prevalence, risk factors, treatment practices and

PREVALENCE, RISK FACTORS, TREATMENT
PRACTICES AND DIRECT COST OF ACUTE
RESPIRATORY INFECTIONS (ARI)
AMONG CHILDREN UNDER FIVE YEARS OF AGE IN RURAL
TRIVANDRUNI DISTRICT
Roy. N
Dissertation submitted in partial fulfilment of the requirements
for the award of the degree of
Master of Public Health
pi-
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala, India.
May 2001
ii
DECLARATION
I hereby certify that the work embodied in this dissertation entitled
'Prevalence, risk factors, treatment practices and direct cost of ARI
among children under five years of age in rural Trivandrum district' is
the result of original research and has not been submitted for any degree in
any other University or Institution.
Thiruvananthapuram
May, 2001
Roy N
iii
Achutha Menon Centre for Health Science Studies,
SCTIMST, Thiruvananthapuram
CERTIFICATE
Certified that this dissertation entitled Prevalence, risk factors,
treatment practices and direct cost of ARI among children under five
years of age in rural Trivandrum district' is a record of bonafide original
research work undertaken by Roy N in partial fulfilment of the requirements
for the Degree of Master of Public Health, under our guidance and
supervision.
Guide:
Thiruvananthapuram
May 2001
Dr. D. Varatharajan
Assistant Professor
AMCI-ISS, SCTIMST
Co-guide: Dr. P. Sankara Sarnia
Associate Professor
AMCI-ISS, SCTIMST
iv
ACKNOWLEDGEMENT
I sincerely extend my gratitude to Dr. D. Varatharajan who was my guide for his
innumerable and valuable suggestions throughout my study and spending his valuable
time to read and correct my writing. My acknowledgement goes to Dr_ P. Sankara Sarma
who was my co-guide for his valuable suggestions, inspiration and help in the analysis.
Dr. K.R Thankappan and Dr. Mala Ramanathan were of immense help by giving me
guidance and directions for the research. My sincere gratitude goes to Dr. Richard Cash
and Mr. Jaysingh who encouraged and supported me through out the process. I extend my
gratitude to Dr. Mohandas, the director of the institute for giving all the support for our
research. Special thanks to Dr. Rajmohan and Mr. Syamalan. The lectures of Dr.
Reingold, Dr. Beaglehole and Dr. Jayaprakash helped me a lot in framing the study. My
sincere gratitude goes to them also. My friends Shiney, Syamnadh, • Sijo, Shamnad,
Subramanyan, Ajith, Pradeep, Rex, Jose and Santhosh were of ceaseless support to me all
through my research. I am obliged to the participants of this study who gave their
valuable time for this research.
Thinwananthaptiram
May, 2001
Roy N
CONTENTS
Titles
Page Number
Abbreviations
- vii
Abstract
- viii
1. Chapter- 1(Introduction)
-1
1.1. Background
1.2. Objectives of the study
1.3. Relevance of the study
1.4. Justification for the study
-1
-5
-6
-6
2. Chapter- II (Review of literature)
-7
3. Chapter- III (Methodology)
-17
3.1. Study design
3.2. Sampling method
3.3. Variables, definitions and measurements
3.4. Data analysis
-17
-18
-20
-24
4. Chapter- IV (Results)
-25
4.1. Sample characteristics
4.1.1. Sample characteristics by taluks
4.1.2. Sample characteristics by age
4.1.3. Sample characteristics by religion
4.1.4. Sample characteristics by SES and type of house
-25
..25
-25
-26
-26
4.2. Prevalence results
4.2.1. Distribution of symptoms of ARI
4.2.2. Prevalence by sex
4.2.3. Prevalence by SES
4.2.4_ Prevalence according to the educational status of parents
4.2.5. Prevalence according to mother's age at delivery
4.2.6. Prevalence according to the employment status of mother
4.2.7. Prevalence according to the breast-feeding duration
4.2.8. Prevalence among different age groups
4 2 9. Prevalence according to body weight and maturity at birth
4 2 10. Prevalence according to other illnesses
4 2 11. Prevalence according to immunization status
4 2 12. Prevalence according to vii A supplementation
4 2 13. Prevalence according to birth order
-26
-26
-27
:27
-28
-29
-29
-30
-30
-31
-31
-32
-33
-33
vi
-34
4.2.14. Prevalence among school going children
-34
4.2A5. Prevalence according to the type of family
-34
4.2.16. Prevalence by the number of underfives in the house
-3 5
4.2.17. Prevalence according to the sleep room sharing
-35
4.2.18. Prevalence according to the characteristics of the house
-36
4.2.19. Prevalence according to the characteristics of kitchen
4.2.20. Prevalence by religion, geo.location, cook fuel and smoking-36
-37
4.3. Results of multivariate logistic regression
-38
4.4. Presence of other illnesses in ARI cases
-38
4.5.Treatment practices and direct cost of ARI treatment
5. Chapter- V (Discussion and conclusions)
-42
5.1. Discussion
5.2. Conclusions
5.3. Limitations of the study
5.4. Policy implications
-42
-46
-46
-47
References
Appendix
-I
-A
Appendix.1- Scale for measuring weight for age
Appendix.2- Questionnaire
Appendix.3- Tables 1 to 9
-A
-B
-F
•
ABBREVIATIONS
ART
Acute respiratory infection
AURI
Acute upper respiratory infection
ALR1
Acute lower respiratory infection
LBW
Low birth weight
WHO
World health org,anization
DALYs
Disability adjusted life years
PEM
Protein energy malnutrition
TB
Tuberculosis
DPT
Diphtheria, Pertussis, Tetanus
DHS
Directorate of health services
BCG
Bacillus Calmette Guerin
MBBS
Bachelor of medicine and surgery
Hib
Hacmophilus influenza type b
SES
Socio economic status
Vit A
Vitamin A
SPSS
Statistical package for social scientists
X'ian
Christian
CI
Confidence interval
Rs
Rupees
PHC
Primary health care
RCH
Reproductive child health
Dr
Doctor
Km
Yr
-
Kilo meter
Year
ABSTRACT
PREVALENCE, RISK FACTORS, TREATMENT PRACTICES
AND DIRECT COST OF ARI
AMONG CHILDREN UNDER FIVE YEARS OF AGE IN RURAL TRIVANDRUM
DISTRICT
Background: In the world as well as in India ARI is the major cause for mortality and
morbidity in children under five years of age. ARI came first in the preNalence list of
major public health diseases in Kerala in 1999. In this context_ this study looks into
the magnitude of the problem among underfives in the rural area of TriA andruin
Objective: To study the prevalence. risk factors, treatment practices and direct cost of
ARI treatment among underfive children in rural Trivandrum district.
Design: Cross-sectional survey of subjects aged 60months or less. using a cluster
sampling technique.
Setting: All the four taluks of (rural) Trivandrum district. Kerala.
Participants: 415 children under five years of age (198 F. 217 M). mean age in
months (28. 5 ± 17. 4).
Results: The overall prevalence of .ARI in rural Trivandrum was 54. 9% (95 % CI 50.
0-59. 8) - females 56. 6 % (95 % CI 49. 6- 63. 6) and males 53. 5 % (95 % CI 49. 663. 6). Asthma in children (OR=2. 50. 95% CI 1. 22- 5. 13) and cases of ARI in
child's family (OR=4. 27. 95% CI 2. 74- 6. 67) are directly related to ARI. Children
in joint families are at lesser risk for ARI (OR=0. 41, 95% CI 0. 24- 0. 70). 38. 6 % of
ARI cases didn't seek health care. The average cost for the treatment of ARI is Rs.23.
39 and the average cost for the transportation of the child to the health facility for
treatment is Rs.3_ 0l.Both these costs were high among low SES.
Conclusion: In this community-based rural sample of underlive subjects around 54. 9
`)/0 of the underfive subjects were having ARI. Treatment seeking for ARI was around
61.4 % only and the practice of self-medication and the belief that ARI symptoms are
common in children and so no treatment is needed were the two main reasons for not
seeking care and making delay in seeking care. Our findings emphasize the need for
community-based measures to combat AR1 problem and measures to make the public
aware of the problem of
its prevention and management.
Chapter I
Introduction
1.1 . Back ground:
Infections of the respirator* tract are perhaps the most common human ailment.
But in pediatric and geriatric populations it increases the mortality and morbidity
rates. Acute respiratory infections (ARI) may cause inflammation of the respiratory
tract anywhere from nose to alveoli. with a wide range of combination of signs and
symptoms. AR] is often classified by clinical syndromes depending on the site of
infection and is referred to as acute upper respiratory infections (AURI) and acute
lower respiratory infections (ALRI).
In WHO estimates. ALRI ranked third in the list of leading causes of mortality
and ranked first in the list of leading causes of burden of diseases (DALYs) in the
world in 1998.' On the average in the world, children below the -ears of age surfer
five episodes of ARI per child per year: thus accounting for about 238 million attacks.
ARI is responsible for about 30-50% of visits by underfive children to health facilities
and about 20-40% of pediatric admissions to hospitals around the Nvorld. Incidence of
ARI could be reduced by universal coverage with pertussis and measles Vaccines.
improved nutritional status. promotion of breast-feeding and control of low birth
weight (LBW). 1 By 1990, it was x\ ell documented that most (70%) childhood deaths
were caused by five conditions - diarrhea, pneumonia, measles, malaria and
malnutrition.''
LBWs have a 3-4 times greater risk of dying from diarrheal diseases, ARI, and if
not immunized, measles. Twenty five million LBWs are born every year in the world:
95 % of them are in the developiml world and the incidence of LBW in south Asia is
32 %. About 1/3 of world's children are affected by protein energy malnutrition
2
(PEM); 76 % of these children live in south Asia. Prevalence of asthma in children
ranges from 1. 5 % -12 % Vitamin A deficiency contributes to some extent to the
estimated 9. 6 lakhs childhood deaths from measles every year worldwide. 4 The
percentage of child deaths attributable to the potentiating effects of malnutrition is 67
°A in India.34 The incidence of LBW in India in 1993 was 30 % and the prevalence of
vit A deficiency in pre-school children in India in 1995 was 0. 7 %. In India during
1992-93, the percentage of children with acceptable weight for age was only 46. 6 %.
In India, during 1992-93, infants reaching their first birth day who have been fully
immunized with DPT vaccine was 46.9 %, with measles vaccine 32.7 % and with
BCG 58.7 %.1 So the above mentioned risk factors have to be considered while
looking into the prevalence of ARI in India.
Most of the respiratory infections are self-limiting and can be treated at home by
their families without anti-biotics. About one-quarter of all children less than five
years old who die in developing countries do so because of pneumonia. Many of the
deaths from pneumonia occur in young infants less than two months of age.8 ARIs
continue to be the leading cause of mortality in young children, accounting for more
than 30 % of deaths among underfives and more than 90 % of these deaths are due to
pneumonia. In south-east Asian region, it is estimated that ARIs take a toll of 1. 4
million deaths in children under five years of age annually. In India in 1995, total
under five population was 116. 97 millions, under five mortality rate per 1000 was
109, total number of under five death was 2. 97 million and ARI associated death was
1 million. i.e. ARI accounted for 33.7 % of underfive deaths in India in 1995_ 6
Every year ARI in underfive children is responsible for an estimated 4.1 million
deaths world wide, or I 1, 000 per day, India, Bangladesh, Indonesia and Nepal
together account for 40 % of the global ARI mortality. The incidence of ARI is
similar in developing and developed countries. Due to the high prevalence of
malnutrition, LBW and indoor air pollution, developing countries have higher
incidence (20- 30%) of pneumonia compared to developed countries (3- 4%).1 The
WHO estimated that in 1998 DALYs lost due to ARI was 85. 1 millions worldwide;
out of this, 83.6 millions was in low and middle-income countries.; In most
developing countries, over 50 °,/c, of all deaths occur among children under five years
of age, even though this age group generally makes up only 15 % of the population;
acute respiratory infections, diarrheal diseases and malnutrition are the principal
causes of illness and death in children in developing countries.2 Main causes of death
among children less than five years of age in developing world in 1995 was like this:
out of 10. 4 million total under five deaths, pneumonia constituted 2.1 million,
measles 1.1 million and pertussis 0. 4 million. In 1997, out of the 10 million deaths
among underfives in the world, 97 % was in the developing world and most of them
due to infectious diseases such as pneumonia and diarrhea, combined with
malnutrition. At least 2 million of these deaths a year could be prevented by existing
vaccines.4 A study analyzed the data from different countries showed that the ARI
mortality is high among infants and old age people.9
Mortality of underfives from respiratory infections in developing countries is 3070 times higher than in developed countries. It has been estimated that about 20% of
infants born in developing countries fail to survive their fifth birthday, and that 1/4th to
1/3 rd of the child mortality is attributable to ARI as an underlying or a contributing
cause. The incidence of severe lower respiratory tract infections, which account for
most of the mortality from ARI, is of particular importance in developing countries
since low birth weight and malnutrition are associated with a very high risk of dying
from respiratory infections. The ARI may be favored by the impairment of immunity
4
in malnourished children, poor environmental conditions and the lack of appropriate
health care.2 In developing countries, the indoor pollutants like house hold use of
bio-mass and coal for heating and cooking involving open fires or stoves without
proper chimneys are common. Over crowding can increase the transmission of air
born infections like respiratory infectious diseases, pneumoriia and TB.4 The above
mentioned risk factors are common in developing countries like India.
In India, the burden of ARI in terms of DALYs lost was 25.6 millions in 1998; out
of this, 24. 8 millions was due to ALRI, 2.74 lakhs due to ALTRI and 4.75 lakhs due to
otitis media.3 Analysis of mortality data of underfives during 1982-84 in Ballabgarh
(India) rural area showed that ARI, malnutrition and diarrheal diseases constituted 69.
7% of deaths in the 1-4 age group.2° In 1996, the estimated access of underfive
children in India to the standard case management for ARI was 55.0 O/ only. In 1992,
WHO's performance indicators of ARI case management in India showed that
inappropriate antibiotic used for cough and cold in 18 % of cases, children with
pneumonia have not been given antibiotic in 75 ',V° of cases and the care taker
(mother) did not know the correct home care for ARI in 40 % of cases.'
In India, underlying malnutrition, high prevalence of LBWs, low immunization
coverage, delayed recognition and care seeking by the family, delayed access to
health care in some areas and inappropr.iate case management by health providers may
contribute to high mortality with pneumonia. This study looks at ARI among
underfives since the morbidity and mortality rates are high with in this age group and
the risk factors for ARI are very much prevalent in our country.
According to directorate of health services (DHS) data, in Kerala during 1998-99
there were around 45 lakhs ARI cases and 354 A.RI deaths and 24,087 pneumonia
cases and 48 pneumonia deaths and 5,322 measles cases, 369 whooping cough cases,
15 diphtheria cases and one diphtheria death in all age groups. Prevalence of AR1 in
Kerala in 1999 in all age groups was 139.77 per 1000 population and ARI came first
in the prevalence list of major public health diseases in Kerala in 1999_
Various factors like immunization, nutritional status, • breast-feeding practices,
maternal education, family income, family expenditure on health, environmental
hygiene, over crowding, treatment practices, its availability, accessibility and cost,
family's health care seeking behavior are some of the variables which interact in
different ways to cause and determine the outcome of ARI. So ARI among underfives
has got medical, social, environmental, cultural and economic dimensions. Hence,
results of this study will be useful for the prevention, control and management of ARI
among under fives in Kerala.
1.2. Objectives:
Primary objective
To study the prevalence of ARI among children under five years of age in the rural
Trivandrum district.
Secondary objectives
1) To study the relationship between ARI and its important risk factors.
2) To study the treatment practices and direct cost of ARI treatment.
6
1.3. Relevance to national or local health objectives:
This study is limited to the rural population of Trivandrum district; similar
studies were not conducted in this population. The rural area of Trivandrum is more
or less homogenous of the rural population of Kerala. Since there are very limited
studies on prevalence of ARI in Kerala especially in this population, this study would
give an overview of the problem as well as help to make decision regarding policy
and future planning especially in terms of health care provision to the underfives
years of age by providing baseline information.
1.4. Justification:
1. There are no specific studies on prevalence, risk factors, treatment practices
and direct cost of ARI among children underfive years of age in this setting.
2. According to DHS data, the prevalence of AR! in all age groups was 13. 98 %
in Kerala in 1999 5 Children under five years of age are the more vulnerable
and fatal subjects of AM; so the prevalence will be more among them.
3. According to 1999 census, 12 % of the population in rural Trivandrum district
was children under six years of age62 and in Kerala majority of the population
is living in the rural area. So we need to know the magnitude of the problem of
a major proportion of our population to help our planners and health providers
by giving base line information for planning health interventions and to make
people aware about their health problem.
4. On the average, a child in an urban area has 5 to 8 attacks of ARI annually
• while in rural areas the incidence seems to be lower.
2.7.10 In Kerala, the rural
urban difference is very small. So a prevalence study in the rural area wine
relevant with respect to the treatment practices, cost and accessibility to health
facilities in the rural area.
7
Chapter II
Review of literature
In a survey conducted in all the districts in Kerala durimz Oct 1992- Feb 91
mothers of children born during the four years preceding the survey were asked a
series of questions about the prevalence of cough_ fever and diarrhea during two
weeks before the survey interview and the type of treatment given to the child. ARI
was defined as cough accompanied by rapid breathing. One in ten children (9.7%)
suffered from ARI during the two weeks preceding the survey. ARI was more
prevalent among older children aged 12 months and abo‘e. The prevalence among=
male children. children of birth order 4 -5. children in urban areas and Christian
children was more. 8I % of children who had AR1 had been taken to health facility for
treatment or treated privately by a doctor or other health professional. Among
children who had ARI children aged less than 24 months. male children. first order
birth and children whose mothers are more educated were more likely to have been
taken to a health facility for treatment.
A community-based study was conducted in rural area of Delhi during 199890 to measure the prevalence and incidence of ARI among underfiyes and the
preNalence was recorded during the initial baseline survey. The mothers of children
were interYiewed by using a pre-structured. precoded questionnaire. .ARI case was
defined as a child suffering from or had suffered from any symptoms of ARI
including cough, breathlessness, fever, nasal discharge, and ear pain or ear discharge
in the past two weeks. The prevalence of AR1 in rural Delhi was 12.1%, was similar
in boys and girls and was seen to decline with age. The incidence was 2.1 % episodes
per child per year, it was not different in boys and girls. There was a statistically
significant decline in the incidence with age. 87.5 % of all cases were upper
8
respiratory infections. 88% were mild, 10% moderate and 2.1 % severe cases of
ARI
A study from India which looked into the prevalence of ARI in underfive
children in the rural part of Pune showed a prevalence of 7. 6 %. The annual incidence
was 2. 6 episodes per child. The prevalence was highest in the 6 months to 2 years age
group. 86. 2 % of the episodes were mild and 1, 7 % was severe. 27_3 % of episodes
did not receive any treatment. There was no association between the severity of ARI
episodes and the treatment received. Registered medical practitioners were the main
source of treatment. Far distance from the hospital was the reason for not receiving
any treatment among untreated cases. The outcome was better in those episode treated
by a IVIBBS doctor, as compared to other sources of treatment.12
A study has been conducted in Delhi slums to look into the prevalence of ARI
in the total population by giving special emphasis to underfives. The symptoms
considered for ARI were cough, difficult breathing, sore throat, running nose, fever
and ear pain. Recall period used for interview was one month. The symptomatic
prevalence of ARI in underfives was around 4. 5% for a period of one month. The
study documented that prevalence of ARI declines with age. Factor analysis revealed
that crowding, economic status and sanitary conditions are important associates of
prevalence of ARI. The study suggested that the occurrence of ARI could be reduced
by improving living and sanitary conditions and pointed out the need to improve the
economic status of people living in these areas. 13
A study from Dinajpur, Bangladesh, to determine the prevalence and risk
factors of ARI among underfives in a rural community showed a prevalence of
58.7%. The incidence in both sexes were similar. It was 14.9% and 14.4% in male and
female respectively. The mean number of episodes of ARI was 1_75 per child per
9
year. Among studied risk factors, malnutrition, illiteracy, poverty, overcrowding and
parental smoking were found in significantly higher proportions in ARI victims
compared to those without ARI. 14
A community based cross-sectional study on prevalence of ARI in children
under seven years old was conducted in Kuala Lumpur, Malaysia and the results
showed that 30 °/0 of the children had ARI in the last two weeks prior to the interview
according to their mothers. 94 % were mild 1 % moderate and 5 % severe cases of
ARI . There was lack of concurrence between mother's perception of severity and that
of the investigator's. 5
For a one year prospective study on ARI among underfives in the rural areas
of Ballabgarh, India in 1986, parents were asked regarding episodes of running nose,
cough, ear pain or ear discharge in the last two weeks in their children. The results
showed that the morbidity due to ARI was 3. 67 attacks/ child/ year with the lowest
attack rates in summer (2. 1) and the highest in winter (4. 78). The modreate and
severe cases constituted [4 7 % of all cases. Proportional mortality rate due to ARI
was 22. 6 % in these children and 66. 5 % of deaths were in infants. But the case
fatality was 1. 31 % and the ARI related mortality was 6. 3 per 1000 children. 1'
A study on AR.I among underfives in urban and rural areas of west Tripura,
India, showed that the annual attack rate per child was more in urban area than in
rural area. The incidence of pneumonia was highest in the infant group. Malnourished
and un-immunized children were at higher risk for developing pneumonia.
Breastfeeding had protective role in pneumonia and severe disease. Lower socioeconomic status had the greater risk of ARI episodes. I7 A case control study was
conducted in Madras to study the risk factors for death among hospitalized children
with acute pneumonia; the results showed that malnutrition, associated illness like
10
diarrhea, presence of congenital malformations, young infants under 6 months of age
are high risk factors for fatal outcome of pneumonia."' An Indian hospital based study
looking into the causes of febrile convulsions in children showed upper respiratory
tract infections as a cause of fever in 60.6 % of febrile convulsion cases.' 9
Many of the deaths from pneumonia occur in young infants less than two
months of age.' A study from east Godavari, India, on ARI in underfives showed that
ART associated mortality rates are 15 times higher in infants than in 1-4 year old
group, a reverse trend in morbidity was noted in which 2 weeks incidence of ARI was
more in 1-4 year old than in infants and the study suggested that standardized
diagnosis and treatment for ARI can reduce the wasteful use of anti biotics. 21 A
hospital-based study from Afghanistan looked into the mortality and morbidity in
underfives admitted in a hospital showed that the relative incidence of respiratory
infection was high in infants, 19 `)./0 of the total morbidity and 25. 5% of the total
mortality among underfives admitted in that hospital was due to respiratory
infections.26 A study from Spain which Iodked into the epidemilogy of an ART out
break showed that high incidence was among under fives compared to 5-14 year
group and cough was the main manifestation (87. 4%), followed by fever (67.4 %),
vomiting (13. 7%) and earache (8. 4%).63
A study on ARI among underfives compared the findings from 10 developing
countries and showed that the incidence rates from six of the community based
studies ranged from 12. 7 to 16. 8 new episodes of ARI per 100 child weeks at risk,
and the rate of lower respiratory tract infections ranged from 0. 2 to 3. 4 new episodes
per 100 child weeks at risk; the incidence rate was highest in younger children and the
incidence of both AURI and ALRI was slightly higher in boys. In Uruguay,
Argentina and Pakistan the incidence was high during winter and the case fatality
11
ratio was highest among infants. Low weight for age measure appeared to be more
important among children less than 18 months of age and some study groups had a
positive relation with ARI and the presence of smoker in the child's household, sleep
room sharing gave a mixed result.` A case control study from Fortaleza, Brazil,
looked into the risk factors of childhood pneumonia among urban poor children under
two years old showed that LBW, malnutrition, non breast-feeding, crowding, high
parity and incomplete vaccination status are associated with childhood pneumonia. 24
A hospital based study from Luknow, India, looked into the viral causes of
ART in underfives showed that 22 % of the time viruses caused the disease, case
fatality was high (43 %) in children with measles virus infection.` A study from
Uganda which looked into the viral etiology of ARI in children aged 0-3 years
showed that more than 113 of ARIs are of viral origin.25
LBWs have a 3-4 times greater risk of dying from diarrheal diseases, ARI, and if
not immunized, measles:1 A prospective study from Bangladesh investigating the
consequences of LBW on infant growth and morbidity showed that AR! was the most
prevalent morbidity among infants under one year, an infant suffers from 3 — 4
episodes of ARI during the first year of life and among infants who got treatment for
ART, 71 % got allopathic treatment and a large proportion of infants did not receive
any treatment for AR1 due to the care taker's perception that for mild illness
treatment is not necessary'.31 A case control study from India showed that a
standardized case management of ARI significantly reduced the incidence of ARI
among LBWs46
A hospital based case control study conducted in Cape Town, S. Africa, showed
that vit A status has strong association with severity of ART infection and in this study
other risk factors significantly associated with ARI were poor housing, lack of
electricity for indoor fuel use.42 A meta analysis, of data from seven countries, was
done to assess the impact of vit A supplementation on pneumonia mortality and
morbidity and the results showed that the vitamin A has no consistent overall
protective or detrimental effect on pneumonia specific mortality in children aged 6
months to 5 years.36 A study conducted in Calcutta, India, among, underfives showed
that children who were undernourished or showed signs of vitamin A deficiency had
significantly greater risk of ARI attacks. '44
A study from Pakistan looked into the causes of measles outbreak showed
wide gaps in the vaccine coverag,e." Reduced childhood vaccination coverage is said
to be one of the reasons for diphtheria epidemic in the former Soviet Union.34- A
community based program to control ALRI in underfives in Matlab, Bangladesh,
showed that non-specific components of maternal and child health . and family
planning program such as immunization (against measles ands pertussis), proper
referral / treatment and family planning (which resulted in fewer children, lees
crowding and prolonged breast-feeding) contributed to the lower mortality from ALRI
and other causes among 1-4 year old children,;`- A community based surveillance of
pediatric deaths of subjects aged less than 15 years in cross river state in Nigeria
showed that II % of the deaths were due to pneumonia and the immunization
coverage was very poor in that area_'' A study conducted in India showed that poordose related knowledge of urban educated parents regarding vaccines as compared to
vaccine awareness contributed to partial immunization of children.37 In a controlled
trial in Gambia, conjugated fhb vaccine reduced severe X-ray proven pneumonia by
20 % and total mortality by 6. 1%. 38 A recent review has described how anti-vaccine
movements can reduce the use of pertussis vaccine, causing an inevitable rise in
pertussis disease.39 A study from l44atlab, Bangladesh, to assess the impact of measles
13
vaccination (9-60 months old children) on childhood mortality. has shown that the
mortality rate of vaccinated children were as much as 46 % less than those of unvaccinated children and immunization of children aged upto 3 years with measles
vaccine appeared to improve significantly their subsequent chances of survival.'" A
study from Varanasi, India, looked into the feasibility of ARI control program in rural
underfives showed that majority of children who died due to ARI were un-immunized
and the moderate and severe ARI related morbidity and mortality was significantly
reduced in immunized children compared to un-immunised children.'"
Adequate breast feeding in a large number of settings is found to be associated
with a 2. 5 to 4 fold lower rate of mortality.4 Even in-developed countries breastfeeding lowers the rate of respiratory and gastro-intestinal illness to 1/4"1 that of non
breast-fed infants.4- A prospective study of infants from birth to one year of age was
conducted on privileged urban and under privileged rural Indian infants to study the
effect of feeding pattern on mortality and morbidity and the results showed that the
frequency of ARI was similar during the first four months of life, but the mixed-fed
and bottle-fed infants suffered from ARI significantly more frequently during 5-12
months period when compared to the breast-fed and higher incidence of otitis media
and allergies was significantly high in artificially-fed urban infants when compared to
the breast-fed.'s A prospective study conducted in Mexico showed that the incidence
and prevalence of ARI were significantly lower in fully breast-fed infants than in
formula-fed infants from birth upto four months and the duration of illness was also
shorter in beast-fed infants and the incidence of ARI was positively associated with
the presence of siblings.47 A case control study from Italy showed that breast-feeding
in infants had a strong protective effect against ALRI in industrialized countries
also." An Indian study showed that almost all artificially-fed infants in the low socio
14
economic class were malnourished while this was not the case in the high SES.32 In
Kerala, breast-feeding is almost universal with 98 % of all children having been
breast-fed and the mean and median length of breast feeding is just under two years. Iu
A WHO review committee looked into the relation between pneumonia and
nutritional factors found out that LBW, malnutrition and lack o'f breast-feeding appear
to be important risk factors for childhood pneumonia and suggested that for all
regions except Latin America, interventions to prevent malnutrition and low birth
weight look more promising than does breast-feeding promotion and in Latin
America, breast-feeding promotion would have an effect similar to that of improving
birth weights.49 A meta analytical study assessing the protective effect of breastfeeding against mortality due to infectious diseases in less developed countries
showed that in Brazil, Pakistan and Philippines the protection provided by breast-milk
declined steadily with age during infancy. In the first 6 months of life, protection
against diarrhea was substantially greater than against deaths due to acute respiratory
infections. But for infants aged 6-11 months, similar levels of protection were
observed. `°
A study from Maragua, Kenya, assessed the levels of indoor air pollutants
showed that the mean of the 24-hour average respirable suspended particles
measurement was 1400 microgram/ cubic meter and in the evening, peak levels upto
36,000 microgram/ cubic meter were observed and the health effects due to the
exposure of smoke from biomass combustion are likely to occur among young
infants.`' A prospective study was conducted in two urban slums of Delhi, India,
during winter season in order to assess relation between indoor air pollution due to the
fuel used for cooking and the incidence of AI,RI. The results showed that higher
15
incidence of ALRI was reported in kerosene users in one study area but which was
otherwise also a high pollution area.52
A case control study from Israel in subjects aged more than 18 years showed
that asthmatics visited their doctors more frequently than patients without asthma,
mainly consulting for various respiratory problems.53 A case control study from Delhi
in subjects 6— 60 months old to differentiate ARI and asthma by using simple
predictors showed that the best predictor for asthma was the history of two or more
earlier similar episodes. 61
A case-control study conducted in Gambian underfives to assess the long term
mortality and morbidity following hypoxaemic lower respiratory infection showed
that low weight for age in both cases and controls was correlated with long term
mortality and another main predictor of long-term mortality was poor nutritional
status.29 A prospective study from Kenya, looked into the prevalence, correlates and
outcome of hypoxaemia in acutely ill children under three years with ALRI showed
that over half of the children were hypoxaemic and short-term mortality was 4. 3
times greater in these children and the clear association of hypoxaemia with mortality
suggested that the detection of early and effective of hypoxaemia are important
aspects of clinical management of ALRI in children in developing countries.55
A qualitative study from Philippines looking into the health seeking behavior
of caretakers in response to ARI in underfives showed that caretaker's cultural beliefs,
financial situation and social contacts are important in their decision to seek
biomedical assistance and are often implicated in delay in presentation and acting
upon referral to hospita1.57 A study from Alwar, India, showed that 50 % of ARI
cases were left untreated and among the treated group, private practitioners were
found to be the main source of health care.22 In an ethnographic ARI study in west
16
Java, Indonesia, the results showed that effective medical care was more likely to be
delayed for infants compared to older children.4{)
A prospective cohort study was conducted in Mexico to assess the antibiotic
non-compliance and waste in upper respiratory tract infections and the results showed
that non compliance (60 '?,./0) and antibiotics waste for ART was high.54 A hospitalbased study from Pakistan on ARI in underfives showed that standard case
management for ARI reduced both antibiotics use and expenditure on drugs and this
strategy significantly reduced the ART case fatality rate also.'{' About the availability
of heath facility in Kerala, 96 % of villages have a sub-center, hospital and dispensary
or clinic located within the village. And 2/3 of the villages have a hospital located
within the village. The median distance from any health facility in Kerala is less than
1 km.111
A study conducted in Egypt to validate the maternal reporting of ARI
manifestations, 2 weeks and 4 weeks after the episode of ARI in under fives
suggested that ARI programs should generally use a recall period of two weeks to
maximize specificity.58 A prospective study conducted over a period of two years on
ARI incidence among pre-school children in a rural area in Punjab used a recall
period of two weeks and the ARI was defined as cough and running nose with or
without fever.°
17
Chapter- I I 1
Methodology
3.1. Study Design:
The study is a cross-sectional descriptive study (prevalence study) in order to
assess the prevalence of ARE in underfive children. A door to door survey was
conducted. The researcher did the survey. In a cluster (ward), from which end of the
road, survey would be started was selected randomly. First house on the left of the
road near a small junction was selected as the first house of the cluster_ If there was
no under five children in that house then next house was selected and then the next of
that house. Like this, the other houses were selected till at least 12 under five subjects
were selected from each cluster. The survey started on 20/12/ 2000 and completed on
31/1/2001. After data collection from each house, questionnaire was checked whether
any entry was missing or not and finally at the end of every day all the questionnaires
were checked again_ Confusion or missing information was corrected before going to
new cluster next morning.
Survey. instruments
All the instruments were arranged prior to the field survey_ The researcher
collected data regarding the signs and symptoms of AR1, other illnesses, sex, age,
birth weight, immunization, vit A supplementation, maternal age at delivery, breast
feeding duration etc and other features of the house and treatment practices by
interviewing mothers of the underfive children by using a pre-structured and pretested questionnaire. Initially an idea about the study, its objectives and the
importance of giving accurate answers were made very clear to the mothers of the
underfive children. Socio-demographic variable such as religion, education and
18
occupation of parents were recorded for each subject. A standardized bath room scale
was used for taking the weight of the children.
Selection of research setting
Rural
Trivandrum district was selected because; firstly, no previous
community based studies looking into the same aspects have been done in this
particular setting. Secondly, the researcher is familiar with this location. Also, the four
taluks of rural Trivandrum district are almost homogenous of the rural area of Kerala.
3.2. Sampling methods:
Sample size was calculated by using the formula,
(Za)2PQ = d
Here.
Z= Confidence limit factor which is 1.96 for 95% confidence interval.
P= Prevalence of ART, which was taken as 20%; since, the DHS data showed a
prevalence of 13.97 % in the general population Kerala in 1999.
The prevalence is assumed to be higher in more vulnerable group, children under five
years of age.
Q=1 -P
A= Precision factor. (Difference between assumed prevalence and lowest
expected prevalence). Here lowest expected prevalence was assumed 15 percent.
So ❑=0. 20 -0. 15-0. 05
d=design effect =1. 5
The formula we used (Zot)2 PQ 3d is for random sampling method.
19
For our study we used cluster sampling so in order to reduce the design effect 20% of
the calculated sample was added to the sample size.
.
So, sample size = 1.962* (0.20 0.8Q
(0.05)2
1 . 5 -.-.368
Sampling was done on the basis of 32 clusters of 12 underfive children. So the
sample size was 384. We used cluster sampling because of convenience and time and
money constraints.
Study subjects, area and population
Study subjects: Children aged 60 months or less (unclerftves) at the time of interview.
Study area and population: The rural Trivandrum district consists of 4 taluksTrivandrum, Chirayinkil, Nedumangad and Neyyattinkara. The number of panchayats
in each taluk are - 29 in Neyyatinkara, 26 in Chirayinkil, 26 in Nedumangad and 12 in
Trivandrum, 62 According to 1991 census, the population of rural Trivandrum district
residing in 4 taluks'was 1,948,407 and the total population of children under six years
in rural Trivandrum was 252,597 (128,638 males and 123,959 females). i.e. 12 % of
the total population was children under six years in rural Trivandrum.62
In
Chirayinkil taluk, the total under six children were 65,688 (33,383 males and 32,305
females), in Nedumangad taluk 67,440 (34,199 males and 33,241 females). in
Trivandrum taluk 30,818 (15,735 males and 15,083 females), and in Neyyatinkara
taluk 88,651 (45,321 males and 43,330 females).
Each panchayat is divided into many wards. Total number of wards in all the
four taluks were listed down first and calculated the cumulative population. And then,
the total population was divided by the needed cluster i.e. 32. Thus we got the class
interval. The first cluster (ward) to start with from the cumulative population was
20
selected by lottery method. And added the class interval to that population to get the
second cluster (ward) and carried on like that to finish with 32 clusters.
3. 3. Variables59, definitions and measurements
Measurement: The data on all the variables except body weight was collected by
interviewing mothers with a pre-structured and pre-tested questionnaire. Body weight
was measured by using a standardized bath room scale.
Acute respiratory infection (ARI): An ARI case is defined as a child sutiering from or
had suffered from at least one of the following symptoms: cold and cough, running
_58. 59_60. 63
nose or ear discharge/ ear pain in the past two weeks of the interview.8
Age: The age of the subjects was recorded in completed months.
Educational status of parents: Number of years of schooling was recorded. Based on
number of years of schooling the educational status was divided into 3 sub groups: 05 years of schooling, 6-10 years of schooling and above 10 years.
Socio economic status (SES): A subjective assessment of SES was done purely on
observation on physical environment and assets. Subjects are classified into lower,
middle and upper socioeconomic group_ Data was collected on household type and
assets like radio, TV, two wheeler, fridge, telephone etc.
Type of house: Housing was assessed based on following criteria.
Pucca: Roof wall and floor are cemented.
Semi-pucca: Wall and floor are cemented. Roof is thatched or made ofcorrugated metal sheet.
Ku/c/ia: Roof, wall and floor are not cemented.
Body weight: Weight of the subject was measured by a standardized bathroom scale.
During measurement the subject was barefooted and with wearing minimum clothes.
Each time weight was measured; it was made sure that the pointer was at the zero
21
mark. Since it was not able to weigh the small babies alone, the weight of the mother
was taken alone first and then the weight of the baby and mother was taken together
while the mother carries the baby and calculated the weight of the baby by reducing
the weight of the mother from the weight of the mother and baby together.
tinder weight for age/ weight for age-low *(weight scale in (ippendix.1): Under
weight are those children whose body weight for the age fall below the 3rd percentile
of the weight chart of affluent Indian children.64
Cooking fuel: Mainly these categories were recorded- wood, kerosene, electricity and
gas. It was grouped into two groups: Wood and/ or kerosene group (chance for indoor
smoke) and electricity and / or gas group (no chance for indoor smoke).
Tobacco smoker in the family: Presence of any cigarette or beedi smoker in the
household of the child.
Infants: Children aged 12 months or less
Low birth weight LBW): is defined as a weight at birth of less than 2500 grams,
irrespective of gestational age.``
Sleep room sharing: is defined as the number of persons sharing the subject's
bedroom excluding the subject.
Mother's age at delivery: is defined as the age of the mother in completed years at the
time of the delivery of the subject.
Kitchen not attached to the house: means that the kitchen is outside the main building
of the house.
Kitchen with chimney: means the kitchen has a smoke outlet for the passage of
cooking smoke.
Diarrhea (loose stools): is defined as at least one episode of loose stools in the last two
weeks of interview as reported by the mother of the child.
22
Cases of cough and cold in the family: means any family member of the child (except
the subject) has cough and cold in the last one month of the interview.
Asthma case: is defined as those children who are under treatment for asthma
currently or were treated for asthma ever in their life.
Birth order: is defined as the order in which the subject is bOrn to the mother, only
live births are taken into consideration.
Number of underfives in the household: means the number of children aged 60
months or less at the time of interview in the household of the child including the
subject.
Nuclear family: is defined as a family in which father, mother and children live; but if
anybody else is living with them it is defined as joint family.
Pre-term baby (Maturity_at birth—low): is defined as any neonate born before 37
weeks of pregnancy irrespective of the birth weight, as reported by the mother.
Full term baby (Maturity at birth —normal): is defined as any neonate born after 37
weeks of pregnancy irrespective of the birth weight, as reported by the mother.
Immunization status and vit A supplementation: Data on immunization was collected
by seeing the immunization card of the child; if card is not available as reported by
the mother.
Immunized for age / vit A doses for age: means whether or not the child has been
given all doses which are supposed to be given by that age. It is classified in to three
groups for analysis - fully immunized means all doses for age are given, partially
immunized means not all doses for age are given and not immunized means no doses
are given so far. The first dose of vit A is given in the 9th month. So children not
completed 9 month of age are not considered for analysis.
13
Breast feeding duration: was recorded in completed months. Only those children who
have stopped breast-feeding were taken for analysis.
()filer illnesses.: Any other illness the child was suffering or had suffered from in the
last two weeks of interview, as reported by the mother.
Treatment practices for ART: includes the healthcare seeking behavior, factors
affecting that, delay in seeking care and its reasons, system of medicine followed and
health facilities used for the current ARI episode in the last two weeks.
Direct cost of ART treatment: includes the doctor's consultation fee, drug charge,
transportation charge to the health facility and if any other spending in connection
with the treatment of current ARI episode in the last two weeks.
Health care seeking for ART: is defined as the professional medical care sought in the
last two weeks for the current ARI episode.
Self-medication: Consumption of drugs for treating ARI without doctor's
prescription.
Home treatment for ARI: Giving traditional remedies made at home for treating ARI
Belief that usual for children: The mother's belief that the ART symptoms are usual
for small children; nothing to worry about that and no need for seeking health care.
Delay in health care seeking: is defined as the postponement of care seeking even
three or more days after finding the symptoms of ARI.
Treatment cost for ART: is the sum of money spent as doctor's consultation fee and
the money spent for purchasing drugs for the current ARI episode in the last two
weeks.
Transportation charge: is the money spent for the to-and-fro transportation of the child
and the accompanying person to the health facility for the current ART episode in the
last two weeks.
24
3.4. Data analysis: Data was entered and into Microsoft Excel software. Data
analysis was done in SPSS statistical software. Chi-square test was done for bivariate
analysis and logistic regression was done for multivariate analysis as the outcome
variable and predictor variables both were categorical.
25
Chapter IV
Results
4. 1. Sample characteristics: The sample population consisted of 415 subjects of
age 60 months or less. Out of these 217 (52.3%) children were males and 198 (47.7%)
were females (M: F= 1: 0.91).
4.1.1. Sample characteristics by taluks
Table.4.1.
Taluk
Chirayinkil
Nedumangad
Neyyattinkara
Trivandrum
Total
Male
49
60
56
52
217
Under fives
Female
43
42
58
55
198
Total (%)
92 (22.2)
102 (24.6)
114 (27.5)
107 (25.8)
415 (100.0)
ToNe.4./. shows the percentage of samples from each taluk is like this: Chirayinkil
(22.2 °A), Nedumanszad (24.6 %), Neyyattinkara (27. 5 %) and Trivandrum (25.8 %).
Samples are more or less in equal proportion from each taluk.
4.1.2. Sample characteristics by age
Table. 4.2.
Age group
(in months)
0-12
13-24
25-36
37-48
49-60
Total
Under fives
Male
Female
41
56
45
4]
43
38
48
36
25
42
217
198
Total (%)
97 (23.4)
86 (20.7)
81 (19.5)
84 (20.2)
67 (16.2)
415 (100.0)
Table.4.2. shows the percentage of samples in different age groups is like this. 0-12
months group (23.4 %), 13-24 months (20. 7%), 25- 36 months (19. 5%), 37- 48
months group (20. 2 %) and 49- 60 month group (16. 2 %).
26
4.1.3. Sample characteristics by religion
Graph.4 .1.
Sample characteristics by religion
Muslim
21%
X, an
12%
IBEX, ian
•Hindu
iCIMuslim
Graph .4.1. shows that 66.3 % of the samples were Hindus, 21. 4 % Muslims and 12.
3 % Christians.
4.1.4. Sample characteristics by SES and type of house
Table.4.3.
SES
Low
Medium
High
Total (%)
Kucha
72
26
0
98 (23.6)
j
4
Semi-pucca
49
134
17
200 (48.2)
Pucca
0
35
82
117 (28.2)
Total (%)
121 (29.2)
195 (47.0)
99 (23.8)
415 (100.0)
Tabk.4.3_ shows that 29.2 % of the samples were from low SES, 47.0 % of samples
were from medium SES and 23.8 % were from high SES. 23.6 % of samples lived in
kucha houses, 48.2 % lived in semi-pukka houses and 28.2 % lived in pucca houses.
4.2.Prevalence Results: The overall prevalence of ARI in rural Trivandrum was
54.9% (95 °,10 Cl. 50 0- 59.8). Prevalence among females was 56. 6 % (95 °,/o CT 49.663.6) and among males was 53. 5 % (95 % CI 49.6- 63.6).
4.2.1. Distribution of symptoms of ARI
Graph. 4.2. shows that 93.0 % of the cases had cough and cold, 89.9 % had running
nose and 5.7 % had ear pain (discharge) as the symptom of ARI.
27
Graph. 4.2.
Distribution of symptoms of ARI (%)
MI (Any one of the symptomsEar pain (discharge) _
Running nose
Cough and cold
:15' '71''
____:_l V.,.9
.
-I:13
0 20 40 60 80 100 120
4.2.2. Prevalence of ARI by sex
Graph. 4.3.
P revalence of ARI by sex (% )
57
56
55
54
53
52
1
56 6
53.5
1
0
.
Fern ale
Male
Grtph.4.3. shows that prevalence of ARI was slightly higher among females (56. 6
%) than among males (53. 5 %). But the difference was not statistically significant
(Chit p-value is 0.52).
4.2.3. Prevalence by socio- economic class
Tahle.4.4.
SES
Low (n=121)
Medium (n=195)
High (n-99)
Total (n=415)
ARI. (%)
73 (6(13)
110 (56.4)
45 (45.5)
228 (54.9)
'
p-value
0.07
28
Table.4.4. shows that the prevalence was highest in low SES (60.
3 ?/0),
in medium
SES, it was 56. 4 % and in high SES, the prevalence was lowes
t (45. 5 %). There is a
clear trend which shows a decrease in prevalence from low SES
to high SES. But the
difference is not statistically significant (Chi 2 p-value is 0.07).
4.2.4. Prevalence according to the education status of _pare
nts
Table.4.5.
Education
status of
. parents
Father
Mother
Years of
schooling
AR1 (%)
p-value
0-5 (n---42)
6-10 (n=276)
>10 (n=97)
Total (n=415)
0-5 (n---32)
6-10 (n=211)
>10 (ri= I 72)
Total (n=415)
25 (59.5)
162 (58.7)
41 (42.3)
228 (54.9)
18 (56.3)
130 (61.6)
80 (46:5)
228 (54.9)
0.016
0.013
Mble.4.5. shows the prevalence according to the educational
status of the
this: highest prevalence in 0-5 years of schooling group (59.
father like
5 %), in 6-10 years
schooling group (58.7 %) and the lowest prevalence in
more than 10 years of
schooling (42. 3 %). The prevalence according to the educational
status of the mother
is like this: prevalence in the 0-5 years of schooling group
was 56.3 %, in 6-10 years
of schooling group (61, 6 %) and in the more than 10 years of
schooling group (46. 5
%). The prevalence showed a trend of decline in prevalence
with the education of
parents. The difference was statistically significant (Chi 2 p-val
ues are 0.02 and 0.01
tbr education for father and mother groups respectively).
29
4.2.5. Prevalence according to the mother's age at delivery
Table. 4.6.
Mother's age at
delivery (in years)
<18 (n=14)
18-26 (n=287)
27-32 (n=100)
>32 (n=14)
Total (n=-415)
ARI (%)
Non-ARI (%)
10 (71,4)
163 (56.8)
44 (44.0)
11 (78.6)
228 (54.9)
•4 (28.6)
124 (43.2)
56 (56.0)
3 (21.4)
187 (45.1)
Table.4.6. shows that the prevalence among children who are born when mother's age
at delivery was less than 18 years is (71.4 %) and among children who are born when
mother's age at delivery was more than 32 years is (78.6%). The prevalence in the
above two groups are high when compared to the prevalence in the other two groups_
i.e. the prevalence among children who are born when mother's age at delivery was
in 18-26 age group is (56.8%) and in 27-32 age group is (44.0%).
4.2.6.Prevalence according_to employment status of the mother
Table.4.7.
Employment status
of mother
House wife (n---389)
Working (n=26)
Total (n=415)
ARI (%)
p-value
214 (55.0)
14 (53.8)
228 (54.9)
0.908
Mble.4.7. shows that the prevalence was more or less same among children whose
mothers are working (53. 8 %) and not working (55.0 %). No statistically significant
difference was observed (Chi 2 p-value is 0.91).
30
4.2.7.Prevalence according to breast-feeding duration
Table.4.8.
Breast feeding
(in months)
1-6 (n=20)
7-12 (rr--44)
13-18 (n=64)
19-24 (n--68)
> 24 (n=49)
Total (n=245)
A R1 ( % )
p-value
14 (70.0)
29 (65,9)
36 (56.3)
37 (54.4)
27 (55.1)
143 (58.4)
0.572
Only children who have stopped breast-feeding have been considered for analysis
here. 7able.4.8. shows that the prevalence among children who are breast-fed for 1-6
months was 70.0%, among children breast fed for 7-12 months (65.9%), among 13-18
months breast-fed children (56.3° ), among, 19-24 month breast-fed children (54.4%)
and among children breast-fed for more than 24 months, 55,1 % was the prevalence.
Generally, the prevalence showed a steady decline with the increase in duration of
breast-feeding though the difference was not statistically significant (Chit p-value is
0.57).
4.2.8. Prevalence in different age grotps
Table.4.9.
Age group
(in months)
0-12 (n--97)
13-24 (n=86)
25-36 (n=811
37-48 (n=84)
49-60 (n=67)
Total (n=415)
ARI (%)
p-value
45 (46,4)
48 (55.8)
48 (59.3)
48 (57.1)
39 (58.2)
228 (54.9)
0.41
lirb/e.4.9. shows that the prevalence was lowest among infants (46. 4 %). The
prevalence in 13-24 months age group was 55. 8 %, in 25-36 months group 59. 3 %,
in 37- 48 months group 57.1 ‘,Yo and in 49- 60 months group 58.2 %. But the difference
31
observed in prevalence in different age groups was not statistically significant (Chi 2
p-value is 0.41).
4.2.9. Prevalence by body weight and maturity at birth
Table.4.10.
Category
Weight for age
(N=288, L=127)
Total (n=415)
Birth weight
(N=333, L=82)
Total (n=415)
Maturity at birth
(N-390, L-25)
Total (n=415)
AR! (%)
Normal (N)
161 (55.9)
P-value
Low (L)
67 (52.8)
0.55
228 (54.9)
47 (57.3)
181 (54.4) I
0.62
228 (54.9)
217 (55.6)
11 (44.0)
0.25
228 (54.9)
Table.-1.10. shows that a slight increase in prevalence was observed among children
with normal weight for age (55.9 %) when compared to those who are low weight for
age (52.8 `,."0). But the difference was not statistically significant (Chi 2 p-value is
0.55). Low birth weight babies had an increased prevalence (57.3 %) than normal
birth weight babies (54.4 %). But the difference was not statistically significant (Chi 2
p-value is 0.62). Full term babies (maturity at birth-normal) had an increased
prevalence (55.6 %) when compared to the prevalence among pre-term babies
(maturity at birth -low), i.e. 44.0 %. But the difference was not statistically significant
(Chi2 p-value is 0.25).
4.2.10. Prevalence of AR1 by illnesses
Table.-1.11. shows that among children whose family member had cough and cold
during the one month of the interview had a very high prevalence (69.8 %) than the
prevalence among those children whose family member did not have cough and cold
(36.1 %). The difference was statistically significant (Chi' p-value is 0.00). Among
32
children who had .loose stools during the last two weeks of the interview, the
prevalence was 66.7 % and the prevalence among children who did not have loose
stools was 54.2 %. The difference was not statistically significant (Chi2 p-value is
0.23). Among asthmatic children, the prevalence was high (74.1%) when compared to
the prevalence among non-asthmatics (52.1%). The difference was statistically
significant (Chi2 p-value is 0.002).
Table4.11.
ARI (')/0)
Illnesses
Cases of cold in family
(Y=232, N=183)
Total (n=415)
Loose stools
(Y=24, N=391)
Total (n=415)
Asthma
(Y=54, N-361)
Total (n=415)
P-value
No (N)
66 (36.1)
0.000
228 (54.9)
16 (66.7) i212 (54.2)
0.23
228 (54.9)
188 (52.1)
40 (74.1)
0.002
Yes (Y)
162 (69.8)
228 (54.9)
4.2.11. Prevalence according to immunization status
Treble 4.12.
Immunized for age
Fully (n=392)
Partially or not (n=23)
Total (n=415)
ARI (%)
214(54.6)
14(60.9)
228(54.9)
p-value
0.556
Table.-1.12. shows that among, children who are fully immunized for age, the
prevalence was low (54.6 %) compared to the prevalence among children who are not
or pariially immunized for age (60.9%). But the difference seen was not statistically
significant (Chi2 p-value is 0.56).
33
4.2.12. Prevalence according to vitamin A supplementation
Table. 4. 13.
Vit A doses for age
No dose (n=17)
Full doses (n-197)
Partial doses (n=129)
Total (n=343)
AR! (%)
11(64.7)
108(54.8)
80(62.0)
199(58.0)
Non-ARI (%)
6(35.3)
89(45.2)
49(38.0)
144(42.0)
p-value
0.371
The first dose of Vit A is given in the 9th month. So children below 9 month old are
not considered for analysis. Table 4. /3. shows that in those children who have been
given all the doses of vit A for age, the prevalence was lowest (54.8%), in children
who have been given no doses of vit A, the prevalence was highest (64.7%) and
among those who are supplemented partial doses, the prevalence was 62.0%, There is
a clear trend showing a gradual decrease in the prevalence with correct doses of vit A
supplementation. But the difference was not statistically significant (Chi" p-value is
0.37).
4.2.13. Prevalence according to birth order
Table.4. 14.
Birth order
I (n=211)
2 (n=166)
>2 (n=38)
Total (n=415)
ARI (%)
119 (56.4)
88 (53.0)
21 (55.3)
228 (54.9)
p-value
0.806
Tc-ible.4. /4 shows that the prevalence among birth order first is (56.4 %), among birth
order second (53.0 %) and among birth order more than two (55.3 %). The prevalence
was more or less same among different birth orders (Chi` p-value is 0.81).
34
4.2.14. Prevalence among school going children
Table. 4. 1 5.
School child
No (n=276)
Yes (n-139)
Total (n=415)
AR1 (%)
143 (51.8)
85 (61.2)
228 (54.9)
p-value
0.071
Thble.4.15. shows that among school going children, the prevalence was high (61.2
%) compared to the prevalence among children who are not going to school (51_8 %).
But the difference was not statistically significant (Chi2 p-value is 0.07).
4.2.15. Prevalence according to type of family
Table. 4.16.
Family type
Nuclear (n=106)
Joint (n=309)
Total (n=415)
ARI ("/0)
73 (68.9)
155 (50.2)
228 (54.9)
p-value
0.001
Tahle.4.16. shows that among children from nuclear families, the prevalence was
significantly high (68.9%) when compared to the prevalence among children from
joint families (50.2 %). The difference was statistically significant. (Chi2 p-value is
0.001).
4.2.16. Prevalence according to the number of underfives in the house
Table.4.17.
No. of under fives
l (n=1 75)
2 (n=190)
3 (n-28)
4 (n=22)
Total (n=415)
111
A RI f%)
97 (55.4)
99 (52.1)
20 (71.4)
12 (54.5)
228 (54.9)
p-value
0.29
this analysis, the study subject also has been counted as an underfive in the
household. Table 4.17. shows that highest prevalence was observed when the number
35
of under fives in the household was three (71.4%), the prevalence when the number of
underfives in the household was one is (55.4 %), when two is (52.1 %) and when four
is (54.5%). The differences observed was not statistically significant (Chi2 p-value is
0.29).
4.2.17. Prevalence according to child's sleep room sharing
Table. 4.18.
Number of persons
sharing child's sleep room
1-2 (n-171)
3-4 (n=232)
5-6 (n=12)
Total (n=415)
ARI ('Yo)
p-value
92 (53.8)
128 (55.2)
8 (66.7)
228 (54.9)
0.683
The study subject is not counted as a person sharing the subject's sleep room.
Table.-I. 18. shows that when 1-2 persons shared the child's sleep room, the prevalence
was 53.8 %, when 3-4 persons shared the sleep room, the prevalence was 55.2 % and
when 5-6 persons shared, the prevalence v,,'as 66.7 A clear increase in prevalence
as the number of persons sharing the child's sleep room increases, though it was not
statistically significant (Chi2 p-value is 0.68).
4.2.18.Prevalence by characteristic of house
Table. 4.19.
Characteristics
of house
Type of house
Type of floor
Classification
Kucha (n=98)
Semi- ucca (n=200)
Pucca (n=117)
Total (n--415)
Mud / cowdung (n=1 18)
Cement ) mosaic (n=297)
ITotal (n=415)
ARI (%)
p-value
53 (54.1)
109 (54.5)
66 (56.4)
228 (54.9)
74 (62.7)
154 (51 9)
228 (54.9)
0.929
0.045
Table.-1.19. shows that there is not much difference in the prevalence according to the
type of house: kucha (54.1%), semi-pucca (54.5 %) and in pucca (56.4 %). No
36
statistically significant difference is observed (Chi 2 p-value is 0.93). The prevalence
among children who are living in houses with mud or cow dung flooring was high
(62. 7%) compared to the prevalence among children who live in houses with cement
or mosaic flooring (51. 9 N. The difference was statistically significant (Chi 2 pvalue is 0.04).
4.2.19. Prevalence according to characteristics of kitchen
Table. 4.20.
Characteristics of
kitchen
Attached to house
(Y-391, N-24)
Total (n=415)
Kitchen with chimney
(Y-132, N=283)
Total (n=415)
ARI (%)
Yes (Y)
218 (55.8)
p-value
No (N)
10 (41.7)
228 (54.9)
160 (56.5)
68 (51.5)
228 (54.9)
0.17
0.33 .
Table.4.20. shows that among children who are living in houses with kitchen attached
to the main building of the house, the prevalence was high (55.8 %) when compared
to the prevalence among children who are living in houses with kitchen is separate
from then main building (41.7 %). Bit the difference was not statistically significant
(Chi2 p-value is 0.17). Among children who are living in houses with kitchen without
chimney, the prevalence was high (56.5 %) when compared to the prevalence among
children who are living in houses with kitchen with chimney (51.5%). But the
difference was not statistically significant (Chi2 p-value is 0.33).
4.2.20. Prevalence by religion, geographical location and tobacco smoking and
cooking fuel (Appendix_ 3: Tables 1,2,3 & 4)
About the prevalence among religions, the prevalence of AR1 was slightly higher
among Christian children (58.8%) compared to the other two religions; the prevalence
among Hindus was 54. 2 % and among Muslims (55. 1 %). But the difference was not
37
statistically significant (Chi 2 p-value is 0.83). When looked into the prevalence inn
different geographical areas, the prevalence was highest in the coastal areas (60. 0 %)
and lowest in the highland (52. 4 %) and in the midland prevalence was 56. 0%. But
the difference was not statistically significant (Chi 2 p-value is 0.62). About the
impact of the presence of a tobacco smoker in the family and ARI prevalence, a high
prevalence was observed among those children whose families had a to tobacco
smoker (56.8 %) when compared to the prevalence among children whose families
did not have a smoker (52.8 %). But the difference was not statistically significant
(Chit p-value is 0.41). The sample size was not adequate to analyze the relation
between AR1 and cooking fuel since the study was in the rural area almost all
households used wood as cooking fuel.
4. 3. Results of multivariate logistic regressions:
Multivariate analysis: The variables those were significant (P <0.05) in bivariate
analysis were taken into multivariate logistic regression analysis.
Floor
Mud or cow dung flooring
Mosaic or cement flooring,
Education of father
0-5 years Of schoolinu
6-10 years of schooling
>10 years of schooling
Education of mother
0-5 years of schooling
6-10 years of schooling
>10 years of schooling
Family type
Nuclear family
Joint family
Case of cold in the family
Case of cold in the family (No)
Case of cold in the family (Yes)
Asthmatic child
Asthmatic child (No)
Asthmatic child (Yes)
("l able. 4.21)
Odds Ratio
1
0.72
1
1.10
0.71
_L.
1
95% CI
1
I
P- value
0.43, 1.20
1
0.20
j
0.29
0.81
0.45
0.50, 2.40
0.28, 1.78
r
1
1.38
0.97
0.57, 3.34
0.38 2.47
0.31
0.47
0.94
1
0.41
0.24, 0.70
0.0009
1
4.27
2.74, 6.67
0.0000
1
2.50
1.22, 5.13
0.0110
38
Tab
shows the results of multivariate logistic regressions. When adjusted for
educational status of parents, family type, cases of cold in the family and asthma
cases, compared to children living in houses with cowdung or mud flooring, children
living in houses with cement or mosaic flooring are at a lower risk for developing
ARI. The odds ratio was 0.72. When adjusted for educational status of parents, type of
floor, family type and case of cold in family, compared to non-asthmatic children
asthmatic children were at a higher risk for developing ARI. The odds ratio is 2.5; the
95 % CI didn't include 1 and p-value is significant (<0.05). When adjusted for
educational status of parents, type of floor, family type and asthma cases, compared to
children whose family member didn't have cold in the last one month, the children
whose family member had cold in the last one month are at a higher risk for
developing AR1. The odds ratio is 4.27; the 95 % CI didn't touch 1 and the p-value is
significant. When adjusted for educational status of parents, type of floor, asthma
cases and case of cold in family, compared to children from nuclear family, the
children from joint families are at a lower risk for developing AR1. The odds ratio is
0.41; the 95 % CI didn't touch 1 and the p-value is significant.
4. 4. Presence of other illnesses in ARI cases (Appendix. 3: Table 5)
7.02 % of ARI cases had loose stools, 5.70 % had skin infections, 3.51 % had
vomiting, 1.32 % had worm infestations, 0.88 % had epilepsy and 1.75 % had other
illnesses in the last two weeks of the interview as reported by the mother. 17. 54 % of
AR1 cases were asthmatics.
4. 5. Treatment practices and direct cost of ARI treatment
Health care seeking for ARI: Among 228 ARI cases, only 140 (61.4 %) sought health
care; means 88 cases (38.6 %) did not seek health care.
39
Reason for not seeking treatment: 38.6 O/ of total ARI cases i.e. 88 ARI cases didn't
seek health care. They told the following reasons for not seeking health care- 48 (54.5
%) of them believed that these ARI symptoms are usual for children and so no
treatment is needed, 29 (33.0%) of them gave self-medication to the child, 7 (8.0%) of
them gave home treatment, 3 (3. 4%) of them believed in prayer and 1 (1.1%) of them
did not have time to go to the health facility.
When the health care is sought: Out of 140 cases sought health care, 125 (89.3%) of
them went to the health facility in 1-2 days after seeing the symptoms, 11 (7.9 %) of
them went to the facility within 3-7 days after the onset of symptoms and 4 (2.9 %) of
them went to the facility 7 days after the onset of symptoms.
Reason for delay in health care sought: Out of the 140 cases sought health care 15
(10. 7%) of them made delay in seeking health care, i.e. went to the health facility 3
or more days after seeing the symptoms (delay in care by definition). Out of this
delayed cases, 10 (66.7%) of them told that these ART symptoms are usual for
children, so they waited to subside the symptoms by itself. And 5 (33.3 %) of them
told that they gave self-medication and waited to subside the symptoms.
System of medicine followed for treatment: Out of the 140 cases sought health care,
129 (92.2 %) of them went to allopathic system, 9 (6.4 %) of them went to
homeopathic system and the remaining 2 (1.4 %) of them went to ayurveda.
Health facility chosen for treatment (Appendix.3: Table.6): Out of the 140 cases
sought care, 59 (42.1 %) went to private doctor for treatment, 18 (12.8 %) went to
private hospital, 27 (19.3 %) went to govt. health center, 36 (25.7%) went to govt.
hospitals.
Who decided to take the child to health facility: Out of the 140 ARI cases sought
care, in 105 cases (75.0 %) the decision to go to health facility has been taken by the
40
mother, in 17 cases. (12.1%) decision was made by the father and in 18 cases (12.9%)
decision was made by a family member of the child.
Distance traveled to get treatment (Appendix 3:1 able.7): Out of the 140 cases sought
care, 95 (67.9 %) of the cases had to travel only 1-3 km to get treatment, 21 (15.0 %)
of them traveled 4 -7 km, 15 (10.7 %) of them traveled 8-12 ki.n and 9 (6.4 %) of them
traveled more than 12 km to get treatment.
Number of facilities visited for current ARI episode: Out of the 140 cases sought
care, 130 (92.9 %) of the cases visited only one facility for the current illness episode
during the last two weeks, 9 (6.4 %) of them visited two facilities and 1 (0.7 %)
visited three facilities.
Cost of treatment (doctor's fee + drug charge) of current ART episode (Appendix.3:
Tab1e.8): Out of 140 cases sought care, 28 (20.0%) of the cases spent Rs. 1-30 during
the last two weeks, for the treatment of current ARI episode, 33 (23.6%) of the cases
spent Rs.31-60, 23 (16.4%) of the cases spent Rs. 61-100, 28 (20.0%) of the cases
spent Rs.101-200, 4 (2.9%) of the cases spent more than Rs 200 and 24 (17.1 %) of
the cases got treatment free of cost.
9):
Transportation charge for the current ART episode treatment (Appendix. 3: Table.
Out of the 140 cases sought care, 25 (17.9%) of cases spent Rs. 1-5 as transportation
charge to take the child and the care taker to the health facility for this illness episode
during the last two weeks, 17 (12.1%) of cases spent Rs. 6-10, 29 (20.7 %) cases
spent Rs. 11-20, 10 (7.1%) cases spent more than Rs. 20 and 59 (42.1 %) had facility
at walkable distance.
41
Average cost for the treatment of current ARI episode
Table.4.22.
SES
Low
Medium
High
Total
(Cost of treatment)
Dr.'s fee+ drugs charge
(in Rs)
26.40
21.65
23.13
23.39
Transportation charge
(in Rs)
3.42
2.98
2.59
3.01
Table.4.22. shows the average cost for the treatment of current ARI episode: Average
cost of treatment (doctor's fee -1- drug charge) was high among low SES (Rs. 26.40),
among medium SES (Rs_ 21.65) and high SES (Rs. 23.13). The average cost for the
treatment of current ARI episode during the last two weeks is Rs 23.39. Average cost
of the transportation charge in last two weeks for the current ARI episode is Rs. 3.01.
It was also high among low SES (Rs 3.42), among medium SES (Rs. 2.98) among
high SES (Rs. 2.59).
42
Chapter V
Discussion and Conclusions
5.1. Discussion:
The main objective of this study was to find out magnitude of the
problems
l
drum. The overal
related to ARI in children under five years of age in rural Trivan
- females 56.
prevalence of ARI in rural Trivandrum was 54.9% (95 °,/0 CI 50.0- 59.8)
6 % (95 % CI 49.6- 63.6) and males 53. 5 % (95 % CI 49.6- 63.6). A
study conducted
in rural Kerala
in Kerala showed the prevalence of ARI (cough with rapid breathing)
as 8.9 %II' and in some other Indian studies also prevalence was low
L2'" The high
prevalence in this study may be partly attributed to the definition
of ARI, which is
highly sensitive compared to the definitions used in other studies. In
addition, inherent
difference of population, seasonal variations, sampling method and
survey design
might have contributed to this geographic variation in prevalence.
s than
Even though the prevalence of ARI was slightly higher among female
among males, the difference was not statistically significant in tune
with some of the
other studies". The prevalence was lowest among infants compared
to the other age
this was in
groups; this was in agreement with a survey conducted in Kerala.'° But
3 No significant
contrast to some studies where the prevalence declined with age."-1
relation between age and ARI has been observed in this study.
ian children
Though not statistically significant, prevalence was high among Christ
compared to others; this was in agreement with the Kerala study
I°. There was no
association between the geographical location and the prevalence
even though in
ation between
coastal areas the prevalence was higher. There was no significant associ
SES and ARI; but a trend of decline in prevalence with increase in SES
was observed
13
in this study also like in some other studies'''. There was no association between the
type of house and the prevalence of ARI.
Bivariate analysis showed a significantly high prevalence (Chi 2 p-value 0.04)
was observed among children who are living in houses with cuwdung or mud flooring
compared to the prevalence among children living in houses with cement or mosaic
flooring. But in multivariate analysis, it was not significant. There was no association
between the employment status of the mother (whether working or not) and ARI. In
bivariate analysis, a significantly low prevalence was observed among children with
the increase in education status of the parents; ARI prevalence by father's education
(Chi2 p-value 0.02) and mother's education (Chi2 p-value 0.01). This is in agreement
with the data that in Kerala infant mortality declines very sharply with increase in
education of mother.'° But in multivariate analysis, the difference observed with
education of both the parents was not significant.
Unlike the other study results, even though it was not statistically significant, a
slight increase in prevalence was observed among children with normal body weight
for age when compared to those who are under weight for age. Though statistically
not significant, low birth weight babies had an increased prevalence than normal birth
weight babies. Unusually, even though it was not statistically significant, full term
babies had an increased prevalence when compared to the prevalence among pre-term
babies. Even though not statistically significant, among children who are fully
immunized for age the prevalence was low when compared to the prevalence among
partially or not immunized children. Though not statistically significant, there is a
clear trend showing a gradual decrease in the prevalence with the supplementation of
correct doses for age of vit A supplementation. There was no significant association
between breast feeding duration and ARI even though a trend showed a decline in
44
prevalence with increase in duration of breast-feeding. There was no association
between birth order of the child and ARI. Among school going children, the
prevalence was high when compared to the prevalence among children who are not
going to school; but the difference was not statistically significant.
Both in bivariate and multivariate analysis, a significantly low prevalence was
observed among children from joint families compared to the children from nuclear
families. When adjusted for type of floor, parent's education, asthma and cases of
cold in the family, the odds ratio for children from joint families was 0.41 and the pvalue was also significant (0.0009). Over crowding in the nuclear families might be
the reason for the high prevalence_ By using the limited sample size of this study it is
not possible to tell concretely the reason for that.
No association was found between the number of underfive children in the
household and ARI. Sample size was inadequate to analyze the relation between
maternal age at delivery and ARI; but a trend seen was that a high prevalence was
observed among those children who are born when the maternal age was < 18 yr. and
> 32 yr. at the time of delivery. Though statistically not significant, a trend of increase
in prevalence was seen as the number of persons sharing the child's sleep room
increased.
Though not statistically significant, a high prevalence was observed
among those children whose familieS had a tobacco smoker compared to the
prevalence among children whose families did not have a smoker. Even though not
significant, the prevalence was low among children who are living in houses where
kitchen is separate from then main building and among children who are living in
houses where the kitchen has chimney compared to the corresponding opposite group.
The sample size was inadequate to analyze the relation between cooking fuel and
ARI.
45
In both bivariate and multivariate analysis, a significant association between cases
of cold in the family during the last one month and ARI has been found out. When
adjusted for educational status of parents, type of floor, family type and asthma,
compared to children whose family member didn't have cold in the last one month,
the children whose family member had cold are at a higher risk for developing ARI.
The odds ratio is 4.27 and the p-value is significant (0.0000). Even though statistically
not significant, among children who had loose stools during the last two weeks of the
interview, the prevalence of AR! was high compared to children who did not have
loose stools_ When adjusted for educational status of parents, type of floor, family
type and cold cases in family, compared to non-asthmatic children, asthmatic children
were at a higher risk for developing AM_ The odds ratio is 2.5 and p-value is
significant (0.01 10).
38.6 % of the ARI cases did not seek health care: the main two reasons for not
seeking health care were the belief that these AR1 symptoms are usual for children
and so no treatment is required and the practice self-medication. 61.4 % of the total
ARI cases sought health care. This was less when compared to the treatment sought
(81%) in a previous Kerala study.1° Among those who sought care, 10.7 % of cases
went to health facility three or more days after seeing the symptoms (delay in care by
definition). The major reasons for this delay in seeking care were - the belief that the
ARI symptoms are usual for children (so they waited to subside the symptoms by
itself) and the practice of self-medication (waited to subside the'symptoms after selfmedication). Among those who sought care, 92.2 °A of them went to allopathic
system. 54.9% of those who sought care went to private doctor for treatment. 75.0 %
of the time, it was child's mother's decision to take the child to the health facility.
Among those who sought care, 67.9 % of them had a health facility within 3 km from
46
their house. This was in agreement with survey in Kerala that the median distance
from any health facility in Kerala is less than 1
The average cost for the treatment of current ARI episode during the last two
weeks is Rs 23.39. Average cost of the transportation charge in last two weeks for the
current ARI episode is Rs. 3.01. Average cost for treatment and transportation was
high among low SES.
5.2. Conclusions:
Overall prevalence of ARI was 54.9 percent, which was very high. There
were no significant sex differentiation though prevalence was higher among females
(56.6%) than among males (53.5%).
1. Significant positive correlation was found between asthma and ARI.
Significant positive relation was found between presence of cough and
cold cases in the family and ARI in underfives. Unusually, ARI prevalence
was significantly low among children in joint families.
2. More than one third of the ARI cases didn't seek health care. The main
reasons for not seeking health care and making delay in care seeking were
same - the belief that the symptoms of ARI are usual for children and the
practice of self-medication. The average cost for ARI treatment and
transportation to the health facility was high among low SES.
5.3.I.,im itations:
Study design had some inherent limitations, it is not possible to say concretely
about 'causal association but our prime objective was to highlight the magnitude of the
problem that was fairly done by this study design. Sampling was not representative of
the country but fairly representative of this rural area, which can represent other
district's rural areas excepting the municipalities in Kerala. Sex ratio of the sample
47
was 1: 0.91, which corresponds to the sex ratio of children under six years in rural
Trivandrum. Survey was conducted during winter season; that might have resulted in
high prevalence, some study results have shown that the incidence of ARI is high
during winter. I '
5.4.Policy implications:
Magnitude of ARI in this age group was quite high. So due importance should be
given to address this problem at the policy making level. Now ARI control in India is
a component of the new RCH program. So all the efforts to combat the ART problem
should be consolidated through the RCI T. A national program will have inherent
limitations; first it may not fit to the local conditions. Here comes the importance of
local studies on ART which will give baseline information for local level planning.
There should be initiative to inform mother's of underfivcs, through mass media as
well as through primary health care set up, about the importance of prevention,
control and professional management of AR1, by which we can improve the health
care seeking and avoid the practice of self-medication and delay in care seeking care.
Special attention should be given to asthmatic children by their family members since
they are at high risk of developing ART. Family members of underfives should have
the knowledge that un-treated ART in the family can spread the disease easily to the
underfives. ART program should give special attention to low SES since they had a
higher prevalence and are spending more money for treatment and transportation.
Fuller use of the existing health care system (primary health care) may be enough for
effective management of ARI if properly directed. Since three-quarter of the Indian
population live in rural areas served by the PHC, ART in rural area should get special
attention. There are reports of the resistance to the drug cotrimaxazole65 which is the
drug of choice in the ARI control program in India. So further studies are needed in
48
this direction. A reliable health information system needed to be established so that
the high quality data available to assist in planning for control of ARI. Accurate
pathogen specific disease burden estimates are needed for formulating an effective
strateay to combat ARI. Then only we can start thinking about the cost benefit
analysis of the Hib vaccination_ Control of these infections has important implications
not only for child survival but also for the success of primary health care, family
health and socio economic development
References: 1) WHO (1999), Health Situation in South East Asian Region 1994-1997,
Regional office for SEAR, New Delhi, 1999,pp- 88-91, pp- 153-155, pp- 233-235.
2) WHO, A joint WHO/ UNICEF Statement. Basic principles for control of acute
respiratory infections in children in developing countries, 1986, pp- 1-18.
3) WHO 1999, World Health Report 1999, Making a difference, pp: 104-105,110111.
4) The world health report, 1998, Life in the2lst century A vision for all, WHO,
pp-3, 48, 62, 67-73, 125 -127, 183.
5) Economic review, 1999, Kerala state planning Board, Trivandrum, and Kerala,
pp.- 5: 217-219).
6) Regional Health Report 1996, WHO, South East Asia Region, pp. 18- 20.
7) Pio. A, et al. The magnitude of the problem of acute respiratory infections.
Proceedings of an international work shop on ARI in childhood (1984), University
of Australia, 1985, pp-3-16.
8) WHO, 1995, The management of acute respiratory tract infections in children,
Practical guidelines for outpatient care, pp-1-4.
9) A. Bulla and K.L. Hitze, Bulletin of WHO (1978), 56, (3): pp-481-498.
10)National Family health Survey, 1992-1993, Population research Center,
University of Kerala, Trivandrum, International Institute of Population
Sciences, Mumbai, June 1995, pp-129, 158-163, 168-172,183.
) P.Chhabra, S. Garg, S.K.Mittal, L. Satyanarayan, M.Mehra, N. Srama.
Magnitude of acute respiratory infections in under-fives, Indian
paediatrics, 1993, 30: pp- l 315-1319.
II
12) M.P.Tumbe, C. Shivaram, and Y_ Chandrasekhar, acute respiratory infection in
children: a survey in rural community, Indian J Medical Sciences 1999, 53 (6):
pp-249-253.
13) Ram Kishore Gupta, Anil Kumar, Padam Singh (ICNIR), Factor analysis of ARI
among underfives in Delhi slums, Indian Pediatrics 1999; 36(11): pp-1144 -1149.
14) Rahman MM, Rahman AM, Prevalence of acute respiratory tract infection and
its risk factors in under five children, Bangladesh Med. Res. Counc. Bull. 1997;
23(2): pp-47-50.
15) M.S. Lye, U. Deavi, K.P. Lai, H. Kaur, et al, Acute respiratory infection in
Malaysian children, J Trop pediatrics, 1994, 40(6): pp-334-340.
16) V.P.Reddaiah and S.K. Kapoor, Acute respiratory infections in rural under fives,
Indian J. of Pediatrics, 1988, 55: pp-424-426.
17) Deb 5K, Acute respiratory disease survey in Tripura in case of children below
five years of age, J Indian Med Assoc 1998; 96(4): pp-111-6_
18)N.Devinayagarn, K. Nedumchelian, S. Ramaswamy, S. Kannan and
S.R.Ratnam, Risk factors for fatal Pneumonia: a case control study, Indian
Pediatrics, 1992,Vol.29, pp-1329-1332.
19)H. Seghal and Kiran Bala, Febrile convulsions in children: a clinical profile of 150
cases, Indian Pediatrics, vol. 16. No.6, pp-479-482.
20) V.P.Reddaiah, J. lobo, S.K.Kapoor and L.M. math, Comprehensive rural
health services project Ballabgarh; trends in under five mortality, Indian
pediatrics, 1988; 55: 287-94.
21) S.K.Patnaik, acute respiratory infection in children — a survey in east Godavari
district of Andra pradesh, J Commu Diseases, 1991, 23(1): pp- 34-37
111
22)Madhav SM, Dixit GC, Prakasam PS, Sundaram NS, Shrivastava KN. Datta KK,
Sharma RS, A study of two-weekly incidence of ARI in under-five children of
rural area of Alwar (Rajasthan), J Common Dis 1990; 22(4): pp-243-6).
23) B.J. Selwyn behalf of BOSTID, The epidemiology of acute respiratory tract
infections in young children: comparison of findings from several developing
countries, review of infectious diseases, vol. 12, 1990, supplement, pp- S 870-888.
24)W. Fonseca, BR_ Kirkwood, C.G. Victora, et al, Risk factors for childhood
pneumonia among the urban poor in Fortalza, Brazil: A case control study,
Bulletin of WHO, 1996, 74 (2): 199-208.
25) 0. Sobeslayskym, S.R.K.Mebikari, P.S,E.G.Harland, et al, The viral etiology of
ARI in children in Uganda, Bulletin of WHO 1977, 55 (5): 625-631.
26) R.N. Srivatava, Shaficia Azamy, Rahima Ahrary, M.K. Bhan and G.D. Mogli,
Morbidity and mortality among under five children hospitalized with medical
disorders in Afghanistan, Indian Pediatrics 1978, vol. 15, No.4, pp-293-299.
27) A. Jain, A. Pande, P.K.Misra, A.Mathur and U.C.Chaturvedi, an Indian hospital
based study of viral causes of ARI in children,
J
Med Microbiology, 1991, 35(4):
pp-219-223.
•
28)E.E. Ekanem, A.A.Asindi and O.U. Okoi, Community based surveillance of
pediatric deaths in cross river state, Nigeria, Tropical and geographical medicine,
1994, vol. 46, No.5, pp-305-308.
29) T.E.West, T. Goetghebuer, P. Milligan, E.K.Mulholland and M.W. Weber, Long
term morbidity and mortality following hypoxaemic lower respiratory tract
infection in Gambian children, bulletin of WHO, 1999, 77 (2), pp-144 -47.
IV
30) D.L. Pelletier, ,E.A. Frongillo, D.G. Schroeder and J.P.Habicht, The effects of
malnutrition on child mortality in developing countries, Bulletin of WHO, 1995,
73 (4): pp- 443-448.
31)Rukhsana Gazi, Faziul Karim and AMR Chowdhurv, Morbidity pattern of infants
in rural Bangladesh, 1997, Research and evaluation Division, BRAG, pp-1-15.
32) S.Rao and V. Rajpathak, Breast feeding and weaning practices in relation to
nutritional status of infants, Indian Pediatrics, 1992,Vol.29, pp-1333-1335.
33)Megan Murray and Zeba Rasmussen, Measles out break in a northern Pakistani
village: Epidemiology and vaccine effectiveness, American journal of
Epidemiology, 2000, vol.151, no.8, pp-811-819.
34) Lain R B 1-tardy, Sieghart Dittmann and Donald W Sutter, current situation and
control strategies for resurgence of diphtheria in newly independent states of the
former soviet union, lancet 1996; 347:1739- 44.
35) V.Fauveau, M.K. Stewart, J. Chakraborty and S.A. Khan, Impact on mortality of a
community based program to control ALRI, Bulletin of WHO (1992), 70(1): pp109-116.
36) The vit A pneumonia working group, Potential interventions for the prevention of
childhood pneumonia in developing countries: a meta analysis of data from field
trials to assess the impact of vit A supplementation on pneumonia morbidity and
mortality, WHO Bulletin OMS, vol. 73, 1995, pp-609-618.
37)Bela Shah, Mahesh Sarma and S.N. Vani, Knowledge, attitude and practice of
Immunization in an urban educated population, Indian J. Pediatrics (1991), 58:
pp-691-695
V
38) Mulhollandk, Hilton S, Sadegbola R, et al, Randomized trial of H. influenzae
type —h tetanus protein conjugate m for prevention of pneumonia and meningitis
in Gambian infants, Lancet 1997, 349; p1191-97.
39) Gangarosa E J, Galezka A NI, Wolfe C R, et al, Impact of anti vaccine movements
on pertussis control: the untold story. Lancet 1998; 351: pp-356-61.
40) Sudarti Kresno. Gail g Harrison, Bambang Sutrisna and Arthur Reingold, Acute
respiratory illness in children under five years in Indramayu, west Java, Indonesia:
a rapid ethnographic assessment, Medical Anthropology 1994, Vol. 15, pp-425434.
41)M.A. Koenig, M.A. Khan, B. Wojtyniak, J.D. Clemens, et al, Impact of measles
vaccination on childhood mortality in rural Bangladesh, Bulletin of WHO, 1990,
68 (4): pp- 441-447,
42) L. Dudley, G. Hussey, J. Huskissen and G. Kessow, Vitamin a status, other risk
factors and acute respiratory infection morbidity in children, S African Med Jor,
1997, 87(1): pp-65-70.
43)D.K.Agarwal, B.D.Bhatia and K.N.Agarwal, simple approach to ARI in rural
under five children, Indian Pediatrics, 1993, 30(5): pp-629-635.
44)Pandey A, Chakraborty AK. Undernutrition, vit A deficiency and ARI morbidity
in underfives, Indian J Public Health 1996,40(1): pp-13-16.
45) V. Kumar, L. Kumar and P. Diy,,edi. morbidity related to feeding pattern in
privileged urban and under privileged rural infants, Indian Pediatrics, 1981, vol.
18 Oct 1981, pp-283-287.
VI
46) N.Datta, V.Kuinar, L. Kumar and S. Singhi, Application of case management
to
the control of ARI in LBW infants: a feasibility study, Bulletin of WHO, 1987,
65(1): 77-82.
47)M. Lopez Alarcon, S. Villaipando and A. Fajardo, Breast feeding lowers the
frequency and duration of AR1 and diarrhea in infants under six months of age, J
Nutrition 1997,
127(3): pp- 436-443.
48)A. Pisacane, L.Graziano, G. Zona, G. Granata, H. Dolezalova, et al, Breastfeeding and acute lower respiratory infection, Acta Pediatrics, 1994, 83(7): pp-714
-718..
49) Victora CG, Kirkwood BR, Ashworth A, Black RE, Rogers S. Sazawal S,
Campbell H, Gove S, Potential interventions for the prevention of childhood
pneumonia in developing countries: improving nutrition, Am J Ciin Nutr 1999
Sep; 70(3): pp- 309-320.
50) Effect of breastfeeding, on infant and child mortality due to infectious diseases in
less developed countries: a pooled analysis. WHO Collaborative Study Team on
the Role of Breastfeeding on the Prevention of Infant Mortality, Lancet 2000 Feb
5; 355(9202): pp-451- 55.
51) WHO, Indoor air pollution study, Maragua area, Kenya. Document WHO/
PEP/
87,1- WHO/ RSD/ 87.32, 1987.
52) S. Sarnia, G.R. Sethi, A. Rolnagi, A. Chaudhary, et al , indoor air quality and
ALRI in Indian urban slums, Environment Health Perspective 1998, 106 (5): pp291-297.
53) Ben-Noun L, Pattern of primary care clinic visits of adult asthmatics, Public
Health Rev 1999; 27(4): pp-321-8.
54) Hortensia Reyes, Hector Guiscafre, Onofre Munoz, et al, Anti biotic non
compliance and waste in URI s and acute diarrhea. J clin Epidemiologyl997, vol.
50; No.11: pp- 1297-- 1304
55) F.E.Onyango, M.C. Steinhoff, E.M. Wafula, S.Wariva, eta], hypoxaemia in
young Kenyan children with ALRI, BMJ, 1993, 6; 306(6878): pp-612-615.
56) S.A. Qazi, G.N. Rehman, and M.A. Khan, Standard management of ARI in a
children's hospital in Pakistan: impact on anti biotics use and case fatality,
Bulletin of WHO, 1996, 74 (5): pp-501-507.
57) McNee A, Khan N, Dawson S, Gunsalam 1, Tallo VL, Manderson L, Riley],
Responding to cough: Boholano illness classification and resort to care in
response to childhood ARI, Soc Sci Med 1995, 40(9):pp-1279- 89.
58)L. H. Harrison, S. Moursi, A.H. Guinena, A.M. Gadomski, et al, Maternal
reporting of acute respiratory infections in Egypt, Int. J Epidemiology, 1995, 24
(5): pp-1058-1063.
59)1.Riley et al, Guidelines for research on ARI: Memorandum from a WHO
meeting, 1982, Geneva, Switzerland, Bulletin of WHO, 60(4): pp-521- 533.
60) B N S Walla, S K Gamdhir, S Singhi and S R Sroa, Socio ecomnomic and
ecologic correlates of ARI in pre school children, Indian Pediatrics, 1988, vol.25,
no.7, pp-607-612.
61) Sachdev HP, Vasanthi B, Satyanarayana L, Pun RK, Simple predictors to
differentiate acute asthma from ARI in children: implications for refining case
management in the ARI Control Program, Indian Pediatr 1994; 31(10): pp-12511259.
62) Population census, 1991, Taluk / village population, 1991, pp-128-131.
VIII
63) A. Dominguez, S. Minguell,
J.
Torres, A. Serrano, et al, Community out break of
acute respiratory infection by mycoplasma pneumoniae, Eur J Epidemiology,
1996, 12(2): pp-131-134.
64) O. P. Ghai, Essential pediatrics, 4th edition, published by Interprint, New Delhi28, India, 1996, pp- 6
65) Invasive bacterial infection surveillance group, INCLEN, Prospective multi center
hospital surveillance of s. pneumoniae disease in India, Lancet 1999 (353): pp1216-1221_
Appendix
Appendix.1
Scale for measuring weight for age
Weight in K(7 (2f affluent India,, children from birth to six years 64
Boys
3 'I percentile
2.54
4,78
6.24
7.17
7.80
8.86
9.77
10.56
11.25
11.89
12,51
13,12
13.77
Age
(in months
0
3
6
9
12
18
24
30
36
42
48
54
60
Girls
j
3 rd percentile
2.23
4.50
5.86
6.79
7.47
8.57
9.44
10.14
10.75
11.31
11.90
12.58
13.40
Under weight for age: is defined as those children whose body weight falls below the
rd
percentile of the weight chart of the affluent Indian children. In order to get the
weight for the missing months in the above table, the average weight gain in each age
interval in the table was calculated and the average weight was added to the first
month's weight in that age interval group in order to get the next month's weight and
so on. For each age interval group the process was repeated.
Appendix.2
Questionnaire for the study on prevalence. risk factors, treatment
practices and direct cost of ARI among children under five years in
rural Trivandrum district
(*-- specify remarks)
I. Identification Data: Code No:
Date:
Panchavat:
Ward No:
Taluk:
Ward Name:
Sex: M / F
Name of the child:
Address:
Age:
months
Religion:
Hindu / Muslim / Christian/Others
Geographical location of the house: Coastal Highland / Midland
2. Information on SES: I. Researchers impression on SES
Low / Medium / High
Type of house : Kucha / Semi- pucca / Pucca
3. House : Own / Rented
4. Assets : Radio / TV / Gas stove / Phone Fridge / Bike/ Others*
5, Number of underfives in the house:
6. Type of floor : Mud / cow dung/ cement/others*
3. Education and occupation of the parents: 7. Education of the mother
years of schooling*
8. Occupation of the mother
9. Education of the father
years of schooling*
10, Occupation of the father
4. Information of the child: Kg.
IL Body weight of the child
12. Was the child low birth weight (<2.5Kg)
Y/N
13, Was the child a full term baby
Y/N
14. Is the child immunized for age
Fully / Partially / Not
15. Did you give vitamin A drops
Y/N
16. If yes, how many doses
17. How long did you breast-feed the child :
months
18. Whether colostrum has been given
Y/ N
19, Is the child under treatment for asthma or was ever treated for
: Y/ N
asthma
20. Birth order of the child in the family
1 / 2 / 3/ 4 / 5*
21. Does the child go to nursery school
Y/ N
si
22. If yes, which type of school
•
: Nursery / Balawadi / Play
school 1 others*
5. Information of house and family members: 23. Type of family
Nuclear / Joint
24. Total number of family members
25. Number of under five children in the house hold
26. Mother's age at delivery
27. How many are sharing the child's bed room
yr_
1 /2 / 3 / 4*
28. Is there any smoker in the house hold
Y/ N
29. If yes, do they smoke inside the house
Y /N
30. Whether the kitchen is attached to the house
31. Whether the kitchen has chimney
Y/ N
Y/N
32. What is the fuel used for cooking: Wood / Wood powder/Kerosene
/ gas / Cow dung / Electricity
33. Did any family member suffer from cough and cold in the last month?
YIN
D
6. Morbidity status bf the child: /N
34. Did the child have running nose in the last two weeks? Y
35. Did the child have ear discharge (pain) in the last two
weeks? Y/ N
? Y /N
36. Did the child have cough and cold in the last two weeks
37. Did the child have loose stools at least once during
the last two weeks?
38. Did the child have any other illness in the last two
weeks? YIN
Y/N
39. if yes, what disease?
7. Treatment practice: - (If 34/ 35136 is yes, proceed)
40. Did you seek health care :
Y/N
(If 40 is no)
en /
41. Why? : Self-medication / home treatment / usual for childr
Others*
: Home treatment / Self-medication /
42. What did you do
Others*
(If 1(1 is yes)
43.When did you seek health care after seeing the symptom
1-2 days/ 3-7 days / > 7 days
44. If not immediately, what is the reason for delay?
Self-medication / home treatment / usual for children /
others*
Iiomoeo/
45.What system of medicine did you select : Allopathy/ Ayunieda/
/ Others*
tional
Tradi
46. Why did you choose this system of medicine?
Family belief/ Peer influence best for kids/ No side effects /
others*
47. Which facility did you choose?
/
Private doctor / Private hospital / I health centre / Govt. hospital
others*
48. Who suggested going to health facility : Your self / husband /
JPE IN/ others*
49. Was the treatment effective
: Fully / Some what / Not / Adverse
reaction / Can not say
Km
SO. How Much distance did you travel for getting treatment?
1/2/3
51. How many facilities did you visit for this illness episode?
52. If more than 1 what are they? 1
8. Cost for ARI treatment: 53. How much did you pay as doctor's fee?
Rs.
54. I low much did you pay for the drugs?
Rs.
55. How much did you spend for the transportation of the child? Rs.
56. Other spending, in connection with the illness?
Rs.
F
Appendix. 3
Tables
1. Prevalence of ARI in different religions
ARI (%)
30(58.8)
149(54.2)
49(55.1)
228(54.9)
Religion
Vian (n=51)
Hindu (n=275)
Muslim (n=89)
Total (n=415)
Non-ARI (%)
21(41.2)
126(45.8)
40(44.9)
187(45.5)
p-value
.
0.829
2. Prevalence in different geographical locations
Geographical
location
Coastal (n=40)
Highland (n=168)
Midland (n=207)
Total (n=415)
ARI (%)
Non-ARI (%)
24(60.0)
88(52.4)
116(56.0)
228(54.9)
16(40.0)
80(47.6)
91(44.0)
187(45.1)
p-value
0.61908
3. Prevalence according to tobacco smoker in the family
Smoker
No (n=195)
Yes (n=220)
Total (n-415)
ARI (%)
103(52.8)
125(56.8)
228(54.9)
p-value
Non-ARI (%)
92(47.2)
95(43.2)
,
187(45.1)
0.4139
4. Prevalence of ARI according to fuel
Fuel
Wood and /or kerosene (n=408)
Gas and/or electricity (n=7)
Total (n=415)
ARI (%)
227 (55.6)
1(14.3)
228(54.9)
Non-ARI (%)
181 (44.4)
6 (85.7)
187(45.1)
5. Presence of other illnesses in ARI cases
Other illnesses in ARI cases (%)
Other illnesses
16 (7.02)
Loose stools
40 (17.54)
Asthma*
13 (5.70)
Skin diseases
3 (1 32)
Worm infestation
4 (1.75)
Others
2 (0.88)
Epilepsy
8 (3.51)
Vomiting
228
,
Total ARI cases '
*Except asthma all other diseases occurred in the last two weeks
6.1Iealth facility chosen for treatment
Health facility
Private doctor
Private hospital
Health center
Govt. hospital
Private clinic
Total sought care
Total ("/o)
59 (42.1)
17(12,1)
27 (19.3)
36 (25.7)
1 (0.7)
140 (100.0)
.
7. Distance traveled to get treatment
Distance (in km)
1-3
4-7
8-12
> 12
Total sought care
Total CYO
95 (67.9)
21 (15.0)
15 (10.7)
9(6.4)
140 (100.0)
8. Cost of treatment of current ARI episode
Dr.'s fee + Drug charge (in Rs)
1-30
31-60
61-100
101-200
> 200
Nil
Total sought care
Total (%
28 (20.0)
33 (23 . 6)
23 (16.4)
28 (20,0)
4 (29.)
24 (17.1)
140 (100.0)
9. Transportation charge for the current ARI episode treatment
Trans ► ortation charge (in Rs)
1-5
6-10
11-20
> 20
Nil
Total sought care (%)
Total (%)
25 (17.9)
17 (12.1)
29 (20.7)
10 (7.1)
59 (42.1)
140(100.0)
/ ///1/11 1 / 1 1 //11/ 1 // //11/ 11
c,r,
4
000
:■■-•,NS-L
ot
1.00
2,:y• .7,— • \*
‘c
-
".•N
%,
‘04