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INDIAN JOURNAL OF PUBLIC HEALTH(Quarterly Journal of Indian Public Health Association)

Indian Journal of Public Health is published quarterly by IndianPublic Health Association.

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Editorial BoardChief EditorDr. V. K. Srivastava

EditorDr. Samir Dasgupta

Associate EditorDr. R. N. ChaudhuriDr. Sanjay Chaturvedi

Joint EditorDr. D. K. RautDr. A. B. Biswas

Assistant EditorDr. Kaushik MishraDr. Prabir Kumar Sen

Managing EditorDr. Dilip Kumar Das

Assistant Managing EditorDr. Rabindra Nath Sinha

MembersDr. D.H. Ashwath NarayanaDr. (Lt.Col.) Atul KotwalDr. B. M. VashishtDr. N. K. GoelDr. Prasant Kr. SabothDr. D. M. SatpathyDr. Chitra ChatterjeeDr. Rabindra Nath RoyDr. Ashok Kr. MallickDr. Kunal Kanti Majumdar

Secretary General (Ex-officio)Dr. (Mrs.) Madhumita Dobe

Vol. 52 No.3 July - September 2008Journal Advisory Committee

Dr. Deoki NandanDr. Sandip Kumar RayDr. Ranadeb BiswasDr. F. U. AhmedDr. J. Ravi KumarMrs. Shuva Kumari

Indian Journal of Public HealthVol.52 No.3 July - September 2008

ContentsEditorialInjury: the most Underappreciated and Unattended Pandemic 115Sanjay Chaturvedi

Original ArticlePrevalence of Risk Factors for Non-Communicable Diseasein a Rural Area of Faridabad District of Haryana 117A. Krishnan, B. Shah, Vivek Lal, D. K. Shukla, Eldho Paul, S. K. KapoorEpidemiology of Disability in a Rural Community of Karnataka 125K. S. Ganesh, A. Das, J. S. ShashiElimination of Iodine Deficiency Disorders – Current Status inPurba Medinipur District of West Bengal, India 130A. B. Biswas, I. Chakraborty, D. K. Das, A. Chakraborty, D. Ray, K. Mitra

Special ArticleIntegrated Diseases Surveillance Project (IDSP) Through a Consultant’s Lens 136K. Suresh

Short CommunicationHypertension and Epidemiological Factors among Tribal LabourPopulation in Gujarat 144Rajnarayan R TiwariRespiratory Morbidity among Street Sweepers Working at HanumannagarZone of Nagpur Municipal Corporation, Maharashtra 147Sabde Yogesh D, Sanjay P ZodpeyNeedle Sticks Injury among Nurses Involved in Patient Care: A study inTwo Medical College Hospitals of West Bengal 150G. K. Joardar, C. Chatterjee, S.K.Sadhukhan, M.Chakraborty, P. Das, A.MandalDietary Profile of Sportswomen Participating in Team Games atState/National Level 153Ritu Jain, S. Puri, N. SainiPerception Regarding Quality of Services in Urban ICDS Blocks in Delhi 156A. Davey, S. Davey, U. DattaA Study on Delivery and Newborn Care Practices in a Rural Blockof West Bengal 159P. Das, S. Ghosh, M. Ghosh, A. MandalHospitalisation due to Infectious and Parasitic Diseases inDistrict Civil Hospital, Belgaum, Karnataka 161A. C. Naik, S. Bhat, S. D. Kholkute

Review ArticleHomelessness: A Hidden Public Health Problem 164S. Patra, K. Anand

Letter to the Editor:HIV/ AIDS Awareness through Mass Media – the Measurement of EffortsMade in an Urban Area of India 171Hem Chandra, K. Jamaluddin, L. Masih, K. Faiyaz, N. Agarwal, D. KumarUndernutrition in 5-10 Year Olds: Experiences from a PHC in Pondicherry 172S. Sarkar, S. Ananthakrishnan

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Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Editorial

Injury: the most Underappreciated and Unattended PandemicInjury accounts for 9% of global mortality and

12% of the global burden of disease in terms ofdisability adjusted life years (DALY) lost. They figurein the leading causes of death throughout the worldand yet remain the most underappreciated pandemic.Every year, an estimated 5 million people die frominjury1. Road traffic injury (RTI) alone accounts for25% of mortality and 22% of DALY lost. Ranked 9th

in terms of worldwide burden, they are projected toascend to 3rd rank by 20202. In many parts of theworld, injury related database is thin and the real loadmay be heavier than the estimates. For every injuryrelated mortality, several thousand more requirehospital treatment and suffer with impairments,frequently with disabling consequences. Injury affectsthe productive work force, youth and school-goingchildren the most. It follows the inverted U-shapedcurve with age. Almost 50% of injury related mortalityis borne by 15-44 years age group. Under-five childrenaccount for 25% of drowning deaths and over 15% offire-related deaths. Males bear the major brunt in allages, gender difference being the highest in 15-44 yearsage group. Mortality from RTI and interpersonalviolence is about 3 times higher among males thanthat in females. Reducing the burden of injury is goingto be one of the main challenges for public health inthis century. In terms of cost, RTI alone accounts for1-2% of the gross national product to most of thecountries. For the low and middle-income countries(LMICs), this exceeds the total developmental aidreceived by them. Assessment of direct and indirectcosts of injury involves complex methods that areseldom free of limitations and compromises. Whatgenerates a great deal of discussion is the economicquantization of human life. Putting monetary valueson pain, suffering and death is ethically unacceptableto many.

The burden of injury related mortality andmorbidity is comparatively very high in low and middle-income countries (LMICs). Over 90% of this burden isborne by such countries. Recent evidence suggests thatvictims of life-threatening but salvageable injury havesix times higher probability of death in a low-income

setting3. South-East Asia (SEA) alone bears 31% ofthe world’s burden of injury and 27% of injury relatedmortality. Thousands of children saved from infectiousand nutritional diseases are killed or crippled by injuryin this region. RTI is the biggest culprit in most of thesecountries - total regional share in the global burden ofRTI being 34%4. It is also estimated that SEA regionaccounts for 57% of the global burden of burn injuryand 53% of burn mortality1. In Bangladesh andMaldives, drowning is the commonest cause ofaccidental deaths. India specific information base oninjury is also very weak and the published data is hardto come by. The latest published review on RTI in Indiahas estimated 2-5 million hospitalizations and over100,000 deaths in 2005. RTI alone accounts for 10-30% of all hospitalizations, being highest in the stateof Tamilnadu and lowest in Nagaland5.

If we take a stock of our response to this ongoingpandemic, the situation looks scary. Let us start withinfo-capture and surveillance. In the absence of atrauma registry system, the injury related informationis not uniformly or systematically captured, analysedor disseminated in several South Asian countries,including India. Even in the tertiary care facilities –where there are functioning medical record divisions –the distal recording units, like emergency rooms, areunable to optimally utilise the provisions provided inChapters XIX & XX of ICD-106 for coding andclassification of injury. Several circumstantial attributes,which are essential for subsequent coding andclassification, are not optimally captured in the distalrecording units. Besides the 3 character alpha-numericcore code, which is mandatory for any internationalreporting, Chapter XX – a newer feature of ICD 10,provides an additional ‘e-code’ for all cases of injury7.This code is about the external cause of injury, and isa significant information for injury surveillance. Noproximal data management facility can generate thise-code once the required information is lost at the distalcapture unit. This is a huge gap in the injury surveillanceprocess, right at the data-generation level. The initialstep in this direction would be to develop sentinel unitsfor injury surveillance in most of the tertiary and

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secondary care hospitals – before going for the goal ofestablishing the ‘National Trauma Registry of India’.Certain short term activities can be identified andoperationalized, e.g.: framing the case definitions;development of data collection tool; development ofdata capture process, protocol, and infrastructure; andidentification and training of stakeholders. The longterm activities would constitute: quality assurancemechanisms; evaluation; knowledge transfer andcollaboration.

The next or parallel step should be to initiate andsustain a population-based programme on injuryprevention. Advocacy starts with identification ofstakeholders. A felt need for such a programme is tobe created so that the programme gains widest possibleacceptance and support. The conceptual frameworkof a ‘National Injury Prevention Programme’ must beinclusive in character to accommodate all the significantactors and agencies. This collaborative network shouldbe most visible at the district and sub-district levels.Governments which improve the organization of injuryprevention services benefit from reduced injury relatedburden, as compared to similarly resourcedgovernments which do not. With improved andsystematic response towards injury prevention, therange of reduction in the mortality alone will bearincremental rewards. Benefit in terms of DALY savedwill go manifold. Such a national response to theproblem of injury is yet to materialize in manydeveloping countries. The rationale to initiate apopulation-based national programme on injuryprevention is quite strong and visible. It just needs tobe effectively advocated.

References:

1. WHO. The injury chart book: a graphicaloverview of the global burden of injuries. Geneva:WHO; 2002.

2. WHO. World report on road traffic injuryprevention. Geneva: WHO; 2004.

3. Rivara FP, Mock C. The 1,000,000 lives campaign(editorial). Inj Prev. 2005;11:321-3.

4. WHO-SEARO. Strategic plan for injury preventionand control in South-East Asia. New Delhi:WHO-SEARO; 2002.

5. Gururaj G. Road traffic deaths, injuries anddisabilities in India: current scenario. Natl Med JIndia 2008;21:14–20.

6. WHO. International statistical classification ofdiseases and related health problems – tenthrevision (ICD-10). vol. 1. Geneva: WHO; 1992.

7. WHO. Foundations and fundamentals of injuryprevention and control, and safety promotion(section 1, lesson 1). In: TEACH VIP [CD-ROM].Geneva: WHO; 2005.

Sanjay ChaturvediAssociate Editor, IJPH &

Professor of Community Medicine,University College of Medical Sciences and GTB

Hospital, Delhi E-mail: [email protected]

Editorial: Injury: the most Underappreciated and Unattended Pandemic

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Introduction

Non- communicable diseases (NCDs) contributed60% of deaths and 43% of global burden of disease inthe year 2002, and by 2020, are projected to accountfor 73% of deaths and 60% of disease burden1. Clearly,NCDs can no longer be regarded as a problem confinedto the developed countries and urban society.Affluence, progressive ageing of population, improvingsocio-economic conditions and changed life styles havecaused an increase in non-communicable diseases andthese are spreading to rural areas as well and theseneed to be documented to dispel myths that NCDs

Original article

Prevalence of Risk Factors for Non-Communicable Diseasein a Rural Area of Faridabad District of Haryana

*A. Krishnan1, B. Shah2, Vivek Lal3, D. K. Shukla4, Eldho Paul5, S. K. Kapoor6

1Associate Professor, Centre for Community Medicine, AIIMS, New Delhi; 2Senior Deputy Director General (NCDs),Division of Non Communicable Diseases, ICMR, New Delhi; 3Junior Resident, Centre for Community Medicine, AIIMS;4Deputy Director General, Division of Non Communicable Diseases, ICMR; 5Statistical Assistant, Centre for communitymedicine, AIIMS; 6Professor Emeritus, Community Health Departt, St Stephens Hospital, Delhi.*Corresponding author: [email protected]

are a problem only in urban areas.

Together NCDs (cardio-vascular diseases, cancer,chronic obstructive pulmonary diseases and diabetes)accounted for 42.7% of deaths in 2000 in India2. Theseare linked by common risk factors related to lifestylelike tobacco use, unhealthy diet, physical inactivity,obesity, high blood pressure, raised cholesterol andglucose levels. These risk factors are measurable andlargely modifiable and thus continuing surveillance ofthe levels and patterns of risk factors is of fundamentalimportance to planning and evaluating preventiveactivities in the control of NCDs.

Abstract

Background & Objectives: To estimate the prevalence and levels of common risk factors for non-communicable disease in a rural population of Haryana. Methods: The study involved a surveyof 1359 male and 1469 female respondents, aged 15-64 years. Multistage sampling was used forrecruitment (PHCs/ sub-centres/ villages). All households in the selected villages were covered,with one male and one female interviewed in alternate household. WHO STEP- wise tool wasused as the study instrument which included behavioural risk factor questionnaire and physicalmeasurements of height, weight, waist circumference and blood pressure. The age adjustingwas done using rural Faridabad data from Census 2001. Results: The age adjusted prevalence ofdaily smoked tobacco was 41% for men and 13% for women. Daily smokeless tobacco use was7.1% and 1.2% for men and women respectively. The prevalence of current alcohol consumptionwas 24.6% among men and none of the women reported consuming alcohol. The mean numberof servings of fruits and vegetables per day was 3.7 for men and 2.7 for women. The percentageof people undertaking at least 150 minutes of physical activity in a week was 77.8% for men and54.5% for women. Among men 9.0 % had BMI > 25.0 compared to 15.2% among women. Theprevalence of measured hypertension, i.e. >140 SBP and/or >90 DBP or on antihypertensivedrugs was 10.7% among men and 7.9% among women. Conclusion: The study showed a highburden of tobacco use and alcohol use among men, inactivity and overweight among womenand low fruit and vegetable consumption among both sexes in rural areas.

Key words : Alcohol, BMI, Hypertension, Physical inactivity, Risk factors, Rural, Tobacco.

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An integrated approach to risk factor surveillanceis vital for NCD control. Surveillance of NCD riskfactors as currently practiced in India has largelyfocused on separate risk factors like tobacco, alcoholor diet. Very few studies have been undertaken toassess physical activity. There is a felt need to have acomprehensive look at the NCD risk factors usingstandard methodology to ensure comparability. Suchtools have recently been developed by WHO and arebeing used by health planners to generate evidencefor advocacy.

Comprehensive Rural Health Services Project(CRHSP), Ballabgarh run by All India Institute ofMedical Sciences (AIIMS) was among the sites whereit was pilot tested and later became a part of themulticentric surveillance site coordinated by IndianCouncil of Medical Research (ICMR). As part of thiswe studied a rural population of Haryana forprevalence of common risk factors of NCDs using WHOSTEPS approach. We report the results of this surveyhere.

Material and methods

We conducted a survey in the rural area ofBallabgarh, in Faridabad district of Haryana from April2003 to January 2004. A total of 2500 participantswere aimed at, with 250 in each age (15-24, 25-34,35-44, 45-54 and 55-64) and sex group. Multistagesampling was used for the purpose of recruitment. TwoPHCs were selected randomly from among a total of5 PHCs in the block. Thereafter, one sub-center in eachPHC was selected randomly. One village was randomlyselected from the list of villages in the sub-center. Ifthe village was small, an additional village was selectedfrom the same sub-center. All the households in theselected villages were covered, with one male and onefemale being interviewed in alternate households. Theselection of the male/female was from the list of eligiblein that house and was done in a random manner. Ifneed be, the household was revisited a second time atleast one of which was on a different day/time.

The WHO STEP-wise tool was used and thebehavioural risk factor Questionnaire was suitablymodified and translated in local language. It includedquestions on socio-demographic status, data ontobacco and alcohol use, measures of dietary habitsand physical inactivity. Standard procedure was

followed as per STEPs protocol for anthropometric andblood pressure measurements. The height wasmeasured using adult portable stadiometer to thenearest 0.1 cm. SECA digital weighing scales were usedto measure weight of the individuals and was recordedin kilograms up to 0.1 kg. A SECA constant tensiontape was used to measure Waist circumference to thenearest 0.1 cm. The blood pressure was measured usingOMRON digital automatic blood pressure monitor. Allmeasurements were done at domiciliary level. Threemale and three female workers were trained by a teamof ICMR and were regularly supervised by theinvestigators and ICMR team.

Definitions: (Source- WHO STEPS manual3)Current daily smokers were defined as those whowere currently smoking cigarettes, bidis orhookah daily.Current daily smokeless tobacco users weredefined as those who were currently usingchewable tobacco products, gutka, naswar, khainior zarda paan daily.Current alcohol drinkers were defined as thosewho reported to consuming alcohol within thepast one year.One standard drink was equivalent to consumingone standard bottle of regular beer (285 ml), onesingle measure of spirits (30 ml) or one mediumsize glass of wine (120 ml).One serving of vegetable was considered to be 1cup of raw green leafy vegetables, ½ cup of othervegetables (cooked or chopped raw) or ½ cup ofvegetable juice.One serving of fruit was considered to be 1medium size piece of apple, banana or orange,½ cup of chopped, cooked, canned fruit or ½cup of fruit juice, not artificially flavoured.Physical inactivity was defined as less than 10minutes of activity at a stretch, during leisure, workor transport.Body mass index (BMI) was calculated by dividingthe weight (in kilograms) by square of height (inmeters). Overweight was defined as BMI ³ 25 and< 30Obesity was defined as BMI ≥ 30Hypertension was defined as BP ≥ 140/≥ 90 orcurrently on antihypertensive drugs.

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

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Ethical clearance for the study was obtained fromAIIMS. Written informed consent was obtained fromeach participant. The results of the measurement wereprovided to the respondents and all case needingreferral were referred to the Civil Hospital at Ballabgarhto consult a physician. Data were enteredsimultaneously. An independent data entry operatordid the reentry of 10 percent data and these werevalidated. The data was analyzed using SPSS forwindows (version 10.0). The age standardizedpercentages for the target age group were computedusing rural Faridabad data from Census 2001.

Results

A total of 1359 men and 1469 women wereincluded in the survey. Among the men, majority wereunskilled or landless labourers (23.95%). Of thewomen, 96% were housewives. About 38% of the menhad studied up to high school, as against 11.1% whohad never been to school. Majority of women hadnever attended school (56.6%), while only 10% hadstudied beyond 8th standard.

Tobacco & alcohol use (Table 1)

The age-adjusted prevalence of daily smoked andsmokeless tobacco use in men was 41.0% and 7.1%respectively. The same for women was 13.0% and1.2% respectively. For men, smoked tobacco use was

highest in 45-54 years age group, whereas smokelesstobacco in the forms of khaini, gutka, snuff and chewedtobacco was most prevalent in 25-34 years age group.There was a steep rise in daily smoking of tobaccoafter 24 years of age from 9.4% in 15- 24 years agegroup to 46.6% in 25- 34 years age group. Thereafterthere was a gradual rise to a peak of 72.2% at 45-54years age group. The prevalence then showed a declinein the later age group. For women both smoked andsmokeless tobacco use was more common in the olderage group of 55-64 years. The median age for startingto smoke among men was 20.0 yrs (IQR 17.0-25.0),while the median duration of smoking was 20.0 yrs(IQR 10.0-29.4). The median age for starting to smokeamong women was 31.0 yrs (IQR 25.0-40.0), whilethe median duration of smoking was 12.9 yrs (IQR5.0-22.0). Smoking tobacco in the form of bidis wasthe most common with the mean number of bidissmoked per day among men being 6.1 and amongwomen being 0.7. Khaini was the commonest form inwhich smokeless tobacco was consumed, among bothmen and women.

None of the women reported consuming alcohol.The prevalence of ever alcohol consumption amongmen was 29.0% and that of current alcoholconsumption was 24.6%. The difference between thetwo was maximum at the age of 55-64 years. Theprevalence was highest in the 35-44 years age group.The current alcohol consumers comprised 84.8% of

Table 1. Prevalence of tobacco use and alcohol use by age & sex

Age in years Men Women Men*Daily Daily Daily Daily Ever Current

smoked smokeless smoked smokeless alcohol alcoholtobacco use tobacco use tobacco use tobacco use consumption consumption(n=1359) (n=1359) (n=1469) (n=1469) (n=1359) (n=1359)

15-24 9.4% 6.5% 0.4% 0.4% 10.0% 9.4%

25-34 46.6% 10.1% 7.3% 0.2% 32.8% 29.7%

35-44 63.8% 6.8% 18.2% 1.7% 47.5% 41.5%

45-54 72.2% 4.9% 34.5% 1.8% 44.1% 34.8%

55-64 67.4% 4.3% 38.7% 4.9% 36.2% 20.2%

Age adjusted 41.0% 7.1% 13.0% 1.2% 29.0% 24.6%prevalence** (38.4-43.7) (5.8-8.6) (11.3-14.8) (0.6-1.8) (26.5-31.4) (22.3-27.0)

* None of the women reported alcohol consumption, **95% Cl values in parenthesis


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those who had ever consumed alcohol. The meannumber of drinks consumed in the past 7 days was12.0 (95% CI 9.2- 14.9). This was highest in the agegroup 45- 54 yrs. A total of 4.6% men consumed, morethan or equal to 5 drinks on any day, in the last week.

Men were consuming more fruits and vegetablesthan women in any age group. The mean number ofservings of fruits and vegetables per day was 3.7(95%CI 3.6-3.8) for men and for women, it was 2.7(95% CI 2.6-2.8). The proportion of men consuming>5 servings of fruits and vegetables per day was 6.6%,while only 1.8% women reported to consuming thismuch amount. Across the age groups, mean numberof servings of fruits and vegetables consumed per daywere similar. The mean number of days in a week whenfruits were consumed was 2.05 (95% CI 1.93-2.16)for men and for women was 1.46 (95% CI 1.36-1.56).

Physical inactivity (Table 2)

The physical inactivity was highest during leisuretime and was least during transport from one place toanother for both men and women. The percentage ofpeople undertaking at least 150 minutes of physicalactivity in a week was lesser for women (54.5%) thanfor men (77.8%) among all age groups. Such level ofphysical activity was highest in the age group 35-44years (81.9% and 72.9% for men and womenrespectively) and lowest in 55-64 years age group(70.2% and 37.9% for men and women respectively).The mean duration of physical activity in minutes forall male subjects for a week was 1103.6 (95%CI1068.5-1192.7) and 781.4 (95%CI 730.9-832.0) forall women. This was more in the age group 35-44 yearsfor both men and women.

Table 2. Pattern of physical inactivity by domains

Age in years Men WomenLeisure Work Transport Leisure Work Transport

(n=1359) (n=1359) (n=1359) (n=1469) (n=1469) (n=1469)

15-24 79.2% 71.4% 15.5% 95.4% 74.1% 54.9%

25-34 89.7% 50.9% 21.0% 99.5% 55.5% 41.1%

35-44 87.5% 43.8% 20.0% 97.3% 39.7% 30.6%

45-54 87.0% 49.1% 19.3% 97.0% 57.1% 41.1%

55-64 90.4% 58.5% 23.2% 98.4% 71.8% 67.5%

Age adjusted 85.2% 57.2% 18.8% 97.3% 59.9% 45.7%Total (95% Cl) (83.1-86.9) (54.4-59.8) (16.7-20.9) (96.3-98.0) (57.4-62.4) (43.1-48.2)

Table 3. Distribution BMI & waist circumference by age & sex

Age in years Men (n=1359) Women (n=1362)Mean BMI Mean waist Mean BMI Mean waist(95%CI) circumference (95%CI) circumference

(95%CI) (95%CI)

15-24 19.7(19.4-20.0) 72.2(71.5-72.9) 19.6(19.3-19.8) 68.7(68.0-69.4)

25-34 20.7(20.4-21.0) 77.8(76.9-78.8) 20.3(20.0-20.7) 71.9(71.0-72.9)

35-44 21.0(20.6-21.4) 81.5(80.2-82.7) 22.0(21.5-22.5) 77.4(76.0-78.7)

45-54 21.0(20.5-21.6) 82.6(80.9-84.3) 22.9(22.2-23.6) 81.1(79.2-83.0)

55-64 20.7(19.9-21.5) 82.3(79.9-84.7) 22.421.5-23.3) 83.4(81.2-85.7)

Age adjustedmean 20.4(20.2-20.6) 77.4(76.9-77.9) 21.0(20.7-21.2) 74.3(73.7-74.9)


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Anthropometry (Table 3 & 4)

A total of 107 women were found to be pregnantand these were excluded for anthropometricexaminations. Both mean BMI and waist circumferencewas highest in 45-54 years age group for men. Forwomen, the mean waist circumference was highest in55-64 years, while mean BMI was highest in 45-54years age group. There was an increase in BMI among

women as compared to men after 25-34 years of agegroup and thereafter for all age groups; obesity wasmore common in women. Across all age groupsoverweight was more common among women thanmen. The prevalence of underweight was similar forboth men and women. After 35 years of age overweightand obesity combined was more than thinness amongwomen while thinness was consistently more prevalentthan overweight and obesity combined, for all age

Table 4 . Prevalence of thinness, overweight and obesity in the study subjects

Age Group Male (n=1359) Female (n=1362)BMI<18.5 BMI BMI BMI BMI<18.5 BMI BMI BM

18.5-24.9 ≥25.0—<30.0 ≥30 18.5-24.9 ≥25.0—<30.0 ≥30.0(%) (%) (%) (%) (%) (%) (%) (%)

15-24 36.3 59.8 2.9 1.0 37.2 57.5 5.3 0

25-34 21.9 69.5 7.5 1.2 32.8 56.3% 9.7% 1.2%

35-44 25.8 61.3 10.6 2.3 22.2 54.7% 17.9% 5.2%

45-54 25.6 59.5 13.0 1.9 16.8 52.7% 21.6% 9.0%

55-64 33.0 51.0 13.8 2.1 24.2 48.4 19.4 8.1

Age adjusted 29.1 61.9 7.5 1.5 29.1 55.8 12.1 3.1prevalence* (26.0-30.9) (59.6-64.8) (6.1-9.0) (1.1-2.6) (26.2-31.3) (52.9-58.3) (10.7-14.2) (2.4-4.3)

* 95% Cl values in parenthesis

Table 5. Distribution of mean systolic & diastolic BP & % hypertensive by age & sex

Age in years Men WomenMean systolic Mean diastolic % Hypertensive Mean systolic Mean diastolic % Hypertensive

BP BP (≥140/≥90 or on BP BP (≥140/≥90 or on(95% CI) (95% CI) antihypertensive) (95% CI) (95% CI) antihypertensive)

15-24 120.6 70.4 4.9 110.2 66.4 1.5(119.6-121.6) (69.7-71.2) (109.2-111.2) (65.6-67.1)

25-34 118.5 72.8 7.1 109.0 68.4 2.9(117.2-119.7) (71.8-73.8) (107.8-110.1) (67.4-69.4)

35-44 118.5 75.6 12.6 111.9 71.4 7.3(116.7-120.4) (74.4-76.9) (110.3-113.6) (70.2-72.6)

45-54 123.0 78.1 21.9 121.6 75.5 22.4(120.4-125.5) (76.3-79.8) (118.6-124.6) (73.7-77.3)

55-64 127.0 76.2 30.1 131.2 76.1 30.9(122.4-131.6) (73.7-78.8) (127.3-135.1) (74.2-78.0)

Ageadjusted 120.4 73.4 10.7 113.3 69.8 7.9mean (119.6-121.1) (72.8-73.9) (9.0-12.4) (112.5-114.1) (69.3-70.3) (6.6-9.4)


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groups among men. A total of 2.2% of men had waistcircumference ≥ 102 cm, which was most commonlyseen in the 55-64 years age. This was against the cut-off for women of ≥ 88 cm which was seen in 13.2%.Again it was more common in the 54-65 years agegroup.

Blood pressure (Table 5)The prevalence of self- reported hypertension was

3.5% in men and 6.8% in women, whereas theprevalence of hypertension (defined as BP ≥ 140/90or currently on antihypertensive drugs) was 10.7% inmen and 7.9% in women. The mean systolic anddiastolic blood pressure among men was 120.4 mmHgand 73.4 mmHg respectively. The same among womenwere 113.3 mmHg and 69.8 mmHg respectively. Therewas a sharp increase in prevalence of hypertensionamong women after 35-44 years age group. The hugemale and female difference in younger age groupsdisappeared post menopause. The prevalence of self-reported diabetes was 0.7% among men and 0.5%among women and showed an increasing trend withage.

DiscussionOur study presents the burden of major NCD risk

factors, in a rural area, using WHO STEPS approach.This is among the first sites to use this comprehensiveapproach to measure the NCD risk factor burden. Itwas not the purpose of this survey to compare thisburden with other risk factor specific surveys done bydifferent people at different places at different timesetc. However, some limited comparison from othersurveys would be meaningful to get an insight into theburden at national level.

Tobacco use in India is high and there areconsiderable differences in the types and methods bywhich it is used. A prevalence of 41% of daily smokersamong men was similar to that reported by NFHS 2for Haryana (40.6%)5, but in women our finding of13% is much higher than that of NFHS 2 (3.6%). Theprevalence of ever smokers in NFHS 2 was 42.4% and3.8% for men and women respectively. A survey oftobacco use in Karnataka and Uttar Pradesh (UP)found the prevalence of ever smoking in Karnataka tobe 33.1% among rural men and 0.6% among ruralwomen4. The prevalence of current smoking was31.2% and 0.6% among rural men and womenrespectively. In UP, the prevalence of ever smokingwas 28.3% among rural men and 2.9% among women.Current smoking showed a prevalence of 28.2% and

2.8% among men and women respectively. Similar toour study, others have also found that khaini and bidisto be the commonest form of tobacco use 4-6. Thedifference between ever use and current use was small,suggesting that tobacco use once initiated, is continuedand quitting of tobacco use is infrequent.

The steep rise in alcohol consumption from 9.4%in 15-24 years age group to 29.7% in 25-34 years agegroup could be due to the economic independencegained during this time in life. The consumption roseto a peak of 41.5% in 35-44 years age group, andgradually declined thereafter. Most of the men whoreported to having consumed alcohol ever in life, hadalso done so in the last one year indicating that fewpeople quit alcohol. Our prevalence rates were similarto that of NFHS 2 for Haryana5 (20.7% for men and0.1% for women) but lower than a previous studyconducted in Punjab, which reported a prevalence of58.3%7 for men and 1.5% for women. In our study,women did not report to consuming alcohol- a findingthat has also been shown by other studies 8,9.

Our study showed that women have a poorerdietary pattern than men for all the age groups, whichmay be a reflection of their poor social status10,11. It isironical that a low vegetable consumption is prevalentin a predominantly vegetarian community. Developingcountries are undergoing various types of transitions-epidemiological, socio-economic, demographic andnutritional. Earlier developing countries had a highprevalence of under-nutrition, but this era of transitionhas also brought a double burden of under-nutritionand over-nutrition in these countries12. Recent datafrom NFHS 2 identified a significant proportion ofIndian women as overweight, coexisting with high ratesof malnutrition. However, the survey was confined onlyto married women in reproductive age group andshowed a prevalence rate of 2.2% for women aged15-49 years using BMI>30.0. The only representativesurveys are the ones conducted by the Food andNutrition Board (i.e. District Nutrition Profiles survey)13, which have reported prevalence of 0.3% and 0.7%in rural men and women respectively, using a BMI cut-off of >30.0. The present study showed that 1.5% menand 3.1% women have obesity. Our study drawsattention to the fact that there exists a pool of womenwho were overweight in rural areas.

Our study showed that physical inactivity wasmore common among women across all domains.Maximum physical inactivity was during leisure timewhile most men were physically active during transport.This could be due to the fact that in rural areas bicyclesor walking are the still the usual mode of transport.


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Physical activity measurement at community level isdifficult with the existing instruments and thereforethese results would need to be interpreted with caution.However it does appear that contrary to generalimpression, physical inactivity is an emerging cause ofconcern in rural areas of India.

Our findings show a high burden of hypertensionamong elderly population. Men had a higherprevalence than women in all age categories. Ourfinding of 10.7% prevalence of hypertension in menand 7.9% in women is lower than that observed inother studies14. In a population-based survey carriedout during 1994-1995 in Raipur Rani block in the stateof Haryana, 4.5% were found to be hypertensive15.Women had significantly higher prevalence ofhypertension than men (5.8% vs 3.0%). This is contraryto our finding of lower prevalence of hypertension inwomen as compared to men across all age groups.

ConclusionOur study confirms the high burden of NCD risk

factors in rural areas and reiterates the need to addressthese issues comprehensively as a part of NCDprevention and control strategy. STEPwise approachof WHO offers an entry point for low and middleincome countries to initiate NCD surveillance, as itallows for the development of a flexible, increasinglycomprehensive and complex surveillance systemdepending on local needs and resources3. Furthersurveys are recommended based on this approach toensure data comparability over time and betweendifferent sites. It is also important to study trends ofvarious risk factors and Ballabgarh offers a sentinelsite for such activity to be conducted in future.

AcknowledgementThis work presents the results of one of the five

sites of the multi-site initiative of ICMR and the authorsacknowledge the contribution of investigators of theother four sites ( Dr. JC Mahanta, Dr. Thankappan,Dr. V Mohan and Dr. Prashant Joshi) in its planningand design. We also acknowledge the technicalguidance provided by WHO - particularly Dr. CherianVarghese ( WHO India), Dr. Jerzy Leowski WHO/SEARO) and Dr. Ruth Bonita ( formerly with WHO/HQ) and ICMR - Dr. Prashant Mathur and Dr. GeetaMenon.

References1. WHO. The World Health Report 2002- Reducing

risks, promoting healthy life. Geneva. WHO. 2002.

2. Ghaffar Abdul, Reddy K. Srinath, Singhi Monica.Burden of non- communicable diseases in SouthAsia. BMJ. 2004; 328:807-810.

3. WHO. STEPS: A Framework- The WHOSTEPwise approach to surveil lance ofnoncommunicable diseases (STEPS).WHO.2002.

4. Chaudhry K. Prevalence of tobacco use inKarnataka and Uttar Pradesh, India. Report.2001.

5. International Institute for Population Sciences(IIPS) and ORC Macro, India: National FamilyHealth Survey (NFHS-2), 1998-1999, Mumbai,India: IIPS. 2000.

6. Sinha Dhirendra N, Gupta Prakash C, PednekarMangesh S. Tobacco use in a rural area of Bihar,India. Indian Journal of Community Medicine.2003 Oct.-Dec; 28 (4): 167-70

7. Mohan D, Sharma HK, Sundaram KR, Neki JS.Pattern of alcohol consumption in rural Punjabmen. Indian Journal of Medical Research. 1980;72:702-711.

8. Sethi BB, Trivedi JK. Drug abuse in a ruralpopulation. Indian Journal of Psychiatry. 1979;21: 211.

9. Singh RB, Bajaj Sarita, Niaz Mohammad A,Rastogi Shanty S, Moshiri M. Prevalence of type2 diabetes mellitus and risk of hypertension andcoronary artery disease in rural and urbanpopulation with low rates of obesity. InternationalJournal of Cardiology. 1998;66: 65-72.

10. United Nations Population Fund. The state ofworld population 1997: the right to choose:reproductive rights and reproductive health. NewYork; UNFPA. 1997.

11. Anandalakshamy S. The Girl Child and theFamily. Department of Women and ChildDevelopment, Ministry of HRD; Government ofIndia, Delhi. 1994.

12. Kapoor SK, Anand K. Nutritional transition: apublic health challenge in developing countries.Journal of Epidemiology and Community Health.2002; 56:804-805.

13. Government of India; Department of Women andChild Development, Ministry of HumanResources. India Nutrition Profile. New Delhi;GOI. 1998.


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14. Gupta R, Gupta HP, Keswani P, Gupta VP, GuptaKD. Coronary heart disease and coronary riskfactor prevalence in rural Rajasthan. J AssocPhysicians India. 1994;42:24-6.


15. Malhotra P, Kumari S, Kumar R, Jain S, SharmaBK. Prevalence and determinants of hypertensionin an un-industrialised rural population of NorthIndia. J Hum Hypertens. 1999 Jul; 13(7):467-72.

53rd Annual National Conference of IPHA

Organized by

Department of Community MedicineKempegowda Institute of Medical Sciences (KIMS), Bangalore - 560 070

Theme : Changing Public Health Scenario in the 21st century

Dates : 8th January, 2009 (Thursday) - Preconference CME9th -11th January, 2009 - Conference(Friday, Saturday& Sunday)

Venue : Kempegowda Institute of Medical Sciences (KIMS), Bangalore.

Registration fees

Only A/c Payee Demand Draft will be accepted, cheques will not be accepted. Demand Draft shall be in the name of“53rd National Conference of IPHA”, payable at Bangalore. Please write your name, place, IPHA membership number(for members) and mobile number on the reverse of the bank draft.

Category Before 01-11-2008 Spot 531-10-2008 to15-12-2008

IPHA member 1 Rs. 1500 Rs. 1800 Rs. 2300Non-member Rs. 2300 Rs. 2600 Rs. 3100Retired member1 Rs. 1000 Rs. 1300 Rs. 1800IPHA member PG1& 2 & UG/ Interns 3 Rs. 800 Rs. 1100 Rs. 1800PG student (Non-member) 2 Rs. 1000 Rs. 1400 Rs. 2000Foreign delegates 4 US$ 100 US$ 125 US$150Institutional delegates2 2000 Rs. 2500 Rs. 3000

(18000 for ( 24000 for (29000 for10 Delegates) 10 delegates) 10 delegates)

Accompanying person6 Rs 1000 Rs 1500 Rs 2000(Spouse & Children only)Pre-conference CME Rs 300 Rs 500 Rs 700

1. Quote IPHA membership number.2. Recommendation letter from Head of Department / Head of Institution is compulsory.3. Recommendation letter from Head of Department and only for those whose papers are accepted for presentation.4. Or equivalent Indian currency.5. Conference kit will be provided subject to availability.6. Conference kit will not be provided.

Contact : Dr. B G Parasuramalu, Professor & HeadOrganizing Secretary - 53rd Annual National Conference of IPHA,Department of Community Medicine,Kempegowda Institute of Medical Sciences (KIMS),BSK 2nd Stage, Bangalore - 560070.(M) 0-99860-03467Email: [email protected]: www.iphaonline.org ; www.kimscommunitymedicine.org

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Introduction

Disability is one of the major public healthproblems of the developing countries, though the datacollected do not reflect the full extent of disabilityprevalence1, 2, 3. This limitation results from theconceptual framework adopted, the scope andcoverage of surveys undertaken, the definitions,classifications and the methodology used for thecollection of data on disability. In India, theimplementation of the strategy for people withdisabilities as stated in the disability act 1995 is beingvigorously perused by the Ministry of Social Welfareand all other concerned ministries4. Therefore it isappropriate time to take stock of the situation of thedisabled population in the country specially in ruralsector where around 80% of the disabled personsreside. Besides, prevalence studies will be useful toolfor developing community based rehabilitationprogrammes for disabled. In view of the above context,the present study was conducted to determine theprevalence and pattern of disability in all age groupsin a rural community of Karnataka.

Original Article

Epidemiology of Disability in a Rural Communityof Karnataka

*K. S. Ganesh1, A. Das 2, J. S. Shashi 3

1Assistant Professor, Community Medicine, Kasturba Medical College, Mangalore, Karnataka; 2Professor, CommunityMedicine, KS Hegde Medical College, Mangalore, Karnataka; 3Assistant Professor, Community Medicine, KMC,Manipal, Karnataka. *Corresponding author: [email protected].

Abstract

Objectives: To determine the prevalence and pattern of disability in all age groups in a ruralcommunity of Karnataka. Methods: A community-based cross-sectional study was conductedduring January-December 2004 among 1000 study subjects of all age groups selected randomlyfrom four villages under rural field practice area of a teaching institution. Subjects wereinterviewed and examined using a predesigned schedule. Percentage prevalence, chi square testand multiple logistic regression analysis were used for statistical analysis. Results: The prevalenceof disability was found to be 6.3%. Both physical and mental disabilities are of great concrn inthis area. 80% of the disabled had multiple disabilities. Knowledge and occupation plays a majorrole as determinants of disability. Chronic medical conditions are also more common amongdisabled.

Key words: Disability, Epidemiology, Cross-sectional, Determinants.

Materials and Methods

This was a community-based cross sectional studycarried out over a period of 1 year from January toDecember 2004. The study was conducted at the ruralfield practice area of a teaching institution, which coversa population of 45 000 spread over 11 villages of aTaluk in Karnataka State of India. Four villages namelyKotemattu, Yenegudda, Kidiyoor and Kadekar wereselected randomly for the present study. The populationcovered by these four villages was 16,298. Sample sizewas estimated for infinite population by using theformula 4pq/d2, where prevalence was taken as 10%1.Required precision of the estimate (d) was set at 20%.Using the above formula, the sample size was estimatedto be 900. After adding non-response rate of 10%, anadditional 100 subjects were included. Thus 1000subjects in all the age group were selected for this study.

Probability proportional to sampling techniquewas used to select the study sample from each village.In each of the four centers, all family folders werearranged in a serial order. Then, the first folder was

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selected randomly from the random number table andthe names of the eligible candidates from thathousehold noted down. Similarly, the next folder wasrandomly picked up and the names of all the eligiblecandidates of that household listed. This procedurewas repeated till the desired number of eligible personswas achieved from each centre. Although householdswere taken as cluster, the design effect would beminimal considering the disability characteristics thatare different for members of the household. So, weanalysed the data taking individual as sampling unit.The study was conducted by making house-to-housevisits, interviewing and examining all the individualsin the family selected with pre-tested questionnaire.Informed verbal consent was obtained from allrespondents. If a designated person could not becontacted or not cooperative during three separatevisits, then the subject was considered as non-respondent.

The demographic and other variables recordedwere age, sex, socio-economic status, marital status,family type, literacy and occupation. Considering thefact that the age, education and occupation areimportant determinants of disability, we analysed thedata after sub categorization of each of these variables.

Socioeconomic status was assessed by modifiedUday Parik scale. Disability was assessed as per thecriteria laid down by WHO5. Mental disability wasassessed by Indian Disability Evaluation andAssessment Scale (IDEAS) developed by theRehabilitation Committee of Indian PsychiatricSociety6. Disability below the age of 5 years wasassessed based on the instrument designed on the linesof questionnaire taken from Action Aid India7. Chronicmedical conditions were assessed based on theprevious diagnosis. The data collected was tabulatedand analyzed by using the Statistical Package for SocialSciences (SPSS) version 11.5 for windows. Chi squaretest was carried out to test the differences betweenproportions. To determine the independent effect ofvarious factors on disability, Multiple LogisticRegression was performed.

Results

Of the 1000 subjects enrolled into the study, 954subjects were available for the final analysis (responserate 95%). Among them 472 (49.5%) subjects were males,635 (67.5%) belonged to the age group of 15 – 59 years,

Table 1: Prevalence of disabilityaccording to socio-demographic variables(n=954)

Variables Total Prevalence χ2, pSubjects No (%)

GenderMale 472 24 (5.1) 2.3Female 482 36 (7.5) 0.1

Age group (years)< 5 72 05-14 122 1( 0.8)15-59 635 30 (4.7) 74.2≥ 60 125 29 (21.5) 0.001*

Socio-economic statusLow 456 34 (7.5)Middle 486 26 (5.3) 1.8High 12 0 0.2

Marital StatusEver married 527 45 (8.5) 10.1Never married 427 15 (3.5) 0.001*

Family TypeNuclear 208 16 (7.7) 0.9Joint/extended 746 44 (5.9) 0.3

Literacy † (years of schooling)Illiterate 84 19 (22.6)1-4 118 16 (13.6)5-10 522 23(4.4) 52.4> 10 125 1(0.8) < 0.001*

Occupation‡Unemployed 104 30 (28.8)Housewife 231 17 (7.4)Unskilled 311 10 (3.2)Skilled 40 1 (2.5)Students 161 1 (0.6) 74.8Professional 21 0 < .0001*

* P value less than 0.05 is considered as significant.†105 (10.6%) subjects are below 7 years. Total numberof disabled among 7 years and above was 59.‡ 86 (8.7%) subjects are below 6 years. Total numberof disabled among 6 years and above was 59.

Ganesh KS et al: Disability in a Rural Area of Karnataka

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870 (92%) were literate, 746 (78.2%) belonged to joint/extended family. About half of the study populationbelonged to the middle socio-economic status (51%),while only 1.3% (12) belonged to high socio-economicstatus. 55.2% of the study subjects were ever married.By occupation, 32.6% were unskilled workers/farmers/petty business people; only 4.2% were skilled workersand 2.2% professionals. Others were housewife (24.2%),students (16.9%) and unemployed (10.9%).

The overall prevalence of disability was found tobe 6.3% (60/954). The most common type of disabilityamong the disabled was mental disability (22/60)followed by loco motor (17/60), hearing (13/60),speech (12/60) and visual (10/60) disability. 80% (48)of the disabled had single disability and the rest 20%had multiple disabilities.

The prevalence of disability among the elderlygroup (>60 years) was very high (21.5%). As the ageadvances, the prevalence increased significantly(χ2=74.26, p=0.001).The present study showed that40% (24) of the disabled were males and 60% (36)were females. The prevalence of disability wasmarginally higher among low socioeconomic andnuclear family group. Among ever married group, theprevalence was two and half times more than nevermarried group and the difference was found to besignificant (χ2=10.11, p=0.001). Nearly one quarterof illiterates (22.6%) were disabled and those witheducation level of above 10th standard had very lowprevalence. As literacy level increased, the prevalencedeclined significantly (χ2=52.4, p= <0.001). Also, theprevalence of disability among the unemployed wasvery high (28.8%). The difference in prevalence ofdisability between different occupation groups wasfound to be statistically significant (χ2=78.846, p=<0.0001). The present study revealed that half of thedisabled were unemployed, 28.3% were housewife and16.7% were unskilled workers, farmers and people withpetty business (Table 1).

Majority of the disabled had joint pain andbackache (35, 58.3%). Hypertension was present in30% (18) followed by asthma/COPD in 15% (9),diabetes mellitus and fits in 10% (6) and heart problemsin 5% (3) of the disabled. Multiple logistic regressionanalysis revealed that illiteracy, primary schooling andunemployment had independent significant associationwith the disability (Table 2).

Discussion

Well documented studies to determine theprevalence and its epidemiological features are few.Some studies had taken only the physical disabilityand some others mental disability. Also, the datacollected by health workers could not detect milddegrees of disability because of their limited knowledgeand lack of training. As our study illustrates, bothphysical and mental disabilities are of great concern inthis area.

Also, knowledge and occupation plays a majorrole as determinants of disability. Chronic medical

Table 2: Correlates of disability: MultipleLogistic Regression analysis

Variables Odds ratio 95% CI P valueadjusted

GenderMale - - -Female 1.9 0.8-4.4 0.1

Age group (years)< 45 - - -45-59 0.8 0.3-2.7 0.8≥ 60 2.3 0.8-6.1 0.1

Marital statusNever married - - -Ever married 1.5 0.5-4.7 0.5

Literacy †(Years of schooling)> 10 - - -5-10 5.9 0.8-47.3 0.11-4 25.7 3.0-221.1 0.003*Illiterate 29.9 3.3-269.2 0.002*

Occupation ‡Professional - - -& SkilledUnemployed 15.9 1.8-138.2 0.012*Housewife 0.9 0.1-8.9 0.9Unskilled 1.3 0.1-10.7 0.8Students 0.3 0.02-6.4 0.5

* P value < 0.05 is considered as significant; † 105(10.6) subjects are below 7 years; ‡ 86 (8.7%) subjectsare below 6 years


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conditions are also more common among disabled.

World Health Organization estimates that 10%of the world’s population has some form of disability1.In contrast, recent National Sample SurveyOrganization report2 and Census data 20013 revealedprevalence as 2%.The present study showed a higherprevalence of disability in comparison to prevalencein general. This is because of detection of even milddegrees of disability in our study. As per populationdata provided by United Nations Population Fund(UNFPA) Geneva 1995, the prevalence in India was4.6%4. Higher prevalence of mental disability and theproportion of people with multiple disabilities wereobserved because of detection of even mild mentaldisability in our study in contrast to other studies2,3,8,9.

The prevalence was more common amonggeriatric age group. Our study findings are consistentwith the results of other studies2, 3,10. Marginally higherprevalence of disability among females in contrast toother studies might be due to favorable sex ratio inthis area 3, 10 . The present study showed that 75% ofthe disabled were married and 25% of them wereunmarried in contradiction to other studies 8,3. In India,about 92% of the disabled lived with their spouse and/or other members in the family. But in the present study,26.7% of the disabled belonged to nuclear family.Others (73.3%) belonged to joint/extended family. Inview of the above, the disabled in this part of thecountry are well placed as far as the family life isconcerned.

Disabled in this area are better educated whencompared to the disabled people of other areas3,8.Various studies have shown that the prevalence ofdisabilities is found to be significantly high among theindividuals suffering from chronic medical condi-tions11,12.

It was observed by univariate analysis that theage group, marital status, literacy, and occupation hadsignificant association with the disability. Age,education and occupation all might act as confoundersin association of exposure variables of the study withdisability. The adjusted Odds Ratio (OR) for illiteracyand primary schooling (1-4) revealed that the chanceof disability was 30 and 25.7 times respectively ascompared to those with education of above 10th

standard. Similarly adjusted OR for unemployment was

15.91 as compared to professionals and skilled. ThusMultiple Logistic Regression analysis after accountingfor confounding factors showed that illiteracy; primaryschooling (1-4) and unemployment were consideredas significant factors in association with the disability.

Considering the fact that the population in thisstudy had a very high literacy rate and favorable sexratio, it is unlikely that the results are generalisable tosimilar settings. We could not interview the non-respondents because of their non-cooperation and non-availability during our field visits. Since the proportionof non-respondents was very small in our studypopulation, we expect only a minimal effect on ourprevalence estimate. There may have been recall bias.Pure tone audiometry was not used while assessinghearing disability due to feasibility constraints. In viewof the above findings it is concluded that the disabledin this area need community assistance. There is anample scope for community based rehabilitation of thedisabled also.

References

1. World Health Organization .Training in thecommunity for people with disabilities. WHO:Geneva; 1989.

2. National Sample Survey Organization. A reporton disabled persons. Department of Statistics,Government of India: New Delhi; 2003.

3. Census of India 2001. Data on disability. Officeof the Registrar general India. (Serial online) 9August 2004. Available from: URL:www.censusindia.net/disability/disability_mapgallery.html.

4. Sharma AK, Praveen V. Community BasedRehabilitation in Primary Health Care System.Indian Journal of Community Medicine 2002;117: 139-142.

5. World Health Organization. InternationalClassification of Functioning, Disability andHealth: A manual of classification relating to theconsequences of disease. WHO: Geneva; 2001.

6. Govt. of India. Guidelines for evaluation andassessment of mental illness and procedure forcertification. Ministry of Social Justice andempowerment, Government of India. New Delhi,2002.


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7. Thomas M, Pruthvish S. Identification and needsassessment of beneficiaries in community basedrehabilitation initiatives. Action Aid India,Bangalore, 1993.

8. Noveymony MA, Raj SS. A study in the familyand socio-economic conditions of the personswith disabilities in Vallioor Panchayat Union.Asian Pacific Disability Rehabilitation Journal2003; 5(1): 14-20.

9. Kishore MT. Psychiatric diagnosis in persons withintellectual disability in India. Journal ofIntellectual Disability Research Jan.2004; 48(1):19-24.

10. Alan MJ, Branch LG. The Framingham DisabilityStudy. American Journal of Public Health 1981;71(11): 1211-1216.

11. Joshi K, Kumar R, Avasti A. Morbidity profile andits relationship with disability and psychologicaldistress among elderly people in northern states.Int. Journal of epidemiology Dec. 2003; 32(6):978-987.

12. Dey AB, Shubha S, Kalpana MN, Jhingan HP.Evaluation of the health and functional status ofolder Indians as a preclude to the developmentof a health programme. The National MedicalJournal of India 2001; 14(3): 135-138.


Announcement

We are happy to announce that the IPHA BHABAN is now ready for use. Memebers are welcome tostay at the Bhaban during their official and unofficial visits to Kolkata. The location is very close to theairport and to the Government and Non government offices at Salt Lake. It is also away from the trafficsnarls and pollution. We request all members to solicit utilization of the Bhaban and spread the message toall concerned.

Type of rooms For members For non members Members staying for IPHA Work

AC Rs. 200 per bed Rs. 400 per bed No charge

Non AC Rs. 150 per bed Rs. 300 per bed ,,

Dormitory Rs. 100 per bed Rs. 150 per bed ,,

AC Seminar Room: Rs. 2000/- (for 8 hours), Rs. 500/- for extra 1 hour* Branch will get 30% concession for conducting their official meetings

For booking rooms / seminar hall please contact:

• IPHA HQ, 110, Chittaranjan Avenue, Kolkata – 700073,Phone : 033-32913895.

• Secretary General,e-mail: [email protected]

• Care taker: Phone - 09433548860; E-mail: [email protected]

Dr. Modhumita DobeSecretary General, IPHA

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Introduction:

Iodine deficiency disorders (IDD), spectrum ofhealth consequences due to iodine deficiency are stillmajor public health problems in many countries. Oneof the most common preventable causes of mentalretardation in the world today is iodine deficiency1, 2.An estimated 1571 million people worldwide lives iniodine-deficient environment, and is at risk of IDD3.In India, about 167 million people are estimated to beat risk for IDD, of which 54 million have goitre andover 8 million have neurological deficits 4. Earlier 275districts in the country have been surveyed for IDDand 235 districts have been found to be endemic5.

For prevention and control of IDD iodisation ofsalt is widely recognised as the most effective and

Original Article

Elimination of Iodine Deficiency Disorders – Current Status inPurba Medinipur District of West Bengal, India

A. B. Biswas1, I. Chakraborty2, *D. K. Das3, A. Chakraborty4, D. Ray5, K. Mitra6

1Professor, Community Medicine, B. S. Medical College, Bankura, 2Professor, Biochemistry, Medical College, Kolkata;3Associate Professor, 4Demonstrator, Community Medicine, R. G. Kar Medical College, Kolkata; 5Assistant Professor,Biochemistry, Medical College, Kolkata; 6 Health and HIV specialist, UNICEF, Kolkata, West Bengal.*Corresponding Author: [email protected], [email protected]

sustainable long-term public health measure6 and isbeing implemented in many countries. In India,compulsory salt iodisation was initiated in 1998 but itwas revoked in 2000. However, the government ofIndia from 15th August 2005 has once again imposedthe ban on sale and production of non-iodised salt.Besides this, since 1992, IDD control programme hasbeen in operation in all the states of India, includingWest Bengal with the aim of eliminating IDD as a publichealth problem.

However, International Council for the Controlof Iodine Deficiency Disorders (ICCIDD), WHO andUNICEF recommend the progress of such programmein any country needs to be monitored using quantifiableindicators 7. The indicators include: 1. Proportion ofhouseholds consuming effectively iodised salt (>90%);

Abstract

Background and Objectives: Towards sustainable elimination of iodine deficiency disorders(IDD), the existing programme needs to be monitored through recommended methods andindicators. Thus, we conducted the study to assess the current status of IDD in Purba Medinipurdistrict, West Bengal. Methods: It was a community based cross-sectional study; undertakenfrom October 2006 - April 2007. 2400 school children, aged 8-10 years were selected by ‘30 cluster’sampling technique. Indicators recommended by the WHO/UNICEF/ICCIDD were used. Subjectswere clinically examined by standard palpation technique for goitre, urinary iodine excretionwas estimated by wet digestion method and salt samples were tested by spot iodine testing kit.Results: The total goitre rate (TGR) was 19.7% (95% Cl = 18.1 – 21.3 %) with grade I and grade II(visible goitre) being 16.7% and 3% respectively. Goitre prevalence did not differ by age butsignificant difference was observed in respect of sex. Median urinary iodine excretion level was11.5 mcg/dL and none had value less than 5 mcg/dL. Only 50.4% of the salt samples tested wereadequately iodised (≥ 15 ppm). Conclusion: The district is in a phase of transition from iodinedeficiency to iodine sufficiency as evident from the high goitre prevalence (19.7%) and medianurinary iodine excretion (11.5mcg/dL) within optimum limit. But, salt iodisation level far belowthe recommended goal highlights the need for intensified efforts towards successful transition.

Key Words: Iodine deficiency, Goitre, IDD, Urinary iodine, Iodised salt

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2. Urinary iodine: proportion below 100 mcg/lt (<50%)and proportion below 50 mcg/lt (<20%) and 3.Thyroid size: proportion of school children 6-12 yearsage with enlarged thyroid, by palpation or ultrasound(<5%).

Using these indicators and prescribedmethodologies by WHO, UNICEF and ICCIDD; duringthe recent years, studies had been done in six districts(Malda, Birbhum, Dakshin Dinajpur, North 24Parganas, Purulia and Howrah) of the state 8-13. Thesestudies have reported mild to moderate goitreprevalence in the surveyed districts and variableproportion of adequately iodised salts. In this context,it was decided to have more objective and scientificallyvalid data in other districts of the state. We thusconducted the present study to assess the status of IDDin Purba Medinipur district of West Bengal with thefollowing objectives: to find out the prevalence of goitreamong school children aged 8 to10 years in PurbaMedinipur district, to determine the status of urinaryiodine excretion (UIE) levels of school children aged 8to 10 years in the district and to assess iodine contentof salts at the household level in the district.

Materials and Methods

It was a cross-sectional, school-based studyconducted during October 2006 to April 2007 in PurbaMedinipur district, West Bengal. The study populationwas school children of 8-10 years of age. We includedthis age group because of their combined highvulnerability to disease, easy accessibility &representative ness of their age group in the community.This age group are recommended for assessment ofIDD7.

No previous data was available on prevalence ofgoitre in Purba Medinipur district. Thus, the samplesize of children to be surveyed was based on theassumed goitre prevalence rate of 50%, 95%confidence interval (CI), a design effect of 3 and arelative precision of 10%. Using these parameters asample size of 1200 was obtained. But as our intentionwas to assess the degree of severity also, we decidedto double the calculated sample size; thus the finalsample size was 2400 children in the age group of 8 -10 years i.e. 80 per cluster in a 30 cluster samplingtechnique7.

Multistage cluster sampling methodology wasfollowed for selecting the study population. We enlistedall the rural & urban population units in the districtwith their respective population. The 30 clusters i.e.population units (villages/urban wards) to be surveyedwere selected using “probability proportional to size”(PPS) sampling method. In each identified cluster allthe primary schools were enlisted and simple randomsampling was used to select one school for detailedsurvey. From the sampling frame of all childrenbetween 8-10 years of the selected school, 80 childrenwere selected following simple random samplingtechnique for inclusion in the study. If the sample couldnot be covered in the school, adjoining school wasincluded to complete the sample of the cluster. Thus atotal of 2400 school children were included in the study.

Prior intimation was given to the identified schoolauthority one week before the survey to ensureattendance of students. The schoolteachers andchildren were also briefed about the activities to beundertaken during the survey. A pre-designed pre-tested schedule was used for data collection.Investigators comprised of faculty members from theDepartment of Community Medicine, R. G. KarMedical College, Kolkata and Depar tment ofBiochemistry, Medical College, Kolkata, West Bengal.An initial training was imparted to minimise interobserver variation during the survey.

Assessment of goitre: The size of the thyroid wasdetermined clinically by standard palpation methodand grading of goitre was done according to the criteriarecommended by the joint WHO/UNICEF/ICCIDD(Grade 0: No palpable or visible goitre. Grade I: Amass in the neck that is consistent with an enlargedthyroid that is palpable but not visible when the neckis in normal position. It moves upwards in the neck asthe subject swallows. Grade II: A swelling in the neckthat is visible when the neck is in a normal positionand is consistent with an enlarged thyroid when theneck is palpated) 7, 14. Goitre grades I and II togetherconsidered as the Total Goitre Rate (TGR).

Estimation of urinary iodine excretion level: Therecommended sample size for collection of biologicalspecimens, such as urine, is 300 (i.e. 10 children x 30clusters) 14. Considering 20% dropout/wastage, finalsample size of urine samples was decided to be 360

Biswas AB et al: IDD in Purba Medinipur, West Bengal

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(i.e. 12 children x 30 clusters). In the present study,systematic random selection was used to select 12children from each school for urine collection, amongthose who were clinically examined. Thus, 360 casualon the spot urine samples (0.5 to 1.0 ml) were collectedin wide-mouthed screw capped plastic bottles (onedrop of toluene was added to inhibit bacterial growthand to minimise odour) and stored in a refrigerator at4oC until analysis. Six urine samples were wasted andfinally 354 samples were available for analysis. TheUrinary Iodine Excretion (UIE) level was measured bywet digestion method15. The result was expressed asmcg iodine/dL urine.

Assessment of iodine content of salt: In eachcluster, all the study children were asked to bring about20 gm of salt which were routinely being consumed intheir respective families. In the present study, Iodinecontent of 2400 salt samples was estimated using spotiodine testing kit.

The data entry and analysis was done at R.G.KarMedical College, Kolkata. We entered the data inMicrosoft Excel and analysed accordingly to find outthe outcome variables.

Results:

Characteristics of the study population:

Of 2400 study children, 47.5% (1139) were malesand 52.5% (1261) females. About 33.5% (805), 32.7%(785), 33.8% (810) of them belonged to eight, nineand ten years of age respectively. Most of the childrenwere from rural area (93.3%, 2240/2400) and Hinduby religion (79%, 1896/2400).

Prevalence of goitre:

Table 1 depicts the prevalence of goitre in PurbaMedinipur district.

Overall total goitre prevalence rate (TGR) was19.7% (95% Cl =18.1 – 21.3 %), of which16.7% and3.0% was grade I and grade II (visible goitre)respectively. Goitre prevalence among girls (22.4%)and boys (16.7%) was significantly different (χ2 =12.55, d.f. = 1, p=0.0003). Overall age specific goitreprevalence among 8, 9 and 10 years old childrenwere17.5%, 20.3% and 21.4% respectively; thedifference was not statistically significant (χ2 =3.99,d.f. = 2, p=0.136).

Urinary iodine excretion level:

We analysed 354 urine samples for urinary iodineexcretion (UIE) levels. Urinary iodine excretion levelsfor 83 (23.4%) of the children were in the mild range(5 – 9.9 mcg/ dL) of iodine deficiency. No childrenhad UIE value in the moderate or severe range of iodinedeficiency. 76.6% children had urinary iodine abovethe recommended level of ≥ 10 mcg/dL (Table 2). Themedian UIE level was 11.5mcg/dL (range = 7.5 – 18mcg/dL).

Iodine content of salts:

In the present study, 2400 salt samples were testedwith spot iodine testing kit.

It was revealed that salt with nil iodine contentwas consumed by 17.7% of the beneficiaries andanother 32% consumed salt with iodine content of <15ppm. Half of the households (50.4%) had adequateiodine content of ≥ 15 ppm (Table 3).


Table 1: Goitre prevalence by age and sex in Purba Medinipur district, West Bengal(n=2400)

Male(n=1139) Female(n=1261) Combined(n=2400)Age (Years) Goitre Grade Goitre Grade Goitre Grade

I II TGR I II TGR I II TGRNo. (%) No. (%) No. (%)

8 (n=805) 49 5 54 (13.2) 77 10 87 (22.0) 126 15 141(17.5)**9 (n=785) 57 4 61(17.2) 84 14 98 (22.8) 141 18 159(20.3)**10 (n=810) 59 16 75 (20.1) 74 24 98 (22.5) 133 40 173(21.4)**All (n=2400) 165 25 190 (16.7)* 235 48 283 (22.4)* 400 73 473(19.7)

* χ2 = 12.55, d.f. = 1, p=0.0003 ** χ2 = 3.99, d.f. = 2, p= 0.136

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Discussion:

In the present study, an overall goitre prevalencerate of 19.7% was found, signifying that the districtPurba Medinipur is mildly endemic for iodinedeficiency. However, recent studies in six other districtsof the state viz. Malda, Birbhum, Dakshin Dinajpur,North 24 Parganas, Purulia and Howrah usingstandard methodology, as has been followed in thepresent one, revealed prevalence of 11.3%, 12.6%,18.6%, 20.1%, 25.9% and 13.7% of goitrerespectively8-13. But less than 5% TGR was found in9 out of 15 districts studied in 11 states by an IndianCouncil of Medical Research (ICMR) study 16.

Urinary iodine concentrations are the mostreliable indicator of IDD. The WHO/UNICEF/ICCIDDhave also recommended that no iodine deficiency beindicated in a population when median urinaryexcretion level is 10 mcg/dL or more i.e. more than50% of the urine samples have UIE level of ≥ 10 mcg/dL and not more than 20% of the samples have UIElevel of less than 5 mcg/dL7.

In Purba Medinipur district, we found a desirablevalue for both these two indicators. Median UIE level(11.5 mcg/dL) was more than the minimum

recommended level of 10 mcg/dL. Overall, 76.6% ofthe children had UIE levels in the ranges of optimaliodine nutrition (≥ 10 mcg/dL), and none hadconcentrations <5 mcg/dL. These results indicate thatcurrent iodine deficiency does not exist in PurbaMedinipur district. Similar median values of urinaryiodine in the desirable range of ≥ 10 mcg/dL were alsoobserved by most of the studies in other districts ofWest Bengal 8-11, 13 and also other states 17- 22.However, median urinary iodine values less than therecommended level was reported from three districtsin other states (Lakhimpur Kheri and Mainpuri in UttarPradesh and Gaya in Bihar) 16 and also from Puruliadistrict of West Bengal 12.

Analysis of the urinary iodine excretion in thepresent study indicated inadequate intake of iodineby a substantial proportion of children, which was notat all unexpected as analysis of salt samples alsorevealed around 50% of the children consumed non-iodised/inadequately iodised salt.

We found, only 50.4% of the children wereconsuming adequately iodised salt (≥ 15 ppm), whichis far below the recommended goal of > 90% coverage7. Compared to this, less proportion was found inBirbhum (37.2%) and Purulia (33.4%) district 9, 12,but much higher proportion was reported from otherdistricts viz. 67.4%, 70%, 80% and 85% in DakshinDinajpur, North 24 Parganas, Howrah and Maldarespectively 10, 11, 13, 8.

For monitoring progress towards elimination ofIDD, the recommended parameters are to beinterpreted cautiously. There may be discrepanciesbetween urinary iodine concentrations and prevalenceof goitre, because urinary iodine excretion level reflectsthe current iodine status, while the prevalence of goitreindicates the long-term iodine status in a population23.Findings of high TGR and optimal urinary iodineexcretion have been reported in most of the earlierstudies in India 8-11, 13, 17 - 22 reflecting a transitionfrom iodine deficient to iodine sufficient state.Observation in Purba Medinipur corroborates withmost of the other districts in the state. However,consumption of iodine from sources other than iodisedsalts needs also to be studied.

Conclusion:

High TGR of 19.7% indicates that the PurbaMedinipur district is mildly endemic for IDD. But,median urinary iodine (11.5 mcg/dL) reflects no

Table 2: Urinary Iodine Excretion levelsin the study population in PurbaMedinipur district, West Bengal (n = 354)

Urinary Iodine Excretion Number Percentagelevels (mcg/dL)

< 5.0 0 0

5.0 – 9.9 83 23.4

≥ 10 271 76.6

Table 3: Iodine content of salts athousehold level in Purba Medinipurdistrict, West Bengal (n = 2400)

Iodine content Number Percentageof salts (ppm)

Nil 424 17.7

< 15 767 31.9

≥ 15 1209 50.4


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existence of current iodine deficiency. Interpreting thesetwo indicators together, it may be concluded that thedistrict Purba Medinipur is in a state of transition fromiodine deficiency to iodine sufficiency. However,adequately iodised salt consumption at the householdlevel (50.4%) is far below the recommended goal of>90%. Towards sustainable elimination of IDD,awareness generation for both sale and consumptionof iodised salt, regular monitoring at household andretailer level through involvement of different sectorsneed to be strengthened.

Acknowledgements

We acknowledge the support and cooperation ofthe district authorities, Department of Health andFamily Welfare as well as Department of PrimaryEducation, Purba Medinipur district, West Bengal. Theschool authorities and children of the surveyed schoolsdeserve special mention for their help and muchneeded cooperation during actual conduct of the study.We express our sincere gratitude to the Department ofHealth and Family Welfare, Government of WestBengal and UNICEF, Kolkata, West Bengal for theirfinancial and other support to carry out the studysmoothly.

References :

1. Hetzel BS. S.O.S. for a billion – the nature andmagnitude of the iodine deficiency disorders.In: Hetzel BS, Pandav CS, Eds. S.O.S. for abillion. The conquest of iodine deficiencydisorders. Delhi, Oxford University Press; 1996,pp 3 -29.

2. Kapil U. Goitre in India and its prevalence.Journal of Medical Sciences and Family Planning,1998, 46 – 50.

3. United Nations Children’s Fund. The state of theworld’s children: focus on nutrition. New York,Oxford University Press; 1998, pp 15 – 20.

4. Ramji S. Iodine deficiency disorders -epidemiology, clinical profile and diagnosis. In:Nutrition in children - developing countryconcern; Editors: H. P. S. Sachdev, PannaChoudhury, Department of Paediatrics, MoulanaAzad Medical College, New Delhi, 1995, 245 –254.

5. WHO. Eliminations of iodine deficiency disordersin South East Asia, SEA/NUT/138, 1997, 1-8.

6. Manner VMG. Control of iodine deficiencydisorders by iodination of salt: strategy fordeveloping countries. In: Hetzel BS, Dunn JT,Stanbury JB, eds.The prevention and control ofiodine deficiency disorders. Amsterdam, Elsevier,1987: 111- 125.

7. Joint WHO/UNICEF/ICCIDD Consultation:Indicators for assessing iodine deficiency disordersand their control programmes, Geneva, WHO,1992.

8. Biswas AB, Chakraborty I, Das DK, Biswas S,Nandy S. and Mitra J. Iodine deficiency disordersamong school children of Malda, West Bengal,India. J Health Popul Nutr 2002 Jun; 20 (2): 180-183.

9. Biswas AB, Chakraborty I, Das DK, Roy RN,Mukhopadhaya S and Chatterjee S. Iodinedeficiency disorders among school children ofBirbhum, West Bengal. Current Science 2004; 87(1): 78 - 80.

10. Das DK, Chakraborty I, Biswas AB, Sarkar GN,Shrivastava P, and Sen S. Iodine deficiencydisorders among school children of DakshinDinajpur district, West Bengal. Indian Journal ofPublic Health, April-June 2005; 49(2): 68-72.

11. Sen TK, Biswas AB, Chakrabarty I, Das DK,Ramakrishnan R, Manickam P, Hutin Y.Persistence of Iodine Deficiency in GangeticFlood-Prone Area, West Bengal, India. AsiaPacific Journal of Clinical Nutrition 2006; 15(4):528 -532

12. Biswas AB, Chakraborty I, Das DK, Roy RN, RayS and Kunti SK. Assessment of iodine deficiencydisorders in Purulia district, West Bengal, India.Journal of Tropical Paediatrics 2006; 52 (4): 288- 292.

13. Das DK, Chakraborty I, Biswas AB, Saha I,Majumder P and Saha S. Assessment of iodinedeficiency disorders in Howrah district, WestBengal, India. (Personal Communication).

14. Kumar S. Indicators to monitor progress ofNational Iodine Deficiency Disorders Control


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Programme (NIDDCP) and some observation oniodised salt in West Bengal. Indian Journal ofPublic Health 1995; 39 (4): 141-147.

15. Dunn JT, Crutchfield HE, Gutekunst R and DunnD. Methods for measuring iodine in urine. A jointpublication of WHO/UNICEF/ICCIDD, 1993, 18-23.

16. Toteja GS, Singh P, Dhilon BS and Saxena BN.Micronutrient deficiency disorders in 16 districtsof India: part 1 report of an ICMR task force study– district nutrition project. ICMR; New Delhi,2001, pp 1- 22.

17. Kapil U. Editorial: Current status of IodineDeficiency Disorders Control Programme,Indian Paediatrics 1998; 35: 831-836.

18. Sohal KS, Sharma TD, Kapil U, Tandon M.Assessment of iodine deficiency in districtHamirpur, Himachal Pradesh. IndianPaediatr1998; 35:1008-1011.

19. Bhardwaj AK, Kapil U. Assessment of iodinedeficiency in district Bikaner, Rajasthan. Indian JMatern Child Hlth 1997; 8:18-20.

20. Sohal KS, Sharma TD, Kapil U, Tandon M.Current status of prevalence of goitre and iodinecontent of salt consumed in district Solan,Himachal Pradesh. Indian Paediatr1999;36:1253-1256.

21. Kapil U, Sohal KS, Sharma TD, Tandon M andPathak P. Assessment of iodine deficiencydisorders using the 30 cluster approach in districtKangra, Himachal Pradesh. Journal of TropicalPediatrics, October 2000: 264 – 266.

22. Kapil U, Sethi V, Goindi G, Pathak F, Singh P.Elimination of iodine deficiency disorders in Delhi.Ind. J Paediatr 2004; 71 (3): 211 – 212.

23. Sebotsa MLD, Dannhauser A, Jooste PL, andJoubert G. Prevalence of goitre and urinary iodinestatus of primary school children in Lesotho.Bulletin of the World Health Organiztion 2003;81 (1): 28 – 34.


Indian Public Health AssociationHeadquarter Secretariate

110, Chittaranjan Avenue, Kolkata-700073Registration under Society Act No. S/2809 of 1957-58

Notice for 53rd Annual Central Council MeetingThe 53rd Annual Central Council Meeting of the IPHA will be held on 8th January, 2009 at 6 PM

at Meeting Hall of Kempegowda Institute of Medical Sciences (New Campus), Banashankari 2nd stage,Bangalore -560 070. (Please reconfirm the exact venue and time from the organizers of the conference)

Sd/-Dr. Madhumita Dobe

Secretary General, IPHA

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Introduction

Three years of implementation of IDSP has taughtmany lessons. In the course of implementation, a few

Special Article

Integrated Diseases Surveillance Project (IDSP)Through a Consultant’s Lens

*K. Suresh1,

1Public Health (Child) Consultant, New Delhi. *Correspondence: [email protected], [email protected]

practical modifications have been affected. This articlelooks at the implementation challenges of each of theactivities originally planned under IDSP and thechanges that occurred over this period as observed by

Summary

India has long experienced one of the highest burdens of infectious diseases in the world, fueledby factors including a large population, high poverty levels, poor sanitation, and problems withaccess to health care and preventive services. It has traditionally been difficult to monitor diseaseburden and trends in India, even more difficult to detect, diagnose, and control outbreaks untilthey had become quite large.

In an effort to improve the surveillance and response infrastructure in the country, in November2004 the Integrated Disease Surveillance Project (IDSP) was initiated with funding from the WorldBank. Given the surveillance challenges in India, the project seeks to accomplish its goals through,having a small list of priority conditions, many of which are syndrome-based at community andsub center level and easily recognizable at the out patients and inpatients care of facilities atlowest levels of the health care system, a simplified battery of laboratory tests and rapid test kits,and reporting of largely aggregate data rather than individual case reporting. The project alsoincludes activities that are relatively high technology, such as computerization, electronic datatransmission, and video conferencing links for communication and training.

The project is planned to be implemented all over the country in a phased manner with a stresson 14 focus states for intensive follow-up to demonstrate successful implementation of IDSP.The National Institute of Communicable Diseases chosen to provide national leadership mayhave to immediately address five issues. First, promote surveillance through major hospitals(both in public and private sector) and active surveillance through health system staff andcommunity, second, build capacity for data collation, analysis, interpretation to recognize warningsignal of outbreak, and institute public health action, third, develop a system which allowsavailability of quality test kits at district and state laboratories and /or culture facilities at identifiedlaboratories and a national training program to build capacities for performing testing andobtaining high quality results, fourth, there must be a process established by which an appropriatequality assurance program can be implemented and fifth, encourage use of IT infrastructure fordata transmission, analysis, routine communication (E-mail etc) and videoconferencing fortroubleshooting, consultations and epidemiological investigations. These five activities must beaddressed at the national level and cannot be left up to individual states/districts.

Keywords: Surveillance, syndrome case, probable case, laboratory confirmed case, epidemic,public health action, rapid test kits.

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the consultant in the course of his association with theproject since March 2006.

Administrative Structure of IDSP:

In January 2007 the project was restructured toprovide nearly half of the total credit (SDR 21.53million) for urgent financing requested by Governmentof India (GOI) for Avian Influenza pandemic preventionand control.

The realization of operational ease has led torelocating the administrative unit located in the ministryof health and family welfare (under a Joint secretary)to National Institute of Communicable Diseases (NICD)under the leader ship of its Director in 2006-07. Thisarrangement facilitated utilizing the services of abouthalf dozen officers (epidemiologists, microbiologistsand statistical officers) to support dedicated NationalProgram Officer in ensuring enhanced technicalsupport, improved state’s oversight and troubleshooting.

Under the project surveillance units have beenestablished at national, state and district levels in 23states covered under first two phases and the processis underway in phase III states. The operationalmanuals have been prepared and to a large extent theplanned training of the health staff has been completedin these 23 states. An effort to enhance coordinationwith national disease control programs has begun withrationalization of fever reporting forms with theNational Vector Borne Diseases Control program.

The project depended on state for technicalhuman resources {complimenting only informationtechnology (IT) and support staff on contractual basis}.Lack of ownership and quick turn over of the statestaff was a challenge and hindering the pace of theprogress of the project during first three years. MakingIDSP as part of National Rural Health Mission has thebiggest gain of 2007-08, leading to creation of 766dedicated professional positions (Epidemiologist,Microbiologists, and Entomologists) under NRHM atcentral, state and district level. While it created a goodopportunity for the professionals (especially PublicHealth /Epidemilogists), recruitment of qualified peopleand their orientation for the project activities is goingto be challenge for the coming years.

Project Implementation: Project imple-mentation has been lagging by about a year. Third

phase states started activities only in later part of 2007-08. Training of phase I districts have been completedand those in phase II are near completion. Supplies ofphase one is complete and that for phase II and III isdecentralized. Adaptation of information technologiesis taking shape, Call Center 24x7 (unique NO: 1075)is functional since beginning of 2008 andvideoconferencing with most of the state headquartersis established. However the electronic online data entry,analysis and transmission have not yet begun.

Establish and operate a Central SurveillanceUnit (CSU):

Central Surveillance Unit will support andcomplement the state surveillance units (SSUs): Centralsurveillance unit by now is well established andsupported by dedicated NICD officers to the state forperiodical visits. Most states were visited 1-2 times asagainst expected quarterly visits. The quality of review,trouble shooting and facilitating action needs to beimproved.

Prepare national guidelines for diseasesurveillance, select priority conditions for surveillance,and standard case definitions for each of them andmethods for surveillance: This task was completed in2006, but some implementation hurdles like difficultyin collecting passive surveillance data, desegregationof data by age and gender were noted. Revision ofsyndromic (‘S’) and probable (“P”) forms by includingonly select priority specific conditions and eliminatingdesegregation of data by age and gender recentlywould facilitate surveillance.

Coordinate timely transport of specimens to theregional, national and international laboratories: Thistask is happening as it used to before IDSP throughNICD Microbiology section

Analyze data, identify epidemiological trends andprepare national epidemiological situation reports: Thedata is being received from about 250 districts of phaseI &II states and periodical analysis is being done sincethird quar ter of 2007-08. The first nationalepidemiological annual report (2006) is ready and theone for 2007 is getting ready.

Coordinate Quality Assurance Surveys: Base linequality of laboratories has been completed and internalquality standards along with waste managementguideline have been shared. The quality of training by

Suresh K: Integrated Disease Suveillance Project

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master training institutes has been evaluated externallyand suitable actions being taken on therecommendations. The key recommendations includemore hands on training particularly in filing up theforms of reporting, better participatory teachingapproaches, more exposure to real field situations andbetter involvement of the microbiologists/laboratorytechnicians.

Integrate and strengthen disease surveillanceat State and Districts level:

A. State-level:

i) Establish state surveillance unit (SSU): Each Statewill establish a SSU headed by technical officer,supported by 3 technical consultants (training,finance and procurement ) and 4 support staff fromproject (data entry operators-2, office assistant andaccountant).

All the states in phase I and II have alreadyestablished the SSU’s and most in phase III also haveestablished the SSU’s. The major hurdle has been thecontinuity in the State technical officers. As it is a seniorlevel post quick turn over is seen due to superannuation/ promotion. It is also a fact that this level officer hasmany other responsibilities and hence not able to givemore than 20-25% of his/her time for IDSP. As far asthe contractual posts are concerned majority of themare filled up in Phase I and II but there is big turn overdue to temporary nature of the post and low paypackage. It has been very difficult to get public healthconsultant and the financial consultants at state level.

ii) The emphasis is on integration of diseasesurveillance activities, laboratory coordination,and involvement of private sector, nongovernmental organizations (NGOs) andcommunity.

Most of the state level officers are struggling insettling their own house (Govt. set up) right, attentionto surveillance activities; laboratory coordination andinvolvement of private sector etc are not getting priority.

iii) SSU will prepare and send weekly/monthlysummaries of the disease situation to CSU.

While most SSUs in phase I & II have been ableto send monthly collated surveillance information from

their districts, only about half of them are sendingweekly summaries to the CSU. However large numbersof districts are sending weekly reports directly to theCSU also.

iv Train state and district level staff;

All the states in phase I have completed thetraining as per their PIP whereas most in phase II arenearing completion of training of staff as envisaged inPIP. All the states had initially given high priority torural health staff @ one worker per sub-center and @one doctor per PHC because of administrativeconvenience and no efforts were made to train hospitaland dispensary doctors, nurses and pharmacists.Therefore the district, sub-district and major hospitalsurveillance is not really established. Realizing thelimitation States like Tamil Nadu, Gujarat andKarnataka were able to complete the training of all thestaff involved in surveillance activities in 2007 anddemonstrate the utility. All states by now have realizedthe need for training of staff involved in IDSP fromhospitals, doctors, pharmacists and laboratorytechnicians and male health workers in sub center andare planning for the same in the 2008 activities.

v) Implement periodical non-communicable diseasesurveys/and or their risk factors

The project has envisaged periodical householdsurveys by states (one third of states each year byrotation) once in 3-4 years. The surveys would capturebehavioral variables (like smoking, alcoholconsumption etc) to mount national/state specificadvocacy and behavior change communicationstrategies. Negotiations between NICD and IndianCouncil of Medical Research (ICMR) took longer timethan expected and the actual survey was delayed andlikely to be completed by September 2008 for the firstgeneration of 8 states.

vi) Support districts in data analysis, transportspecimens, and outbreak investigations.

The SSU’s have been supporting outbreakinvestigations and specimen transportations. However,SSUs are still not in a position to support data analysisas the requisite software is not yet developed by theNational Informatics Center (NIC).

vi) Oversee the implementation of IDSP, monitorquality of laboratory services etc.


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Due to quick turn over of both the regular statesurveillance officer (SSO) and the contractual technicalstaff the mechanism of oversight and monitoring ofthe laboratory services is poor.

District level:

i) Establish district surveillance unit (DSU): EachState will establish a DSU in each district headedby medical graduate with a background of Publichealth, supported by one microbiologist and 4support staff from project (data entry operators-2, office assistant and accountant).The emphasisis on integration of disease surveillance activities,laboratory coordination, and involvement ofprivate sector, NGOs and community.

All the states in Phase I &II and some in phase IIIhave established DSU by now. District Vector BorneDiseases control Medical officers or a Deputy ChiefMedical (Additional /Assistant) officer of Health at theDistrict Chief Medical office (District Health and FamilyWelfare Office) has been given additional responsibilityof IDSP. This again is an impediment for the progressof the project as the officer is able to give about onethirds of his time only. It is also a fact that most ofthese officers do not have public health background.Lack of qualified microbiologists at the district level(except in Karnataka and Maharashtra) has left theoversight and coordination responsibility oflaboratories loose. One thirds of the district are ableto involve private sector that too on a small scale.Majority of the districts surveillance units with medicalcolleges have not been able to negotiate with them fora productive partnership for surveillance and improveddiagnostic capabilities. Integrating the surveillance atthe district level is a distant dream due to differentdevelopmental status of vertical programs like nationalvector borne disease control program (NVBDCP),national tuberculosis control program ( NTCP) etc.

ii) Analyzing the surveillance data from theperipheral institutes and providing feedback.

Most of the districts are able to input the dataonline. Analyzing surveillance data and feedbackduring monthly meetings and on visit to the peripheralunits has started in states like Gujarat, Tami Nadu,Karnataka, Uttarkhand.

iii) Train sub-district health staff

Training of the health staff at the primary healthcenter (PHC)s and sub-centers has been completed inphase I & near completion in phase II. The staff(doctors, pharmacists and lab technicians etc) at thedistrict and sub-district hospitals was taken up in late2007 and being intensified in 2008.

iv) Initiate investigation of suspected cases/outbreaks& institute public health action.

Investigation of suspected cases and out breakshas been initiated in majority of the districts. Identifyingthe outbreak from routine reporting (based on alert ofmore than expected cases) and taking investigation isstill wanting. On outbreak investigation public healthaction is invariably taken.

v) Support for collection and transport specimensto laboratory networks

The specimen collection and transportation in adistrict is mainly done by the district staff.

vi) Responding promptly to the information providedby the community.

The system of recording the communityinformation and responding is yet to be developed.

Community Level:

i) Notify the nearest health facility of a disease orhealth condition selected

There is no official formalization of communityreporting, though sometimes community does reportto the nearest PHC. Use of call center is limited tohealth staff only.

ii) Support health workers during outbreakinvestigations

Most communities do support during outbreakinvestigations for fear of spread of disease.

iii) Community mobilization and empowerment forcommunity par ticipation in containmentmeasures.

Community mobilization and empowerment ofcommunity participation for containment measure isstill a distant dream.


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Strengthen data quality, analysis and links toaction:

i) ‘Real-time’ on-line entry, management andanalysis of surveillance data using computers,internet and www:

Real-time on line entry of data at the district levelis happening in phase I & II districts. Collation, analysisusing computers and internet is waiting for thedevelopment of appropriate software.

ii) Email services between CSU, SSU, DSU andlaboratories and other stakeholders

E-mail services between CSU, SSU and DSU areestablished but need to stabilize. The laboratories andother stakeholders (medical colleges) are yet havesimilar facilities.

iii) Rapid dissemination of health alerts to public,health staff and civil societies

Rapid dissemination of health alerts to publichealth staff and civil societies is being developed,through 24X7 call service center (1075).Videoconferencing facilities are established in stateheadquarters and the CSU is interacting with statesperiodically. Converting state units as teaching ends isunder consideration.

iv) Quality assurance surveys of laboratoryinformation

The mechanisms of quality assurance and controlof laboratory information is being developed.

Improve laboratory Support:

Currently, laboratory capacity in India fordiagnosis of infectious diseases is fragmented withsome capacity at the National Institutes ofCommunicable Diseases, at the Indian Council forMedical Research and at Medical Colleges around thecountry. Presently, laboratory services exist in anumber of categorical programs with limitedcoordination and, compounding the problem, there isno apparent perceived need for coordination orleadership at the national level.

There is no focal point within this mixture oflaboratories to ensure services are available whereneeded and assure quality of testing. For example, thereis no place that assures quality of rapid diagnostic kits

purchased within the country. As would be expectedin a country of great diversity, there is also greatdiversity of capability and capacity in laboratoryservices. States like Maharashtra and Karnataka havecapability and have already embarked on buildinglaboratory capacity for IDSP. Where laboratory servicesexist, there is a need to improve quality and to addressfundamental problems in the system related toprocurement and subsequent distribution of supplies.In general, limited testing should be offered at thedistrict level. Peripheral health centers and sub-centersare often performing microscopy (AFB and malaria)should be left at that level. At the district level, testingof human specimens should be limited to those testsfor which high quality rapid assays are available (e.g.,dengue, leptospirosis). Presently, culture should belimited to those laboratories designated as “state”laboratories or facilities where there is a very cleardemonstration of sufficient volume of specimens toretain the necessary skills. A process for qualityassurance needs to be established at each site identifiedfor laboratory strengthening.

1. The upgrading of laboratories at the state anddistrict level to improve laboratory support forproviding on time and reliable confirmation ofsuspected cases, monitoring drug resistance

2. The introduction of quality assurance system forlaboratories:

3. Establishing External Quality Assurance System(EQAS):

IDSP had envisaged 4 levels of laboratories namely:L1 = Peripheral laboratories that will have

diagnostic facilities for Malaria, TB, Typhoid andchlorination of well water and fecal contamination ofwater, L2= District Public health laboratories will carryout tests for Malaria, TB, Typhoid and chlorination ofwell water and fecal contamination of water primarilyto confirm results from L1, and for quality control. Theywould also have oversight responsibility of L1laboratories. L3= Regional/State laboratories will carryout all tests to confirm L1 and L2 results and for somestate specific diseases (e.g. Leptospirosis, KFD, Anthraxetc). They would also have culture facilities for bacteriaand viruses along with drug sensitivity studies. L4=Central and L4 reference laboratories for routine workand specific outbreak investigations.


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Based on three years’ experience and challengesin establishing the Public Health laboratories it is nowagreed that under IDSP apart from state Public HealthLaboratories and specialized laboratories (L3&L4) only50 District laboratories (2 per focus state and 1 in restof the states each)will be strengthened to take up PublicHealth laboratories responsibilities. Revised laboratorystrengthening plan of action under IDSP is addressingthe regional and referral laboratories. In the first phase,states used the money for renovating and minoradditions to physical structure of all laboratories in thedistricts. It was observed that most of the money wasdistributed (based on average per unit) withoutconsidering the needs of individual laboratories.Vertical programs like NVBDCP and NTCP hadsupported L1 laboratories up gradation in entirecountry in last few years. Therefore from 2006 nomoney is released for renovation unless a definite needis ascertained.

Training for Disease Surveillance and Action:

The project aims to train both in formal andinformal sector for disease surveillance, specific trainingfor disease control, and special training of state/districtsurveillance officers in epidemiology and specializedtraining in laboratory work, data management andcommunications.

In addition to the routine program trainings aslisted above, the training under IDSP has to cater tolarger need of epidemiologists and Microbiologists ableto organize and oversee IDSP activities at state anddistrict level. This would involve training epidemiologistand microbiologists and rapid response team membersat the SSU and DSU. Two weeks Field Epidemiologytraining has been field tested in 2007. It is decided totrain the Microbiologist and a lab. technician from eachof the 50 identified laboratories in quality assuranceand specific disease tests. The challenge now is to taketo scale both the training.

With GOI sanctioning of 766 posts ofepidemiologists, Microbiologists and Entomologists, onone side there is good opportunity for public healthqualified professionals, on the other it is going tobecome a challenge. NICD need to identify some moreregional institutions to take up 2 weeks fieldepidemiology training in addition to the training oftrainers (TOTs) they are already handling.

Way Forward:

Infrastructure strengthening: Despite recentimprovements, obtaining information regularly fromthe larger public hospitals and private sector from theurban areas still remains a challenge for the IDSP. Theinitiative started to rationalize the weekly reportingforms needs to be implemented to reduce the burdenof nonspecific conditions on the surveillance system.More importantly, the ability to analyze and act on theinformation being generated is critically lackingespecially at the district level. Frequent turn-over ofstate and district surveillance officers also slowed downthe effective implementation of surveillance activities.To address this, a specialized cadre of epidemiologists- which was not originally envisaged under the projecthas been strongly recommended by the Bank as wellas Centre for Disease Control (CDC) teams that recentlyreviewed the project. Similarly, due to limitedavailability of microbiologists, the original plan forlaboratory strengthening has been revised focusingon making 50 public health laboratories functional andlink each district to such labs. The GOI has createdpositions of epidemiologists, Microbiologist andentomologists under the National Rural Health Mission(NRHM). The challenge is to fill in these posts urgentlywith motivated people and arrange for their inductiontraining with necessary field epidemiology andmicrobiology training. Scaling down the laboratorystrengthening component to make 50 public healthlaboratories functional during the next 6 monthsappears to be doable task. Piloting of diseasesurveillance in 4 metro cities needs acceleration toprovide lessons for scaling-up urban surveillance inother cities.

I. Outbreak response:

1. The enhanced reporting and investigation ofoutbreaks by IDSP is an importantaccomplishment of the project, and warrantsrecognition. However it will be important tofurther strengthen IDSP capacity for earlyoutbreak detection by emphasis on promptoutbreak reporting to the district surveillanceofficer. Special emphasis is required on seekingsuch information from the health providers anddifferent options such as giving mobile telephonesto the sub center (SC) reporting units should beexplored.


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2. In addition to enhancing detection and promptreporting of outbreaks, determining the qualityof outbreak investigations should be an essentialevaluation component of the project. This willrequire expanded and standardized recording ofinformation about outbreaks investigated: thenumber of cases and deaths, causative agent,timeliness of detection and response, results ofsystematic investigation, including epidemiologiccharacterization and determination of source(s),and public health response. In some states, it willalso be important to improve coordinationbetween IDSP and epidemiology cells/responseunits.

3. IDSP should invest substantial efforts to assurethe proposed Call Center is effectivelyimplemented. This will require strategic marketingof the system to the providers and healthpersonnel in the area covered by the call center.It will also require links to SSU (DSU) for promptlyevaluating the information, and giving feedbackto the provider (e.g. expedited access to referencediagnostic tests, information about clinicalpresentation of rare conditions, access to limitedtherapy—e.g. diphtheria anti-toxin) and initiatingappropriate actions. Information from callsshould be routed simultaneously, not sequentially,to relevant SSU (for follow-up) and CSU (forinformation and to recognize cross-stateoutbreaks).

4. Media scanning can detect possible outbreaks,as well as identify rumors which need addressing.Although it can be the responsibility of an SSU tosystematically monitor local newspapers, webpages, etc, media scanning can also be done bya contracted service. The benefit of a contractedservice is systematic, prompt scanning which isnot contingent on public health personnel; also,any items noticed can be routed immediately tothe appropriate (and possibly multiple) district,state, or national units.

II. Conditions to be reported under IDSP

1. IDSP should continue to refine strategies forimproving the interpretability of data byemphasizing a) reporting units/data sources mostlikely to provide usable and important

information, b) enhancing specificity of casedefinitions, c) encouraging laboratory confirm-ation and laboratory repor ting and d)encouraging consistency in reporting

2. Continued collection of S form data from sub-centers reinforces community engagement withIDSP so that outbreaks at the village level will berecognized and reported through IDSP reportingchannels; for a single SC data collection burdenis not too high, and the proposed revision of Sform to eliminate age and sex breakdown of caseswill further minimize burden.

3. However, other reporting units (PHC’s, hospitals,private hospitals, medical colleges, ID hospitals)should report a revised list of conditions usingmore specific case definitions. Revision of P formmay consider dropping non-specific and highvolume conditions e.g. fever, ARI AcuteGastroenteritis (leaving cholera) etc. as they createa large burden of data collection on the system,but the data are difficult if not impossible tointerpret.

III. Strengthen laboratory diagnosis ofcases 1

1. Doctors in Hospitals with large load of outpatientsdo not generally demand for investigations toarrive at a diagnosis. The states need to promoteutilization of existing laboratory investigationsroutinely and also make efforts to improvediagnostic capabilities in these facilities.

2. Routine specimen transportation (from outbreaksand hospitals) to the laboratories both in publicand private sector system (especially L3, L4 andL5) needs streamlining.

3. Keeping vigilance on the quality of investigationsin these laboratories by external quality assurancemechanism is equally important.

4. Promote reporting of laboratory confirmed datausing laboratory investigations reporting forms (L-to L5 forms). Line listing of cases with positivelaboratory tests, and adding a column for type ofspecimen {a cerebrospinal fluid (CSF) or bloodculture result is quite different from sputum} willimprove the utilization. IDSP should consider


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collecting reports of positive tests for Hib,rotavirus, pneumococcus, and other salmonellaspecies.

5. At the present, linkage of reports from clinical andlaboratory sources is not feasible (outside of theindividual patient record), so one may need toaccept some degree of duplication in order tohave information on the number of laboratoryconfirmed cases.

IV. Sentinel Reporting Units

1. Continue to implement initiatives such as urbansurveillance and sentinel ID hospitals to targetlarge and strategically located hospitals for specialattention as reporting units. These sources arelikely to draw more severely ill patients from alarge population, thus efficiently providing“sentinel” information about a large area. Inaddition, they are likely to have, or can besupported to have, better laboratory and clinicaldiagnostic facilities.

2. Targeting reporting units such as strategic hospitalsand laboratories is a reasonable priority in all sites,but it may be particularly important in states thatare less advanced in their IDSP activities, so thatat least some surveillance information is availablefor these areas.

V. Rapid completion of the network (both fordata transmission and for video-conferencing) is urgently needed; getting thedistricts operational will be critical to realize thefull impact for IDSP. Videoconferencing shouldbe viewed as an “essential public health tool” forsurveillance and for outbreak management. Oncethe system is operational at districts, there will beeven greater oppor tunities for frequentcommunication without difficult travel.

References:1. Integrated Diseases Surveillance Project, Project

Implementation Plan 2004-09, GOI, MOH &FW(Department of Health) Nirman Bhavan NewDelhi 110001.

2. Project appraisal Document, June 7 2004 TheWorld Bank, New Delhi-11003

3. Integrated Disease Surveillance Program Annualreport- NICD 2007

4. Integrated Disease Surveillance Program Annualreport- Commissioner HFW&ME Gujarat 2007

5. IDSP Aid Memoirs, the World Bank, New DelhiNovember 2006 & May 2007.

6. IDSP Mid-Term Evaluation, the World Bank, NewDelhi November 2007.


Indian Public Health AssociationHeadquarter Secretariate

110, Chittaranjan Avenue, Kolkata-700073Registration under Society Act No. S/2809 of 1957-58

Notice for 53rd Annual General Body MeetingThe 53rd Annual general Body Meeting of the IPHA will be held on 9th January, 2009 at 6 PM at

Kuvempu Kalakshetra Auditorium, KIMS Hospital Campus, K.R.Road, V.Puram,Bangalore - 560 004. (Please reconfirm the exact venue and time from the organizers of the conference).



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World is in the stage of epidemiological transitionand the non-communicable diseases are overtakingthe communicable diseases. This phenomenon is notonly seen in developed countries but is also evident inthe developing countries like India. Among the majornon-communicable diseases, cardiovascular diseasesare recognized as major public health problems byWHO1. Though several studies have been carried outamong the workers with sedentary lifestyle to assessthe risk factors for NCD, but very few studies havebeen carried out among labour population especiallyin India. One argument towards this can be nonexposure to risk factors like decreased physical activityand obesity among the labourers by virtue of theiroccupation but other side of the coin suggests that therisk factors like smoking and alcohol consumption isincreasing among the lower socio-economic strata.With this background the present study was carriedout to find out the prevalence of hypertension as wellas different cardiovascular risk factors and to assessassociation of different risk factors with hypertensionif any.

The present cross-sectional study was carried outin 2005 among the labourers of different tribes ofChhotaudepur region of Gujarat. The selected villageshave about 30,000 tribal population; mostly beingengaged in labour work. From the sampling frame oflabour population aged 20 years and above, 154 study

Short Communication

Hypertension and Epidemiological Factors amongTribal Labour Population in Gujarat

*Rajnarayan R Tiwari1

1Scientist C, Occupational Medicine Division, National Institute of Occupational Health, Ahmedabad, Gujarat.*Corresponding author: [email protected].

Summary

A cross sectional study was carried out in 2005 to find out the magnitude of hypertension among154 tribal labourers of Gujarat belonging to Naika, Rathwa and Damor tribes. WHO classificationof hypertension was taken as operational criteria and data was collected in pre-designed, pre-tested schedule. Blood pressure measurement was done twice on each subject using mercurysphygmomanometer. Overall magnitude of hypertension was found to be 16.9%, and onlysmoking was found to have significantly associated with it.

subjects were included by simple sampling randomtechnique in the present study. Pre-designed, pre-testedschedule was used to collect data regardingdemographic characteristics and different risk factorslike smoking and alcohol. For the present study all thosewho have smoked at least one cigarette or bidi in thelast one-month period were considered as currentsmoker while those who have left smoking since ≥1year were considered as ex-smokers. For the purposeof ever smokers the current smokers and ex-smokerswere added together. Similarly those who reported tohave taken alcohol at least once in last one monthwere considered as current alcohol users. This wasfollowed by measurement of blood pressure, heightand weight.

Two blood pressure readings were obtained onleft arm after the subject had rested for at least 5minutes in a seated position using mercury sphygmo-manometer, 10 minutes apart. Finally average of tworeadings was taken. SBP ≥ 140 mm Hg and/or DBP ≥90 mm Hg and/or treatment with anti-hypertensivemedication were labeled as hypertensive2. Subjectshaving hypertension were refereed to the PrimaryHealth Centre of Chhotaudepur for fur thermanagement. Body weight was measured on theweighing scale, wearing minimum outerwear (asculturally appropriate) and without any footwear.Height was measured using a non-stretchable tape with

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the subject in an erect position against a vertical surface,with the head positioned so that the top of the externalauditory meatus was level with the inferior margin ofthe bony orbit. Body mass index was calculated bydividing the weight in kilograms with the square ofheight measured in meters. WHO classification ofobesity was used for the categorization3. Percentageswere calculated and chi-square test was done usingEpi Info software.

Out of 154 subjects, 59.1% were male while40.9% were female. Majority of the study subjectsbelonged to less than 25 years of age. Overallmagnitude of hypertension was found to be 16.9%.38.5% of the subjects were ever smokers while only5.5% have taken alcohol. Only 9 (5.4%) subjects wereoverweight-pre-obese. The mean BMI for the femaleswas found to be 19.3 ± 3.5 kg/m2. The distribution ofhypertension according to the risk factors is shown inTable 1. Except for smoking all other factors were foundto be non-significant.

In the present study the overall magnitude ofhypertension was found to be 16.9%.

However a study among tribal“Oraon” population of Orissa revealedlower prevalence of hypertension (4.6/1000population)4. Similar finding (prevalence5.8%) was also noted by Chadha SL et al5

among Gujaratis residing in Delhi. Incontrast a study among primitive tribes ofOrissa reported prevalence of hypertensionamong males and females as 31.8% and42.2%, respectively6. Recent studies haveshown that Asian Indians are particularlysusceptible to non-communicable diseases.Comparison with studies shows that thereis a clear increase in magnitude ofhypertension in urban Indians from 6.2%in 1970 to 26.9% in 20007, 8. This can beattributed to the epidemiological transitionand changing lifestyles.

Although the magnitude ofhypertension is age related, being highestin those over 50 years of age9,10, but thenon-significant association of age withhypertension in present study can beattributed to comparatively young age

group of study population; mean age being 31.7±10.1years. All the hypertensive subjects were non-obeseand this could be due to very low magnitude of obesein the study population. However the mean BMI ofthe females was similar to that reported in NFHS surveydata while the proportion of those females havingBMI<18.5 kg/m2 was found to be 38.1% which waslower than 47.7% as reported in NFHS survey.

Magnitude of smoking is higher in this study andsmoking has been found a significant factor for theoccurrence of hypertension. There is a plethora ofstudies suggesting the tobacco smoking as an importantand independent risk factor for hypertension andcardiovascular diseases11.

Thus to summarize, this study reveals that themagnitude of hypertension in the tribal labour workersis comparable to the magnitude found in the otherIndian studies. It is likely that a systematic and largerstudy may give better understanding of the prevalenceand the underlying risk factors among these workers.

Table 1: Distribution of hypertension according todifferent risk factors

Risk Factors Number Hypertensives χ2;df, p-valueNo (%)

Age (in years)<45 132 23 (17.4)≥45 22 3 (13.6) 0.017; 1; >0.05

SexMale 91 15 (16.5)Female 63 11 (17.5) 0.025,1, >0.05

Smoking history*Ever smokers 35 9 (25.7)Never Smokers 56 6 (10.7) 3.52; 1; <0.05

Alcohol use*Present 5 1 (20.0)Absent 86 13 (15.1) 0.407; 1;>0.05

Body mass indexOverweight-pre-obese 9 -Non-obese 145 26 (17.9) -

* Included only males

Tiwari RR: Hypertension among Tribal Labour Population

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References:

1. Integrated NCD management and prevention. Inthe official website of WHO. http:// www.who.int

2. WHO. Epidemiology and prevention ofCardiovascular diseases in elderly people. WHOTechnical Report Series No. 853, World HealthOrganization, Geneva, 1995.

3. WHO. Obesity: Preventing and managing theglobal epidemic. WHO Technical Report SeriesNo. 894, World Health Organization, Geneva,2000.

4. Dash SC, Sundaram KR, Swain PK. Bloodpressure profile, urinary sodium and body weightin the ‘Oraon’ rural and urban tribal community.J Assoc Physicians India. 1994; 42: 878-80.

5. Chadha SL, Gopinath N, Ramachandran K.Epidemiological study of coronary heart diseasein Gujaratis in Delhi (India). Ind J Med Res 1992,96:115-121.

6. Kerketta AS, Bulliyya G, Babu BV, MohapatraSS, Nayak RN. Health status of the elderlypopulation among four primitive tribes of Orissa,India: A clinico-epidemiological study. Zeitschrift

für Gerontologie und Geriatrie. Published onlineon 10 April 2008. http://www.springerlink.com/content/6g424u36581868wq/ last visited on 10th

July 2008.

7. Malhotra SL. Studies in arterial blood pressurein the North and South India with reference todietary factors in its causation. J Assoc PhysiciansIndia 1971; 19:211-224.

8. Chadha SL, Radhakrishnan S, Ramachandran K,Kaul U, Gopinath N. Epidemiological study ofcoronary heart disease in urban population ofDelhi. Indian J Med Res 1990; 92: 424-30.

9. Anand MP. Epidemiology of hypertension. In:Anand MP, Billimoria AR, editors. Hypertension:an international monograph. New Delhi. IndianJ Clin Practice 2001:10-25.

10. Singh RB, Suh IL, Singh VP et al. Hypertensionand stroke in Asia: prevalence, control andstrategies in developing countries for prevention.J Hum Hypertens 2000; 14: 749-763.

11. Noel H. Essential hypertension: evaluation andtreatment. J Am Acad Nurse Pract 1994; 6: 421-435.

Tiwari RR: Hypertension among Tribal Labour Population

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Street sweepers are exposed to significantly moreamount of dust, microorganisms, toxins and vehicleexhaust than the recommended norms1-3. Due to thisoccupational exposure they are very much vulnerableto develop the chronic diseases of respiratory systemsuch as chronic bronchitis, asthma, etc. The problemis further compounded by various socioeconomicfactors like habit of smoking, poor housing conditions,etc4-8. Therefore a need was felt to study the proportionof chronic respiratory morbidity and the role of variousrisk factors contributing to chronic respiratory morbidityin this occupational group.

The present study was designed as a cross-sectional study with a comparison group. The studygroup comprised of all the street sweepers working inHanumannagar Zone of Nagpur MunicipalCorporation (N=273). The comparison group includedall the class IV workers working in the office buildingsof Nagpur Municipal Corporation, Nagpur (N =142).The study was undertaken during November 2003 to

Short communication

Respiratory Morbidity among Street Sweepers Working atHanumannagar Zone of Nagpur Municipal Corporation,

Maharashtra*Sabde Yogesh D1, Sanjay P Zodpey1

1Department of Preventive and Social Medicine, Government Medical College and Hospital, Nagpur, Maharashtra,India. Corresponding author: [email protected]

January 2005.

Pretested proforma was used to record thenecessary information such as socio-demographicfactors, occupational history, past and present medicalhistory & findings of clinical examination. Standardclinical methods were used and opinion was soughtfrom specialists of Government Medical CollegeNagpur to confirm the diagnosis.

International Classification of Diseases version 10(ICD 10) was used to make the final diagnoses e.g.Chronic bronchitis (ICD No. J44) defined as presenceof a chronic productive cough on most of the days forthree months, in each of the two successive years, inpatient in whom other causes of chronic cough havebeen excluded (Other causes of chronic cough wereexcluded by sputum microscopy and chest X-ray).

As occupational exposure to dust is known tocause chronic respiratory morbidity like chronicbronchitis, bronchial asthma and bronchiectasis, the

Summary

Due to the occupational exposure street sweepers are very much vulnerable to develop the chronicdiseases of respiratory system. Therefore this study was undertaken to find out the proportionof chronic respiratory morbidity among the street sweepers and the role of various associatedrisk factors. The study included two groups: study group i.e. street sweepers and comparisongroup (Class IV workers working in the office buildings). Various risk factors studied were age,sex, socioeconomic status, length of service, smoking habit, type of house, area of residence,cooking fuel and pets. Proportion of chronic respiratory morbidity (chronic bronchitis, asthmaand bronchiectasis) was higher (8.1%) among street sweepers compared to comparison group(2.1%), the difference being statistically significant. Unconditional multivariate logistic regressionrevealed that risk of having chronic respiratory morbidity among street sweepers was 4.24 (95 %CI of OR = 1.24 to 14.50) times higher than that in the comparison group and the risk increasedsignificantly with increasing length of service (OR = 1.75, 95 % CI = 1.09 to 2.81).

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effect of various risk factors on the occurrence ofchronic respiratory morbidity was studied in detail.

Bivariate analysis was initially done to study theeffect of various risk factors associated with respiratorymorbidity, viz. age, sex, socioeconomic status,occupation, length of service, smoking habit, house,area of residence, cooking fuel and pets. The chi-square(χ2) test was applied to test the significance. In thesecond step, unconditional multiplelogistic regression (MLR) analysis wascarried out to estimate the adjusted oddsratios (OR) for the abovementioned riskfactors for chronic respiratory morbidity.The Full Model of MLR comprised of allthe risk factors included in the study. Ofthese, the factors significant at α = 0.25were identified and included in the FinalModel 1. The factors which weresignificant in Final Model 1 at α = 0.05were then included in Final Model 2 andagain tested at α = 0.05. The factorsthus identified were considered to be thesignificant risk factors. STATA version 8was used for the analysis of the data.

There were a total of 273 streetsweepers working in HanumannagarZone of Nagpur Municipal Corporation,Nagpur and 142 class IV employees(comparison group) working in officebuildings of Nagpur MunicipalCorporation, Nagpur. All of them

participated in the study.

Table 1 shows the distributionof various respiratory morbidconditions among the subjects. Itwas observed that the proportionof chronic bronchitis wassignificantly more (p = 0.0346)among street sweepers (5.9%) ascompared to the comparisongroup (1.4%). The other chronicrespiratory morbidity includedbronchial asthma andbronchiectasis. While consideringchronic respiratory morbiditycollectively, it was found that theproportion was more among street

sweepers (8.1%) than the comparison group (2.1%),the difference being significant statistically (p =0.0157).

None of the 273 street sweepers was using protectivedevices like masks, goggles, etc. while working.

Proportion of chronic respiratory morbidityincreased with increase in age and length of service.This increase was statistically significant when chi

Table 1: Distribution of respiratory morbid conditionsamong the study subjects

ICD code Morbid Street ComparisonConditions sweepers group P value

(n=273) (n=142)No. (%) No. (%)

J41 Chronic bronchitis 16 (5.9) 2 (1.4) 0.0346*

J45 Bronchial asthma 5 (1.8) 1 (0.7) 0.3613

J00 URI 20 (7.3) 10 (7) 0.9156

J49 Bronchiectasis 1 (0.4) 0 0.5214

* Statistically significant

Table 2: Distribution of chronic respiratory morbidityaccording to age and length of service

Street sweepers Comparison group (n=273) (n=142)

Subjects Morbidity Subjects MorbidityNo. (%) No (%)

Age group (years)20 - 29 19 0 13 0

30 - 39 104 6 (5.8) 35 1 (2.9)

40 - 49 114 11 (9.6) 69 2 (2.9)

≥50 36 5 (13.9) 25 0

Length of Service (years)0-9 80 3 (3.8) 42 0

10 - 19 103 7 (6.8) 48 1 (2.1)

20 - 29 78 11 (14.1) 45 2 (4.4)

≥30 12 1 (8.3) 7 0

χ2 test for linear trend p < 0.05

Sabde YD et al: Respiratory Morbidity among Street Sweepers at Nagpur

149


square test for linear trend was applied (p<0.05) (Table2).

In full model of unconditional multiple logisticregression analysis (MLR), it was found that theoccupation as street sweeper was significantlyassociated with the proportion of chronic respiratorymorbidity (p = 0.019). None of the other hypothesizedrisk factors were found to be significant at α (level ofsignificance) = 0.05. However to include the marginallysignificant risk factors in the final reduced model, weidentified the risk factors having p value less than 0.25in full model of MLR. These factors were lowersocioeconomic status (p = 0.204), occupation as streetsweeper (p = 0.019), increasing length of service (p =0.156), and smoking habit (p= 0.152).

In the final model of multiple logistic regressionanalysis it was observed that the p value was significantfor two factors viz. occupation as street sweeper (p =0.021) and increasing length of service (p = 0.021).The Odds Ratio for occupation as street sweeper was4.24 (95% CI = 1.24 to 14.50) and that for increasinglength of service was 1.75 (95% CI = 1.09 to 2.81).

Thus the findings of the present study revealedthat the proportion of chronic respiratory morbidity(chronic bronchitis, bronchial asthma andbronchiectasis) was significantly higher among streetsweepers than the comparison group subjects. Thehigher proportion of chronic respiratory morbidityamong the street sweepers having longer length of theirservice as a street sweeper could be because of theincreasing duration of occupational exposure. Theseresults indicated a duration response relationshipbetween the occupational exposure and the outcomeas chronic respiratory morbidity. These findings weresupported by the fact that none of the street sweepersused masks during sweeping.

These findings were in agreement with the studyconducted among Danish Waste Collectors, where thepropor tion of chronic bronchitis (7.8%) wassignificantly more than that among park workers4.Raaschou-Nielsen O et al also found a significantlyhigher proportion of chronic bronchitis and asthma inCopenhagen Street Cleaners compared with CemeteryWorkers5. Nagraj C et al at Bangalore7 and Diggikar

UA at Pune8 also detected higher proportion ofrespiratory morbidities among the street sweepers.

Thus it is recommended to use protective devicesfor these street workers to ward off respiratorymorbidity.

References:

1. Krajewski JA, Tarkowski S, Cyprowski M,Szarapinska-Kwaszewska J, Dudkiewicz B.Occupational exposure to organic dust associatedwith municipal waste collection and management.Int J Occup Med Environ Health 2002; 15(3):289-301.

2. Heederik D, Douwes J. Towards an occupationalexposure limit for endotoxins. Ann Agric EnvironMed 1997;4:17–19

3. Wilkins K. Gaseous organic emissions fromvarious types of household waste. Ann AgricEnviron Med 1997; 4:87–89.

4. Hansen J, Ivens UI, Breum NO, Nielsen M, WürtzH, Poulsen OM et al. Respiratory symptomsamong Danish waste collectors. Ann AgricEnviron Med 1997; 4: 69–74.

5. Raaschou-Nielsen O, Nielsen ML, Gehl J. Traffic-related air pollution: exposure and health effectsin Copenhagen street cleaners and cemeteryworkers. Arch Environ Health 1995; 50(3):207-13.

6. Meer G, Kerkhof M, Kromhout H, Schouten JP,and Heederik D. Interaction of atopy and smokingon respiratory effects of occupational dustexposure: a general population-based study.Environ Health 2004; 3:6.

7. Nagaraj C, Shivram C, Jayanthkumar K, MurthyNNS. A study of morbidity and mortality profileof sweepers working under Banglore CityCorporation. Ind J of Occup and Environ Med2004; 8(2):11-16.

8. Diggikar UA. Health status of street sweepers withreference to lung function tests [Dissertation].Pune University; 2004.

Sabde YD et al: Respiratory Morbidity among Street Sweepers at Nagpur

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The health care workers who deal with patients,especially who are exposed to blood, body fluids andpotentially contaminated instruments or wastes, are athigh risk of contracting serious blood-borne infectionslike hepatitis B (HBV) , hepatitis C (HCV) and HIVthrough occupational injuries during their professionalactivities1 - 5. Percutaneous injury is the most commonmethod of exposure to blood borne pathogens6. Inthe USA approximately 6,00,000 to 8,00,000 needlestick injuries occur annually among the health careworkers, and as a result more than 1000 of themcontract hepatitis C or HIV. The most affected categoryof health care workers is the nurses who are involvedin 42% to 74% of the reported needlestick injuries1.

This hospital-based retrospective study wasconducted among the nurses involved in patient careto quantify the incidence and risk of needle stick injuriesduring patient care in the hospital setting and to assescertain aspects of their practice profiles during and aftersuch events. The study places were North BengalMedical College & Hospital, located in a rural area ofDarjeeling district and the city-based N.R.S. MedicalCollege & Hospital, Kolkata, West Bengal. The studyperiod was from May 2004 to April 2005. Upon

Short Communication

Needle Sticks Injury among Nurses Involved in Patient Care:A study in Two Medical College Hospitals of West Bengal

*G. K. Joardar1, C. Chatterjee2, S.K.Sadhukhan3, M.Chakraborty4, P. Das5, A.Mandal6

Summary

A hospital-based retrospective study on a sample of 228 nurses involved in patient care, in twomedical college hospitals of West Bengal, showed that 61.4% of them sustained at least one NeedleStick Injury (NSI) in last 12 months. The risk of such injuries per 1000 nurses per year was foundto be 3,280. Out of the most recent injuries among 140 nurses, 92.9% remained unreported toappropriate authorities; in 52.9% events hand gloves were worn by the nurses; only 5% of thosenurses received hepatitis B vaccine, 2.1% hepatitis B immunoglobulin and none of them receivedpost exposure prophylaxis for HIV.

approval by the administration and getting lists of total725 such nurses from the nurses’ authorities, one-thirdof the nurse population was selected for the study. Witha random start, every third subject from the list wasselected by systematic random sampling technique.Thus a total of 228 nurses comprised the sample size.The inclusion criterion was to work in hospital settinguninterruptedly for last 12 months.

After review of literatures on similar studies andgetting inputs from experts in epidemiological studiesthe draft questionnaire was prepared. The finalquestionnaire for data collection was prepared afterthe draft questionnaire was pre-tested among thestudent nurses. The nurses themselves reported dataon their experience in the last 12 months period. Incase of multiple injuries, the detail information aboutthe most recent injury was elicited. The anonymity ofthe respondents was ensured. The data analysis wasdone using suitable descriptive statistics (rates, ratioand proportion). The risk of needle stick injury per1000 nurses per year was calculated as follows: Thecumulative incidence of needlestick injuries among allnurses in last 12 months ÷ total number of nursesstudied x 1000.

1Associate Professor, 5Assistant Professor, Community Medicine, 6Principal, NRS Medical College, 2AssistantProfessor, Community Medicine, Medical College, Kolkata, 3Assistant Professor, MCH, All India Institute of Hygiene &Public Health, Kolkata, 4Professor, Community Medicine, North Bengal Medical College, Darjeeling.*Corresponding author: [email protected].

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Regarding specific protection against hepatitis Binfection, it was observed that only 21.1% (n=48) ofthe nurses were fully immunized with hepatitis Bvaccine. Out of the total 228 nurses studied, 61.4%(140) experienced at least one needle stick injury inthe last 12 months. The frequency distribution of theinjuries showed that 21.1%, 15.8%, 9.6%, 9.2% and5.7% of those nurses sustained 1-3, 4-6, 7-9, 10-12and 13 to ≥ 15 injuries, respectively, in the last 12months. The cumulative incidence of the needle injuryevents during the last 12 months was 748; and the risk

of NSI per 1000 nurses per year came to 3,280.

Table no. 1 shows that out of 140 most recentinjuries all were puncture in nature and 84.3% of themdrew blood; 53.6% were associated with disposableneedle & syringe devices; 20.7% were associated withreusable needles and 25.7% with suture needles. Itwas revealed that 92.3% of those injuries were notreported to the appropriate authorities. Regarding thereasons of non-reporting, it was revealed that in morethan half of the events the nurses had not enough time;and in almost one-third of the events they wereunaware of the reporting procedure.

Regarding certain aspects of their practice profilesit was observed that out of those 140 nurses (withtheir recent injuries), 52.9% had worn gloves in theirhands during the procedures involved; 92.1% had theirhands washed with soap and water after the events;only 5% of them received hepatitis-B vaccine and 2.1%hepatitis-B immunoglobulin. Regarding post-injurylaboratory testing, as far as the knowledge of the injurednurses, only 5.7% of the source patients were testedfor both HIV and hepatitis-B, and none for hepatitis-C. Only 3.6% of those nurses were tested for hepatitis-B and two were tested positive (HBsAg +ve); 2.1%for HIV - all of them found non-reactive; and nonewere tested for hepatitis-C. The injured nurses had noknowledge regarding the test results of the sourcepatients.

Similar studies in different areas of the worldshowed variations in the proportions of health careworkers sustaining needle stick injuries during patientcare in the hospital settings. A study in the USA showedthat at least one needle stick injury occurred among27.5% nurses in last one year1. A study in three tertiarycare hospitals in south India showed that 75% of thehealth care workers sustained at least one injury inlast 12 months7. Chaudhary and Agarwal fromLucknow (India) observed that 53% of health careworkers experienced at least one injury within 0 - 6years period 8. Regarding the risk of needlestick injuriesper 1000 nurse per year, the present study observedmuch higher value of 3280 compared to 448 asobserved by Jennifer M. Lee et al1.

Compared to 92% non-reporting of injuries (toappropriate authorities), 70% to 78% non-reportingwere observed among nurses in the USA, wherereporting of all such events is a national mandate1.

Table 1: Profiles of the most recentneedle stick injuries and certain aspectsof practice among the nursesexperiencing the injuries (n=140)

Profile No. (%)

Character of injuryPuncture, drew blood 118 (84.3)Puncture, did not draw blood 12 (15.7)

Devices involvedDisposable needles 75 (53.6)Reusable needles 29 (20.7)Suture Needles 36 (25.7)

Reporting of injuriesReported 10 (7.1)Not reported 130 (92.9)

Practice during the procedureUsed gloves 74 (52.9)

Hand washing after the injureWashed hands with soap & water 129 (92.1)

Received post-exposure prophylaxisHepatitis B vaccine 7 (5.0)Hepatitis B immunoglobulin 3 (2.1)Anti Retroviral Therapy for HIV 0

Tests done on source patientsFor HIV 8 (5.7)For Hepatitis B 8 (5.7)For Hepatitis C 0

Tests done on nurses themselvesFor HIV 3 (2.1)For Hepatitis B 5(3.6)For Hepatitis C 0

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The source analysis in a study among 380 health careworkers who sustained needle stick injuries (in a tertiarycare hospital in Mumbai) observed that 6.1%, 3.9%and 3.2% of the sources were positive for hepatitis-B,HIV and hepatitis-C, respectively 6. A similar study,among 38 health care workers in Mumbai observedthat 26.3% of the sources tested positive for HIV and10.5% positive for hepatitis B 9. A study conducted inLucknow observed that out of the 79 health careworkers who sustained needle stick injuries, nonereceived post exposure prophylaxis (PEP) for HIV 8.

The nurses involved in patient care in the hospitalsettings are at great risk of sustaining needle stickinjuries and acquiring dreaded blood borne infectionslike HIV, hepatitis-B and hepatitis-C as a consequenceof their occupational exposures. There is lots of scopein improving their awareness and practices as how tominimize this risk and adverse consequences of suchinjuries through appropriate IEC activities (includingin-service training), strict adherence to universal safetyprecautions and universal immunization for them withappropriate vaccine(s) like hepatitis-B vaccine.

Acknowledgement

The authors acknowledge their thankfulness toauthorities of North Bengal Medical College &Hospital, Sushrutanagar, Darjeeling and N.R.S.Medical College & Hospital, Kolkata for their supportand help

References:

1. Jennifer M. Lee, Marc F.Botteman, LarsNicklasson et al. Needle stick injury in acute carenurses caring for patients with diabetes mellitus.Current Medical Research & Opinion 2005; 21(5):741-747.

2. Anthony S. Fauci, H. Clifford Lane. HumanImmunodeficiency Virus Disease: AIDS & RelatedDisorders. Harrison’s Principles of InternalMedicine; Mc Graw Hill, 2005; 16th edition:1076-1139.

3. Reproductive & Child Health, Module for MedicalOfficers (Primary Health Care) MO (PHC),Integrated Skill Development Training, NationalInstitute of Health & Family Welfare, Munirka,New Delhi. November, 2002: 489-516.

4. Park K. Park’s Text Book of Preventive & SocialMedicine; M/s Banarasidas Bhanot, Jabalpur(India), 2005; 18th edition: 167 – 175 and 271 -281.

5. Physician’s Guide, HIV/AIDS Prevention &Awareness (2006); National AIDS ControlOrganization, William J. Clinton Foundation HIV/AIDS Initiative in association with Indian MedicalAssociation: 45-66 and 111-142.

6. Mehta A, Rodrigus C, Ghag S, Bavi P, Shenai S,Dastur F. Needle stick injuries in a tertiary carecentre in Mumbai, India. Journal of HospitalInfection 2003; 60 (4): 368-373.

7. Tetali S, Chaudhary P L. Occupational exposureto sharps and splash: Risk among health careproviders in three tertiary care hospitals in southIndia. Indian Journal of Occupational &Environmental Medicine 2006; 10: 35-40.

8. Chaudhary R, Agarwal P. Prevalence of NeedleStick injury (NSI) and its knowledge among healthcare workers in a tertiary care hospital in northIndia. Int Conf AIDS 2004 Jul 11-16; 15: abstractno. ThPeC7488.

9. Rele M, Mathur M, turbadkar D. Risk ofneedlestick injuries in health care workers – Areport. Indian Journal of Medical Microbiology2002; 20 (4): 206-207.

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The equation for success in sports is complex.Proper nutrition forms the foundation for physicalperformance as it provides both the fuel for biologicwork and chemicals for extracting and using potentialenergy contained within this fuel. Food also providesessential elements for the synthesis of new tissues andthe repair of existing cells. Nutrition thus plays animportant role in attaining a high level of achievementin sports. Importance of nutrition in sports should reachall sports personnel to maximise their performance1.

In recent times there has been a great emphasison various aspects of nutrition for sportsmen but a verylittle attention has been paid to sportswomen. This islargely due to lack of opportunities for women inathletic participation and lack of interest and expertisein this area. The available research findings do notprovide adequate information regarding diet patternand nutritional profile of Indian sportspersons, andespecially of sportswomen. Moreover, there is paucityof data on nutrition education interventions amongIndian sportsmen2.

With the Commonwealth Games in 2010 beingheld in New Delhi, it is important to meet the gap innutrition research in sportswomen and formulate plansfor nutrition intervention.

Short Communication

Dietary Profile of Sportswomen Participating inTeam Games at State/National Level

*Ritu Jain1, S. Puri2, N. Saini3

1Research Nutritionist, Public Health Nutrition and Development Centre, 2Reader, Department of Foods and Nutrition,Institute of Home Economics, University of Delhi; 3Senior Lecturer, Physical Education, Institute of Home Economics,University of Delhi. *Corresponding author: [email protected]

Summary

A cross sectional study was conducted to assess dietary profile of 100 Delhi based national /state level sportswomen, aged 18 – 25 years, participating in team games – volleyball, hockey,football and kabaddi. Mean energy intake was found to be 1471 + 479 Kcal. Only 24 percent ofthe sports women met the recommendations of 60 – 65 energy percent from carbohydrates and87 percent were consuming more than 25 energy percent from fat. The mean macronutrients andmicronutrient intakes of all the subjects were much lower than the recommendations. Improperfood choices were also observed in majority. It becomes necessary to generate awareness amongsports personnel regarding proper nutrition practices.

In this perspective, the present study wasundertaken in an attempt to study the dietary profileof sports women participating in team games at stateor national level.

We planned a cross-sectional descriptive studyduring September 2006 to February 2007.

The sample consisted of 100 college sportswomen participating in different team games – hockey,football, volleyball and kabaddi at state or nationallevel. Players between 18-25 years of age, havingtraining period of atleast one year, playing at state ornational level, bonafide students of Delhi UniversityColleges and willing to participate in the study werepurposively selected for ease in follow up from SportsAuthority of India training centers where camps andpractice sessions were organized on regular basis. Apre-tested structured questionnaire was used to gatherinformation on lifestyle patterns, health status anddietary habits. Dietary assessment was done using 24-hour dietary recall and food frequency questionnaire.The subjects were asked to report the food intake overthe past 24 hours, which included the foods consumedas well as the quantity in household measures. Thehousehold measures were then converted to raw foodamounts based on the values given by Raina et al3.The energy, macronutrients and micronutrients

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contents were then calculated based on Nutritive Valueof Indian foods4. Physical activity profile of the subjectswas studied by means of 24-hour activity recordmethod. The total daily energy expenditure wascalculated using Satyanarayan codes5 that involvesestimation of energy expenditure of 9 groups ofactivities. 24-hour activity record and 24-hour dietaryrecall were done for the same day to find out the energybalance.

The data collected was subjected to qualitativeand quantitative analysis using a statistical packagefor social sciences (SPSS, Version 9.0). Percentagesand frequencies of distribution were calculated for thegeneral information, lifestyle related information,health profile and dietary patterns. The mean andstandard deviations were calculated for energy intakesand intake of other nutrients.

Results

Of 100 subjects enrolled, 60 percent were nationallevel players. Even though participating in sports, 22percent of the subjects did not perceive themselves asfit. Around 60 percent of subjects skipped atleast oneof the meals and 40 percent subjects reported changesin their menstrual cycle that could be due to arduousexercise training.

Table 1 depicts the mean intakes of differentnutrients by the study sportswomen.

It was observed that the mean energy, protein,fat, carbohydrate and micronutrients intakes of all therespondents were found to be much lower whencompared with NIN recommendation 6. Mean vitaminC and calcium intakes of majority of subjects werehigher than the ICMR7 recommendations for normaladult female but were lower than the values given byRao8 for Indian sports people.

We tried to further categorize the intakes into thelevels of macronutrient adequacy. It was found that74 percent subjects met the protein recommendationsof 10 – 15 energy percent. For 15% subjects proteinconstituted >15 energy percent and the rest (11%) <10 energy percent. However, only 24 percent of thesports women met the recommendations of 60 – 65energy percent from carbohydrates with 71 percentconsuming less than 60 energy percent fromcarbohydrates. Correspondingly, 87 percent of therespondents were consuming more than 25 energypercent from fat, while only 7% subjects met therecommendations of 20 – 25 energy percent from fat.Data also revealed that 67 percent, 87 percent and 99percent of the subjects had their intakes of thiamin,riboflavin and niacin respectively lower than one-thirdof recommended values.

Further analysis revealed that 95 percent ofsubjects used to eat chapatti daily. Items like rice (57%),paranthas (49%), biscuits (50%) and bread (43%) wereconsumed frequently. Protein foods consumedincluded pulses, animal foods and milk and milkproducts like curd paneer etc. Pulses either whole orwashed constituted an integral part of their daily meal.All subjects reported to be consuming vegetables andfruits daily including a variety of these foods in theirmenu i.e. green leafy vegetables (67%), root vegetables(65%), other vegetables (62%) and seasonal fruits andvegetables (72%). Ghee, butter and refined oil werealso used daily. Almost all the subjects took one or theother beverage to rehydrate themselves after theirpractice as well as competitions. Most frequentlyconsumed beverages by the subjects include tea/coffee, juices and aerated drinks. 51 percent of therespondents never took aerated drinks as they provideonly empty calories. 47 percent of the subjects nevertook any sports drink for rehydration.

Energy expenditure for most of the playersexceeded their intake thus putting them into negativeenergy balance.

Table 1: Mean intakes of various nutrientsby the sports women (n=100)

Nutrient Mean + SD (Range)

Energy (kcal) 1471 ± 479 (629-3429)

Protein (g) 46.1 ± 16.3 (15.9-114.4)

Fat (g) 50.8±20.4 (14.9-127.8)

Carbohydrate (g) 207.6±68.8 (82.9-455.7)

Calcium (g) 609.8±246.3 (166.2-1271.4)

Iron (mg) 10.1±3.9 (3.3-26.4)

Thiamin (mg) 1.13±0.43 (0.36-2.52)

Riboflavin (mg) 1.02±0.44 (0.20-2.49)

Niacin (mg) 8.28±3.28 (3.33-22.40)

Vitamin C (mg) 76.96±69.95 (7.20-326.05)

Vitamin A (mcg) 487.33±488.79 (72.28-1211.93)

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The findings revealed that many of the subjectswere initiated into sports in their early childhood eventhough it may not be the same sport that they arepursuing at present. Only 44 percent of the subjectsenrolled for the study have regular meals. In fact 20percent of respondents had less than three meals aday; 31 percent of them skipped breakfast. Theyrepor ted that these three meals included therefreshment provided to them by the camp organizers.

It was found that the dietary energy was beingderived from fat rather than from carbohydrate as friedsnacks and namkeens was consumed frequently. Faultyfood choices, preference for junk foods could be thereason and therefore counseling for proper foodchoices at low cost becomes imperative.

Since most of the subjects have reported suboptimal energy intakes, their menstrual irregularitiescould be addressed if their energy intakes wereimproved in the future as regular menstruation helpsto maintain bone mineral density9 and thus womenwho do not menstruate regularly may have a higherrisk for the development of a stress fracture. Decreasingthe amount of training or increasing energy intake andbody weight restores regular menstrual cycles10.

Thus in order to maximize the physicalperformance, it is imperative to develop informationbooklets for these players to generate awarenessregarding proper nutrition practices. Information couldalso be elaborated with special reference to theparticular game keeping cost factor in mind.

Acknowledgements

With a deep sense of gratitude, the author wishesto express sincere thanks to lecturers in physicaleducation of the selected colleges, statistician and therespondents for their cooperation in completion of thework. The author is also grateful to Dr. Sheila Vir,Director, Centre for Public Health Nutrition, New Delhifor her encouragement and useful discussions duringthe course of preparation of this paper.

References:

1. Meti R, Sarawathi G. Impact of nutritioneducation and carbohydrate supplementation onperformance of high school football players. IndJ Nutr Dietet 2002; 43: 197 – 206.

2. Kelkar G, Subhadra K, Chengappa RK. Nutritionknowledge, attitude and practices of competitiveIndian sportsmen. Ind J Nutr Dietet 2005; 43:293 – 303.

3. Raina U et al. Basic food preparation-a completemanual. Third Edition. Orient Longman 2002.

4. Gopalan C, Ramasastri BV and BalasubramanianSC. Nutritive value of Indian foods. IndianCouncil of Medical Research. Reprint 2004.

5. Satyanarayana K, Venkataramana Y, SomeswaraRao M, Anuradha A and Narasinga Rao BS.Quantitative assessment of physical activity andenergy expenditure pattern among rural workingwomen. In: Update Growth, pp 197-205 [K.N.Agarwal and B.D. Bhatia, editors]. Varanasi,India: Banaras Hindu University. 1988.

6. NIN / ICMR Recommended dietary intakes forIndian sports men and women, 1985.

7. Indian Council of Medical Research. NutrientRequirements and Recommended DietaryAllowances for Indians, 1990.

8. Rao BSN. Nutrient requirements of sportspersonand athletes. Proc Nutr Soc India, 1996; 43: 79-103.

9. Cann C, Martin M, Genant H, Jaffe R. Decreasedspinal mineral content in amenorrheic women.JAMA 1984; 251:626.

10. Nelson M, Fisher E, Catsos P, Meredith C, TurksoyR, Evans W. Diet and bone status in amenorrheicrunners. Am. J Clin Nutr, 1986; 43: 910.

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Integrated Child Development Services (ICDS)scheme, recognized as the world’s most unique largestcommunity based outreach system for women andchild development, had been launched in 1975 in only33 blocks on experimental basis. With immense successin the initial years it was periodically expanded to theextent that in the Tenth Five Year Plan ICDS schemewas universalized in the whole country1.

But merely increasing the infrastructure/availability of the services does not increase theutilization of the services from the centre. It dependson many factors and one of them is client’s satisfaction.For client’s satisfaction critical factor is the quality ofservices. Client rated quality as ‘very good’ when theyfound three elements viz Doctors, Facilities and Workersto be of good quality2. The good quality of the servicesis necessary for acceptability of a programme in acommunity as it determines how beneficiaries wouldperceive about the services and make further demand.Though AWCs have long standing reputation amongcommunity by its existence but how far it is successfulto satisfy the expectations of the end users through itsservices is not clear. Therefore, the present study wasundertaken to assess perception of the beneficiariesfor the quality of the services provided from AWCs.

Short Communication

Perception Regarding Quality of Servicesin Urban ICDS Blocks in Delhi

*A. Davey1, S. Davey2, U. Datta3

1Senior Resident in Subharti Medical College, Meerut; 2Medical Officer, Government of Uttar Pradesh. 3Reader,Education and Training Department, NIHFW, New Delhi *Corresponding author: [email protected]

Summary

The good quality of the services is an important determinant for acceptance of a programme in acommunity. It not only enhances the credibility of a worker at the ground level but also generatethe demand for the services. In this paper perception for the quality of the services was assessedthrough the exit interview of the beneficiaries at the Anganwadi centres (AWCs). 200 beneficiarieswere included from 20 AWCs in a period of one and half month. 52.5% respondents weredissatisfied for the services provided from the AWC for one or more reason. The most commonreason mentioned was the not easy accessibility of the AWC and less space available at the AWC(68.6%), followed by the poor quality of the food distributed (66.7%) and irregular pre schooleducation (57.1%) from AWCs.

The cross-sectional community based study wasconducted during July-August 2004, among 200women respondents selected through stratified randomsampling technique. In Delhi total 28 ICDS blocks areexisting, 5 in rural areas and remaining in urban slumsof nine districts. The study blocks running in the urbanareas are divided into four geographical zones byarbitrary lines. From each zone one ICDS block wasselected randomly and five anganwadi centers wereselected from each block by systemic random selectiontechnique, thus a total of 20 AWCs were included. Ateach AWC, every third respondents was interviewedin depth at the exit by open-ended interview schedule,till they make sub sample size of 10. Thus, total samplesize of the respondents was 200. Respondents werecomprised of pregnant women, lactating mothers andmothers of the children registered with the anganwadicenters.

Respondent women were interviewed to ascertaintheir opinion on various aspects like approachabilityof AWC, utilization of services by the beneficiaries andtheir satisfaction towards services of the AWCs.

Out of 200 respondents interviewed, 72.5% (145)were mothers of the children, 16.5% (33) pregnantwomen and 11% (22) lactating women. Out of 145

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children (for whom mothers are taken as respondents),28.3% (41) were in the age group of less than 3 yearsand 71.7% (104) in the age group of 3-6 years. Overall,44% respondents (88) were illiterate and 56% (112)were literate. Majority of the respondents (70%) werestaying in the area since more than 5 years.

When beneficiaries were asked about how theycame to know about the AWC running in their areas,37.5% said by themselves, 23% said from their motherin law, 20% from neighbors, 12% by helpers and 2.5%by ANM. Only 5% women came to know about theAWCs through AWWs, indicating their poorapproachability in the community.

89% of the respondents had mentioned thatAWW had visited them in last one year. 51.7%respondents said that their frequency for visit was oncein 3 months. Reasons for visit were reported to be poliovaccination (69%), immunization services (51.7%);health education (11.8%); nutrition services (11.2%)and pre-school education was the least common reason(1.1%) mentioned by the respondents.

Overall drive against Polio might have influencedthe worker to go house to house. Pre school educationcould be the neglected component of the servicesdelivered from AWC, so did the respondents mentionit as the least common reason.

Regarding utilization of services for the childrenall the mothers mentioned that they receivedsupplementary nutrition from the AWCs. 56.6%mothers told growth monitoring was done of theirchildren in last 6 months. Only 15.9 % had utilizedservices for immunization purposes from the AWCs.However, Benjamin et al3 reported growth monitoringwas rare phenomena in Ludhiana district and SharmaA et al in the national evaluation of the ICDS serviceshad observed that 36.3% of the AWWs were not ableto monitor growth of the children4.

For the 104 children of the preschool age group,only 42.3% mothers mentioned about utilization ofservices for preschool education from the AWCs, butnot regularly. Irregular services of pre school educationcould be due to secondary emphasis for the monitoringof the AWW performance as primary importance isgiven to their growth monitoring activities andsupplementary nutrition distribution and may be dueto non availability of space and lack of education and

teaching aids at the AWC. Roy S et al had alsoconcluded in their interventional study that lack ofconceptual curiosity and skills of the AWWs also limitplay way activities at the AWCs 5.

94.5 % of the pregnant and lactating women weremainly utilizing the services for the supplementarynutrition. Only 23.6% women told they were givenhealth and nutrition education and 5.5% utilized AWCsfor immunization services. None of pregnant andlactating women had ever received tablet iron and folicacid from the AWCs in last one year and had neverbeen provided antenatal or postnatal care. Benjaminet al had also observed less dispensing of Iron andFolic Acid to the pregnant and lactating women by theAWWs in the Ludhiana district 3.

47.5% (95) of the respondents were satisfied withthe services provided from the AWCs. Rest of the 105dissatisfied beneficiaries (52.5%) had mentionedvarious reasons (Table 1); the most common reasonbeing non-accessibility of the AWCs and inadequatespace to run AWCs (68.6%). Other studies6, 7 alsoreported distance/unapproachable state as reasons fornon-utilization of services.

Further analysis revealed that, 22 of 70 (31.4%)dissatisfied respondents due to poor quality of foodand 20 of 72 (27.8%) dissatisfied respondents due non

accessibility, were satisfied with the overall functioningof the AWCs; however all the mothers, who were notsatisfied with the pre school services, were also not

Table 1: Distribution of the respondentsby their satisfaction for services providedfrom AWC (n=200)

Variables Numbers (%)

Satisfied with the services Yes 95 (47.5) No 105 (52.5)Reasons for non satisfaction Non-accessibility 72 (68.6) Less space at AWC 72 (68.6) Poor quality of food 70 (66.7) Irregular pre school education 60 (57.1) No frequent change in recipe 45 (42.9) No immunization at center 45 (42.9)

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satisfied with the services of AWCs.

The findings of the present study also indicatedthat client’s satisfaction about quality influenced theacceptance and utilization of services. Therefore,function of the AWWs should not be restricted to thedistributing of supplementary nutrition to beneficiariesonly, but need to focus to raise satisfaction level of theend users by developing good rapport through periodicsurvey and delivering optimum level of services.

References:

1. Govt. of India. Nutrition and Food, Tenth FiveYear Plan, 2002; p 341-346.

2. State of India’s Health. Voluntary HealthAssociation of India, 1992; pp 53-57.

3. Benzamin AI, Panda P and Zachariah P. Maternaland Child Health Services in Dehlon block ofLudhiana district: Results of the ICDS evaluationsurvey. Health and Population: Perspective andIssues, 1994; 17(1-2): 67-85.

4. Sharma A. National consultation to review theexisting guidelines in ICDS scheme in the field ofHealth and Nutrition. Indian Pediatrics 2001;38:721-731.

5. Roy S, Parmar P; Sundram. Impact of theintervention programme on the knowledge,content and skil ls of AWW and selectedconceptual skills for the pre school, Indian Journalof Maternal and Child Health 1994 Jan-March; 5(1): 20-22.

6. Agnihotri S P, Pandy D N, Nandan D. The impactof Rural Health Services in Agra. Indian Journalof Public Health 1984; 28 (1): 25-29.

7. Jain M, Nandan D, Misra S.K. Qualitativeassessment of health seeking behaviour andperception regarding quality of health careservices among rural community of district Agra.Indian Journal of Community Medicine 2006; 31(3): 140-143.

Davey A et al: Quality of Services in ICDS in Delhi

Attention

All the newly enrolled Life Membersof Indian Public Health Association

Dear Sir / Madam

You are aware that the 53rd All India Annual Conference of IPHA is going to be held from 9th to11th January 2009 at Kempegowda Institute of Medical Sciences (KIMS), Bangalore – 560070, Karnataka.During the conference Life Membership Certificate (MIPHA Scroll) will be distributed. In case, you areunable to attend the conference at Bangalore, the Certificate will be sent to you. The certificate can alsobe collected from the HQ Secretariat at Kolkata personally or through your authorized representative.



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A good number of neonatal morbidity andmortality is attributed to improper delivery andnewborn care practices1. Neonatal care practicesdepend on the knowledge, attitude and practice of thecommunity as well as the availability and accessibilityof the services. Several interventions have beenadopted to address the unmet needs for BasicReproductive and Child Health Services, supplies andinfrastructures since 19722. In spite of all this, neonatalmorbidity and mortality are considerably high in ourcountry and neonatal mortality accounts for two-thirdof the infant deaths. 40 – 70% of neonatal deaths areseen during 1st week of life and majority occurs athome. Presently in our country only 34% births occurin health institution3 and 42% deliveries are assistedby skilled attendants4. There are considerable localvariations in delivery and newborn care practicesadopted by the community and interventions must takeinto account the prevailing practices in the area. It ishighly relevant to generate area specific data regardingsome of the key delivery and newborn care practicesat the community level to initiate appropriateintervention.

The present study was conducted in a rural blockof West Bengal to assess the proportion of homedeliveries, to identify the different categories of careproviders and to find out the prevailing practicesregarding some essential components of newborn care.

Short Communication

A Study on Delivery and Newborn Care Practices in aRural Block of West Bengal

*P. Das1, S. Ghosh2, M. Ghosh3, A. Mandal4

Summary

A cross-sectional study was conducted in a rural block of the State of West Bengal to generatearea specific data on the proportion of home deliveries and certain newborn care practicesprevalent in that area. The study was done through house-to-house survey among 165 motherswho delivered in last six months. 83.6% deliveries were conducted at home and untrained personsattended 36.3% deliveries. Bath within 24 hours of delivery was given to 17.58% newborns. Birth-weight was not recorded in 38.18%. High proportion of newborns, 78.5%, was given prelactealfeeding. The health system should urgently address the deficiencies in the delivery and newborncare practices in the study area.

The study was conducted in Basirhat – 1 block ofNorth-24 Parganas district of West Bengal. The blockhad 19 subcenters and have a population of 1, 59,000.The respondents were mothers, who delivered livebabies in the last six months (January to June 2005).Sample size was estimated to be 144 to providecoverage estimate at 95% confidence level and 8%error margin at 40% previous coverage level. Single-stage random sampling was used for selection of themothers. All 19 subcentres were taken and from eachsub-centre 10 mothers were selected randomly. 25mothers denied providing information. Finally 165mothers were studied.

Majority of the deliveries, 138 (83.6%), wereconducted at home. Only 26 (15.8%) deliveries tookplace at government health facilities (Table 1). Similarhigh proportion of home deliveries were observed inother studies like one in Jamnagar, Gujrat5.

More than one-third of the deliveries (36.3%)were conducted by untrained persons. Untrained daisattended 31.5% deliveries and 4.8% deliveries wereby friends, relatives and unqualified practitioners.Skilled birth attendance was available in only 14%deliveries (nurse 10.4% and doctors 3.6%) (Table 1).

17.6% newborns were given bath within 24 hoursof delivery. Bath-after-delivery was found higher(32.0%) in a study in Egypt6. Birth-weight was not

1Assistant Professor, 3Ex-Professor, Community Medicine, 2Assistant Professor, Psychiatry, 4Principal, N R S MedicalCollege, Kolkata, West Bengal. *Corresponding author: [email protected]

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recorded in 63 (38.2%) newborns. This was similar(33.33%) to study done in Jamnagar district of Gujrat5but very high in comparison to the study result (4.0%)obtained from a hilly district of North India7. Among102 (61.8%) newborns where birth weights wererecorded, 19 (18.6%) were low birth weight (Table 2).

Newborn feeding practices were studied and itwas found that breast-feeding was almost universally

practiced (98.79%) among the study population.Breast-feeding was initiated within half-an-hour in42.4% infants. In 25.5%, it was initiated between half-an-hour to one hour and in 32.1% beyond one hour.The practice of prelacteal feeding was found to behighly prevalent (78.2%). Varieties of prelacteal feedobserved, such as plain water (17.6%), sugar water(9.8%) and honey (51.1%). Honey was foundpredominant prelacteal food in another study done athilly district of North India6 (46.14%) but sugar waterwas found to be dominant prelacteal food in Egyptstudy6.

The present study identified several deficienciesin delivery and newborn care practices in the studyarea. The health system must urgently address theissues by adopting appropriate behaviour changecommunication strategies.

References:

1. Reproductive and Child Health Module for HealthWorkers Female (ANM). National Institute ofHealth and Family Welfare, New Delhi, 2000.

2. National Population Policy, 2000. Ministry ofHealth and Family Welfare, Govt. of India,Nirman Bhavan, New Delhi.

3. National Family Health Survey (NFHS-2), Keyfindings, 1998-99. International Institute ofPopulation Science, Deonar, Bombay, 2001, 13-4.

4. The state of the World Children 2004. UNICEF,New York, USA.

5. Suda Yadav, BS Yadav, SS Nagar, A Study onNeonatal Mortality in Jamnagar District of Gujrat,Indian Journal of Community Medicine 1998; 23(3):130-135.

6. Home Neonatal Care Practices in Rural Egyptduring 1st Week of Life Md. H. Hussein et al http://www.gfmer.ch/ IAMANEH_ISMANEH_Cairo_2006

7. Anmol K Gupta, Rajesh K Sood, Ajay Vatsayan,Dineswas K Dhadwal, Surender K Ahluwalia,Rajesh K Sharma; Breast Feeding Practices inRural and Urban Communities in a Hilly Districtof North India, Indian Journal of CommunityMedicine 1997; 22 (1) : 33-37.

Table 1: Place of delivery and assistanceduring delivery (n=165)

Factors Number (%)

Place of delivery Home 138 (83.6) Health Centre 4 (2.4) Hospital 22 (13.4) Nursing Home 1 (0.6)

Provider Type: Doctor 6 (3.6) Nurse 17 (10.4) Trained Dai 62 (49.7) Untrained Dai 52 (31.5) Others 8 (4.8)

Table 2: Newborn care practices: Bath-after-delivery and birth weight (n=165)

Practices Number (%)

Bath-after-DeliveryBath given 29 (17.6)Bath not given 32 (80.0)Do not know 14 (2.4)

Birth WeightLBW 19 (18.6)Normal 83 (81.4)Total 102 (61.8)Birth Weight not taken 63 (38.2)

Initiation of breast feedingWithin ½ hour 70 (42.4)½ - 1 hour 42 (25.5)After 1 hour 53 (32.1)

Prelacteal feedingHoney 84 (51.1)Sugar water 16 (9.8)Plain water 29 (17.6)Total 129 (78.2)

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Hospital discharge records are important sourceof data which can provide important information andserve as an essential tool for decision making.Furthermore it is an indicator of early warning signalfor impending health problems1.

In District Civil Hospital (DCH), Belgaum,diagnoses are coded as per International Classificationof Diseases, 10th Revision (ICD-10). As per WorldHealth Organization (WHO) there are 21 classificationsunder certain infectious and parasitic diseases2.Infectious diseases caused by pathogenic bacteria,viruses and protozoa are the most common and widespread health risk associated with drinking water3. InNew Zealand, rates of some infectious diseasescontinue to remain high for a developed country andthere are also large inequities in the distribution of thisburden4. Globally waterborne and sanitation-relatedinfections are one of the major contributors to diseasesburden and mortality5. Infectious diseases kill morethan 11 million people a year and diminish the lives ofcountless others6. Virtually all deaths due to infectiousdiseases occur in low-and middle-income countries.This study attempts to find out the distribution ofhospitalisation due to infectious and parasitic diseases.

Short communication

Hospitalisation due to Infectious and Parasitic Diseases inDistrict Civil Hospital, Belgaum, Karnataka

*A. C. Naik1, S. Bhat1, S. D. Kholkute1

Summary

To assess the burden of infectious and parasitic diseases on hospital services at District CivilHospital (DCH) Belgaum, a retrospective study was carried out using discharge recordsconcerning 8506 inpatients due to infectious and parasitic diseases among 95655 patients admittedfor all causes during the reference period 2000-2003. Out of the 21 causes of infectious and parasiticdiseases, only 5 contributed maximally towards hospital admission. The most frequent causewas intestinal infections (44.0%) followed by tuberculosis (35.4%). 57.5% of these admissionswere from the productive age group of 20-54 years. Tuberculosis is the most important disease interms of hospital bed days (59.7%). Tuberculosis and intestinal infectious diseases represent morethan three-fourth of the overall burden in terms of hospital bed days.

This is a retrospective study carried out at DCH,Belgaum based on ICD-10 diagnosed codes devisedby WHO. DCH is a major government multi-specialtyhospital in Belgaum district having 740 beds and isattached to a medical college. The hospital also has aoutpatient department (approximately 377000consultations annually) and a community healthdepartment.

Out of 95655 patients admitted during the fouryears reference period (2000-2003), 8506 patientsadmitted were due to infectious and parasitic diseases.Data was collected during 2005-06 and analysis madeusing Statistical Package for Social Sciences (SPSS)version 13.0 software. If any patient was readmittedafter discharge this was considered as a new patient.The multiple co-infected patients are included in thefrequency distribution based on the primary infectionand not counted in other co-infection categories. Fromdischarge certificates two things were noted e.g.frequency of admissions due to the condition, andduration of the service provided (expressed in days ofhospital stay).

Out of 95655 admissions, 8506 patients wereadmitted due to infectious and parasitic diseases. Theadmissions by age showed that proportion of

1Regional Medical Research Centre, Indian Council of Medical Research, Nehru Nagar, Belgaum, Karnataka.*Corresponding author: [email protected]

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admissions below 5 years of the children constituted12.7%. Most productive age group (20-54 years)constituted the maximum (57.5%) number of patients.Although male admissions are more in all the 5infectious diseases, in case of tuberculosis and intestinalinfections, a statistically significant difference betweenmale and female admissions was observed (p<0.001).

Among the 21 classification of infectious andparasitic diseases, only five contributed towards 93%of burden on hospital services namely intestinalinfections, tuberculosis, other bacterial diseases(Septicemia, Leprosy, Tetanus, etc), HIV and protozoaldiseases. Intestinal infectious diseases contributedmaximum of 44% with proportional mortality rate(PMR) of 6.9%. Diarrhea, gastroenteritis and fever(96%) were more commonly reported among the 9categories of intestinal infectious diseases in the DCH.Tuberculosis with 35.4% of admissions with a PMR of44.6% was the second highest. Even thoughcontribution from other bacterial diseases was only5.9%, but PMR was considerably high (34%).Percentage of admissions due to HIV was only 4.5%;however PMR was 7.6%. Protozoal diseasescontributed least (3.3%) compared to the above fourcategories of infectious diseases with PMR of 1.4%(Table-1). Malaria (85.7%) was more commonlyreported among 11 categories of protozoal diseasesand in 3.1% cases HIV-TB co-infection was found.

Considering the number of bed days occupieddisease wise, tuberculosis was the major contributorwith 59.7% and average length of stay (ALOS) perpatient was 18 days. The next category was the

intestinal infections with 21.2% of bed days occupiedwith ALOS of 5 days. Other bacterial diseases(Septicemia, Leprosy, Tetanus, etc) also contributed asignificant number of bed days with 7.6% and highALOS of 13 days. HIV patients occupied 4.1% of beddays with ALOS of 10 days.

The total number of children below 5 yearsadmitted was 1084. The highest number of admissionswas due to intestinal infectious diseases (72%) withPMR 10.1%. The admission for tuberculosis was 10.4%with PMR of 11.2%. In case of children, other bacterialconditions also contributed 10.1% and PMR was veryhigh with 70.9% compared to other infectious diseases.

Although hospital data has some limitations, butit provide important information for planning,evaluation of hospital services and epidemiologicalstudies.

Using the percentage of hospital bed days (relatedto both frequency of admission and duration of stay)as a proxy of a condition’s relative burden on hospitalservices, childhood diseases as a whole account forless than 15% of the total burden. In a similar studyconducted in Uganda, it was observed to be more thanone-fourth of the total burden1. However the studyreferred above was carried out after a war and faminewhile the present study was conducted in normalsituation.

The present study reveals that the total load in allage groups of intestinal infectious diseases was 44%where as in case of children below 5 years this washigher (72% of 1084 admissions). These diseases are

Table 1: Different parameters for the five leading causes of admissions in District CivilHospital, Belgaum.

Causes Admissions Bed days ALOS(days) Deaths PMR (%)No (%) No (%) No (%)

Intestinal Infectious Diseases (A00–A09) 3740 (44.0) 18904 (21.2) 5 48 (1.3) 6.9Tuberculosis (A15–A19) 3013 (35.4) 53354 (59.7) 18 312 (10.4) 44.6Other Bacterial Diseases (A30–A49) 501 (5.9) 6572 (7.6) 13 238 (47.5) 34.0HIV diseases (B20–B24) 380 (4.5) 3623 (4.1) 10 53 (13.9) 7.6Protozoal Diseases (B50–B64) 280 (3.3) 2176 (2.4) 8 10 (3.6) 1.4Other Infectious Diseases* 592 (7.0) 4746 (5.3) 8 38 (6.4) 5.4Total 8506 (100.0) 89375 (100.0) 11 699 (8.2) 100.0

*Other Infectious Diseases=A20–A28, A50–B19, B25–B49, B65–B99. PMR=Proportional mortality rate;ALOS=Average length of stay.

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caused by contamination of human/animal feces andpathogenic microorganisms in drinkingwater. Infectious diseases caused by pathogenicbacteria, viruses, and protozoa are the most common.There is an urgent need to control this disease to reducethe hospital burden. The ALOS for TB patients was18 days in DCH, Belgaum compared to 57 days inLacor Hospital, Uganda and 86 days in Russia1, 7.However study undertaken in USA has found ALOSfor TB patients is 14 days8 which is comparable to ourresults. The huge difference between Uganda andRussian studies compared to Indian and USA studiescould be treatment policy for TB patients. TB patientsrequire labor intensive care and a high volume oflaboratory, radiology and ancillary services. In otherwords, the burden of TB in terms of use of hospitalservices is much higher than its burden in terms ofnumber of admissions. It is expected that the burdenof TB shall be reduced in future as DOTS strategy isbeing implemented in Belgaum district since 2002.

The percentage of admissions due to HIV wasonly 4.5% of the total admissions. Further, HIV patientsALOS was 10 days compared to tuberculosis (18 days)and other bacterial diseases (13 days). The interestingobservation in the present study is HIV-TB co-infectedpatients admission was 3.1% of the infectious andparasitic diseases which is comparable to the hospitaldata from USA (3.2%)8.

Thus, the present study clearly suggests thatintestinal infectious diseases and tuberculosis causemaximum burden on hospital services at DCH,Belgaum which can be reduced by proper and timelyinterventions. Burden of intestinal infections can bereduced by providing potable water and propersanitary measures. The integration of preventive andcurative care, implementing health educationprograms, improving the accessibility of health facilitiesand the availability of effective treatment, are alsocrucial for controlling infectious diseases. Burden ofTB on hospital services can also be considerablyreduced by proper awareness about DOTS (DirectlyObserved Treatment Short-course).

Acknowledgments

We wish to thank District Surgeon and Mr. KeshavRao of district civil hospital, Belgaum for permitting toutilize the data. We thank Mr. Vinayak Upadhya andMr. Shankar V. Belchad for support in data entry.

References:

1. Accorsi S, Fabiani M, Lukwiya M, Onek PA, MatteiPD, Declich S. The Increasing Burden of InfectiousDiseases on Hospital Services at St. Mary’sHospital Lacor, Gulu, Uganda. Am. J. Trop. Hyg.2001; 64(3, 4): 154-158.

2. World Health Organization. InternationalStatistical Classification of Diseases and RelatedHealth Problems, tenth revision (ICD-10).Geneva: World Health Organization, 1994.

3. World Health Organization. Report on InfectiousDiseases. World Health Organization, 1999. http://www.who.int/infectious-disease-report (Accessedon 06/03/2007).

4. Clair FM, Martin T, Michael B. A re-appraisal ofthe burden of infectious disease in New Zealand:aggregate estimates of morbidity and mortality.NZMA 2002; 115:1-8.

5. Hunter PR. Climate change and waterborne andvector-borne diseases. Journal of AppliedMicrobiology 2003; 94:37S-46S.

6. Disease Control Priorities Project. Infectiousdiseases. Changes in Individual Behavior CouldLimit the Spread of Infectious Diseases. DiseaseControl Priorities Project, 2006. http://www.dcp2.org (Accessed on 08/03/2007).

7. Marx FM, Atun RA, Jakubowiak, Mckee M, CokerRJ. Reform of tuberculosis control and DOTSwithin Russian public health system: an ecologicalstudy. European Journal of Public Health 2006;17 (no.1):98-103.

8. Hansel NN, Merriman B, Haponic EF, Diette GB.Hospitalization for Tuberculosis in the UnitedStates in 2000: Predictors of In-Hospital Mortality.Chest 2004; 126: 1079-1086.

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Introduction

Homelessness has major public healthimplications for not only those affected but also forthe general population. Homeless people are potentialreservoirs of infectious diseases like tuberculosis, AIDSetc. Homelessness among youth leads to increasedcrime and substance use related disorders and is ofpublic concern. Health in homelessness state iscompromised by physical environment includinghazards of street life, poor nutrition, lack of facilities tomaintain personal hygiene1 and increased risk ofinfectious diseases through crowding, negligencetowards disease and enforced lifestyle2. Initial healthimpairments and disabilities can lead to homelessnessand a vicious cycle of deprivation.

However, homelessness is not recognized as apublic health problem. An inadequate information basehas affected the public health response tohomelessness. Health care providers need toacknowledge that there are an unknown, but large,number of persons who become homeless as a resultof a residual impairment and disability and also asbeing victim of social and economic inequity.

Review Article

Homelessness: A Hidden Public Health Problem*S. Patra1, K. Anand1

Summary:

Homelessness is a problem, which affects not only the people who are homeless but the wholesociety. This problem is not well recognized among the public health professionals. This paperattempts to discuss the issues in the context of homelessness starting from the definition used tomethodology of estimation of their numbers as well as their health problems and health careneeds. There is lack of data on the health problems of homelessness from India. There is nospecial health or social programmes or services for this subsection of the society. The existingnumber of shelters is inadequate and as there are multiple barriers, which prevent them to haveproper access to the existing health care system. With the changing social and economic scenario,homelessness is likely to increase. We need to recognize homelessness as a public health problemand attempt to target this group for special care in order to promote equity in health system.

Key words: Homeless, shelter, census, barriers

This paper tries to review issues related tohomelessness in general and specifically in the Indiancontext. We did a review of literature by searchingthrough electronic database like Pubmed and Indmedand google. Key words used for search were “homelesspeople, health problems, causes, and health systems”in different combinations. We also did manual searchfor articles published in un-indexed journals, andreviewed different research articles both published aswell as unpublished.

Definition of Homelessness

There is wide variation in the definition ofhomelessness, between studies, between countries, andoften definition has been affected by services and socialsupport provided to them. A wider definition ofhomelessness is the absence of a personal, permanent,adequate dwelling.

Homeless Assistance Act of 19873 of USA defined‘homeless’ to mean: An individual who lacks a fixed,regular, and adequate night-time residence; or whohas a primary night-time residence that is a supervised

1Centre for community Medicine, All India Institute of Medical Sciences, New Delhi.*Corresponding Author: [email protected]

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publicly or privately operated shelter designed toprovide temporary living accommodations or a publicor private place not designed for, or ordinarily usedas, regular sleeping accommodations for humanbeings.

The Census of India (2001) uses the notion of‘houseless population’, defined as persons who are notliving in ‘census houses’ but are in houselesshouseholds. Houseless household, as the namesuggests is an oxymoron, has been defined as thosewho do not live in buildings or census houses but livein the open on roadside, pavements, in hume pipes,under flyovers and staircases, or in open in places ofworship, railway platforms etc. are to be treated ashouseless household 4.

A uniform definition of homelessness is essentialin order to have recognition of the condition and policytowards homelessness.

Counting the Homeless

By very nature of their mode of living it is verydifficult to enumerate the homeless. Some strategiesfor enumerating are: one-night counts or point in time;extrapolations from partial counts; windshield streetsurveys; adaptations of area probability designs;service-based designs5. In India the method adoptedwas point in time estimation. Enumeration of thehouseless households was done on the night of 28thFebruary, 2001 when the enumerators on basis of preidentified areas visited places of worships, railwayplatforms, and flyovers etc where such households weregenerally found. There are 447,552 houselesshouseholds consisting of 1,943,476 persons in thecountry4.

Point-in-time counts method attempts to countall the people who are homeless on a given day orduring a given week. There are many people whoexperience homelessness at a particular point of timebut do not remain homeless. Another importantmethodological issue is regardless of the time periodover which the study was conducted, many people willnot be counted because they are not in placesresearchers can easily find. Due to both these reasons,magnitude of the problem of the homelessness is likelyto be unreliable by point in time method.

Capture-recapture methods overcome problemsof ascertainment by calculating the size of the

unobserved population and completeness of survey.The plant-capture method was used to estimate thenumber of homeless people in southern Manhattan aspart of the 1990 US decennial census6 and to estimatenumber of street children in Brazil7. Underestimationwas to the tune of 63% in Brazil.

Identifying people who are at risk ofhomelessness

There are a certain subgroups of persons whoare of high risk for becoming homeless. These includepersons who live in poverty, have mental disability,victimized persons (domestic violence), persons withdrug and alcohol addiction or health problems, andpersons who lack sufficient social support 8. Otherpersons at risk are single women with young childrenand unskilled workers9 and people who are victims ofnatural disaster, racial discrimination, or those releasedfrom prison.

In pediatric homeless population, we find 90%of street children are working children who live withtheir families. Remaining 10% are abandoned andneglected children with no family ties10. Insufficientresearch has been done to look for the factorscompelling children to make street, their home. In astudy, in India, it was found that the most commonreason for running away from home was; beating byparents or relatives, followed by a desire for economicindependence, both parents dead, argument withparent etc11.

Health problems of homeless people

Studies on health of homeless have found thatthere are high prevalence of premature death anddiseases like respiratory tract disease, sexuallytransmitted diseases and chronic diseases12-21 (Table1). In Baltimore study2 average number of problemsper person in men were 8.3 and in women it was 9.2.Chronic diseases often go unrecognized anduntreated21. Even if the condition is detected andtreated, lack of compliance and consistent follow-upoften results in disease progression, disability, morbidity,and premature death22. Besides physical healthproblems, mental health problems, substance usedisorders and behavioral problems23-31 are also veryhigh among this subsection of the society(Table 2). This section clearly highlights that there is

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little data from India on health problems of homeless.The data are mainly from the western world especiallyUS for many of the health conditions.

Barriers to health care seeking

Homeless people are also plagued by multipleinternal and external barriers to obtain effectiveprimary care32. Internal barriers include denial of

health problems and pressure to fulfill needs likeobtaining food, clothing and shelter as well as lack ofself-esteem and feelings of worthlessness. Externalbarriers include unavailable or fragmented health careservices, and prejudices and frustrations on part ofhealth care professionals8. One-fifth of homeless adultswho had not obtained needed medical care stated thatthis was due to inability to pay for medical services33.

Table 1: Summary of selected studies on health problems of homeless

Domain Authors/ Year Place of Study Major FindingsReference

Premature-death

MMWR12 1987 Atlanta Median age at death: black men 43, white men 53 years

MMWR13 1991 San Francisco Average age at death was 41 years

Hibbs et al14 1994 Philadelphia Age-adjusted mortality rate 4 times that of generalpopulation

Hwang et al15 1997 Boston Average age at death : 47 years

Hwang et al16 2000 Toronto Mortality rate ratios were 8.3 for men aged 18 to 24 years,3.7 for aged 25 to 44 years, and 2.3 for aged 45 to 64years higher compared to general population

Sexual Health

Hwang et al15 1997 Boston AIDS was the leading cause of death among persons 25to 44 years of age

Ray Sk etal17 2001 Kolkata, India Health problems of women were leucorrhoea, menstrualirregularities, infertility and STDs and 3/4th of this illnesswas uncared for.

Talukdar A et al18 2007 Kolkata, India 90% of married homeless men visited Commercial SexWorkers, but 3.3% consistently used condoms.

Brito VO et al19 2007 Sao Paulo, Brazil Prevalences were 1.8% for HIV, 30.6% for previous hepatitisB infection, 3.3% for acute infection by hepatitis B virus, and5.7% for syphilis. Consistent use of condoms was referred toby 21.3% and injecting drugs by 3% of them.

Respiratory Problems

Hwang et al15 1997 Boston Pneumonia and influenza, were found to cause death inhomeless persons

WHO20 1999 London, 25 and 30 percent of population were reported to beSan Franscico infected with TB, chronic diseases

Ropers R etal21 1987 US 40% reported at least one chronic health problem

Hwang et al16 1997 Boston Heart disease and cancer were the leading causes of deathamong persons 45 to 64 years of age


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Homeless people frequently lack identification or otherdocumentation to prove indigent status in order toqualify for free or reduced services in mainstreamhealth care settings. For this reason even if neededthey are denied treatment under national programmeslike RNTCP (Revised National Tuberculosis ControlProgramme). Similar reasons were also found by HeathNeed Assessment Survey team of Aashray AdhikarAbhyan34. Often the homeless people are deniedservices because of their appearance35. Homelessadolescents confront further hurdles stemming from

their age and developmental stage. These include lackof knowledge of clinic sites, fear of not being takenseriously and fears of police or social servicesinvolvement36.

Available health care facilities:

In India we have only shelters for homelesspeople. In Delhi, the capital of India, there is a total of22 temporary and 12 permanent shelters with acapacity of 400034. By any estimate over 1 lakh people

Table-2: Summary of selected studies on psychosocial and behavioral aspects of homeless

Domain Authors/ Year Place of Study Major FindingsReference

Substance use disorder and high-risk behaviorShaffer D et al23 1984 New York 70% of the runaways were using illegal drugsMMWR13 1991 San Francisco Drugs or alcohol were detected in 78% of the study

population.UNDP24 2002 14 states of India Out of all substance dependents about 1/4th was homeless.

Ahmedabad (83%), Hyderabad (65%), Mumbai (54%) andDelhi (39%) reported a higher prevalence

Kramer CB et al25 2008 Seattle More abuse of alcohol (80.6% vs 12.8% and drug (59.4% vs12.8%) compared to domicile population.

ViolenceHwang et al15 1997 Boston Homicide, injuries, and poisoning were the leading causes of

death among persons 18 to 24 years of age.

Kramer CB et al25 2008 Seattle Homeless people have more severe injuries(13.9% vs 2.0%,P < .001), assault by burning (17.8% vs 11.2%, p < .001)

Physical Abuse and VictimizationBanerjee SR26 2001 Calcutta, India 26.9% of study children reported to experience physical

abuse.Rosenthal D et al27 2003 Australia Incidence of involuntary sex among homeless young people

is considerably higher than in the general populationKushel MB et al28 2003 San Franssico Housing is associated with lower rates of sexual assault

among womenRew L et al29 2003 Texas Sixty percent of the sample reported sexual abuse.

Mental Health ProblemsTyler et al (30) 2004 Seattle Dissociative behavior is widespread among these youth and

may pose a serious mental health concernWilliam R Breakey (2)1989 Baltimore Major mental illnesses were present among 42% of men and

48.7% of womenWhitbeck LB et al (31)2007 USA 35.5% of the adolescent met lifetime criteria for Post

Traumatic Stress Disorder. Significant correlates were ageof adolescent, being female, having experienced seriousphysical abuse and/or sexual abuse etc.


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are homeless in Delhi. In June 2000, Ashray AdhikarAbhiyan (a NGO) counted 52,765 homeless people,in cer tain areas of Delhi alone. Even DelhiDevelopment Authority (DDA) admits that at least 1%of the population is homeless, i.e. 1.4 lakh atpresent”37.

More or less the shelters just provide physicalprotection and are not linked to any health interventionprograms of the government. In one survey undertakenby Aashray Adhikar Abhyan, Institute of HumanBehaviour and Allied Sciences34 it was found thathomeless population considered visit or these placesunfruitful for want of proper identity document andlack of support to guide them through cumbersomeprocedure, many feared past hostile experiences ofdiscrimination and neglect.

The issue of homelessness and health system hasnot been addressed at all in India. Thus, at this stagewe have to learn from the experience of other countries.

The Health Care for the Homeless (HCH),program USA38 emphasizes a multi-disciplinaryapproach to deliver services, combining aggressivestreet outreach with primary care, mental health andsubstance abuse services.

In Philadelphia and New York City a pilot projecthas started with aim to identify neighbourhoods fromwhere a disproportionate number of homeless comeand focus on activities like job training, health careservices, drug and alcohol treatment etc39.

Conclusion

In conclusion high mortality and morbidity rateamong homeless population are caused by preventableand treatable conditions but health care providers needto be aware of the unique difficulties faced by thissubsection. There is need to improve accessibility andavailability of health services in order to serve homelesspopulation.

Medical care facilities for the homeless areinadequate for a number of reasons: first, themagnitude of homelessness, is under defined. Secondthere is lack of studies on health problems of homelesspeople in India. Third, the shortage of facilities andthe legal complications to provide them treatment.Fourth, behavior of the homeless and the inability ofthe providers to deal with such people. Fifth, in India

we do not have any proper existing health care servicesand programmes for homeless, all that we have aremostly supported by voluntary organizations.

Recommendations

In view of all these conditions, we suggest that1. There is urgent need of proper definition and

development of proper methodology to have aproper estimate of their number.

2. A national study to provide reliable data on healthproblems and health care needs of homelesspeople.

3. An attitude of dignity is essential when workingwith people, who are homeless. Providemotivational training to health providers (HealthWorkers, Medical Officers, and Supervisors) tobe more sensitive towards this group.

4. Development of guideline to have a programme,which should be accessible (outreach services),affordable (free), comprehensive (both curativeand preventive component). It should includemental health and substance abuse problems.This programmes should also have preventivecomponent like screening for acute and chronichealth problems, immunization and specialservices for women including family planning,antenatal and perinatal care. The National UrbanHealth Mission40 should look in to these aspectsand identifying and caring for homeless could beone of the activities based incentives identifiedfor the Urban Social Health Activist (USHA).

5. Linking the programme with programmes likeNational Rural Employment Guarantee (NREG)Act41 which for rural area provides employmentopportunities. Effort should be taken to see thathomeless people can also avail this opportunityand its counterpart in urban area needs to beimplemented.

6. Public health professionals also need to focus intothose social and economic issues, which arecompelling people to lead a life of homeless. Theyalso need to focus on operational aspects ofcertain programmes (eg, RNTCP) which need tobe modified to include this particular group andalso to have effective control on the disease.


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Dear Editor,

Growing threat of HIV/AIDS to the people hasbecome a great concern of India and other developingcountries. The awareness of HIV/AIDS is the preventionof the infection/ disease. Mass media such as Television,Radio, Print Media, Hoardings, role plays etc. are the firstsource of information and most effective modes ofcommunication between the media and the generalpopulation where as health care providers are less sourceof information1. It has been proved by many studies thatthe main source of information for AIDS awareness in thestudent is mass media 2-5. National AIDS ControlOrganization (NACO) in collaboration with WHO andother international agencies is dedicated and made manyefforts to develop the awareness among the people butstill prevalence is growing day by day.

In view of above, Hospital Administration, SanjayGandhi Post Graduate Institute of Medical Sciences(SGPGIMS) and Uttar Pradesh Hospital and HealthAdministration Reforms Society (UPHHAR), Lucknow,Uttar Pradesh, India intended to conduct a study of effortsmade by the government, NACO, NGOs etc to developthe awareness through mass media for urban populationof Lucknow, Uttar Pradesh, during November – December2005. The objectives were to find out the level of effortsmade through the mass media to develop the awarenessof HIV / AIDS amongst the general population by BestMedia Practices and to find out the level of contributionmade by hospital and the public places for HIV/AIDSawareness.

Seven newspapers were considered; out of which 3were English daily editions, 3 Hindi daily editions and 1Urdu daily edition, all widely circulated in the city ofLucknow. All these were scanned thoroughly for a periodof one month (8th November 2005 to 8th December 2005)for the contents such as: general health awareness,awareness about HIV / AIDS, health seminars /programmes, central government health programmes andmiscellaneous (these include articles on rally’s, road shows,surveys, camps, etc.) Of 143 contents of different healthrelated issues 52 (27%) were on HIDS/ HIV awareness. Itindicates that newspaper print media is contributingreasonably adequate for HIV/AIDS awareness.

Six major pre-identified routes, which connect thecity to the railway stations, airport, bus stands coveringapprox. 50 km. length network were covered to study

Letter to the Editor

HIV/ AIDS Awareness through Mass Media – the Measurement ofEfforts Made in an Urban Area of India

informative hoarding, banners & posters displayedproviding information about HIV/AIDS. The studyrevealed that only 5% (7 out of 132) contribution is madeby the hoarding/ banner on road for HIV/ AIDS awarenessin comparison to other health related matters. Out of thefive hospitals visited, only two hospitals were found to beactively involved in HIV/AIDS awareness through posters/banners etc. This was quite an astonishing revelationbecause hospitals are the main places where considerableamount of awareness can be generated through posters,banners and hoardings. Only 04% (2 out of 48) effortshave been made by the hospitals to develop the AIDS/HIV awareness in comparison to other health matters.

On the primary channel of All India Radio, 6programs on AIDS were broadcasted in the month ofNovember 2005. In addition to this there was one phone–in program on AIDS. 4 programs on AIDS were telecastedby Doordarshan and only 1 on general health includingKalyani I & II programs.

Traveling through various routes in Lucknowrevealed the fact that very few banners / hoardings aredevoted for the purpose of spreading AIDS awareness.Out of the 6 routes covered (approx. 50 km. network area)only 4 hoardings of AIDS were found. The number ofhealthcare hoardings was unexpectedly low.

There is an urgent need to significantly scale-uppublic health interventions in relation to HIV/AIDSawareness that work (both in terms of coverage andquality) to make a meaningful impact. While NGOs andcommunity-based organizations have a critical role to playin implementing these interventions amongst the variouspopulation groups, the government must shoulder theoverall responsibility for planning, coordinating,mobilizing, and facilitating the various HIV/AIDSprevention, care, and treatment services in the country.

References:1. Ndlovu RJ, Sihlangu RH. Preferred source of

information on AIDS awareness among high schoolstudents from selected school in Zimbabwe: Journalof Advance Nursing, 1992 April; 17 (4): 507- 13.

2. Anochie L, Ikpeme E. AIDS awareness andknowledge among primary school children in PortHarcourt Metropolis: Niger Journal of Medicine,2003 Jan – Mar; 12 (1); 27-31.

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3. Maswanya E et al. Knowledge and attitude towardsAIDS among female college student in Nagasaki,Japan, Health Education, Res. 2000 Feb; 15 (1): 5-11.

4. Lihiri s et al. Women in 13 states have littleknowledge of AIDS: National Family Health SurveyBulletin 1995 Oct; (2): 1-4.

5. Carducci A et al. AIDS related information, attitudeand behaviors among Italian male young people:

European Journal of Epidemiology 1995 Feb; 11(1): 23-31.

Hem Chandra, K. Jamaluddin, L. Masih,K. Faiyaz, N. Agarwal, D. Kumar

Hospital Administration, Sanjay Gandhi Post GraduateInstitute of Medical Sciences and Uttar Pradesh

Hospital and Health Administration Reforms Society,Lucknow, Uttar Pradesh, India

Chandra H et al: HIV/ AIDS Awareness through Mass Media

Dear Editor,

Child health care in India focuses on the under-fivesunder national programmes of ICDS and CSSM. Launchof RCH programme in 1997, drew attention to the needsof adolescents (10-19 years) also. But there remains a gapin delivering health care to 5-10 years old children. Thisage group is supposed to be addressed by the school healthprogramme, which in India is very inadequate, withoutfollow-up or accountability.

In the union territory of Pondicherry, one of the topachievers of human development in the country havinglow infant and child mortality rates 1 we compared thenutritional status of 5-10 year old children with under-fives attending out patient clinic of Primary Health Centre(PHC), Mettupalayam, in Pondicherry town. Weight forage was used to measure undernutrition. Weights of allchildren less than 10 years was measured by the physiciansusing a baby weighing machine (pan type) for infants anda personal weighing scale for others in the months ofAugust and September 2007. Each child was consideredonce in spite of multiple visits. According to IAPclassification, underweight was measured as percentageof the median of NCHS standard.

Undernutrition in 5-10 Year Olds: Experiencesfrom a PHC in Pondicherry

The total number of children observed was 518. Thisbeing a primary care centre, most children in both agegroups had minor ailments. We observed that a higherproportion (58%) of 5-10 year old children weremalnourished as compared to under-fives (50%), thoughnot statistically significant. However, significantly greaterproportion of children in 5-10 years had severemalnutrition i.e., < 60% of the expected weight for age(χ2 = 10.94, p = 0.00094).

The deprivation in nutrition will have long-term implications such as poorer work capacityand reproductive performance in adulthood2. But,this population is not representative of the childrenin the community as this was hospital based. So,this study needs to be extended to the communityto assess the overall scenario. We recommendcontinuum of care from under-five through 5-10years to the adolescents by strengthening theschool health services.

References:

1. Profile of the Union Territory of Pondicherry. http://ncw.nic.in/pdfreports/Gender%20 Profile Pondi-cherry.pdf (last accessed on 8.5.08)

2. Kliegman: Nelson textbook of pediatrics, 18th ed.Saunders: Philadelphia; 2007. p 228.

S. Sarkar1, S. Ananthakrishnan2

1Dept. of Community Medicine, 2Dept. of Paediatrics;PKMC&RI, Puducherry, India

Correspondence: [email protected]

Table 1: Undernutrition in 5-10 year olds ascompared to under-fives

Age groups % of expected weight for age>80% 71-80% 61-70% <60% Total

F 78(49.4) 61(38.6) 16(10.1) 3(1.9) 158<5 yrs M 111(50) 68(30.6) 38(17.1) 5(2.3) 222

Total 189(49.8) 129(33.9) 54(14.2) 8(2.1) 380

F 31(43.1) 20(27.8) 14(19.4) 7(9.7) 725-10 yrs M 27(40.9) 18(27.3) 16(24.2) 5(7.6) 66

Total 58(42.1) 38(27.5) 30(21.7) 12(8.7) 138

Figures in parentheses are row percentages

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