
complication of chlamydial genital infections3
and during last few years C trachomatis has been
cited as important and progressively increasing
cause of salpingits1. The infection most often
spread to the fallopian tubes canalicularly
through the genital tract4. Its significance lies in
the fact that it is a direct cause of infertility.
Females accounts for about one-third of cases of
infertility with tubal factor being responsible in
30 to 50 percent cases i.e. obstruction of fallopian
tubes is the most common cause of sterility in
females5 with tubal occlusion being most
common sequel after pelvic infections1.
Infertility rates ranges from 12.8% after one
episode to 75% after three or four episodes of
chlamydial infections6. Tubal occlusions hence
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infertility is more common after non-gonorrheal
than after gonorrheal salpingitis7. This may be
attributed to high rate of asymptomatic
infections, a persistent carrier state, reactivation
of latency and difficulty in eradicating
chlamydial infection8.
A strong positive correlation has been found to
exist between seropositivity for antichlamydial
antibodies and infertility due to tubal
blockade8,9. Infertile women with tubal disease
are two to four times more likely to have
elevated antibodies to C trachomatis than either
infertile women with normal tubes or pregnant
women10 which is of diagnostic value.
Diagnosis of chlamydial infections can be made
by both cultural and serological methods.
Cultural methods are cumbersome. In contrast,
serological methods as ELISA are specific, cost
effective and can provide rapid diagnosis
thereby helping in prompt institution of specific
therapy
and
consequently
preventing
developments of complications as infertility.
MATERIAL AND METHODS
The study population consisted of 50 females of
reproductive age group with acute PID and 50
females with primary infertility that presented
at the outpatient Department of Obstetrics and
Gynecology of Jawaharlal Nehru Medical
College, Ajmer. The clinical diagnosis of acute
PID was made, based on the criteria defined by
Felmon et al11. 50 age-matched healthy females
with no clinical evidence of genital tract
infection or trachoma were taken as control in
this study.
5 ml of venous blood was drawn from all the
females included in the study for the laboratory
measurement of the serum IgM specific
antibodies against C .trachomatis by ELISA
(Novum Diagnostics, Assar – Gabrielsson – Str.
1A, Germany). The kits manual was strictly
followed while conducting the tests. Initial
screening of all the sera was done for syphilis by
Venereal Disease Research Laboratory Test
(VDRL—Immutrep, Rapid Plasma Reagin Card
Test) and Human Immunodeficiency Virus
(HIV)
antibody
by
Dot
Immunoassay
(Combaids-RS). The whole study group was
found to be non-reactive for syphilis and H.I.V,
thereby ruling out simultaneous presence of
these infections with chlamydial genital
infection.
OBSERVATION AND DISCUSSION
An overall seropositivity of 45.33% for
antichlamydial IgM by ELISA among the study
group was observed. The seroprevalence of
chlamydial infection among acute PID and
primary infertility subjects (54%) was found to
be roughly double than that in the control group
(28%).
Among the control group, results in
concordance with the present study, were also
obtained by Ray, et al12 with IgM positivity rate
of 27.7%. In studies of Joshi, et al13 15% females
were positive for Chlamydia with 81% of them
being asymptomatic; this high seropositivity
may be due to the fact that their study group
comprised only of cases positive for C
trachomatis. These observations suggest that
there is a significant prevalence of sub-clinical
chlamydial infections in asymptomatic form in
general population. These studies also hint
towards the importance of a screening test,
which can provide early and specific diagnosis,
thereby helping in preventing long-term sequel
as infertility etc. in asymptomatic population.
Table 1: Age wise distribution among various study parameters and chlamydial serology
Age Groups
Acute PID
Primary Infertility
Healthy Control
(in years)
Subjects (50) IgM +ve (24) Subjects (50) IgM +ve (30) Subjects (50) IgM +ve (14)
15-20
10
4
14
8
12
4
21-25
20
12
18
12
22
8
26-30
8
4
10
6
8
2
31-35
6
2
4
2
4
-36-40
6
2
4
2
4
-41-45
------Antichlamydial IgM positivity observed in acute
PID and primary infertility cases was 48 % and
60% respectively. Results comparable to those of
present study were also obtained in studies
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conducted by Bhujwala et al14with seropositivity
in acute PID and primary infertility cases of 63%
and 60% respectively. Likewise in studies
conducted by Treharne, et al15, 73% women
having
salpingitis
were
positive
for
antichlamydial IgM. This slightly higher
prevalence may be due to the fact that the study
was carried out exclusively among highly
selective group of females with clinically proven
salpingitis.In contrast, Sweet, et al16 was unable
to isolate C trachomatis from the exudates of
inflamed tubes, while isolation rate was 5% from
cervical samples in the same subjects. These
studies suggest that the IgM seropositivity in
present study parallels to those of other Asian
countries but is much higher than that of
western countries.
In the present study, all the females belonged to
age-group spread over the span of 15 to 45 years
(table 1). Highest incidence of chlamydial
genital infections was observed in third decade
with slight preponderance in its first half i.e.
peak seropositivity was noticed in 21-25 years
age group i.e. 60% for acute PID, 66.66% for
primary infertility and 36.36% for healthy
controls. The seropositivity was found to
decrease in later decades of life. These
observations indicate that chlamydial genital
infection, are most prevalent in adolescents and
young adults i.e. sexually active age group.
Results supporting this were also obtained by
Nagasawa, et al10; Ohwada, et al17with highest
incidence of chlamydial infections in twenties.
Similarly, in studies conducted by Sessa, et al5;
Bontis et al6; Douveir, et al7 high prevalence of
antigen and IgM seropositivity (both markers of
active infection) was seen in 15–30 years age
group. Thus, the present study further affirms
previous observations that there is higher IgM
seropositivity among earlier decades of sexual
life.
Table 2: Correlation between chlamydial seropositivity among different Socio-Economic (SE) class
Study Parameter
Acute PID
Primary Infertility
Healthy Control
Upper SE Class
Subjects
IgM +ve
8
2
6
2
8
2
The chlamydial seropositivity was found to be
highest among the lower socioeconomic class
(table 2) and rural population (table 3). These
findings may be attributed to inability to seek
proper diagnosis and treatment for venereal
diseases due to social stigmata’s attached to
them besides illiteracy especially lack of sex
Middle SE Class
Subjects
IgM +ve
12
4
14
6
24
4
Lower SE Class
Subjects
IgM +ve
30
18
30
22
18
8
education. Increase incidences of broken homes,
sexual disharmony, and prostitution among
lower socioeconomic class may be additional
contributory factors.
The subjects with acute PID and primary
infertility presented with multiple signs and
symptoms (figure 1).
Table 3: Chlamydial seropositivity among rural and urban population
Study Parameter
Acute PID
Primary Infertility
Healthy Control
Rural
Subjects
36
28
22
The most common symptom seen was of
menstrual
irregularities
while
highest
seropositivity was observed among subjects
complaining
of
pelvic
pain.
Slight
preponderance of pelvic pain and backache was
seen in acute PID cases, while that of menstrual
irregularities was observed in cases with
primary infertility but no statistical correlation
Urban
IgM +ve
20
18
4
Subjects
14
22
28
IgM +ve
4
10
10
could be generated. Similar results with higher
seropositivity were also obtained in studies
carried by Treharne et al16. Among various signs
mucopurulent pus at cervical os showed highest
seropositivity (50%). Similar results were also
obtained in studies carried out by Brunham, et
al18. Dyspareunia, fever, itching vulva, vaginits,
cervicitis, per vaginal discharge, bad B.O.H. etc
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constituted other signs and symptoms among
the subjects but no statistical correlation could
be derived among above them indicating that no
single sign or symptoms of C trachomatis genital
infections is pathognomic and clinical diagnosis
of acute PID and primary infertility per see
implies a comparatively low degree of accuracy.
40
35
34
Subjects (100)
IgM positive
30
26
24
25
20
18
16
14
15
10
10
8
5
0
Menstrual
problems (52.94%)
Pelvic Pain
(53.84%)
Backache (43.75%) Pus at cervical os
(50%)
Fig 1: Relationship of chlamydial serology with symptoms and signs
SUMMARY AND CONCLUSION
High seroprevalence with peak incidence in
third decade of C trachomatis infection in clinical
and sub-clinical form was observed in the
present study highlighting its increasing role in
causing genital infections. It was also perceived
that the symptoms and signs of chlamydial
infections are not pathognomic. Both these
findings strongly suggest the need of high
degree of clinical suspicion and a screening test
which can provide rapid and specific diagnosis
thereby preventing not only long-term sequel as
infertility among asymptomatic population but
also allowing early institution of appropriate
therapy.
Culture though considered gold standard for
diagnosis is not proficient for rapid diagnosis.
At present, antibody detection by ELISA is very
cost effective and practical method for rapid and
specific diagnosis of chlamydial genital
infections, though further studies are required to
further affirm its diagnostic utility.
1.
2.
3.
4.
5.
6.
7.
Harris JRW, Forster SM, editors. Genital chlamydial
infections: clinical aspects, diagnosis, treatment and
prevention; in Recent Advances in Sexually
Transmitted Diseases and AIDS. No 4. London
Churchill Livingstone, 1991:219-62
Westrom L., Mardh PA. Pelvic inflammatory disease:
epidemiology, diagnosis, clinical manifestations, and
sequelae International perspective on neglected STD’s,
New York: Hemisphere Publishing, 1983: 235-50.
Westrom L. Incidence, prevalence, and trends of acute
pelvic inflammatory disease and its consequences in
industrialized countries; American Journal of Obstetrics
and Gynecology, 1980; 138:880-92.
Birger R. Møller, Märdh PA. Experimental Salpingitis
in Grivet Monkeys by Chlamydia Trachomatis. Modes
of Spread of Infection to the Fallopian Tubes; Acta
Pathologica,
Microbiologica
et
Immunologica
Scandinavica, 88:107-111.
Sessa R, Latino MA, Magliano EM, Nicosia R, Pustorino
R, Santino I, et al. Epidemiology of urogenital infection
caused by Chlamydia trachomatis and outline
characteristic features of patients at risk. J Med
Microbiol 1994);41:168-172.
Bontis J, Vavilis D, Panidis D, Theodoridis T,
Konstantinidis T, Sidiropoulou A. Detection of
Chlamydia trachomatis in asymptomatic women:
relationship to history, contraception and cervicitis.
Advances in Contraception. 1994; 10(4):309-15.
Douvier S, Sainte-Barbe C, Oudot C, Habert F, Fritz
MT. Chlamydia trachomatis infection: risk factors.
Contracept Fertil Sex. 1996;24(5):391-8.
REFERENCES
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 490
pISSN: 0976 3325 eISSN: 2229 6816
8.
9.
10.
11.
12.
13.
Videla C, Carballal G, Kekiklian G, Juárez C, Gómez
MM, Filippo E, García A. Chlamydia trachomatis and
tubal obstruction. Medicina (B Aires). 1994; 54(1):6-12.
Nagasawa I, Takada M, Ishi. K. Positive rate of
Chlamydia trachomatis antigen detected by the
simultaneous sampling of uterine cervix, uterine cavity
and urinary tract and its relation to serum antibody
titers. Nippon Sankaa Fuiinka Gakkai Zasahi. 1991;
43(4): 399-404.
W.H.O task force on the prevention and management
of infertility- Tubal infertility: Serologic relationship to
past chlamydial and gonococcal infection. Sex Transm
Dis. 1995; 22(2): 71-7.
Felman YM, Nikilas JA. Pelvic Inflammatory Disease.
New York State; J. Medicine 1980; 80:35.
Ray K. Yadav S. Prevalence of Chlamydia Trachomatis
and Other Sexually Transmitted Pathogens in Female
Reproductive Tract Infections. Indian Journal of
Medical Microbiology 1997;15(4):173-6.
Joshi JV, Palayekar S, Hazari KT, Shah RS, Chitlange
SM. The prevalence of Chlamydia trachomatis in young
women. Natl Med J India. 1994;7(2):57-9
14. Bhujwala, RA, Seth P, Gupta A, Bhargava, NC. Nongonococcal urethritis in males -- A preliminary study.
Indian Journal of Medical Research. 1982;75: 485-8.
15. Treharne JD, Ripa J D, Mårdh P A, Svensson L,
Weström L, Darougar S. Antibodies to Chlamydia
trachomatis in acute salpingitis. Br J Vener Dis 1979;
55:26-9.
16. Sweet R, Draper DL, Schachter J, James J, Hadley WK,
Brooks GF. Microbiology and pathogenesis of acute
salpingitis as determined by laproscopy: What is
appropriate site to sample? Am J Obstet Gynecol. 1980;
138(7 Pt 2):985-9.
17. Ohwada N, Tsukagoshi T, Kosuge T, Nagayama M,
Ibuki Y, Hagiwara H. Incidence of Chlamydia
trachomatis isolated from endocervical columnar cells
of the uterine cervix. Nippon Sankaa Fuiinka Gakkai
Zasahi 1991; 43(4): 417-21.
18. Brunham RC, Binns, Bernard, Mcdowell, Jackie,
Paraskevas, Maria. Chlamydia trachomatis infection: In
women
with
ectopic
pregnancy.
ClinObstet.Gynecol.1986; 67:722.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
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pISSN: 0976 3325 eISSN: 2229 6816 SHORT COMMUNICATION.
CROSS-SECTIONAL STUDY OF LOCOMOTOR
DISABILITIES IN URBAN SLUM AREA OF MUMBAI
Shekhar B Padhyegurjar1, Manasi S Padhyegurjar2
1Professor, 2Associate
Professor, Department of Community Medicine, Karpaga Vinayaga Institute of
Medical Sciences (KIMS), Kancheepuram
Correspondence:
Dr Shekhar B. Padhyegurjar
C/o Dr B. K. Padhyegurjar, 9, Narmada Niwas,
Topiwala Wadi, Station Road, Goregaon (West), Mumbai 400 062.
E-mail : [email protected] Mobile: 08015129473, 08122695816
Key words: Loco motor disability, Prevalence
INTRODUCTION
Human life is enriched by mechanical,
recreational and innovative activities performed
by an individual. These actions are restricted by
minor impairments and disabilities which
results into handicap to perform even regular
work thus affecting personal, family and
professional life of an individual. In the early
stages, intervention for impairment has large
medical component, however in the later stage,
disability and handicap have huge social and
environmental components in terms of
dependence and social costs.1 When compared
to auditory, speech or visual disabilities, in loco
motor disabilities, scale of measurements is
complex due to involvement of multiple
components. This study attempts to estimate the
prevalence of loco motor disabilities and to
assess its relationship with demographic factors.
MATERIALS AND METHODS
The study was carried out in an urban slum
which is the field practice area of a municipal
teaching hospital in Mumbai. The study is cross
sectional and observation. A minimum sample
of 3600 was estimated based on 10%prevalence
of locomotor disability as found in pilot study.
A household was taken as a single unit by
stratified systematic random sampling in two
demarcated areas of the slum. All members of
the household were included in the study. A
sample of 3665 individuals was taken. A
structured questionnaire was administered in
the local language. Participants were screened
for detection of loco motor disabilities by
physical examination carried out by trained
health professional. The study was conducted
over a period of 3 months. The data was
analysed using SPSS software (Version 16). 95 %
confidence limits for prevalence, Z-test of
difference between two proportions and
Pearson’s correlation co-efficient with t-test were
applied.
RESULTS
Mean age of the sample was 27.16 years with
standard deviation 16.8 years. The sample
consisted of 49.33 % females and 50.67 % males.
Out of the total sample, 74.4 % were unemployed, 49.3 % were illiterate and 69.3 %
were married. Majority of the sample (62.5 %)
belonged to lower socio economic class. Among
3665 individuals 205 were identified with loco
motor disabilities. The prevalence of loco motor
disabilities is 5.59 % (95 % C.L. 4.85 % to 6.33 %).
As observed in Table 1, almost half of the
screened
population
were
females
(49.33%).However
among
the
affected
individuals, 71.22% were females. This
difference was statistically significant. (Z=6.69,
p=0.0000). Significant difference is also observed
in the prevalence among males (3.18%) and
females (8.08 %) (Z=6.45, p=0.0000).
The mean age of affected individuals is 38.89
years with standard deviation 15.1 years. The
difference between mean age of screened (27.16
yrs) and affected individuals (38.89 years) is
statistically significant (Z = 10.76, p = 0.0000).
Also, the prevalence of loco motor disabilities
was found gradually increasing with the
advancing age groups (Figure 1). The correlation
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 492
pISSN: 0976 3325 eISSN: 2229 6816 of age group against prevalence was significant
(r=0.992, t=13.69, p=0.00000).
Table 1: Sex-wise distribution of screened and
affected individuals
Sex
Individuals
screened
(%) (n=3665)
Female 1808 (49.33 )
Male
1857 (50.67 )
*Z=6.45, p=0.0000
Individuals Prevalence
affected
(%)
(%) (n=205)
146 (71.22 )
8.08 *
59 (28.78 )
3.18 *
CONCLUSION
Vast majority 197 (96.1 %) of the individuals are
aware about their disabilities. Disability
duration of 1 to 5 years was reported by 47.32 %
of affected individuals. Injury of some kind was
stated as a cause of their disability by 21.46 %
individuals.
16%
15.23%
Prevalence
14%
10.62%
12%
10%
7.53%
8%
5.49%
6%
4%
2%
0.80%
0%
< / = 15 16 - 30
prevalence 5.01 % in the adults with 0.62 % in 15
to 24 years age group and 26.47 % in the age
group >85 yrs.5 Similar results were reported by
many studies.2-7
Injury as a cause of their disability was reported
by many affected individuals in the current
study. Similar results were also observed in
other studies, where loco motor disability due to
injury was reported as 31.6 % and 41.2 %
respectively.3, 4
31 - 45
46 - 60
> 60
Age in years
Fig1: Prevalence of locomotor disability
DISCUSSION
The prevalence of loco motor disability was
observed to be 5.59 % in the current study. This
is high as compared to other studies, where
prevalence of <2 % has been reported.2,3,4
Prevalence of loco motor disability was found
significantly higher in females than in males.
Similar findings were observed in several
international studies. The study by Reynolds DL
et al displays 3.86% prevalence in males and
6.1% in females. 5 The Rotterdam study shows
prevalence of 24.5 % in males and 40.5 % in
females in the population above 55 years age
group.6 A study conducted in Malaysian
community shows a prevalence of 5.2 % in
males and 2.6 % in females.7
The prevalence of loco motor disabilities
increased as age advanced. A study of loco
motor disabilities in Malaysian community in
Kuala Selangor shows that the prevalence
increased with age, being as low as 0.6% in the
7-14 year age group and as high as 20.5% in the
above 55 year age group.7 Similarly physical
disability among Canadians reporting overall
This study has focused attention on the loco
motor disabilities in an urban slum area of
Mumbai. The overall prevalence of loco motor
disabilities is 5.59% showing gradual increase as
age advances. India is witnessing a rise in
geriatric population due to a steady rise in life
span. This will also lead to the increase in the
prevalence of loco motor disability in future.
The current study indicates significantly high
prevalence among females. Thus this health
issue needs to be focused on specially through
the various health programmes for the females.
Policies to control accidents and injury, which
have been reported to be the major cause in the
current study, will be an effective prevention
strategy. The problem of loco motor disability
needs to be adequately addressed in the existing
National Health Policies, and rehabilitative
services at primary health care level especially
for females and the geriatric age group, will help
to improve the quality of life of affected.
REFERENCES
1. The uses of epidemiology in the study of elderly ;Report
of WHO Scientific group on the epidemiology of aging
.Technical Report Series 1984;706: 59-61
2. Disler PB, Jacka E, Sayed AR, et al. The prevalence of
loco motor disability and handicap in the Cape
Peninsula. Part III. The white population of Fish Hoek. S
Afr Med J. 1986 ;69(6):355-7.
3. Disler PB, Jacka E, Sayed AR, et al. The prevalence of
loco motor disability and handicap in the Cape
Peninsula. Part II. The black population of Nyanga. S Afr
Med J. 1986;69(6):353-5
4. Disler PB, Jacka E, Sayed AR, et al. The prevalence of
loco motor disability and handicap in the Cape
Peninsula. Part I. The coloured population of Bishop
Lavis. S Afr Med J. 1986; 69(6):349-52.
5. Reynolds DL, Chambers LW, Badley EM, et al. Physical
disability among Canadians reporting musculoskeletal
diseases. Rheumatol. 1992 ;19(7):1020-30.
6. Odding E, Valkenburg HA, Algra D, et al. Association of
loco motor complaints and disability in the Rotterdam
study. Ann Rheum Dis. 1995;54(9):721-5.
7. Osman A, Rampal K G. A study of loco motor
disabilities in a Malay community in Kuala Selangor.
Med J Malaysia, 1989;44(1):69-74.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 493
pISSN: 0976 3325 eISSN: 2229 6816 SHORT COMMUNICATION.
OCCUPATIONAL EXPOSURE & TREATMENT SEEKING
BEHAVOIUR OF HCWs FOR POST EXPOSURE
PROPHYLAXIS AT TERTIARY LEVEL HOSPITAL OF
WESTERN RAJASTHAN, INDIA
Prabhu Prakash1, Arvind Mathur2, Suman Bhansali3, Sneha Ambuwani4, Ekta Gupta5
1Associate
Professor & In-charge ICTC Centre; 2Professor & Head, Department of Medicine and Incharge ART Centre 3Associate Professor, Department of Community Medicine, 4Associate Professor,
Department of Pharmacology, 5Private Practitioner, Jodhpur, Rajasthan
Correspondence
Dr. Suman Bhansali,
Associate Professor, Department of Community Medicine,
Dr. S.N. Medical College, Jodhpur, Rajasthan
Email: [email protected]
Keywords: Occupational Exposure, Post Exposure Prophylaxis, Health Care Worker, HIV
INTRODUCTION
Health Care Workers are at risk of getting blood
born infections like HIV, HBV & HCV1. This
study was done in ICTC (Microbiology
Department) and ART centre of Dr. S.N.
Medical College, Jodhpur (Raj.) since April 2006.
In ART centre more than 8500 HIV sero-postive
patients are being cared for. HCWs are at
occupational exposure. Therefore there is
frequent reporting of occupational exposure to
HCWs.
METHOD
Analysis of 60 subjects, who came for PEP to this
centre, was done. All were evaluated clinically
as per NACO guidelines and subjected to HIV,
HBV, HCV &CBC testing at zero day, 28th days,
3 months and 6 months intervals are done and
given PEP according to NACO guidelines.
RESULT
Total 60 subjects were given PEP in 5 years.
Male to Female ratio was2:1[40:20]. 20% were
Doctors and 80%Paramedical staff. 60% had
Exposure
by
Hollow
Needle.
Only
41.67%reported&started PEP Within <2 hours.
All exposed were HIV, HBV and HCV negative
on zero day testing but for follow up testing
after 6 months only 50% turned up & reported
Negative.
Table 1: Regular Training on HWM & on
Infection Control in HCW should be part of JOB
(n=60)
Mode of Exposure
Hollow Needle Injury
Blunt [suturing] Needle Injury
While Recapping Used Needle
With M P QBC Capillary In
Microbiology Lab.
Contact with blood or body fluid
Human Bite
12 (20)
2 (3.33)
Table 2: Time When Pep Was Started After
Exposure (n=60)
Time Duration (In Hours)
< 2 hours
2 – 24
24 – 48
48 – 72
>72
Cases (%)
25 (41.67)
8 (13.33)
10 (16.66)
8 (13.33)
9 (15.00)
Complications of PEP were seen in form of
Gastritis, Vomiting, Skin rash but all Subjects
had 100%adherence for treatment. When no one
questioned was having proper knowledge of
‘How To Manage Accidental Spillage Of Seropositive Blood or Fluid (About Disinfection
Process).
OBSERVATIONS AND DISCUSSION
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Cases (%)
36 (60)
6 (10)
2 (3.33)
2 (3.33)
Page 494
pISSN: 0976 3325 eISSN: 2229 6816 60 cases for PEP were registered in 5 years of
duration. There was gradual increase in number
with time. Males 40 outnumbered the females 20
(2:1ratio). There were75% paramedical staffs;
20% Doctors and 5% others. 20% were from
peripheral hospitals, 80% from Jodhpur Medical
College. 60% had injury with hollow needle;
20% by contact with blood and body fluid while
conducting delivery; 13.33% had accidental
injury in laboratory while performing laboratory
tests with HIV positive blood, 3.33% with
suturing needle and 3.33% had human bite from
HIV positive patients. In 41.67% HCWs, PEP
with basic regime as NACO guidelines started
within 2 hours, while in 45% HCWs, they
reported in ART centre after 24 to 72 hours of
duration.
Table 3: Type of Occupation (n=60)
Occupation
Doctor (MS, MD & residents)
Nurses
Laboratory technicians
Research scholar
Ward boys in art center
Cases (%)
12 (20)
39 (64.01)
6 (10)
1 (1.66)
2 (3.33)
In laboratory investigations, all HCWs were
HIV, HBV and HCV negative. In 50% HCWs
even after 6 months follow up, these tests were
negative. Remaining subjects did not turn up for
follow up. No one know management of
spillage of blood or first aid treatment of
accidental exposure of HIV positive blood. No
one was having knowledge about management
of blood and bloody fluid spillage.
CONCLUSION:
It is evident that most of affected HCWs were
paramedical staffs. There was delay in reporting
and even among them, 50% did not turn up for
follow up. It indicates: lack of understanding
and motivation amongst clinicians and
paramedical staffs regarding PEP. A study
involving areas other than medical college is still
a need of time to find exact number of exposed
persons and need of training to
preventing knowledge among HCWs.
impart
RECOMMENDATION
All HCW should be vaccinated for HBV. All
health care workers should be trained regarding
management & handling of HIV positive
patients, their all body secretions e.g. blood;
blood products; infected or used syringes /
needles / blades / all sharp objects or
instruments. Any accidental exposure should be
reported to Infection Control Committee or
Officers In-charge. PEP should be started within
2 hours of exposure. At least 5 doses of PEP
should be Available in all ICU; OT; Wards;
Emergency; so that in case of emergencies in
odd hours; PEP can be delivered to expose
HCW without any panic. Management of
exposed site; should be by washing with soap,
water &disinfectants immediately [not by
injecting in wound site]. If HIV Status of patient
is not confirmed in ICTC or single test report is
available; still PEP should be started without
waiting for confirmatory test report from ICTC
which generally takes 2 to3 days. Do not test
used or exposed needle or testing of p24 antigen
is not at all recommended for PEP. Adherence to
treatment is must for 28 days ignoring side
effect of ART Drugs & follow up testing should
be advised. Management of any Blood spillage
should
be
known
to
all
HCW
by10%hypochlorite solution. Protocols of
“.Hospital Waste Management Policy & Proper
Disposal of used Needle & Syringe” should be
followed meticulously. Needle Cutter &
disinfectants
(10%
Hypochlorite
or
Gluteraldehyde) should be available in
Laboratories/Wards / OT / ICU / Emergencies
for use in emergency.
REFERENCE
1.
National AIDS Control Organization. Operational
Guideline for Integrated Counseling & Testing Centre.
New Delhi: NACO, Health & Family Welfare, Govt. of
India; 2007.p 25-6.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 495
pISSN: 0976 3325 eISSN: 2229 6816 LETTER TO EDITOR.
EVIDENCE INFORMED COMMUNITY HEALTHCARE IN
DEVELOPING COUNTRIES: IS THERE A ROLE FOR
TERTIARY CARE SPECIALISTS?
N Asokan1, K Praveenlal2, K S Shaji3
1Additional
Professor, 2Professor of Psychiatry & Principal, 3Professor of Psychiatry, Department of
Dermatology, Government Medical College, Thrissur, Kerala, India
Correspondence:
Dr. Asokan N, Prashanthi,
KRA- 11, Kanattukara P.O., Thrissur – 11,
Kerala, India PIN: 680011
E-mail address : [email protected]
Keywords: Evidence informed, community health, tertiary care specialists, developing countries
Dear Sir,
Escalating cost of medical care is making good
quality health care less accessible to
disadvantaged sections of the society. We need
to strengthen the primary care services to
overcome this challenge. There should be a shift
of focus from specialized clinic based services to
community outreach services. For the latter to be
capable of delivering evidence informed health
care, support and guidance from secondary and
tertiary levels are needed.
Here we describe an effort to scale up primary
health care services in a coastal village in the
southern Indian state of Kerala. This was aimed
to improve access to evidence informed health
care by developing simple inexpensive
community based services.
Thalikulam Grama Panchayath has a population
of 24,180. Thalikulam Vikas Trust (TVT) is a
nongovernmental organization (NGO) active in
various sectors like health, housing, social
security and employment generation. In 2008,
TVT launched a community health care
program named Thalikulam Health Programme
(THP) with inputs and support from
Government
Medical
College,
Thrissur
(GMCT).
The representatives of the NGO and an expert
group from GMCT met many times to set goals
for research and service development. A data
entry system was designed to record the health
related information. TVT recruited forty women
from the local community as community health
volunteers (CHVs) to act as links between
specialists and the community. They were given
a brief training at GMCT by the expert group.
In the first phase, CHVs completed a health
survey of the population. This was followed by
a series of medical camps in which the patients
identified by the health workers were examined
by the experts from GMCT. Management plans
were discussed with the patients, caregivers and
the local CHV. Follow up care of those with
chronic diseases was also taken up.
We have initiated three research projects to
address health problems of older people like
diabetes, hypertension, depression, dementia
and skin diseases. A special team comprising of
specialists from psychiatry, internal medicine
and dermatology supervise this. We have
designed information booklets related to
dementia care, depression and skin diseases.
The NGO has started a primary care clinic. This
service will be complementary to the existing
primary care facilities in public and private
sectors. The medical officer of this clinic will
supervise and monitor the health care services
provided by the NGO at primary and
community care settings.
Kerala has many achievements to its credit in
health sector. Though the state is industrially
and economically underdeveloped, its health
parameters are comparable to many industrially
advanced countries. 1,2 But several recent studies
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 496
pISSN: 0976 3325 eISSN: 2229 6816 have pointed to a high morbidity – low
mortality paradox prevailing in the state. 3,4 The
health care scenario in Kerala appears to be
stagnant now. There is an urgent need to
strengthen the accessibility as well as the quality
of primary health care to overcome this
challenge.
Some
countries
like
United
Kingdom
incorporate training in various specialties within
the training of General Practitioners (GP). 5
Creation of General Practitioners with a Special
Interest (GPwSI) who supplement their main GP
role by delivering an additional high quality
service in a particular area of expertise helps to
achieve the aim of delivering evidence informed
health care to the community. But in most of the
developing countries including India, such
systems are non-existent. These countries need
to develop new models to link the primary care
team to a network of experts from secondary
and tertiary levels of care.
In the present initiative, locally selected CHVs
are given a pivotal role. They are trained in case
finding, encouraging follow up care of patients,
health information dissemination and other
health promotional activities. We are examining
the possibility of enhancing the community case
finding abilities of these CHVs in several chronic
diseases. An earlier study in the same
community had shown that it is possible for
health workers to identify cases of dementia in
the community.6
Involvement of specialist teams in community
health care delivery allows the specialists to gain
useful feedback from the primary care. This
would help them to make decisions on the
ingredients of interventions to be delivered by
non-specialist health care providers.
The
mhGAP initiative from the World Health
Organization has adopted such an approach .7
We hope to develop this initiative as a new
model of community health care, one which
combines the expertise of an academic
institution with the volunteerism of the local
people. Partnership with NGOs could help
academic institutions to foster community led
health care initiatives. This makes scaling up of
evidence based clinical practice feasible. This,
we believe, will lead to better outcomes for a
larger number of people who bear the burden of
disease in resource poor countries. It is hoped
that initiatives such as THP will result in
bringing in the expertise of specialist clinicians
to non specialized settings through an ongoing
mechanism which makes them stake holders in
community health care.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Parayil G. The "Kerala model" of development:
development and sustainability in the Third World.
Third World Q. 1996; 17:941-57.
Nag M. The Kerala formula. World Health Forum.1988;
9:258-62.
Soman CR, Damodaran M, Rajasree S et al. High
morbidity and low mortality--the experience of urban
preschool children in Kerala. J Trop Pediatr.1991; 37:1724.
Michael EJ, Singh B. Mixed signals from Kerala's
improving health status.J R Soc Promot Health. 2003;
123:33-8.
http://www.rcgpcurriculum.org.uk/pdf/curr_Quick_Ref_Guide_to_GP
_Training_and_Prof_Devt_mar09.pdf.
March
2009
(accessed 1.9.2011).
Shaji KS, Arun Kishore NR, Lal KP et al. Revealing a
hidden problem.
An evaluation of a community
dementia case-finding program from the Indian 10/66
dementia research network. Int J Geriatr Psychiatry.
2002;17:222-5.
http://www.who.int/mental_health/mhgap/en/
(accessed 17.9.2011).
Page 497
pISSN: 0976 3325 eISSN: 2229 6816 LETTER TO EDITOR.
CATCH THEM YOUNG
Kapil H Agrawal1
1Assistant
Professor, Dept. of Community Medicine, A.C.P.M. Medical College, Dhule
Correspondence:
Dr. Kapil H. Agrawal
2, Nagai colony, Deopur, Dhule-424002, Maharashtra
E-mail: [email protected], Phone numbers 9422824600
Keywords: Youth, tobacco, education programme
Dear Sir,
Tobacco is a major public health problem1.
Given the current pattern of tobacco use
globally, it is estimated that 250 million children
and adolescents who are alive today, would die
prematurely, most of them in developing
countries2. According to the WHO estimates, 194
million men and 45 million women use tobacco
in smoke or smokeless forms in India1. In India,
tobacco consumption is responsible for half of
all cancers in men and a quarter of all cancers in
women, in addition to being a risk factor for
cardiovascular diseases1. India also has one of
the highest rates of oral cancer in the world,
mostly attributed to high prevalence of tobacco
usage. In India tobacco is smoked in the form of
cigarettes, bidis and hukkas. Smokeless use
includes betel quid, gutkha, mawa, zarda, khaini
and snuf. Many of these products are chewed
while some are applied in the oral cavity.
Various studies have demonstrated that tobacco
use (which includes smoking) among school
going children in India is very high 1, 3, 4. India
global youth tobacco survey, 2006 confirmed the
high prevalence of tobacco usage in school
going children (among 13-15 years) 5.
Many of the risks to health and life caused by
tobacco consumption develop over a long
period, and take decades to become fully
evident. But tobacco use also inflict immediate
harm on users and their families, damage is
wreaked little by little each day. Scarce family
resources are spent on tobacco products instead
of on food, or other essential needs. Even a small
diversion of resources of poor families who live
at or below the edge of poverty can have a
significant impact on their health and nutrition.
This has been shown in many studies from
Southeast Asia. Disadvantaged adolescents use
tobacco at the cost of their meals. They spent
four times on gutkha purchase as compared to
their protein (eggs) 6. Tobacco spit creates
environmental pollution. Red splotches on the
pavement everywhere in Southeast Asian
countries are evidences of the copious spitting
which is so deeply and culturally engrained in
Southeast Asia. The major health consequences
associated with smokeless tobacco include
cancer of several sites and poor reproductive
outcome. Thus tobacco consumption has serious
individual,
family
and
environment
implications.
The prevention of tobacco use in young people
appears to be the single greatest opportunity for
preventing
non
communicable
disease
(including oral cancer) in the world today3.
If we believe in Supply-Demand cycle of
economics there is a demand to the tobacco
products that is why there is a supply. Curbing
the supply without stopping the demand will
lead to illegal manufacturing and distribution of
tobacco products. What we need to do is to stop
the demand. There are 7.67 lakh elementary
schools in India in which 13.8 crore children (614 years) are enrolled (2004-2005)7. In other
words it is an opportunity to reach these 13.8
crore plus students at a same time and also their
families through them. We need to introduce an
anti-tobacco curriculum in schools across the
country in order to decrease the tobacco usage
rate among students. The message is “Catch
them Young” in the schools before it is too late.
According to estimates, every US 1 Dollar
investment in schools on effective anti-tobacco
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 498
pISSN: 0976 3325 eISSN: 2229 6816 education saves US 18.8 Dollars in the costs of
addressing health and non health problems
associated with smoking. Additionally schools
can reach about 1 billion students worldwide
everyday and through them, their families and
communities that is the world’s broadest and
deepest channel for putting information at the
disposal of its citizens8.
The schools will play an imperative role in
shaping student tobacco behaviors. Anti-tobacco
education curriculum should train the students
in health implications of tobacco consumption,
refusal skills, involve parents, teachers and
peers. Following instructional concepts can be
put across the schools.
Table1: Instructional concepts
Knowledge: Students will learn that
Attitudes: Students will demonstrate
Most young persons and adults do not smoke.
A personal commitment not to use tobacco.
Tobacco use is an unhealthy way to manage stress Pride about not choosing tobacco.
and weight.
Tobacco use during pregnancy has harmful effects Responsibility about personal health.
on the fetus.
Smoking cessation programs can be successful.
Confidence in personal ability to resist tobacco use.
Cigarette smoking and smokeless tobacco use Support for others' decisions not to use tobacco.
have direct health effects.
Many persons find it hard to stop using tobacco,
despite knowledge about the health hazards of
tobacco use.
Skills: Students will be able to
Encourage other persons not to use tobacco.
Support persons who are trying to stop using
tobacco.
Demonstrate skills to resist tobacco use.
Modified from Morbidity and Mortality Weekly Report, CDC-Atlanta, Feb 25, 1994; 43
Carefully planned school anti-tobacco education
programs can be very effective in reducing
tobacco use among students if school and
community leaders make the commitment to
implement and sustain such programs.
3.
4.
5.
REFERENCES
1.
2.
Kumar Madan PD, Poorni S, Ramchandran S. Tobacco
use among school children in Chennai city, India.
Indian Journal of Cancer 2006;43:127-131
Petro R, et al. Developing populations: The future
health effects of current smoking patterns.In: Mortality
from smoking in developing countries, 1950-2000.
Oxford university press.Oxford;P101-103
6.
7.
8.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Sinha DN, Gupta PC, Pednekar MS. Tobacco use
among students in the eight North-eastern states of
India. Indian Journal of Cancer 2003;40:43-59
Sinha DN, Gupta PC. Tobacco use among students in
Uttar Pradesh and Uttaranchal, India. Indian Journal of
Public Health, 2004;48:132-137
India global youth tobacco survey, 2006. Available from
http://www.corecentre.co.in/Database/Docs/DocFile
s/India_Global_Youth.pdf (Last accessed 14th October
14, 2011)
Sinha DN. Report on oral tobacco use and its
implications in Southeast Asia. Available from
www.searo.who.int/linkfiles/nmh_oraltobaccouse.pdf
(Last accessed 15th October, 2011)
Sarva
Shiksha
Abhiyan.
Available
from
http://pib.nic.in/archieve/flagship/ssa_faq.pdf (Last
accessed 14th October 14, 2011)
J. Kishore. National Health Programmes of India: New
Delhi. Century Publications;2002.P 217.
Page 499
pISSN: 0976 3325 eISSN: 2229 6816 LETTER TO EDITOR.
YOUTH AND HIV
Kanan Desai1
1Rsident,
Department of Community Medicine, SMIMER, Surat
Keywords: Youth, HIV, AIDS
Respected Sir,
“Young people are the key person in fight against HIV-AIDS. By giving them support they need, we
can empower them to protect themselves against the virus; by giving them honest and
straightforward information, we can break the circle of silence across all societies; by creating
effective campaign for education and prevention, we can turn young people’s enthusiasm, drive and
dreams for future into powerful tools for tackling the epidemic.”
-Kofi Annan, United Nations Secretary-General, in a speech given at Zhejiang University, China, in
October 2002, where he received an honorary doctorate1
Youth is man, youth is woman, youth is straight,
youth is MSM, youth is street worker, and youth
is injecting drug user, too, youth is also orphan;
infect youth is everyone…they represents
everyone. They are the generation ‘X’. Whatever
happens to them today will determine what
becomes of our communities, societies and
nation in a decade ahead, because youth is the
future. But, the future does not seem
good...Future is dying…Everyday 6000 of 15-24
year old youngsters become infected with a tiny
virus, known to us as HIV. Almost half of all
new HIV infections occur amongst youngsters;
leaving 11.8 millions of them suffering from
HIV.1 Young generation also have amongst
them the highest rate of STIs. From denial of
information, education and services; to gamble
that youngsters play for curiosity and
experiment; from their tender age of rapid
emotional, physiological and hormonal changes;
to their anatomical vulnerability….make young,
especially young women, the easiest prey of this
deadly disease, AIDS. And, it’s only and only in
their hands to do whatever they need to do to
protect themselves from this moron.
Provided with necessary means, skills &
training, youngsters can become important
advocates for their special reproductive and
sexual health needs. Given the possibility to
speak up, they can introduce more youth
sensitive perspective to the policy making
process. By being responsible persons and
having responsible sexual behavior, by
indulging only in protected sex and consistently
using condoms, by delayed indulgence in sexual
activity and avoiding sex with prostitutes; they
can protect themselves and by spreading the
same take home message to their friends, they
can protect other youngsters, too. From
participating in regional groups and conferences
on HIV-AIDS to organizing drama, street plays,
sports tournaments etc. for awareness purpose;
from joining red-ribbon club at colleges to
following Global Youth Collision on AIDS
(GYCA) on facebook; from appreciating efforts
of making Pretty Zinta like young face goodwill
ambassador of UNAIDS and launching of red
ribbon express to active participation by
youngsters themselves in peer education activity
of their isolated under privileged friends to
reduce their risk taking behavior, by reaching to
each other and identifying with each other
linguistically and culturally, by understanding
each other’s problems and respecting each
other’s decisions non judgmentally and non
critically, by acting as role models to each other
…whoever, however can do whatever little
should and must do…
Youngsters today form 47% of India’s
population2 and they are not a mere HIV
statistic. They are living dynamic persons who
happen to love life. According to Gurucharan
Das, former chief executive of Procter & Gamble
Co. India, youngsters are the ‘found’ generation
of new India.2 And henceforth, the youth has a
request to make to the adults, “Can adults find it
in themselves to trust the young generation a
little bit? Youth is responsible and capable of
making sensible decisions, in matters of life that
affect them the most.1 Allow them to do that.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 500
pISSN: 0976 3325 eISSN: 2229 6816 Treat them as partners and not inferiors. Youth
is waiting for a dawn when there will be
dynamic fusion of their creativity, enthusiasm
and fresh ideas with elder’s knowledge,
experience and wisdom. Afterall those were the
elders, who gave world the convention on right
for children and youngsters. So now, break this
web of stigma, discrimination, ostracism and
shoo...shaa... about AIDS. Can’t ‘Grown-ups’
see, those are the root fertilizers of this
epidemic? Start talking with youth! Youngsters
have made their choices, now it’s for the elders
to decide, ‘Which is more embarrassing for
them? Talking with their child of sex or seeing
him die of HIV?1 Choice is all theirs.”
What needs to be done is no secret, by not
fulfilling our promises we all are simply
running out of excuses.
REFERENCES:1.
2.
UNAIDS.HIV/AIDS and young people, hope for
tomorrow. Geneva: UNAIDS, United Nations
Department of Public Information;2003 Aug.31 p.
Report No.: UNAIDS/03.40E
Kripalani M. India's Youth: They’re capitalist-minded-and they're changing the nation forever. Bloomberg
Business week (int’l edition).1999 Oct 11.
This article has been awarded first price in Inter College Elocution Competition organized by Gujarat
State AIDS Control Society and Surat Municipal Corporation on occasion of World AIDS Day 2011
Celebration at Surat.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 501
pISSN: 0976 3325 eISSN: 2229 6816 SPECIAL ARTICLE .
HISTORY OF HIV & AIDS
L B Chavan1
1State
Epidemiologist, Gujarat State AIDS Control Society, Ahmedabad
Correspondence:
Dr. Laxmikant Chavan, Email: [email protected]
Keywords: HIV, AIDS, History
HIV is thought to have originated in nonhuman primates in sub-Saharan Africa and was
transferred to humans late in the 19th or early in
the 20th century.1,2,3 The first paper recognizing
a
pattern
of
opportunistic
infections
characteristic of AIDS was published in 1981.4
Both HIV-1 and HIV-2 are believed to have
originated in West-Central Africa and to have
jumped species (a process known as zoonosis)
from non-human primates to humans. HIV-1
appears to have originated in southern
Cameroon through the evolution of simian
immunodeficiency virus (SIV) that infects wild
chimpanzees.5,6 The closest relative of HIV-2 is a
virus of the sooty mangabey, an Old World
monkey living in litoral West Africa (from
southern Senegal to western Ivory Coast. New
World monkeys such as the owl monkey are
resistant to HIV-1 infection, possibly because of
a genomic fusion of two viral resistance genes.7
HIV-1 is thought to have jumped the species
barrier on at least three separate occasions,
giving rise to the three groups of the virus, M,
N, and O.8
There is evidence that humans who participate
in bushmeat activities, either as hunters or as
bushmeat vendors, commonly acquire SIV.9
However, SIV is a weak virus, it is typically
suppressed by the human immune system
within weeks of infection. It is thought that
several transmissions of the virus from
individual to individual in quick succession are
necessary to allow it enough time to mutate into
HIV.10 Furthermore, due to its relatively low
person-to-person transmission rate, it can only
spread throughout the population in the
presence of one or more of high-risk
transmission channels, which are thought to
have been absent in Africa prior to the 20h
century.
Specific proposed high-risk transmission
channels; allowing the virus to adapt to humans
and spread throughout the society, depend on
the proposed timing of the animal-to-human
crossing. Genetic studies of the virus suggest
that the most recent common ancestor of the
HIV-1 M group dates back to circa 1910.11
Proponents of this dating link the HIV epidemic
with the emergence of colonialism and growth
of large colonial African cities, leading to social
changes, including a higher degree of sexual
promiscuity, the spread of prostitution, and the
concomitant high frequency of genital ulcer
diseases (such as syphilis) in nascent colonial
cities.12 There is evidence that transmission rates
of HIV during vaginal intercourse, while quite
low under regular circumstances, may be
increased tens, if not hundreds of times, if one of
the partners suffers from a STD resulting in
genital ulcers. Early 1900's colonial cities were
notable due to their high prevalence of
prostitution and genital ulcer STD's, to the
degree that, as of 1928, as many as 45% of female
residents of eastern Kinshasa were thought to
have been prostitutes, and, as of 1933, around
15% of all residents of the same city were
infected by one of the forms of syphilis.13
An alternative view holds that unsafe medical
practices in Africa during years following World
War II, such as unsterile reuse of single use
syringes during mass vaccination, antibiotic and
anti-malaria treatment campaigns, were the
initial vector that allowed the virus to adapt to
humans and spread. 10, 13, 14
The earliest well documented case of Human
Immunodeficiency Virus in human dates back to
1959.15 The virus may have been present in the
United States as early as 1966,16 but the vast
majority of infections occurring outside subSaharan Africa (including the U.S.) can be traced
back to a single unknown individual who got
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 502
pISSN: 0976 3325 eISSN: 2229 6816 infected with HIV in Haiti and then brought the
infection to the United States sometime around
1969.17 The epidemic then rapidly spread
among high-risk groups (initially, sexually
promiscuous gay men). By 1978, the prevalence
of HIV-1 among gay male residents of New
York and San Francisco was estimated at 5%,
suggesting that several thousand individuals in
the country had been infected by then.17
AIDS was first clinically observed between late
1980 and early 1981.18 Injection drug users and
gay men with no known cause of impaired
immunity showed symptoms of Pneumocystis
carinii pneumonia (PCP), a rare opportunistic
infection that was known to present itself in
people with very compromised immune
systems.19, 20, 21 Soon thereafter, additional gay
men developed a previously-rare skin cancer
called Kaposi’s sarcoma (KS).22, 23 Many more
cases of PCP and KS quickly emerged, alerting
U.S. Centers for Disease Control and Prevention
(CDC). A CDC task force was formed to monitor
the outbreak. After recognizing a pattern of
anomalous symptoms presenting themselves in
patients, the task force named the condition
Acquired
Immune
Deficiency
Syndrome
(AIDS).24
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Salemi, M. (2000). "Dating the common ancestor of
SIVcpz and HIV-1 group M and the origin of HIV-1
subtypes by using a new method to uncover clock-like
molecular evolution". The FASEB Journal 15 (2): 276–78.
Korber, B.; Muldoon, M; Theiler, J; Gao, F; Gupta, R;
Lapedes, A; Hahn, BH; Wolinsky, S et al. (2000).
"Timing the Ancestor of the HIV-1 Pandemic Strains".
Science 288 (5472): 1789–96.
Worobey M, Gemmel M, Teuwen DE, et al. (October
2008). "Direct evidence of extensive diversity of HIV-1
in Kinshasa by 1960".Nature 455 (7213): 661–4.
"Pneumocystis Pneumonia – Los Angeles". Retrieved
2008-05-05.
Gao F, Bailes E, Robertson DL, et al. (February 1999).
"Origin of HIV-1 in the chimpanzee Pan troglodytes
troglodytes". Nature 397(6718): 436–41.
Keele, B. F., van Heuverswyn, F., Li, Y. Y., Bailes, E.,
Takehisa, J., Santiago, M. L., Bibollet-Ruche, F., Chen,
Y., Wain, L. V., Liegois, F., Loul, S., Mpoudi Ngole, E.,
Bienvenue, Y., Delaporte, E., Brookfield, J. F. Y., Sharp,
P. M., Shaw, G. M., Peeters, M., and Hahn, B. H. (28
July 2006). "Chimpanzee Reservoirs of Pandemic and
Nonpandemic HIV-1". Science 313 (5786): 523–6.
Goodier, J., and Kazazian, H. (2008). "Retrotransposons
Revisited: The Restraint and Rehabilitation of
Parasites". Cell 135(1): 23–35.
Sharp, P. M.; Bailes, E.; Chaudhuri, R. R.; Rodenburg,
C. M.; Santiago, M. O.; Hahn, B. H. (2001). "The origins
of acquired immune deficiency syndrome viruses:
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
where and when?".Philosophical Transactions of the Royal
Society
B:
Biological
Sciences
356:
867–76.
doi:10.1098/rstb.2001.0863.PMC
1088480.
PMID
11405934.
Kalish ML, Wolfe ND, Ndongmo CD, McNicholl J,
Robbins KE, et al. (2005). "Central African hunters
exposed to simian immunodeficiency virus". Emerg
Infect Dis 11 (12): 1928–30.
Marx PA, Alcabes PG, Drucker E (2001). "Serial human
passage of simian immunodeficiency virus by unsterile
injections and the emergence of epidemic human
immunodeficiency virus in Africa". Philos Trans R Soc
Lond B Biol Sci 356 (1410): 911–20.
Worobey, Michael; Gemmel, Marlea; Teuwen, Dirk E.;
Haselkorn, Tamara; Kunstman, Kevin; Bunce, Michael;
Muyembe, Jean-Jacques; Kabongo, Jean-Marie M. et al.
(2008). "Direct evidence of extensive diversity of HIV-1
in Kinshasa by 1960". Nature 455(7213): 661–4.
Sousa, João Dinis de; Müller, Viktor; Lemey, Philippe;
Vandamme, Anne-Mieke; Vandamme, Anne-Mieke
(2010). "High GUD Incidence in the Early 20th Century
Created a Particularly Permissive Time Window for the
Origin and Initial Spread of Epidemic HIV Strains".
PLoS ONE 5 (4): e9936.
Chitnis, Amit; Rawls, Diana; Moore, Jim (2000). "Origin
of HIV Type 1 in Colonial French Equatorial Africa?".
AIDS Research and Human Retroviruses 16 (1): 5–8.
Donald G. McNeil, Jr. (September 16, 2010). "Precursor
to H.I.V. Was in Monkeys for Millennia". New York
Times. Retrieved 2010-09-17.
Zhu, T., Korber, B. T., Nahmias, A. J., Hooper, E.,
Sharp, P. M. and Ho, D. D. (1998). "An African HIV-1
Sequence from 1959 and Implications for the Origin of
the epidemic". Nature 391 (6667): 594–7.
Kolata, Gina (28 October 1987). "Boy's 1969 Death
Suggests AIDS Invaded U.S. Several Times". The New
York Times. Retrieved 11 February 2009.
"The emergence of HIV/AIDS in the Americas and
beyond.".
Centers for Disease Control (CDC) (June 1982). "A
cluster of Kaposi's sarcoma and Pneumocystis carinii
pneumonia among homosexual male residents of Los
Angeles and Orange Counties, California". MMWR
Morb. Mortal. Wkly. Rep. 31 (23): 305–7.
Centers for Disease Control (CDC) (June 1981).
"Pneumocystis pneumonia—Los Angeles". MMWR
Morb. Mortal. Wkly. Rep. 30(21): 250–2. PMID 6265753.
Masur H, Michelis MA, Greene JB, et al. (December
1981).
"An
outbreak
of
community-acquired
Pneumocystis carinii pneumonia: initial manifestation
of cellular immune dysfunction". N. Engl. J. Med. 305
(24): 1431–8.
Gottlieb MS, Schroff R, Schanker HM, et al. (December
1981)."Pneumocystis carinii pneumonia and mucosal
candidiasis in previously healthy homosexual men:
evidence
of
a
new
acquired
cellular
immunodeficiency". N. Engl. J. Med. 305 (24): 1425–31.
Friedman-Kien AE (October 1981). "Disseminated
Kaposi's sarcoma syndrome in young homosexual
men". J. Am. Acad. Dermatol. 5 (4): 468–71.
Hymes KB, Cheung T, Greene JB, et al. (September
1981). "Kaposi's sarcoma in homosexual men-a report
of eight cases".Lancet 2 (8247): 598–600.
Basavapathruni, A; Anderson, KS (December 2007).
"Reverse transcription of the HIV-1 pandemic". The
FASEB Journal 21 (14): 3795–3808.
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pISSN: 0976 3325 eISSN: 2229 6816 ORIGINAL ARTICLE .
STUDY OF IMPORTANT PSYCHOSOCIAL FACTORS IN
INSTITUTIONALIZED BLINDS
Uddhav T. Kumbhar1, Armaity Dehmubed2
1Assistant
Professor, Department of P.S.M., Bharati Vidyapeeth University, Medical College &
Hospital, Sangli – 416 414 Maharashtra 2Associate Professor, Department of P.S.M., G.S.M.C. & KEM
Hospital, Parel, Mumbai
Correspondence:
Dr. Uddhav T. Kumbhar
Assistant Professor, Department of P.S.M.,
Bharati Vidyapeeth University, Medical College & Hospital,
Sangli – 416 414 Maharashtra
Email: [email protected]
ABSTRACT
Background: Blindness probably is the most feared infirmity of mankind. The blind individuals were
considered useless for the centuries till recent development in culture and civilization. Present study
was conducted with the aim to study important psychosocial aspects of blinds undergoing formal
vocational training in institutes. Objective: to identify candidates’ psychosocial profile using Self
Reporting Questionnaire (S.R.Q.). Materials and Methods: it was a cross sectional study conducted in
two vocational training institutes for blinds (one for males and other for females) in Mumbai. The
individuals were subjected to pre tested S.R.Q. and the individuals found positive with this tool and
double the number of matched S.R.Q. negative controls from the institute were subjected to
psychiatric examination done by qualified psychiatrist. Analysis: analysis was done using fisher’s
exact test and chi square test results: 15 (7.18%) blinds were found S.R.Q. positive indicating they
either have or prone to have psychiatric morbidity. Conclusion: Psychological rehabilitation of the
blinds should be considered before planning the vocational training of blinds.
Key words: S.R.Q., Psychiatric Morbidity, Psychological Rehabilitation
INTRODUCTION
“The
Biggest
Disease Today Is
Not
TB/HIV/AIDS But The Feeling Of Being
Unwanted.”1
Man predominantly is a visual animal. Our
language reflects this primacy of vision in our
life. Words like ‘light,’ ‘bright’ & ‘glowing’ have
positive connotations, whilst ‘darkness’ is a
metaphor for ignorance or evil. Therefore it is
for no surprise that loss of vision has a
devastating effect on person’s health.2
From ancient times, blindness like other
handicaps has been the cause of fear and
rejection throughout the world. For centuries
together blinds were considered useless to
themselves and to the society and hence they
were deprived of all social status and were
rejected.3
Blindness has always been one of the most
feared of physical infirmities and therefore the
problems of blinds are not only physical and
economical, but also social and psychological.
Social Life of Blind:
The position of blind child is peculiar, not
normal. His arrival is generally regarded as
‘misfortune’ by the poor family. In the rich
family though he is a source of distress, he is an
object on which wealth is lavished. In one case,
he is economic burden; in the other, he
commands ‘luxurious indulgence’ by arousing
the sympathetic sentiments of the family. In
both cases he develops abnormal personal traits.
In the poor uneducated home, he is not
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 504
pISSN: 0976 3325 eISSN: 2229 6816 understood and is purposely neglected; in the
rich home, he is patted and pampered to
noticeable neglect of his sighted brothers and
sisters. This over fondness and partiality on the
part of parents are detrimental to the proper
growth and development not only of the blind
child but also of his normal siblings. Because of
lack of factual and conceptual experiences in the
home environment, a blind child may appear to
be retarded. Social life of the blind school pupils
consist mostly of their relationship with one
another and their surroundings. The attitude of
neighbors, social circles will have definite
impact on their behavior. Their visual disability
will force them to change their lifestyle in
various fields like education, recreation and also
their hunt for job will have a lot of impact on
their day to day thinking. Their rehabilitation
has a big role in their personality development
so when they are in training institutes they will
like training in the fields where they find they
could get lucrative earning with that knowledge.
All Those aspects which were deemed to have
substantial direct impact on the prognosis of
rehabilitation process were selected for the
study
METHODOLOGY
The study was conducted in the two vocational
training institutions in Mumbai one for the men
and other for the women. Written permission
was obtained from respective authorities of
institutions for conducting the study. All the
blinds enrolled in these two institutions at the
time of the study were included. Information
was given to all blinds included in the study
about types of questions and answers were
obtained by interview technique.
A detailed pre-tested pro forma was used which
consist of Demographic information, General
clinical examination, Psychological aspects,
Attitude of the subjects towards life and social
attitudes of parents, spouses, neighbors and
society.
General clinical examination was done only to
build rapport with subjects. For studying
psychological aspects S.R.Q.4 i.e. Self Reporting
Questionnaire was used. All S.R.Q. positive
subjects and a double number of matched S.R.Q.
negative subjects from the institutes were
examined by qualified psychiatrist for finding
out psychiatric morbidities. S.R.Q. status of the
subjects was not made known to the examining
psychiatrist.
RESULTS AND DISCUSSION
Table 1: Candidates’ response to question
regarding adequacy of training programme
Candidates response
Good
Satisfactory
Not satisfactory
Total
Percent
28.71
32.06
39.23
100
Most candidates were not satisfied with the
disciplines they were trained in the institutes
and wanted some new or modified disciplines
like computer education, industrial training to
be included in their tenure. These views of the
blinds though suggest their positive attitude to
walk with time but it is doubtful how much they
will be benefited with it; because even though it
is proved that blinds can efficiently do most of
the work sighted can do it is said, ‘employer’s
perception of inability is often the biggest
limitation that people who are blind face’ and
this attitude need to be changed. 5
Table 2: S.R.Q. results in subjects
S.R.Q. Result
S.R.Q. +VE
S.R.Q. –VE
Total
Number
15
194
209
Percent
7.18
92.82
100
7.18 % of the total 209 study subjects were S.R.Q.
positive and were prone to have psychiatric
morbidity. These individuals when subjected to
psychiatric examination with double the number
of S.R.Q. negative individuals following results
were obtained.
Table 3: S.R.Q. result and psychiatric diagnosis
S.R.Q. Results
Morbidity Morbidity Total
present (%) absent (%)
S.R.Q. Positive
10 (83.33 )
2 (8.33 )
12
S.R.Q. Negative
2 (16.67 ) 22 (91.67 ) 24
Total
12*
24
36
* 3 S.R.Q. positive subjects couldn’t be examined
due to death in 1 and inability to follow in other
2 cases.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Number
60
67
82
209
Page 505
pISSN: 0976 3325 eISSN: 2229 6816 Remaining 12 out of 15 S.R.Q. positive subjects
and double number i.e. 24 matched S.R.Q.
negative subjects were subjected to psychiatric
clinical exam to find psychiatric morbidity.
When S.R.Q. positive results were correlated
with psychiatric morbidity using Fisher’s exact
test there was statistically significant difference
between the two (P = 0.00000147). The result
here indicates that significantly high proportions
of cases were conglomerated in true positive
and true negative categories. This would mean
that S.R.Q. results served as a good indicator of
psychiatric morbidity.
25
20
22
SRQ Positive
SRQ Negative
15
10
5
10
2
2
0
Morbidity Present
Morbidity Absent
Fig 1: S.R.Q. Results and Psychiatric Diagnosis
As mentioned in the methodology all S.R.Q.
positive subjects and a double number of
matched S.R.Q. negative subjects were subjected
to psychiatric clinical examination by qualified
psychiatrist. When S.R.Q. results were co-related
with psychiatric diagnosis using Fisher’s exact
test of significance, there was statistically
significant difference between the two (P =
0.00000147).
It was observed that subjects
having psychiatric morbidity belonged to
diagnostic categories of ICD-10 classification6 of
mental and behavior disorders with morbidities
such as disthymic disorder, mixed anxiety and
depressive disorder, anxiety and dependent
disorder and adjustment disorder.7
Bansal et al8 in their study observed that
visually
handicapped
subjects
showed
significantly high scores in the areas of
depression and tension. Fitzgerald 9 in his study
found that blind goes through phases of
disbelief, protest, depression and finally
recovery.
The result here indicates that significantly high
proportions of cases were conglomerated in true
positive and true negative categories. This
would mean that S.R.Q. results served as a good
indicator of psychiatric morbidity. As revealed
in the table 83.33 % of S.R.Q. positive subjects
were confirmed to be having psychiatric
morbidity, while 91.67 % S.R.Q. negative
subjects did not have any psychiatric morbidity.
RECOMMENDATION AND CONCLUSION:
The institutions are doing commendable job by
bringing the blinds in the main stream of
society. They are helping make the blinds self
reliant and thus increasing their self esteem.
These institutions are the places where blinds
start to learn newer skills and newer job options.
It now becomes responsibility of society and
government to provide these blinds with the aid
in whatsoever form so that they cease to be a
burden to society.
Candidates completing training in the institutes
should
be
assured
income
generating
opportunities like financial support for utilizing
their newly acquired skills in starting small scale
businesses. Such institutions can be in
collaboration with private firms train these
individuals in various activities with which their
firms can be benefited and blinds can get job
placements.
All vocational training centers for blind should
be persuaded to incorporate psycho-social
screening of newly admitted trainees, before the
actual training process is started. These
individuals should again be subjected to such
type of screening in the midterm and at the end
of the training program so that if any risk factor
found can be taken care and purpose of these
institutes will be accomplished.
REFFREENCES
1.
2.
3.
4.
5.
6.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Fasina F O, Ajaiyeoba A I. The prevalence and causes
of blindness and low vision in Ogun state, Nigeria.
African journal of biomedical research. 2003;6:63-7.
J S Gill. For Your Eyes Only. Indian Journal of
Community Medicine 1994; 19 (2): 68-71
Roy I. S. Changing pattern of blindness and its
prevention Indian J. of Public health. 1984; 28(4):221-6.
Mari J.J. and Williams P. A validity study of a
psychiatric screening questionnaire, (S.R.Q.-20) in the
primary health care in the city of Sao Paulo, British J
psychiatry. 1986; 148:23-26.
Independent Living Research Utilization publication what blind can do?. Available on www.dlrp.org . Accessed on 1st Dec, 2011.
International Statistical Classification of Diseases (ICD)
and Related Health Problems 10th Revision Version for
Page 506
pISSN: 0976 3325 eISSN: 2229 6816 9.
associated with visual impairment. Indian J psychiatry.
1980; 22:173-175.
Fitzgerald R.G. Reactions to blindness. An exploratory
study of adults with recent loss of sight. American J
Psychiatry 1970; 22: 370-379.
National Journal of Community Medicine Vol 2 Issue 3 Oct-Dec 2011
Page 507
7.
8.
2006.
Available
on
http://www.who.int/classifications/icd/en/. Accessed on
1st Dec, 2011.
Ray, Dutta S. Social stratification of mental patients.
Indian Journal of Psychiatry 1962; 4: 3.
Bansal R.K., Jain I.S., Kohli T.K. Psychological factors
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